Treatment Resistant Depression - Episode 2

Interventional Treatment Options for Patients: ECT, VNS, and TMS

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Eveleigh Wagner, MD, discusses the role of electroconvulsive therapy and transcranial magnetic stimulation in depression treatment.


Eveleigh Wagner, MD: We'll start with the most historic [therapy]. So ECT is electroconvulsive therapy. By definition, it's a brief electrically induced generalized seizure. It is the oldest form of neuromodulation and [was] first used in Italy in the 30s and has been used since. The FDA needed to catch up with the ECT being used as a treatment and only recently started to regulate the devices. In 2018, the FDA [put] out regulation for the devices themselves and also giving us specific indications for using ECT.

We have three [indications] listed here. One would be the treatment of catatonia and then we won't get into too much to what catatonia is, but I would conceptualize [as] a severe syndrome that can be associated with depression along with other medical illnesses. People are incredibly withdrawn, maybe not eating [regularly], kind of having odd movement behaviors. So [it’s] a very severe illness that can be attached to major depressive episodes. Which leads us into our second [indication]. We can use ECT to treat a severe major depressive episode within the unipolar, so only depression, or within the bipolar illness, so the depression and the mania. [As for the third indication,] we also are able to treat younger patients, 13 and up, with ECT who have severe illness. That really is the name of the game with ECT, why that would come up for us as a recommended treatment. [It] often has to do with severity. It's the quickest way to treat severe depression and it also allows us to treat people with the catatonia, also with psychotic features and especially in patients who are more complex, like even such as pregnant ladies, and that would be very, very safe.

ECT, like we said, had been around for a long time. Insurance covers the procedure. It is a very medicalized treatment. So, what I mean by that is anesthesia is involved and specific monitoring. So, it's often done in a hospital setting. Patients may be admitted to a psychiatric hospital, start ECT inpatient, to really get those severe symptoms under control, and then may discharge and continue ECT but in a maintenance phase.

So that is ECT. [Now] we'll move on to our next option. This is the VNS, or vagus nerve stimulation. That is an example of the VNS device. I assure you that it is much smaller than that, maybe the size of two quarters put together. It is a device that has a battery in it. It's all enclosed and would be implanted in a patient and pulsed to stimulate their vagus nerve. It's linked through leads to the vagus nerve, which is indicated in depression, so it involves a surgical procedure.

The technology has been FDA approved since 2005 for adults with treatment-resistant depression. It has been used over 4 ,000 times. We'll go into some reasons [why] we aren't able to use this more for folks, but with the data that's already available to us, we can see it's a really great option. With those initial trials, we have a higher response rate a higher remission rate than the treatment as usual. We also have durability, meaning that it lasts as long as the device is implanted and active. What's really nice about this is that there is minimal risk of non-adherence. It's implanted, it’s on, it's firing. There is a way for people to turn it off briefly by putting a magnet over the device, for instance if they are doing public speaking because one of the side effects is some hoarseness [of voice]. But otherwise, it's on and working for you.

The last one I'll speak of is the newest, but still not all that new, TMS or transcranial magnetic stimulation. It was FDA cleared in 2008 and has been used since with wider and wider insurance coverage. It's [an] office-based [procedure]. These are two pictures of what our chairs look like in our offices. Each of our sites has at least one. [It’s] kind of like a dentist chair, and then the key is the magnet that is hanging above the chair, and then it's hooked up to a machine that is delivering the power to the magnet. Here's examples of other chairs that are marketed. There are other indications that are available for TMS that use different types of coils and protocol (OCD [and] smoking cessation are also available). We'll just talk about major depressive disorder today.

This is how we would conceptualize TMS. What that refers to is the treatment that is delivered with repetitive changing magnetic fields or pulses towards the brain. This picture is an example of the coil, the magnet coil and with the fields dispersing on either side and we place it close and over the location of the prefrontal cortex where we want that power to be targeted to stimulate the brain. The magnetic fields turn into electrical fields and alter our functioning at our brain level and that helps our brain kind of reboot again. The original outcome studies with TMS were decent: 30% response, but that was that had some limitations, not including medications, and we think we can do a lot better and we have. In our clinics we get much higher rates of remission and response. That has to do with that we keep people on their medications, and we encourage them to be talking with our staff and using CBT techniques to really get the most out of this stimulation of their brain and the majority of them do very well.

Transcript was AI-generated and edited for clarity.