Electroconvulsive Therapy (ECT) and Repetitive Transcranial Magnetic Stimulation (rTMS)
Electroconvulsive therapy (ECT) is the treatment of last resort for severe, chronic depressive symptoms. ECT is never the initial treatment for depression, and there are serious questions regarding memory loss which have yet to be adequately answered by the research literature. Please see ECT.org for more information about ECT.
Repetitive transcranial magnetic stimulation (rTMS) is now the preferred treatment method over ECT. It uses an electromagnet placed on the scalp that generates magnetic field pulses roughly the strength of an MRI scan. The magnetic pulses pass readily through the skull and stimulate the underlying cerebral cortex.
In the treatment of depression, rTMS is generally used with high frequencies, stimulating the left dorsolateral prefrontal cortex of the brain. This gives positive results with significant decrease of scores on depressive scales applied to resistant and non-resistant depressions.
The procedure is generally not painful, but can be uncomfortable: A tingling or knocking sensation is produced against the scalp. Scalp and facial muscle contractions sometimes occur during TMS. There is a very small risk of seizure; the risk is significant only for patients who have a prior history of seizures.
NeuroStar TMS Therapy is specifically FDA-approved for the treatment of major depressive disorder in adults who’ve failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode. In clinical trials, patients had been treated with a median of four medication treatment attempts, one of which achieved criteria for adequate dose and duration.
NeuroStar TMS Therapy is an outpatient procedure prescribed by a psychiatrist and performed in a psychiatrist’s office. The treatment typically takes around 20 to 40 minutes, and is administered 5 days a week for 4-6 weeks.
The benefits of TMS observed in its clinical trials include: no systemic side effects, such as weight gain, sexual dysfunction, sedation, nausea, or dry mouth; no adverse effects on concentration or memory; no seizures; and no device-drug interactions.
The most common adverse event related to treatment was scalp pain or discomfort at the treatment area during active treatments, which was transient and mild to moderate in severity. The incidence of this side effect declined markedly after the first week of treatment.
There was a less than 5 percent discontinuation rate due to adverse events. During a 6-month follow-up period, there were no new safety observations compared to those seen during acute treatment.
Hospitalization is necessary when a person with depression has attempted suicide or has serious suicidal thoughts (ideation) or plans. Most individuals who suffer from major depression, however, are usually only mildly suicidal and most often lack the energy (at least initially) to carry out any suicidal plan.
Care must be taken with regard to any hospitalization. When possible, your consent and full understanding should first be obtained and you should be encouraged to check yourself in. Hospitalization is usually relatively short, until you’re fully stabilized and the therapeutic effects of an appropriate antidepressant medication are realized (3 to 4 weeks). A partial hospitalization program also should be considered.
Suicidal ideation should be assessed during regular intervals throughout therapy (every week during the therapy session is not uncommon). Often, as you start to feel the energizing effects of a medication, you’ll be at higher risk for acting on your suicidal thoughts. Care should be used at this time and hospitalization may need to be considered again.
One of the most effective self-help strategies is to join a depression-focused support group (in-person or online). Support groups provide the opportunity to socialize, develop healthy relationships, and be around other people who are experiencing common experiences and feelings. Psych Central has online support groups.
Another excellent strategy is to read self-help books or workbooks on overcoming depression (a classic example is The Feeling Good Handbook). In fact, some self-help books are effective for some people and no other type of treatment is needed, especially for people who have a mild form of depression. Some books emphasize a cognitive-behavioral approach, which is similar to those used within individual therapy and therefore may be helpful even before you begin therapy.
In addition, engaging in physical activities and getting outside are critical. Both sunlight and exercise are well-established mood boosters. If there’s currently not much sunshine, consider buying a light box (which can be especially helpful for winter-time seasonal affective disorder).
Herbal supplements — including St. John’s wort and kava — have extensive clinical research demonstrating their effectiveness and safety for the treatment of mild to moderate clinical depression. While they should not be taken if you’re already taking an antidepressant, many people turn to supplements as a first-line treatment, especially if their episode isn’t severe. Like medications, these herbal supplements may or may not work for you, but are generally safe to try. Always talk to your doctor first before starting any supplements or other kinds of alternative treatments, as some may interact with other medications or treatments you’re currently using.
Acceptance and commitment therapy (ACT). Retrieved from https://www.mentalhealth.va.gov/depression/act-d.asp.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Bauer, M., Severus, E., Moller, H., Young, A.H., et al. (2017). Pharmacological treatment of unipolar depressive disorders: summary of WFSBP guidelines. International Journal of Psychiatry in Clinical Practice, 21 (3), 166-176.
Carey, B. (2019, March 5). Fast-Acting Depression Drug, Newly Approved, Could Help Millions. The New York Times. Retrieved from https://www.nytimes.com/2019/03/05/health/depression-treatment-ketamine-fda.html.
Cuijpers, P., de Wit, L., Kleiboer, A., Karyotaki, E., Ebert, D.D. (2018). Problem-solving therapy for adult depression: An updated meta-analysis. European Psychiatry, 48, 27-37.
Driessen E., Abbass A.A., Barber J.P., et al. (2018). Which patients benefit specifically from short-term psychodynamic psychotherapy (STPP) for depression? Study protocol of a systematic review and meta-analysis of individual participant data. BMJ Open, 8, (2).
Driessen, E., Cuijpers, P., de Maat, S.C.M., Abbass, A.A., de Jonghe, F., & Dekker, J.J.M. (2010). The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis. Clinical Psychology Review, 30 (1), 25–36.
FDA approves new nasal spray medication for treatment-resistant depression; available only at a certified doctor’s office or clinic. (2019, March 5). Retrieved from https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm632761.htm.
Gotlib, I.H. & Hammen, C.L. (2015). Handbook of Depression: Third Edition. New York: Guilford.
Muneer, A. (2018). Major Depressive Disorder and Bipolar Disorder: Differentiating Features and Contemporary Treatment Approaches. In Yong-Ku Kim (Ed.), Understanding Depression: Volume 2. Clinical Manifestations, Diagnosis and Treatment (pp.15-34). New York: Springer.
Schroeder, M.O. (2016). Behavioral Activation: The Depression Therapy You’ve Likely Never Heard of. U.S. News & World Report. Retrieved from https://health.usnews.com/wellness/mind/articles/2016-11-24/behavioral-activation-the-depression-therapy-youve-likely-never-heard-of.
Simmonds-Buckley, M., Kellett, S., Waller, G. (2019). Acceptability and efficacy of group behavioral activation for depression among adults: A meta-analysis. Behavior Therapy.
John M. Grohol, M. (2020). Depression Treatment. Psych Central. Retrieved on September 27, 2020, from https://psychcentral.com/depression/depression-treatment/