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Transcranial Magnetic Stimulation and Electroconvulsive Therapy
Richard Holbert, MD, helps us to identify treatment-resistant depression. He examines the indications for transcranial magnetic stimulation and electroconvulsive therapy and he describes the potential side effects and outcomes of these therapies.
Featuring:
Richard Holbert, MD
Dr. Richard Holbert is an associate professor in the UF Department of Psychiatry. He also serves as the medical director of UF Health Shands Psychiatric Hospital and director of transcranial magnetic stimulation.
Transcription:
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I’m Melanie Cole and today, we’re discussing transcranial magnetic stimulation and electroconvulsive therapy for treatment resistant depression. We’ll examine the indications for these therapies and discuss the potential side effects and outcomes. Joining me is Dr. Richard Holbert. He’s an Associate Professor in the UF Department of Psychiatry. He also serves as the Medical Director of UF Health Shands Psychiatric Hospital and the Director of Transcranial Magnetic Stimulation. Dr. Holbert, it’s a pleasure to have you join us and we are talking about an absolutely fascinating topic today. Let’s set the stage first for other providers. Please define treatment resistant depression for us. What is the course it takes? How common it is. Tell us what you’re seeing in the trends with this.
Richard Holbert, MD (Guest): Absolutely. A major depressive episode that fails to respond to at least two adequate antidepressant trials is considered treatment resistant depression. And an adequate antidepressant trial is at least four weeks of an antidepressant at an adequate dosage. Unfortunately, remission rates decrease in subsequent relapse increase with each subsequent episode. The lifetime prevalence of major depression is approximately 20%. And 30 to 40% of those, with major depressive disorder, have treatment resistant depression.
Host: Have researchers observed that certain populations are more vulnerable than others? Tell us a little bit about the risks and how providers can identify these risks.
Dr. Holbert: Yes, so researchers have found that certain populations are at increased vulnerability to treatment resistant depression. First, females are at more risk. Those over the age of 65 are. As well as those who have more severe depression. So, clinicians need to be very careful for those who fall into those classes. Also, those who have comorbid substance use disorders and anxiety disorders have increased risk of treatment resistant depression.
Host: So, now let’s talk about the indications for electroconvulsive therapy. Let’s start with that one. Tell us a little bit about the potential side effects, outcomes. Also, Dr. Holbert, tell us a little bit about the history of it. What’s different now because boy this has been touted in the media as something that could be very scary for patients, but it’s not that way anymore, is it?
Dr. Holbert: No, it is not. So, electroconvulsive therapy is a very sophisticated medical procedure today. What happens is a patient undergoes a medically induced seizure while under general anesthesia and with muscle relaxants so that you can barely see that the patient moves at all. Also, an electroencephalogram is performed which can indicate whether treatment is successful. Now the indications for electroconvulsive therapy include one, treatment resistant depression, and major depressive episodes in which a very fast response is needed such as in patients who are acutely suicidal with a plan and intent to harm themselves or those who are not taking care of themselves such as they are not eating, not bathing, not drinking and therefore putting themselves at risk. Also patients who have catatonia are good candidates for electroconvulsive therapy.
The potential side effects of electroconvulsive therapy include confusion. So immediately after the treatment for a few minutes up to a few hours, patients may experience some confusion. The most concerning side effect with electroconvulsive therapy is memory loss. And the memory loss there is primarily retrograde autobiographical amnesia. So, they may forget certain events that have happened in their lives. Other side effects include headaches, nausea, muscle aches, jaw pain. The outcomes with ECT are very, very good, 80 to 90% of patients get better with the treatment.
Host: When you mentioned that it’s used as rapid response and it’s indicated for that; when we’re talking about patient selection, and we’re going to ask this same question about transcranial magnetic stimulation but is this ever considered a first line treatment?
Dr. Holbert: No. in general, neither of these treatments are considered first line unless the patient comes in in one of these acute crises. Once again, meaning that they are acutely suicidal with a plan and intent or just gotten to a point they are not caring for themselves.
Host: So, then discuss the indications for transcranial magnetic stimulation for us and its side effects and outcomes. Tell us a little bit about it.
Dr. Holbert: Transcranial magnetic stimulation is indicated for treatment resistant depression and it also recently received FDA indication for obsessive compulsive disorder. One of the huge advantages of transcranial magnetic stimulation is its side effect profile. In general, it doesn’t have what we call systemic side effects. The side effects of TMS include application site discomfort, headaches, muscle twitching in the face during treatment, lightheadedness and jaw pain. Now there is a potential risk of seizures, but that risk of seizures is less than with antidepressant medications.
TMS outcomes would be about 70 to 80% of people have a positive response to treatment.
Host: Wow, that’s very encouraging. And how do you decide which one to pursue with the patient?
Dr. Holbert: As we have spoken about, if a rapid response is required, electroconvulsive therapy would be the way to go. But obviously, if at all possible, the most important one to pursue is the one that the patient prefers. And in general, most patients do prefer transcranial magnetic stimulation because with transcranial magnetic stimulation you don’t have to undergo general anesthesia, you can walk in, receive the treatment, walk home, walk out I should say and drive home. So, there’s nothing that interferes with your daily routine except for the time of the treatment.
Host: And also, I would think, that there’s a reputation that goes along with ECT that people may not want to consider. So, tell us a little bit about some of the positives. Now we’ve even read some in the literature about brain growth benefits from either one of these. Is that a myth? Is that true? Or are there any long term negative effects?
Dr. Holbert: With electroconvulsive therapy, there is a risk of long term retrograde autobiographical amnesia. Meaning that patients may well have forgetting of events at different points in their life. Now that risk is relatively low, and that side effect usually resolves within a few months after the treatment. The main advantage of electroconvulsive therapy is its higher success rate. So, electroconvulsive therapy is considered the best treatment we have for major depressive disorder. However, transcranial magnetic stimulation is very effective as well. But also offers the advantage of less side effects, relatively speaking and the noninterference in one’s life.
Host: Is there a standout case you were involved in? Can you tell us something interesting about a particular case or diagnosis you’d like other providers to know about?
Dr. Holbert: Yes, one very interesting case that we had was a gentleman who was a professional and he came in with such a severe depression, he was not able to work. Neuropsychological testing was performed, and he was only functioning at the second percentile. He underwent ECT. He had a rapid response to the ECT within six treatments and at the end, his neuropsychological testing showed him to be at the 98 percentile. He was able to return to work and it was just an absolutely wonderful, wonderful story.
Host: Isn’t that amazing? So, looking forward to the next ten years in the field, what do you feel will be the most important areas of research and wrap it up for us with your best information about transcranial magnetic stimulation, electroconvulsive therapy and when you feel it’s important to refer.
Dr. Holbert: In the next ten years, with electroconvulsive therapy, the primary areas of research I feel will be on how often and how the ECT is delivered, trying to decrease the cognitive side effects of it. With transcranial magnetic stimulation, research will be looking at the exact location to treat, how much to treat and how often to treat. In addition, many other neuromodulation techniques such as magnetic seizure therapy, focal electrically administered seizure therapy and deep brain stimulation will be studied more and more.
I think it is very important for physicians to refer to psychiatrists when they have patients with treatment resistant depression because after a person has failed two antidepressants; their chances of responding to future treatment is only about 20%. And the risk and the morbidity of major depression and the risk of suicide is so high.
Host: Thank you so much Dr. Holbert. Absolutely fascinating topic. Thank you for joining us today. And that concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please also remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I’m Melanie Cole.
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I’m Melanie Cole and today, we’re discussing transcranial magnetic stimulation and electroconvulsive therapy for treatment resistant depression. We’ll examine the indications for these therapies and discuss the potential side effects and outcomes. Joining me is Dr. Richard Holbert. He’s an Associate Professor in the UF Department of Psychiatry. He also serves as the Medical Director of UF Health Shands Psychiatric Hospital and the Director of Transcranial Magnetic Stimulation. Dr. Holbert, it’s a pleasure to have you join us and we are talking about an absolutely fascinating topic today. Let’s set the stage first for other providers. Please define treatment resistant depression for us. What is the course it takes? How common it is. Tell us what you’re seeing in the trends with this.
Richard Holbert, MD (Guest): Absolutely. A major depressive episode that fails to respond to at least two adequate antidepressant trials is considered treatment resistant depression. And an adequate antidepressant trial is at least four weeks of an antidepressant at an adequate dosage. Unfortunately, remission rates decrease in subsequent relapse increase with each subsequent episode. The lifetime prevalence of major depression is approximately 20%. And 30 to 40% of those, with major depressive disorder, have treatment resistant depression.
Host: Have researchers observed that certain populations are more vulnerable than others? Tell us a little bit about the risks and how providers can identify these risks.
Dr. Holbert: Yes, so researchers have found that certain populations are at increased vulnerability to treatment resistant depression. First, females are at more risk. Those over the age of 65 are. As well as those who have more severe depression. So, clinicians need to be very careful for those who fall into those classes. Also, those who have comorbid substance use disorders and anxiety disorders have increased risk of treatment resistant depression.
Host: So, now let’s talk about the indications for electroconvulsive therapy. Let’s start with that one. Tell us a little bit about the potential side effects, outcomes. Also, Dr. Holbert, tell us a little bit about the history of it. What’s different now because boy this has been touted in the media as something that could be very scary for patients, but it’s not that way anymore, is it?
Dr. Holbert: No, it is not. So, electroconvulsive therapy is a very sophisticated medical procedure today. What happens is a patient undergoes a medically induced seizure while under general anesthesia and with muscle relaxants so that you can barely see that the patient moves at all. Also, an electroencephalogram is performed which can indicate whether treatment is successful. Now the indications for electroconvulsive therapy include one, treatment resistant depression, and major depressive episodes in which a very fast response is needed such as in patients who are acutely suicidal with a plan and intent to harm themselves or those who are not taking care of themselves such as they are not eating, not bathing, not drinking and therefore putting themselves at risk. Also patients who have catatonia are good candidates for electroconvulsive therapy.
The potential side effects of electroconvulsive therapy include confusion. So immediately after the treatment for a few minutes up to a few hours, patients may experience some confusion. The most concerning side effect with electroconvulsive therapy is memory loss. And the memory loss there is primarily retrograde autobiographical amnesia. So, they may forget certain events that have happened in their lives. Other side effects include headaches, nausea, muscle aches, jaw pain. The outcomes with ECT are very, very good, 80 to 90% of patients get better with the treatment.
Host: When you mentioned that it’s used as rapid response and it’s indicated for that; when we’re talking about patient selection, and we’re going to ask this same question about transcranial magnetic stimulation but is this ever considered a first line treatment?
Dr. Holbert: No. in general, neither of these treatments are considered first line unless the patient comes in in one of these acute crises. Once again, meaning that they are acutely suicidal with a plan and intent or just gotten to a point they are not caring for themselves.
Host: So, then discuss the indications for transcranial magnetic stimulation for us and its side effects and outcomes. Tell us a little bit about it.
Dr. Holbert: Transcranial magnetic stimulation is indicated for treatment resistant depression and it also recently received FDA indication for obsessive compulsive disorder. One of the huge advantages of transcranial magnetic stimulation is its side effect profile. In general, it doesn’t have what we call systemic side effects. The side effects of TMS include application site discomfort, headaches, muscle twitching in the face during treatment, lightheadedness and jaw pain. Now there is a potential risk of seizures, but that risk of seizures is less than with antidepressant medications.
TMS outcomes would be about 70 to 80% of people have a positive response to treatment.
Host: Wow, that’s very encouraging. And how do you decide which one to pursue with the patient?
Dr. Holbert: As we have spoken about, if a rapid response is required, electroconvulsive therapy would be the way to go. But obviously, if at all possible, the most important one to pursue is the one that the patient prefers. And in general, most patients do prefer transcranial magnetic stimulation because with transcranial magnetic stimulation you don’t have to undergo general anesthesia, you can walk in, receive the treatment, walk home, walk out I should say and drive home. So, there’s nothing that interferes with your daily routine except for the time of the treatment.
Host: And also, I would think, that there’s a reputation that goes along with ECT that people may not want to consider. So, tell us a little bit about some of the positives. Now we’ve even read some in the literature about brain growth benefits from either one of these. Is that a myth? Is that true? Or are there any long term negative effects?
Dr. Holbert: With electroconvulsive therapy, there is a risk of long term retrograde autobiographical amnesia. Meaning that patients may well have forgetting of events at different points in their life. Now that risk is relatively low, and that side effect usually resolves within a few months after the treatment. The main advantage of electroconvulsive therapy is its higher success rate. So, electroconvulsive therapy is considered the best treatment we have for major depressive disorder. However, transcranial magnetic stimulation is very effective as well. But also offers the advantage of less side effects, relatively speaking and the noninterference in one’s life.
Host: Is there a standout case you were involved in? Can you tell us something interesting about a particular case or diagnosis you’d like other providers to know about?
Dr. Holbert: Yes, one very interesting case that we had was a gentleman who was a professional and he came in with such a severe depression, he was not able to work. Neuropsychological testing was performed, and he was only functioning at the second percentile. He underwent ECT. He had a rapid response to the ECT within six treatments and at the end, his neuropsychological testing showed him to be at the 98 percentile. He was able to return to work and it was just an absolutely wonderful, wonderful story.
Host: Isn’t that amazing? So, looking forward to the next ten years in the field, what do you feel will be the most important areas of research and wrap it up for us with your best information about transcranial magnetic stimulation, electroconvulsive therapy and when you feel it’s important to refer.
Dr. Holbert: In the next ten years, with electroconvulsive therapy, the primary areas of research I feel will be on how often and how the ECT is delivered, trying to decrease the cognitive side effects of it. With transcranial magnetic stimulation, research will be looking at the exact location to treat, how much to treat and how often to treat. In addition, many other neuromodulation techniques such as magnetic seizure therapy, focal electrically administered seizure therapy and deep brain stimulation will be studied more and more.
I think it is very important for physicians to refer to psychiatrists when they have patients with treatment resistant depression because after a person has failed two antidepressants; their chances of responding to future treatment is only about 20%. And the risk and the morbidity of major depression and the risk of suicide is so high.
Host: Thank you so much Dr. Holbert. Absolutely fascinating topic. Thank you for joining us today. And that concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please also remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I’m Melanie Cole.