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Depression

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of depression.


Alternative Names

Seasonal affective disorder


Other Treatments

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is commonly called shock treatment. It has received bad press, in part for its potential memory-depleting effect. Since its introduction in the 1930s, ECT has been significantly refined, and is now considered to be the best treatment for severe depression. It is especially effective for patients with severe depression who experience delusions and hallucinations. Maintenance ECT may also help prevent relapse. In a 2000 study, continued use of ECT in responsive patients, along with long-term antidepressant use, prevented relapse in 73% of patients after 5 years compared to 18% in patients on antidepressants alone.

Candidates for ECT. About 40,000 Americans receive ECT each year. Many are elderly women who are psychiatric inpatients. Many experts urge that ECT be used earlier in the course of major depression, although most insurers or HMOs will not pay for early treatment. ECT may be beneficial for the following patients with severe depression:

The Procedure. In general, hospitalization is not necessary. ECT involves the following steps:

This procedure is associated with a great deal of anxiety and the patient should be reassured. One form of ECT called right unilateral ECT (RUL ECT) may provide equal therapeutic benefits to more traditional bilaterally applied forms of the therapy, and more importantly, may have a less potentially deleterious effect on memory.

Side Effects. Side effects of ECT may include temporary confusion, memory lapses, headache, nausea, muscle soreness, and heart disturbances. Administering the drug naloxone immediately before ECT may help reduce its adverse effects on concentration and some (but not all) memory impairment. Concerns about permanent memory loss appear to be unfounded. One study that used brain scans before and after ECT found no evidence of cell damage. In another small study of teenagers who had undergone ECT for severe mood disorders, only 1 of 10 reported memory impairment more than 3 years after the treatment.

Phototherapy

Phototherapy is recommended as the first-line treatment for seasonal affective disorder (SAD).

The Procedure. The procedure is noninvasive and simple. It is best performed immediately after waking in the morning. The patient sits a few feet away from a box-like device that emits very bright fluorescent light (10,000 lux) for about 30 minutes every day.

Some people report mood improvement as early as 2 days after treatment. In others depression may not lift for 3 - 4 weeks. (If no improvement is experienced after that, the depression is probably caused by other factors.)

Side Effects. Side effects include headache, eye strain, and irritability, although these symptoms tend to disappear within a week. Patients taking light-sensitive drugs (such as those used for psoriasis), certain antibiotics, or antipsychotic drugs should not use light therapy. Patients should be examined by an ophthalmologist before undergoing this treatment.

Cingulotomy

A surgical technique called cingulotomy interrupts the cingulate gyrus, a bundle of nerve fibers in the front of the brain, by applying heat or cold. A variation of this procedure using MRI scans to guide the surgeon produced long-term improvement in 53 - 78% of patients with severe intractable depression. The procedure is generally safe with few serious complications. It does not affect intellect or memory.

Transcranial Magnetic Stimulation

Transcranial magnetic stimulation (TMS) employs high frequency magnetic pulses that target affected areas of the brain. The intention is similar to electroconvulsive therapy (ECT) but, unlike ECT, it is more precise and has the potential of having the same benefits as ECT. A 2001 review reported that it was superior to sham treatments, although it was not clear whether benefits were significant. Investigators continue to try various techniques that might produce consistent improvements.

Vagus Nerve Stimulation

Vagus nerve stimulation (VNS) is a procedure that is effective for certain patients with epilepsy, and is now showing some success in patients with treatment-resistant depression

VNS involves implanting a battery-powered device under the skin in the upper left of the chest. The neurologist programs the device to deliver mild electrical stimulation to the vagus nerve. (The patient may also pass a magnet over the device to give it an extra dose if they sense a seizure coming on.) The two vagus nerves are the longest nerves in the body. They run along each side of the neck, then down the esophagus to the gastrointestinal tract. The vagus nerve travels to areas of the brain that control functions such as sleep and mood.

Studies report response rates of 35 - 46% in appropriate candidates with treatment-resistant depression. VNS is approved by the FDA for long-term treatment of chronic depression in adults who have not responded to typical treatments for their major depressive episode. Patients who use VNS may continue to show improvement in both their depression symptoms and quality of life.

Vagal stimulation can cause shortness of breath, hoarseness, sore throat, coughing, ear and throat pain, or nausea and vomiting. These side effects can be reduced or eliminated by reducing the intensity of stimulation. Long-term studies on patients with epilepsy have reported no serious adverse side effects, although the treatment may cause lung function deterioration in some people with existing lung disease.

Treatment of epilepsy
The vagus nerves branch off the brain on either side of the head and travel down the neck, along the esophagus to the intestinal tract. They are the longest nerves in the body, and affect swallowing and speech. The vagus nerves also connect to parts of the brain involved in seizures. In many seizures disorders, electrical stimulation of the vagus nerves may help relieve symptoms.

Acupuncture

Some evidence suggests that acupuncture may help in relieving depression in some women. Small studies, including one in 2001, have found it comparable to medications or psychotherapy. Larger studies are required to confirm its benefits.

Sleep Deprivation

Research suggests that even one night of total sleep deprivation can reduce depression 40 - 60% of the time. Improvement in mood generally occurs during the night or on the following day. About 10 - 15% of people who respond to this treatment have reduced depression only after fully sleeping again. Some people may respond to sleep deprivation that occurs only in the second half of the night (3 - 6 a.m.). However, in 2 - 7% of cases depression may worsen after sleep deprivation.


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