There are a number of non-medication, non-therapy options for treatment-resistant depression. Somatic treatments involve brain stimulation through the application of energy. ECT and TMS are the most well-known, but there are some more obscure options as well. And then there’s cranial electrotherapy, which isn’t in the same ballpark at all. So let’s dive in!
Electroconvulsive therapy (ECT) has a bad public reputation. People think it’s barbaric and much like what happened to Jack Nicholson’s character in One Flew Over the Cuckoo’s Nest. Modern ECT isn’t like that at all, though. You’re knocked out with anaesthetic, an electrical stimulus is applied to induce a seizure (electrically; there’s no physical seizure because of a muscle relaxant), and then you wake up a little while later.
ECT is the most effective treatment for depression, and it works far faster than medication, making it a good choice for people who are actively suicidal. A 2016 study published in Biological Psychiatry found that ECT promoted neuroplasticity and growth in areas of the brain like the hippocampus and amygdala where depression had already reduced the volume compared to normal. Smaller volumes of the hippocampus prior to ECT were associated with a greater clinical response.
The biggest downside is the potential for memory loss, which is dependent in part on how many treatments you need and whether you need unilateral or bilateral placement of electrodes during the procedure. For some people it’s not an issue, for others it’s a huge problem, and there’s a whole range of territory in between. I experienced a fair bit of memory loss, but it was a price I was willing to pay for how well it works.
Transcranial magnetic stimulation
Transcranial magnetic stimulation involves the application of a magnetic field across the brain to stimulate certain areas beneath the surface. Typically, people receive rTMS, but there is a deep TMS that can reach deeper brain structures.
Treatment is administered five days a week over 6 weeks. The patient is awake and sitting up during the treatment.
TMS can help with both bipolar and unipolar depression. It’s generally considered to be less effective than ECT.
Deep brain stimulation
Deep brain stimulation (DBS) is most often done in Parkinson’s disease, but it is sometimes used to treat depression as well. Electrodes are implanted into the brain and connected to a neurostimulator that’s implanted below the collarbone, which generates electrical signals.
Getting the electrodes implanted involves neurosurgery, which can come with complications. The scary image above shows implantation surgery. The whole contraption thingy is to keep the head steady, because I suppose you don’t want to have an oopsey while doing brain surgery.
Vagus nerve stimulation
The vagus nerve, also known as the tenth cranial nerve, runs from the brain down through the neck to the heart and several other organs. Vagus nerve stimulation (VNS) involves surgery to connect lead wires to the vagus nerve, and then attach those to an impulse generator implanted below the collarbone.
It takes several months to see a therapeutic effect, and side effects are common, so it’s not used very often. It’s far more common for the treatment of epilepsy.
Transcranial direct current stimulation
Transcranial direct current stimulation (tDCS) delivers low direct current through electrodes placed on the head, which induces electrical activity in the brain areas underneath. MRI or PET imaging may be done beforehand to determine the correct area for electrode placement. Treatments are done daily over a period of several weeks.
Cranial electrotherapy stimulation
So far these have been evidence-based treatments for depression. Cranial electrotherapy stimulation (CES) deviates from that. There’s some similarity between this and tDCS, but CES uses alternating rather than direct current. This is a buy it online, do it yourself at home kind of deal. There’s a stimulator device and clips that you connect to your earlobes; these can run you upwards of $500.
What makes these devices a bad deal is that there’s no evidence that they work. They may be advertised as FDA approved, but when it comes to medical devices, FDA approval basically only says that they’re pretty convinced it won’t electrocute you. When it comes to CES devices, the FDA has said outright that there’s no evidence they work for depression.
Ah, good ol’ treatment-resistant depression. Never a dull moment. At least the transorbital lobotomy has gone by the wayside.
Speaking of which, this is a weird Canadian musical short film called Lotobotomobile, about lobotomist-in-chief Dr. Walter Freeman and his travelling roadshow (the roadshow existed, but it apparently wasn’t called the Lobotomobile).
Have you ever tried, or contemplated trying, any of these brain stimulation treatments?