There are times when medication alone is not effective in the treatment of mental illness. That is why throughout this blog you will hear me talking a great deal about the benefits of mindfulness, CBT, DBT & etc.
There are still times for many individuals when these conventional therapies, matched with medications does not completely ease the symptoms of mental illness.
In these instances, it may be recommended that you see a specialized psychiatrist who can discuss the possibility of some sort of brain stimulation therapy.
There are different options when it comes to brain stimulation, including electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), magnetic seizure therapy (MST), deep brain stimulation (DBS), and repetitive transcranial magnetic stimulation (rTMS).
Here are here is a brief overview of the facts about these therapies:
Some of these treatments involve inducing seizures and while others do not.
VNS and DBS therapies involve implants, while the other therapies mentioned do not.
ECT is the oldest and most researched therapy on this list.
For the sake of this post I will only be discussing ECT and rTMS therapies at any great length, as I was myself just in an appointment being assessed for one of these treatments.
As I’ve mentioned in recent posts, I have been taking Saphris (asenapine) for approximately 2 weeks now it has had an incredibly positive impact of my life. I had thought that perhaps my having an office now and a reason to get up everyday had been the trigger to most of this turnaround, but my psychiatrist seemed quite certain that I would not have seen such progress without the influence of my new med.
I suppose I am slightly let down that I haven’t made these improvements to my life under my own steam, but regardless, I am grateful that there has been some turnaround.
I had been referred for my appointment with a psychiatric specialist at CAMH during a very difficult time that I recently had to endure over the holidays. It is a difficult time for many people, but this year for me, it was especially trying.
I had been given a prescription for an antidepressant (remember that antidepressants are not recommended for individuals with bipolar) and there was some unfortunate miscommunication between my doctor and I regarding the load dose. I essentially started too high, was manic for an evening, and then crashed.. and I stayed crashed for several weeks while the medication worked its way out of my system after I was instructed to discontinue it. All in all, it was a total fail.
When I saw the doctor at CAMH yesterday, my assessment was based on the last 30 days. Half of which have been extremely positive, while the other half have been some of the most difficult that I have been forced to endure in years. Prior to my ill reaction to the antidepressant, there had still been nearly a decade spent almost exclusively in bed suffering from anhedonia and just a total lack of energy.
I am still extremely new to the Saphris and if my long history of taking psychiatric medications has taught me anything, it is that you cannot trust a new med right out of the gate. I’ve been here before, where I have started a new med and it has done wonders, only for my whole world to totally fall apart just a few weeks later.
My assessment lasted for about 45 mins and was extremely thorough. I really liked my doctor (Dr. K) who I found to be extremely knowledgable. She asked me several questions that I have never even been asked in a psychiatric appointment. It was mostly very pleasant, up until the point that she was informing me that brain stimulation is still not a magical cure.
Of course I am aware of this, but if the Saphris should fail and stimulation therapy not work, I really can’t bare to think of going back to the existence that I’ve been prisoner to for so many years, up until recently. That was the only time that I kind of broke down a little bit. It was brief and I am sure that she deals with a lot of tears, but I wish that they didn’t have to come from me.
Considering where I am now and where I have been in my recent history, Dr. K recommended rTMS to augment my current regimen of psychiatric medication.. which at present consists of Epival (dival proex 1250mg) and Saphris (asenapine 10mg).
I had thought that I would be able to reduce at least the Epival if I were to begin a course of brain stimulation therapy, but for me, that was not the case.
If I had been put on the waiting list for ECT, then I would have had to be taken off the Epival completely, as it is an anticonvulsant. However, as rTMS does not induce seizure, there is no reason for me to come off of that medication.
Both Epival and Saphris cause weight gain to varying degrees. The Saphris, moreso than the Epival (anti-psychotics are always to culprit). Since starting the Saphris, I have already gained a little over 7lbs, which is an enormous bummer. I have been on anti-psychotics for approximately 8yrs from when I got my initial prescription. When I first started taking them, I put on over 60lbs almost immediately and haven’t been able to shake the weight since. In the brief time, between the last drug and Saphris, that I was finally without an anti-psychotic, I had been making great progress losing all of the weight that I had gained.. (I was down like 20lbs!).
The prospect of reducing or even eliminating either of my psyche drugs was extremely tempting, but I would rather be sane than slim any day of the week.
So what is repetitive transcranial magnetic stimulation?
It is a fairly new therapy first developed in 1985 to treat depression, psychosis, anxiety, and other disorders. The therapy uses magnets to activate the brain. Unlike ECT, rTMS can be specifically targeted, which is especially useful when treating conditions that can be allocated to different regions of the brain. Scientists also believe that the ability to target reduces the chances of the type of side effects most often associated with ECT.
The FDA approved rTMS for the treatment of major depression in 2008 for patients who do not respond to at least one anti depressant medication, as well as for patients who not good candidates for ECT.
Study results on rTMS were mixed until the first large clinical trial was published in 2010, in which 14% of patients achieved remission with treatment, compared to 5% with a placebo treatment. After the trial ended, there was a second phase in which all patients received proper rTMS treatment and remission rates climbed to 30%.
Typical treatment sessions will last between 30 and 60 mins and, unlike ECT, it does not require anesthesia. During the procedure, an electromagnetic coil is placed against the forehead near the area of the brain that is thought to involve mood and then short electromagnetic pulses are administered through the coil. The pulses easily pass through the skull and then cause small electrical currents that stimulate nerve cells in the targeted brain region.
The stimulation does not penetrate deeper than 2″ into the brain, which means that scientists are able to carefully select with to target and which to avoid. The magnetic field used in rTMS is approximately the same strength as a magnetic imaging scan (MRI).
Apparently, the procedure feels like a slight knocking or tapping on the head as the pulses are administered. Dr. K mentioned that most patients will only find it annoying, but some have reported feeling some pain.
There is currently not a consensus on where to best position the magnet, nor have they determined whether continued medication paired with psychotherapy is truly a requirement. Research continues to establish the best and safest way to administer rTMS therapy.
Should I remain eligible when I am reassessed in 4 weeks and choose to move forward with treatment, I will actually be participating in a pilot study where they will be testing the efficacy of administering the therapy in several short sessions over the course of an hour, rather than one long, consistent session.
Some side effects that may occur with rTMS include some discomfort where the magnet has been placed, some contraction or tingling of the muscles of the scalp, jaw, or face during the procedure, mild headache, or a brief lightheadedness.
There is also the possibility that the patient may suffer from a seizure, however, these occasions are extremely rare and when they do happen, they happen during the procedure when you are under the supervision medical professionals.
There have been 2 large scale studies that found that most side effects, such as headaches or scalp discomfort, were mild – moderate. It should also be noted that during the course of this study, no seizures occurred.
What about ECT?
I didn’t want to do this post without addressing ECT, as it is the oldest form of brain stimulation therapy and an extremely common therapy. Way more common than you’d think!
…and it’s changed a lot from what you might remember.
These days electroconvulsive therapy is only done after the administration of muscle relaxants and anesthesia. It is true that the electric current is still inducing a seizure in the patient, but it is a much gentler picture than ‘One Flew Over the Cuckoo’s Nest’.
ECT is considered only after a patient’s condition has not improved after other treatments, such as medications and psychotherapy, or when rapid treatment is required (such as instances of suicide risk, self harm, catatonia, etc), as it typically begins to work within the first week of treatment.
It is most often used to treat severe, treatment-resistant depression, but it is also commonly used to treat other psychiatric conditions, such as bipolar and schizophrenia.
As I said, prior to the ECT being administered, the patient is sedated with a general anesthesia and a muscle relaxant to help prevent movement during the procedure. An anesthesiologist is continuously present to monitor breathing, heart rate, and blood pressure during the procedure. The actual treatment is conducted by an entire medical team, including physicians and nurses.
During the procedure, electrodes are placed on the head, through which an electric current passes through the brain, causing a seizure. This will typically last for less than one minute. Since the patient is completely unconscious during the procedure, there is no pain and the patient is not aware of the pulses.
5 – 10 mins later, the patient will awaken feeling groggy as the anesthesia wears off. After treatment, you have to wait at least one hour before you are permitted to leave the hospital premisses. I am unsure if this is the case at all hospitals, but I had also been instructed that I would need someone to drive me home once I was safe to leave.
Treatments are typically administered about 3 times a week until there is improvement in the patient’s condition, which usually occurs within 6 – 12 sessions. Following that, maintenance ECT is sometimes required to reduce symptoms and chance of relapse. Maintenance treatment varies and may range from one session/wk – one session every few months.
Frequently, ECT is paired with a mood stabilizer or anti-depressant, just as long as that drug is not also an anti-convulsant.
The most common side effects associated with ECT are headache, stomach ache, muscle discomfort, and/or memory loss.
I have read that up to one third of patients may experience memory loss and if you do your research and/or spend some time in online ECT forums, memory loss in some patients can be significant. I had determined, after some contemplation, that I would proceed with ECT, had it been an option.. regardless of any potential memory issues. Most often, memory loss will improve in the days and weeks following your appointment.
It will depend on your personal situation and what you are willing to give up to achieve wellness.
Research has shown that these issues may be associated with the type of ECT treatment that is given. Traditional ECT is called bilateral ECT, where the electrodes are placed on both sides of the head. Modern ECT is called unilateral ECT, where the electrodes are placed on just one side of the head.
There are some doctors who were involved in the development of ECT who feel unilateral placement under sedation is both less effective and may be responsible for more side effects due to the need more electrical current to achieve efficacy.
Still, most doctors, patients, and families prefer unilateral ECT. Personally, if I were given the option, I would go with the bilateral ECT as sober as possible. If you are going to do it, I would say that you do it in the best way and most effective way possible.
Has anyone else in the community had experience with any of the treatments mentioned in this post? I would love to hear about your experiences in the comments!