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Physical treatments
Treatment Strategies
Physical treatments
What’s new?
Ross Dunne
• National Institute for Health and Clinical Excellence guidance is now available for electroconvulsive therapy (2003) and transcranial magnetic stimulation (2007)
Declan M McLoughlin
• A molecular mechanism of action for electroconvulsive therapy is emerging • Other brain stimulation techniques (e.g. transcranial magnetic stimulation, vagus nerve stimulation and deep brain stimulation) are under investigation
Abstract Electroconvulsive therapy (ECT) is the most effective treatment available for severe depression, with a remission rate of 60%. It is a safe procedure and the major medical risks are related to anaesthesia (mortality 1:80,000). Early use of ECT is associated with shorter and less costly hospital stays and it is reported to enhance health-related quality of life and activities of daily living. Bilateral ECT is more powerful than unilateral ECT but is associated with more cognitive side-effects. The precise mechanism of action of ECT is not yet known, but in animal models it upregulates neurotrophic factors and induces hippocampal neurogenesis. No convincingly useful antidepressant effect has yet been demonstrated for transcranial magnetic stimulation (TMS) or vagus nerve stimulation (VNS), and these methods, along with deep brain stimulation (DBS) are best considered for research purposes only. Stereotactic neurosurgery for mental illness is practised only in specialized centres for intractable illness, but has a good outcome.
bilaterally (bifrontotemporal position) or unilaterally on the right side. The charge rapidly spreads through the brain, inducing a generalized tonic–clonic seizure required for therapeutic effect. It is standard practice to use electroencephalogram (EEG) monitoring. ECT is administered repeatedly during a course, e.g. twiceweekly for 6–10 treatments. The National Institute of Health and Clinical Excellence (NICE) recommends ECT for resistant depression, mania and catatonia.4 Early use of ECT is associated with shorter and less costly hospital stays. ECT has also been reported to enhance health-related quality of life and activities of daily living.5 Bilateral ECT is more powerful than unilateral ECT but is associated with more cognitive side effects.1 ECT can cause anterograde amnesia (i.e. failure to form new memories) that is usually short-lived. ECT may also cause retrograde amnesia (failure to retrieve older already-formed memories), although the extent is not clear. A qualitative systematic review of patients’ experiences reported that one-third complained of persisting memory loss.6 A large (n = 347) prospective community-based study found that 12.4% of patients had evidence of persisting retrograde amnesia six months afterwards and this was related to use of bilateral ECT and the old-fashioned method of sine-wave (rather than brief-pulse) stimulation.7 The precise mechanism of action of ECT is not yet known, but induction of hippocampal neurogenesis is implicated and believed to be important for antidepressant effect.8
Keywords electroconvulsive therapy; depressive disorder; hippocampus; neurosurgery; transcranial magnetic stimulation
Electroconvulsive therapy (ECT) is the most effective treatment available for severe depression and often the treatment of choice.1 About 30% of patients fail to respond to antidepressants. Frequently these patients, and those who are severely ill, are treated with ECT. About 60% of treatment-resistant patients achieve remission.2 ECT has been widely criticized in the popular media and often inaccurately portrayed in books and films such as ‘One flew over the cuckoo’s nest’ and ‘The bell jar’, notwithstanding their artistic merit. Contemporary modified ECT is a safe procedure; the major medical risks are related to anaesthesia, with a mortality of 1:80,000.3 There are few absolute contraindications but patients must be fit for general anaesthesia. Under carefully controlled conditions, an electrical charge is passed through the brain of an anaesthetized patient given muscle relaxant. The brief-pulse charge is administered via two hand-held electrodes placed either
Other brain stimulation techniques for depression These include both transcranial magnetic stimulation (TMS) and vagus nerve stimulation (VNS). These differ from ECT in that they involve focal brain stimulation, no seizure is induced and no anaesthesia is required. No convincingly useful antidepressant effect has been demonstrated and these methods are best considered for research purposes only.9
Ross Dunne MB BCh BAO is Research Registrar on the EFFECT-Dep study, a randomized controlled double-blind trial of right high-dose unilateral versus bilateral ECT, at Trinity College Dublin, St Patrick’s Hospital, Dublin, Ireland. Competing interests: none declared.
Neurosurgery Stereotactic neurosurgery for mental illness is practised in just a few specialized centres. Patients must be suffering from treatment-resistant depression or obsessive–compulsive disorder (OCD) for 3 to 5 years before evaluation for surgery. Under the UK Mental Health Act 1983, a panel of three persons, one who
Declan M McLoughlin PhD MRCPsych MRCPI FTCD is Research Professor of Psychiatry at the Department of Psychiatry, Trinity College Dublin, St Patrick’s Hospital, Dublin, Ireland. Competing interests: none declared.
MEDICINE 36:9
499
© 2008 Elsevier Ltd. All rights reserved.
Treatment Strategies
is a registered medical practitioner and two who are not, have to satisfy themselves that the patient is capable of understanding the nature, purpose and likely outcome of the proposed operation and has consented. Under Section 57 of the Act, neurosurgery may never be used on a patient who does not consent. This is also stated by the United Nations High Commission for Human Rights (1991).10 The most common procedure is anterior cingulotomy after which improvements on the Yale-Brown Obsessive Compulsive Scale are 36–48%.11 Deep brain stimulation (DBS) of selected neuronal circuitry implicated in depression and OCD is a non-ablative form of neurosurgery that is currently under evaluation.9 ◆
Psychiatrists’ Special Committee on ECT, 2nd edn. London: Gaskell, 2005. 4 Available from: http://www.nice.org.uk/nicemedia/pdf/ 59ectfullguidance.pdf 5 McCall WV, Dunn A, Rosenquist PB. Quality of life and function after electroconvulsive therapy. Br J Psychiatry 2004; 185: 405–9. 6 Rose D, Fleischmann P, Wykes T, Leese M, Bindman J. Patients’ perspectives on electroconvulsive therapy: systematic review. BMJ 2003; 326: 1363. 7 Sackeim HA, Prudic J, Fuller R, Keilp J, Lavori PW, Olfson M. The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology 2007; 32: 244–54. 8 Santarelli L, Saxe M, Gross C, et al. Requirement of hippocampal neurogenesis for the behavioral effects of antidepressants. Science 2003; 301: 805–9. 9 McLoughlin DM. Vagus rules still apply. Psychol Med 2008; 38: 625–27. 10 Office of the United Nations High Commissioner for Human Rights. Document on the protection of the rights of the mentally ill. Adopted by General Assembly resolution 46/119 of 17. Available from: http://www.un.org/documents/ga/res/46/a46r119.htm, December 1991 (accessed 12 June 2008). 11 Steele JD, Christmas D, Eljamel MS, Matthews K. Anterior cingulotomy for major depression: clinical outcome and relationship to lesion characteristics. Biol Psychiatry 2008; 63: 670–77.
References 1 UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and metaanalysis. Lancet 2003; 361: 799–808. 2 Eranti S, Mogg A, Pluck G, et al. A randomized, controlled trial with 6-month follow-up of repetitive transcranial magnetic stimulation and electroconvulsive therapy for severe depression. Am J Psychiatry 2007; 164: 73–81. 3 Scott AIF, Royal College of Psychiatrists, Special Committee on ECT. The ECT handbook: the third report of the Royal College of
MEDICINE 36:9
500
© 2008 Elsevier Ltd. All rights reserved.
Physical treatments
What’s new?
Ross Dunne
• National Institute for Health and Clinical Excellence guidance is now available for electroconvulsive therapy (2003) and transcranial magnetic stimulation (2007)
Declan M McLoughlin
• A molecular mechanism of action for electroconvulsive therapy is emerging • Other brain stimulation techniques (e.g. transcranial magnetic stimulation, vagus nerve stimulation and deep brain stimulation) are under investigation
Abstract Electroconvulsive therapy (ECT) is the most effective treatment available for severe depression, with a remission rate of 60%. It is a safe procedure and the major medical risks are related to anaesthesia (mortality 1:80,000). Early use of ECT is associated with shorter and less costly hospital stays and it is reported to enhance health-related quality of life and activities of daily living. Bilateral ECT is more powerful than unilateral ECT but is associated with more cognitive side-effects. The precise mechanism of action of ECT is not yet known, but in animal models it upregulates neurotrophic factors and induces hippocampal neurogenesis. No convincingly useful antidepressant effect has yet been demonstrated for transcranial magnetic stimulation (TMS) or vagus nerve stimulation (VNS), and these methods, along with deep brain stimulation (DBS) are best considered for research purposes only. Stereotactic neurosurgery for mental illness is practised only in specialized centres for intractable illness, but has a good outcome.
bilaterally (bifrontotemporal position) or unilaterally on the right side. The charge rapidly spreads through the brain, inducing a generalized tonic–clonic seizure required for therapeutic effect. It is standard practice to use electroencephalogram (EEG) monitoring. ECT is administered repeatedly during a course, e.g. twiceweekly for 6–10 treatments. The National Institute of Health and Clinical Excellence (NICE) recommends ECT for resistant depression, mania and catatonia.4 Early use of ECT is associated with shorter and less costly hospital stays. ECT has also been reported to enhance health-related quality of life and activities of daily living.5 Bilateral ECT is more powerful than unilateral ECT but is associated with more cognitive side effects.1 ECT can cause anterograde amnesia (i.e. failure to form new memories) that is usually short-lived. ECT may also cause retrograde amnesia (failure to retrieve older already-formed memories), although the extent is not clear. A qualitative systematic review of patients’ experiences reported that one-third complained of persisting memory loss.6 A large (n = 347) prospective community-based study found that 12.4% of patients had evidence of persisting retrograde amnesia six months afterwards and this was related to use of bilateral ECT and the old-fashioned method of sine-wave (rather than brief-pulse) stimulation.7 The precise mechanism of action of ECT is not yet known, but induction of hippocampal neurogenesis is implicated and believed to be important for antidepressant effect.8
Keywords electroconvulsive therapy; depressive disorder; hippocampus; neurosurgery; transcranial magnetic stimulation
Electroconvulsive therapy (ECT) is the most effective treatment available for severe depression and often the treatment of choice.1 About 30% of patients fail to respond to antidepressants. Frequently these patients, and those who are severely ill, are treated with ECT. About 60% of treatment-resistant patients achieve remission.2 ECT has been widely criticized in the popular media and often inaccurately portrayed in books and films such as ‘One flew over the cuckoo’s nest’ and ‘The bell jar’, notwithstanding their artistic merit. Contemporary modified ECT is a safe procedure; the major medical risks are related to anaesthesia, with a mortality of 1:80,000.3 There are few absolute contraindications but patients must be fit for general anaesthesia. Under carefully controlled conditions, an electrical charge is passed through the brain of an anaesthetized patient given muscle relaxant. The brief-pulse charge is administered via two hand-held electrodes placed either
Other brain stimulation techniques for depression These include both transcranial magnetic stimulation (TMS) and vagus nerve stimulation (VNS). These differ from ECT in that they involve focal brain stimulation, no seizure is induced and no anaesthesia is required. No convincingly useful antidepressant effect has been demonstrated and these methods are best considered for research purposes only.9
Ross Dunne MB BCh BAO is Research Registrar on the EFFECT-Dep study, a randomized controlled double-blind trial of right high-dose unilateral versus bilateral ECT, at Trinity College Dublin, St Patrick’s Hospital, Dublin, Ireland. Competing interests: none declared.
Neurosurgery Stereotactic neurosurgery for mental illness is practised in just a few specialized centres. Patients must be suffering from treatment-resistant depression or obsessive–compulsive disorder (OCD) for 3 to 5 years before evaluation for surgery. Under the UK Mental Health Act 1983, a panel of three persons, one who
Declan M McLoughlin PhD MRCPsych MRCPI FTCD is Research Professor of Psychiatry at the Department of Psychiatry, Trinity College Dublin, St Patrick’s Hospital, Dublin, Ireland. Competing interests: none declared.
MEDICINE 36:9
499
© 2008 Elsevier Ltd. All rights reserved.
Treatment Strategies
is a registered medical practitioner and two who are not, have to satisfy themselves that the patient is capable of understanding the nature, purpose and likely outcome of the proposed operation and has consented. Under Section 57 of the Act, neurosurgery may never be used on a patient who does not consent. This is also stated by the United Nations High Commission for Human Rights (1991).10 The most common procedure is anterior cingulotomy after which improvements on the Yale-Brown Obsessive Compulsive Scale are 36–48%.11 Deep brain stimulation (DBS) of selected neuronal circuitry implicated in depression and OCD is a non-ablative form of neurosurgery that is currently under evaluation.9 ◆
Psychiatrists’ Special Committee on ECT, 2nd edn. London: Gaskell, 2005. 4 Available from: http://www.nice.org.uk/nicemedia/pdf/ 59ectfullguidance.pdf 5 McCall WV, Dunn A, Rosenquist PB. Quality of life and function after electroconvulsive therapy. Br J Psychiatry 2004; 185: 405–9. 6 Rose D, Fleischmann P, Wykes T, Leese M, Bindman J. Patients’ perspectives on electroconvulsive therapy: systematic review. BMJ 2003; 326: 1363. 7 Sackeim HA, Prudic J, Fuller R, Keilp J, Lavori PW, Olfson M. The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology 2007; 32: 244–54. 8 Santarelli L, Saxe M, Gross C, et al. Requirement of hippocampal neurogenesis for the behavioral effects of antidepressants. Science 2003; 301: 805–9. 9 McLoughlin DM. Vagus rules still apply. Psychol Med 2008; 38: 625–27. 10 Office of the United Nations High Commissioner for Human Rights. Document on the protection of the rights of the mentally ill. Adopted by General Assembly resolution 46/119 of 17. Available from: http://www.un.org/documents/ga/res/46/a46r119.htm, December 1991 (accessed 12 June 2008). 11 Steele JD, Christmas D, Eljamel MS, Matthews K. Anterior cingulotomy for major depression: clinical outcome and relationship to lesion characteristics. Biol Psychiatry 2008; 63: 670–77.
References 1 UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and metaanalysis. Lancet 2003; 361: 799–808. 2 Eranti S, Mogg A, Pluck G, et al. A randomized, controlled trial with 6-month follow-up of repetitive transcranial magnetic stimulation and electroconvulsive therapy for severe depression. Am J Psychiatry 2007; 164: 73–81. 3 Scott AIF, Royal College of Psychiatrists, Special Committee on ECT. The ECT handbook: the third report of the Royal College of
MEDICINE 36:9
500
© 2008 Elsevier Ltd. All rights reserved.