10. Other Physical Therapies

A review of ketamine in affective disorders: current evidence of clinical efficicacy, limitations of use and pre-clinical evidence on proposed mechanisams of action.. (2013). Naughton M, Clarke G, O’Leary O,
http://dx.doi.org/10.1016/j.jad.2013.11.014
This 45 page review of the literature concluded that there was evidence for a rapid antidepressant effect for ketamine but mixed results for the effect of ketamine on the speed of response to ECT. Limitations include the fact that the effect is short lived and the potential for abuse. The authors outline possible mechanisms involving the glutamatergic neurotransmitter system and how this might help in the understanding of the pathophysiology of depression.

 

Effectiveness and acceptability of deep brain stimulation (DBS) of the subgenual cingulated cortex for treatment-resistant depression: a systematic review and exploratory meta-analysis. (2013) Berlim M, McGirr A, denEynde F, et al.
http://dx.doi.org/10.1016/j.jad.2014.02.016
This is a metanalysis of published literature on DBS for treatment resistant depression. Four studies were found, totalling 66 patients. Response rate was around 40%. Maximal antidepressant effects were seen within the first six months.

 

Deep transcranial magnetic stimulation as a treatment for psychiatric disorders. (2013). Bersani FS, Minichino A, Enticott PG et al. European Psychiatry 28; 30-39.
As the name implies deep transcranial magnetic stimulation reaches brain regions and neural circuits which are deeper in the cortex than reached by standard TMS (6cm cf 1.5-2.5cm). This is a review of studies carried out to date; most are for treatment of major depressive disorder with the target area being the left prefrontal cortex. There are also case reports of TMS being used for a variety of neurological conditions but as yet no evidence from double blind placebo controlled trials and no direct comparison with ECT or other brain stimulation techniques.

 

Rapid effects of deep brain stimulation for treatment- resistant major depression. (2013). Schlaepfer T, Bewernick B, Kayser S et al. Biological Psychiatry. http://dx.doi.org/10.1016/j.biopsych.2013.01.034
This was a pilot study carried out in Germany to assess the safety and efficacy of deep brain stimulation to the supero-lateral branch of the medial forebrain bundle in seven treatment resistant patients. Implants were inserted stereotactically via a burr hole with the patient awake and two days later pulse generators were implanted subclavicularly or abdominally under general anaesthesia. Stimulation was initiated one week after surgery. A battery of outcome measures were used at 1 week, 1 month, 2 months and 3 months. Six of the seven patients achieved a response as defined as >50% reduction in MADRS score.

 

Vagus nerve stimulation for chronic major depressive disorder: 12 month outcomes in highly treatment-refractory patients. (2013). Christmas D, Steele D, Tolomeo et al. J of Affective Disorders. http://dx.doi.org/10.1016/j.jad.2013.05.080
The outcome for twenty eight treatment resistant patients in a European open clinical trial and thirteen patients in the treatment resistant programme in Dundee, Scotland was similar at just over 30% response as defined in a 50% reduction in symptoms.

 

Comparable seizure characteristics in magnetic seizure therapy and electroconvulsive therapy for major depression (2013). Kayser S, Bewernick B, Hurlemann et al., European Neuropsychopharmacology. http://dx.doi.org/10.1016/j.euroneuro.2013.04.011
The group compared the EEG characteristics produced by MST and ECT. Ictal characteristics were similar but the MST produced more focal seizures and the authors postulate that this might be the reason for reduced cognitive side-effects with MST.

 

Transcranial direct current stimulation (tDCS) for depression: Analysis of response using a three-factor structure of the Montgomery-Asberg depression rating scale. (2013). Alonzo A, Chan G, Martin D et al., J of Affective Disorders 150; 91-95.
This study of 64 patients concluded that tDCS appeared to be effective in treating dysphoria and retardation but not vegetative symptoms of depression.

 

Similar seizure characteristics of electroconvulsive therapy and magnetic seizure therapy in treatment resistant depression. (2012). Kayser S., Bewernick B., Hurlemann R et. al., P.2.a.025 Affective disorders and antidepressants.
EEG and EMG tracings relating to 7 patients resistant to both ECT and MST were studied. There were no differences in characteristics, including length of seizure and post ictal suppression. In contrast the MST group showed shorter post ictal recovery and orientation times; these are thought to be related to cognitive side effects.

 

Effect of magnetic seizure therapy on regional brain glucose metabolism in major depression. (2012). Hoy K., Thomson R., Cherk M. et. al., Psychiatry Research: Neuroimaging. http://dx.doi.org/10.1016/j.pscychresns.2012.08.003 Ten patients underwent PET scans before and after ECT. Areas of increased glucose metabolism were found in basal ganglia, orbitofrontal cortex, medial frontal cortex and dorso-lateral prefrontal cortex. Differential findings according to clinical response were related to the ventral anterior cingulate. This finding could be consistent with the limbic cortical dysregulation theory of depression.

 

Transcranial direct stimulation for depression: 3-week, randomised, sham-controlled trial (2012). Loo C.K., Alonzo A., Martin D. et al., BJPsych. 200, 52-59

Early studies using low intensity rTMS produced variable outcomes. This group used higher intensity currents of 2mA and found a significant difference between real and sham treatment in a cohort of sixty four depressed people. One individual became hypomanic. There were no cognitive side-effects.

Deep brain stimulation for treatment-resistant depression: efficacy, safety and mechanisms of action. (2012) Anderson R, Frye M, Abulseoud O et al. Neurosci. Biobehav. Rev.; http://dx.doi.org/10.1016/j.neubiorev.2012.06.001

This was an open label design trial involving small patent numbers but adding to the evidence for physical therapies in a treatment resistant population.

Transcranial direct stimulation for depression: 3-week, randomised, sham-controlled trial (2012). Loo C. K., Alonzo A., Martin D. et al., BJPsych. 200, 52-59

Early studies using low intensity rTMS produced variable outcomes. This group used higher intensity currents of 2mA and found a significant difference between real and sham treatment in a cohort of sixty four depressed people. One individual became hypomanic. There were no cognitive side-effects

Deep brain stimulation for treatment-resistant depression: efficacy, safety and mechanisms of action. (2012). Anderson R, Frye M, Abulseoud O et al. Neurosci. Biobehav. Rev.; http://dx.doi.org/10.1016/j.neubiorev.2012.06.001

This was an open label design trial involving small patent numbers but adding to the evidence for physical therapies in a treatment resistant population.

Repetitive transcranial magnetic stimulation versus electroconvulsive therapy for the treatment of major depressive disorder, a randomised controlled clinical trial. (2011). Keshtkar M., Ghanizadeh A. & Firoozabadi. J of ECT, 27: 310-314

Seventy five patients who were referred for ECT were randomly enrolled in this study to receive either ECT or rTMS. Patients in both groups improved but the antidepressant effect in the ECT group was greater and ECT led to greater reductions in suicidal behaviour.

Low-frequency repetitive transcranial magnetic stimulation inferior to electroconvulsive therapy in treatment depression. (2011). Hansen P, Ravnkilde B, Videbech \p et al. J of ECT 27;26-32.

This was a prospective study comparing rTMS and unilateral ECT. Sixty inpatients were treated and the Hamilton Rating Scale for depression was used to measure outcome. rTMS was significantly less effective but was associated with fewer adverse effects on cognitive outcome.

Some considerations in choosing electroconvulsive therapy versus transcranial magnetic stimulation for depression(2011). Rasmussen K. J of ECT 27;51-54.

This editorial sets out to describe the pros and cons of rTMS compared to ECT for depression in terms of efficacy, adverse effects and risks, cost and inconvenience. The conclusion appears to relegate rTMSin current format to that of a placebo response.

Focal electrically administered therapy. Device parameter effects on stimulus perception in humans. (June 2009), Borckardt et al. J of ECT; 25:91-98.

A description of this type of transcranial magnetic stimulation, which is reported to be capable of more focal modulation of cerebral activity. The stimulation area was the left forehead and differing experiences of pain and discomfort were recorded  in relation to intensity and type of current used in an attempt to provide a model for accessing scalp pain in relation to non convulsive treatments.

Cost-effectiveness of transcranial magnetic stimulation vs electroconvulsive therapy for severe depression: a multi-centre randomised controlled trial. 2008. Knapp et al. Journal of Affective Disorders, 109:273-285.

46 patients were randomised to one  treatment arm of this study. RTMS was not as effective as ECT as evidenced by a reduction in Hamilton Rating Scale for Depression and other outcome measures. The cost of a course of treatment was the same for both groups although informal costs were rated as higher in the rTMS group.

Concomitant use of vagus nerve stimulation and electroconvulsive therapy for treatment resistant depression. Burke M & Husain M. September 2006. J of ECT;22(3):218-222.

A report on 14 patients who received both treatments. The authors suggest that both treatments can be use safely and effectively, either sequentially or concurrently.

Adjunctive fast repetitive transcranial magnetic stimulation in depression. Anderson I et al. June 2007. Brit J of Psychiatry, 190,533-534.

29 patients were divided into two groups receiving sham or real rTMS for the treatment of a major depressive episode; the majority of patients had been resistant to treatment with antidepressant drugs. Improvement was noted in 55% receiving active treatment compared to 7% receiving sham treatment. The authors acknowledge that numbers were small but think this type of rTMS might be worth further study.

Vagal nerve stimulation: a review of its applications and potential mechanisms that mediate its clinical effect. Groves D and Brown V. Neuroscience and Biobehavioural reviews 29.(2005). 493-500.

This review outlines the history of VNS and its application for the treatment of depression. The authors, from the department of psychology at St Andrews, UK, conclude that studying the action of VNS might help in determining the neuropathology of depression.

A one-year comparison of vagus nerve stimulation with treatment as usual for treatment resistant depression. George M et al. Biol Psychiatry 2005;58:364-373.

This multicentre study compared two non randomised groups of chronically depressed patients. 205 patients had been  given VNS in addition to TAU (including medication changes and ECT) and outcome at twelve months was compared to 124 patients given TAU alone. VNS + TAU was associated with a greater antidepressant effect over a twelve month period.

Neurosurgery for mental disorder. Christmas et al. May 2004. Advances in Psychiatric Treatment vol10,189-199

This is a review of contemporary indications for neurosurgical interventions in the management of chronic and refractory mental disorder from the Dundee, Scotland group. Information on neurosurgery, vagus nerve stimulation and deep brain stimulation is presented.

Transcranial Magnetic Stimulation in the Treatment of Depression. Fitzgerald B et al. Arch Gen Psychiatry. October 2003;60:1002-1008

Three groups of 20 patients with medication resistant depressive illness were assigned to either high frequency left sided, low frequency right sided or sham rTMS. After four weeks here was a significant improvement as measured by the Mongomery Asberg Depression Rating Scale in both treatment groups compared to controls but not between the treatment groups. Psychomotor agitation was a predictor of response to treatment.

Repetitive Transcranial Magnetic Stimulation for the Treatment of Depression. Systematic Review and Meta-Analysis. Martin et al. British Journal of Psychiatry June 2003, 182:480

This review of the current literature includes fourteen trials. However, to date, the conclusion is that there is insufficient evidence to support the use of TMS in the treatment of depressive illness.

Transcranial Magnetic Stimulation of Left Temporal Cortex and Medication-resistant Auditory Hallucinations. Hoffman et al. Arch Gen Psychiatry January 2003, vol 60, 49-56.

Twenty four patients were randomly allocated to sham vs real rTMS for nine days at 90% motor threshold. Results showed an improvement in the active treatment group with 52% of patients maintaining improvement at fifteen weeks.

Status of neurosurgery for mental disorder in Scotland. Selective literature review and overview of current clinical activity. Matthews K and Eljamel M. British Journal of Psychiatry May 2003, vol 182, 404-411.

This update explores the role of neurosurgery in modern clinical practice. It looks at the evidence for efficacy, outlines adverse effects and describes the experience of the Dundee service, the only unit in Scotland to offer this treatment.

Vagus nerve stimulation and refractory depression. Please can you switch me on doctor? Matthews K and Eljamel M. British Journal of Psychiatry September 2003, vol 183, 181-183.

An editorial describing the theory and practice of vagal nerve stimulation, an intervention which results in a cascade of central neurochemical changes and was first used for the treatment of intractable epilepsy. Definitive clinical trials on outcome in the treatment of chronic depression are awaited.

Mechanisms and the State of the Art of Transcranial Magnetic Stimulation. George M et al. Journal of ECT December 2002;18(4):170-181

This article reviews the major recent advances in this non-invasive treatment, which have taken place over the last eight years. Safety data and possible mechanisms of action are presented and a review of the literature on outcome in the treatment of mood and other disorders is discussed.

Update on Magnetic Seizure Therapy: a Novel Form of Convulsive Therapy. Lisanby S. Journal of ECT December 2002;18(4):182-188.

This type of therapy, still at the developmental stage, uses a powerful magnet rather than electricity to induce a therapeutic seizure. Because the magnetic fields can be directed, there is a suggestion that this form of convulsive therapy may result in fewer side-effects. The article reviews the research and the early clinical trials to date.

Mechanisms and State of the Art of Vagus Nerve Stimulation. Kosel M & Schlaepfer T. Journal of ECT December 2002;18(4):189-192.

Vagal nerve stimulation takes advantage of the fact that the vagus nerve carries afferent as well as efferent nerves. Stimulation is known to help treat refractory epilepsy and recent unconfirmed data has suggested that it may also be useful in drug resistant depression. The technique involves neurosurgical implantation.

Update on Deep Brain Stimulation. Greenberg B. Journal of ECT December 2002;18(4):193-196.

This is a neurosurgical intervention designed to stimulate target areas of the brain. To date it has been used for movement disorders but it remains at the investigational stage for neuropsychiatric conditions. Possible mechanisms of action are proposed.

Dannon P. N., et al., Three and six-month outcome following courses of either ECT or rTMS in a population of severely depressed individual--preliminary report. , Biol Psychiatry 2002 Apr 15;51(8);687-90

Transcranial magnetic stimulation for depression and other psychiatric disorders. McNamara et al. Psychological Medicine. October 2001, 31(7): 1141.

This is a literature survey of trials to date on repetitive transcranial magnetic stimulation (rTMS), a technique which involves exposure of the dorso-lateral pre-frontal cortex to a high intensity magnetic field applied to the scalp surface. Some benefits relative to placebo were found in a meta-analysis of five controlled trials.

Veronica O'Kane. Ir J.,Transcranial magnetic stimulation: an alternative physical treatment in depression. Psych Med 2001; 18(3): 79-81.

Another review of the literature with the conclusion that transcranial magnetic stimulation (TMS), whilst displaying antidepressant actions, is not effective in 'psychotic depression'.

Brookes G, Barnes R. & Rigby J., Implementing the Royal College of Psychiatrists guidelines for the practice of electroconvulsive therapy. . (2000), Psychiatric Bulletin, vol 24, 9, 329.