Magnetically Induced 'Shocks' May Aid Patients
By Benedict Carey, Los Angeles Times July 5, 2004

Until doctors find an answer for severe depression whose costs are not as steep as those of electroconvulsive therapy, the controversy is not likely to diminish. Drug companies have been working to find better antidepressants for years, so far without significantly improving on what's been available for the last 10 years or so. Now, Columbia University's Sarah Lisanby and other researchers are investigating the possibility of using magnetically induced convulsions as an alternative to electricity. A strong magnetic field near the head can also induce a brief seizure. The hope is that the magnetic stimulation might 'break" the depression in the same way ECT does, but for longer than a few months or weeks and without the memory loss.

"ECT is an important treatment, and has helped to save the lives of many patients, many of my own patients, but we need to do better, to find treatments that are more tolerable and accessible," Lisanby said.

In order to determine safety and side effects, doctors at Columbia and the New York State Psychiatric Institute induced brain seizures in 10 severely depressed men and women with bursts of magnetic stimulation. They report that these shocks induced fewer memory problems than ECT.

As for the effect on depression, psychiatrists in Europe have reported on one person who got a full treatment course of magnetic shocks. A 20-year-old woman, she felt an almost immediate lifting of her mood, according to psychological measures done after the treatment.

But to prevent relapse, doctors decided she needed further treatment — with ECT.

Implant Might Help Treat Depression
Vagus Nerve Stimulation Therapy Device for Treating Psychiatric Disorder is Undergoing FDA Approval.
By Jennifer L. Boen of The News-Sentinel

For people suffering with chronic depression, options have been medication, shock treatment and therapy.

Even then, 15 percent-25 percent of the 19 million Americans with depression might not respond to treatment, said Dr. A. John Rush, a psychiatrist at University of Texas Southwestern Medical Center in Dallas.

There soon could be another option for use alongside antidepressants. The first implant for treating a psychiatric disorder is on target for final approval by the Food and Drug Administration within 60 days. In mid-June, the electrical nerve stimulator was recommended by an FDA committee.

Meanwhile, doctors in Fort Wayne are following the innovation and beginning to discuss its possible use here.

Vagus Nerve Stimulation therapy, used since 1997 to reduce seizures in epilepsy patients who did not respond to medication, might give hope to people whose depression keeps them from working, caring for families and enjoying life. The suicide rate for people with treatment-resistant depression can be 15 percent or higher, according to the National Institute on Mental Health.

"Depression can kill. It can destroy your life," said Sarah Lisanby, associate professor of psychiatry at Columbia University in New York and director of the Magnetic Brain Stimulation Laboratory at Columbia Depression Center. She also was a lead researcher in one of the first human trials of the vagus nerve stimulator, or VNS, made by Houston-based Cyberonics Inc. It is the only company manufacturing the device.

The concept for using the VNS for depression came serendipitously after epileptic patients noted improvements in their moods. The implant works like this: A small generator, similar to a cardiac pacemaker, is surgically implanted into the left side of the chest. Wires from the generator are wrapped around the left vagus nerve, which runs alongside the carotid artery.

The vagus nerve sends messages to deep regions of the brain, stimulating and changing brain activity, particularly in areas regulating mood, Lisanby said. The generator delivers electrical pulses for 30 seconds, about once every five minutes, for people with depression.

The generator can be turned on and off using a hand-held magnetic wand. While epileptic patients with the VNS implant are taught how to control the stimulator according to seizure activity, for people with depression, the generator is on continuously, Lisanby said.

The first studies for VNS, in which the devices were implanted in a group of people but turned on in only half the subjects, failed to show a difference in depression improvement between the two groups. But Lisanby said the subjects were followed for only a few months.

As was found with long-term VNS use for seizure control, later studies found 40 percent improvement in mood in patients who used the therapy for a year or longer.

"Although 40 percent may not seem like a lot, it is significant when you think of the fact these are people who have failed other medical treatments for severe depression," Lisanby said.

Fort Wayne neurosurgeon Dr. Michael Munz, who has implanted hundreds of the VNS systems in people with epilepsy, said he has been discussing pending use of the implant with local psychiatrists. His office already has received several inquiries.

"I think it could help treatment-resistant patients with depression. These are patients who have already failed everything else," he said, noting the FDA panel has recommended the implant only for those who have had no success with at least four antidepressants.

Dr. Kevin Murphy, psychiatrist and medical director of Parkview Behavioral Health, said statistically about 60 percent-70 percent of people with depression respond to medication, but in only 30 percent-40 percent of those patients does depression actually remit, or leave. About 30 percent of the remitters are treatment-resistant.

"Psychiatrists tend in this community to see patients who are treatment-resistant," he said, with primary-care physicians treating responders and people with single-episode depression.

Although electroconvulsive, or shock, therapy -- also known as ECT -- is used more commonly today than a decade or two ago, it is not without side effects, too, which include memory loss.

However, Lisanby said ECT can be used for acute depression in patients with the VNS implant, although it must be turned off during the procedure.

Two of the seven FDA panel members opposed approval of the VNS implant for depression, citing that not enough randomized, controlled studies had been done and antidepressant drugs the subjects continued to take might have skewed results. Concerns also were raised about some subjects in one study whose depression worsened.

"The data presented to the FDA says there are benefits," Lisanby said. "The longer they have the device, the better the improvements. It may be a matter of dosage, and we may learn how to dose this, too," as neurologists have learned to do for controlling seizures. "No one is suggesting that VNS be used alone. It is an adjunct therapy.

"This is a very exciting time in psychiatry and represents one of many emerging techniques to stimulate the brain to treat psychiatric disorders," Lisanby said. Another non-pharmacologic treatment in human trials is transcranial magnetic stimulation, involving use of an external magnetic tool to cause electrical changes in the brain.

Precisely how the VNS Therapy controls seizures and depression remains uncertain. Further research on effects VNS has on neuro-chemicals in the brain is under way.

"We didn't know how aspirin worked for 100 years. We just knew it did," Murphy said. "You don't need to know how something works in medicine in order to use it."

More on therapy
For information on VNS therapy, currently FDA-approved only for seizure control, log onto www.vnstherapy.com on the Web.