rtms Versus ECT The Future of Neuromodulation & Brain Stimulation Therapies
rtms Treatment Equipment rtms Equipment Positioning of coil
ECT & rtms Innovative Treatment Options for Patients Only a fraction of individuals suffering from depression seek treatment. Of those that do, greater than 30% fail to achieve satisfactory improvement. As we know not all patients improve when treated with medication or psychotherapy. Up to 25% of people suffering from depression will not respond to multiple trials of medication due to a lack of efficacy or difficulty tolerating medication. Likewise many people struggle to respond to the best efforts of psychotherapy either due to a lack of response or lack of time and/or financial recourses that are necessary for psychotherapy intervention. Alternative treatment modalities such as Electroconvulsive therapy (ECT) or Repetitive Transcranial Magnetic Stimulation (rtms) are critical to addressing the ongoing needs of patients who suffer from the debilitating effects of depression.
Evidence ECT Treatment Considered gold standard for Treatment- Resistant and Severe Depression ECT is the most effective neuromodulation technique with 70-90% remission rate in most studies Safe and effective, approved for use and has been used for over 60 years rtms Treatment Developing evidence base TGA approved treatment modality Not yet approved by MSAC Evolving over 30 years
Indications ECT Severe Major Depressive Disorder Melancholia Psychosis Bipolar Depression Postpartum (Depression) Mania Other Conditions Psychosis Catatonia Parkinson s rtms Moderate to severe depression in patients with a history of treatment resistance Other Conditions Early Research ONLY Non-Urgent Emergency, rapid response Treatment-Resistance
Mechanism of Action ECT Treatment Convulsive Mechanism of action unknown rtms Treatment Non-Convulsive Depression linked to abnormal neuronal functioning in specific brain regions rtms targets magnetic field pulses to stimulate or inhibit these neurons
Disadvantages ECT General Anaesthesia Potential allergic reaction and/or side effects to anaesthetic, muscle relaxant, risk of infection due to need for IV access Memory loss varies Headache & Nausea Myalgia Average 8-9 treatments = 3 weeks Supervision for 24 hours Cannot drive on ECT days Likely cannot work on ECT days rtms Risk of seizure but minimal Mild discomfort but usually dissipates by end of first treatment Facial twitching Skin redness coil site Headache Sleep Disturbance 20 Treatments over several weeks Can take up to 30 treatments of up to an hour in length to establish efficacy Currently inpatient only No funding provided
Advantages ECT Clear Efficacy, especially in Severe Depression Most Rapid Response ECT Maintenance treatment has been shown to help patients when medications are no longer effective Treatment either inpatient or outpatient Improvements have resulted in a better tolerated treatment with fewer side effects Covered by the Private Health Funds rtms VERY well tolerated No Memory Impairment Does not require anaesthesia or muscle relaxant Non-invasive May be alternative for those who have previously responded to ECT
Maintenance ECT Rapid deterioration and requires maintenance treatment ECT Maintenance treatment has been shown to help patients when medications are no longer effective Treatment can be either inpatient or outpatient basis rtms Emerging data suggests benefits of rtms maintained for about 6 months Various protocols under investigation Currently Inpatient only
So what s right for your patient? ECT & rtms are both procedures that treat depression and can be an option when a patient has failed traditional treatments or does not tolerate medications There are biological options other than medication
Future of ECT and rtms Researchers continue to look for ways to reduce the side effects of ECT whilst retaining the benefits rtms studies in Melbourne PET, Functional MRI
Future of Neurostimulation Brain stimulation therapies involve activating or inhibiting areas of the brain with electricity or electromagnets Non-invasively and with implants Magnetic Seizure Therapy (MST) Vagus Nerve Stimulation (VNS) Deep Brain Stimulation (DBS)
MST MST Like ECT it involves the induction of a seizure produced through the use of rapidly applied transient magnetic fields rather than electrical current which is used for ECT. Like ECT, requires general anaesthetic and muscle relaxant. The goal of MST is to retain the effectiveness of ECT whilst reducing the cognitive side effects usually associated with ECT. MST is currently under clinical evaluation and in the early stages of testing.
Vagus Nerve Stimulation (VNS) VNS This works through a surgically implanted device under the skin in the upper left side of the chest about the size of a stopwatch that sends electrical pulses through the left vagus nerve which in turn delivers the signals to the brain. It was originally developed as a treatment for epilepsy but it became evident it also had effects on mood. The pulses appear to alter certain neurotransmitters associated with mood, including serotonin.
Deep Brain Stimulation (DBS) First developed as a treatment for Parkinson s disease to reduce tremor, stiffness, walking problems and uncontrollable movements. In DBS a pair of electrodes is implanted in the brain and controlled by a generator that is implanted in the chest. Stimulation is continuous and its frequency and level is customised to the individual. DBS being researched as a treatment for depression and OCD.