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Other Treatment Options
CBS CARES: If someone is depressive, are there activities they should engage in that would make them less depressed? For example, art, music, volunteering to help others?
DR. KAHN: Activities intended to provide pleasurable experiences or to help other people may indeed lift the mood of people with mild to moderate depression, particularly if they have been in a situation where they have been socially isolated. However, such approaches can run up against the wall of the illness itself, where the capacity to interact with others or to experience pleasure can be severely blunted, and people told to just do more enjoyable things can feel even more like a failure.
CBS CARES: What role do lifestyle, exercise and diet play in avoiding or treating depression?
DR. KAHN: We don't know the role of diet in depression, but it is unlikely to account for serious or ongoing cases. Some people crave carbohydrates or chocolate when depressed, so there may in fact be food elements that can at last briefly elevate mood, or that our body tells us are needed in some way. Several research studies show that fairly vigorous exercise definitely helps some people with mild to moderate depression, particularly older people. It is difficult, however, for the most severely depressed people to engage in such activities. Lifestyle may be important; research suggests that keeping regular hours of sleep, work and leisure, and reducing emotional stressful communication within families, can help reduce episodes of recurrent depression and mania in bipolar disorder.
CBS CARES: Regarding diet and depression, are there foods and vitamins to take or to avoid?
DR. KAHN: There are no special diets other than sensible, balanced nutrition. The main vitamin that has shown promise in depression is folic acid, where one British study showed that women, but not men, had a better response rate to fluoxetine (Prozac) when they also took folic acid at a daily dose of 800 mcg.
CBS CARES: Is acupuncture effective on depression?
DR. KAHN: Many Chinese psychiatrists currently combine traditional medicine, including acupuncture, with modern medications and psychotherapeutic approaches. In the West, a modest amount of research is underway to evaluate whether there is a good scientific basis to applying this technique, but there are no well-validated studies yet.
CBS CARES: How safe and effective are herbal remedies such as St John's Wort and Sam-E?
DR. KAHN: Initial optimism about the benefits of many herbal or so-called "natural" remedies faded with careful research studies, particularly St. John's Wort. Some studies suggest benefits from SAM-E and DHEA, but the benefits and safety of these compounds need better research. There have not been careful studies, comparing drug to placebo in large populations, for homeopathic treatments.
CBS CARES: What effect does daylight have on mood and depression?
DR. TERMAN: We respond in three ways to daylight exposure. First, it is energizing. Second, it helps our internal biological clock stay in sync with day and night in the world outside. Third, we sleep better when we get daylight. All three factors affect mood, and daylight deprivation can cause depression. In winter, natural daylight is restricted, so the population as a whole is vulnerable to downward mood swings and energy loss, accompanied by "vegetative" symptoms including longer sleep, difficulty waking in the morning, appetite increase and weight gain. When these become severe -- in about 5% of the population -- we have a full-blown major depression called Seasonal Affective Disorder (or SAD).
CBS CARES: What are the symptoms of Seasonal Affective Disorder?
DR. TERMAN: In addition to the vegetative symptoms, work becomes exceedingly difficult, family relations are disturbed, sex drive plummets, and one can begin to wonder whether life is worth living. This will pass, usually by early May. Many more people experience seasonal swings short of major depression: the winter doldrums. Finally, some people become depressed in a non-seasonal pattern, or even remain depressed continuously for years. Part of the problem may be not going outdoors into broad daylight even when it is plentiful.
CBS CARES: What exactly is light therapy?
DR. TERMAN: Light therapy uses specialized technology to bring optimum lighting exposure into your home when outdoor light is unavailable (for example, during winter, bad weather, or with an incompatible work schedule). The best-tested method presents an early-morning full daylight level (10,000 lux white light) from a table-top device that shines the light downward toward your head while you concentrate on activities like reading, writing and breakfast. We have learned that as little as 30 minutes of morning light therapy can be effective in relieving symptoms, and alternate regimens with longer exposure sessions or multiple exposures at different times of day have no advantage. The efficient use of light lies in its action on the internal biological clock, which relies on appropriately timed morning light exposure to stay in sync with outdoor day and night. Physiology tells us that the internal clock varies by as much as six hours between people, so each person needs to find the optimum time for treatment.
CBS CARES: Are there side effects to worry about with light therapy?
DR. TERMAN: Side effects are relatively rare compared to antidepressant drugs. However, like with drugs, there are dosing issues that will vary from patient to patient. For patients who have a history of bipolar disorder, whether or not it is seasonal, too high a dose of light can trigger the hypomanic or manic state. It is especially important for patients with Bipolar I disorder to begin light therapy only after establishing medication with a mood-stabilizing drug.
CBS CARES: Is light therapy compatible with antidepressant medications?
DR. TERMAN: Some people with long histories of antidepressant medication still find they remain depressed or improvement is only partial. New research points to light therapy as an adjunct to drugs, with marked gains. In some cases, the drug dose can be tapered, even to discontinuation.
CBS CARES: Is light therapy a cure for depression? Will patients be tied to it forever?
DR. TERMAN: No antidepressant cures the disorder. For SAD, however, treatment is needed only in the bad half of the year, and it can be discontinued in mid- to late spring. During the winter, though, daily maintenance is important to keep the symptoms at bay. Once the effect kicks in, some people can skip one or more days and still feel well. However, most will start to slump whenever they skip a day.
CBS CARES: What is electro convulsive therapy (ECT)?
DR. GLASS: ECT involves giving a charge of electricity across the skull into the brain, using electrodes. The patient receives a short acting anesthetic as well as a muscle relaxant. It is a very effective treatment for severe depression, though the patient requires several treatments.
CBS CARES: How does ECT work?
DR. FINK: The electricity causes a convulsion, a brain seizure. The muscles also contract in a convulsion. But we use muscle relaxants to ease the process. To be clear, the effective part is not the muscle contraction, but the brain convulsion.
When a person has a mental illness, their neuroendocrine system is markedly disturbed. The hypothalamus and the pituitary of the brain and the adrenal glands (called the "HPA" axis) are affected. As a consequence, the functions of the thyroid, testes and ovaries are disturbed. In severe depression, melancholia and psychotic depression the HPA axis functions poorly. Within 6 ECT treatments the neuroendocrine system reverses itself and the patient feels much better as a result.
CBS CARES: How effective is ECT?
DR. GLASS: ECT has had response rates reported in the range of 80% to 90% as a first line treatment for severe major depression, and in the range of 50% to 60% for patients who have not responded to one or more trials of treatment with antidepressant medications.
CBS CARES: Is it effective when antidepressants have failed?
DR. GLASS: Yes. Specifically it often works when antidepressant drugs and psychotherapy have failed.
CBS CARES: How long do these benefits of ECT last?
DR. FINK: Like with psychiatric medicines, if you stop ECT, there is a quick relapse. To sustain the benefit, continuation ECT is necessary. In half the depressed patients, after four months of ECT, there is a long-term benefit. Depression is a lifelong disease that we cannot cure so relapse is likely unless treatment is carefully tailored. We just don't know how to permanently change the neuroendocrine system.
CBS CARES: So neither therapy nor medications nor ECT can cure severe or psychotic depression?
DR. FINK: Right.
CBS CARES: Would it be accurate then to see depression as similar to diabetes-not curable, but controllable with continuous treatments so that people can lead a good quality life?
DR. FINK: That is a very good analogy. Just like with diabetes, depression is a lifelong disease, which has to be monitored and treated for life.
CBS CARES: Why is ECT so controversial?
DR. GLASS: Because it does seem strange to shock the brain and cause a seizure. This creates an image of a punitive procedure. But, this very fact shows that, if such a procedure were not effective, it would have fallen out of favor a long time ago.
CBS CARES: Would you describe ECT as a drastic procedure?
DR. GLASS: I wouldn't say drastic. But, it does require hospitalization due to the need for an anesthetic and the procedure is a significant step beyond antidepressant therapy.
CBS CARES: What are the main risks of ECT?
DR. GLASS: I would say the risk of anesthesia.
CBS CARES: Does ECT cause brain damage or memory loss?
DR. FINK: This question has been widely studied and no study has shown that brain cells die from ECT. Actually, ECT increases neurogenesis- the number of brain cells increases. There is no evidence of long-term memory loss due to ECT although some persons complain about it.
CBS CARES: If, as you just said, ECT increases neurogenesis and the number of and brain cells, could it have some benefit in delaying or treating Alzheimer's or some neurological diseases?
DR. FINK: Very good question. Possibly, but there have really been no studies. ECT does relieve the rigidity of Parkinson's Disease.
CBS CARES: What is Vagus Nerve Stimulation (VNS)?
DR. FINK: The concept goes back to the pacemaker device developed to stimulate the heartbeat in a patient with a cardiac arrhythmia. About 1985, neurologists thought that epilepsy that could not be controlled by medicine might be ameliorated by brain stimulation using a similar stimulator through electrodes to a nerve in the neck.. The treatment has some benefit, but epilepsy is not a big market, and the manufacturer asked whether such stimulation could be effective in mental illness - a much bigger market. A particular company convinced some psychiatrists and psychologists to use it for depression. The stimulator is implanted in the chest and stimulus wires go up the chest wall into the carotid sheath in the neck,where they are attached to the vagus nerve.
CBS CARES: You just said they saw mental illness as an ideal market; why is this the case?
DR. FINK: Because we lack cures for mental diseases, just palliative treatments that make people feel better. Tests have been done with VNS in the U.S., Canada, and Germany. Some depressed people respond to palliatives- placebo pills, natural foodstuffs, exercise/running, and light therapy are examples. I am not aware of any random assignment controlled trial showing that VNS is clinically effective, and surely none against ECT. I understand that the results of two large open clinical trials of outpatient depressed patients were presented to the FDA; the expert committee voted to approve marketing for therapy-resistant cases. The final FDA decision has yet to be published. In my opinion, the benefits from VNS are modest.
Vagus Nerve Stimulation to be another placebo wrapped in electronics. Apart from whether it is effective, I also have additional concerns that VNS involves a surgical procedure with risks and high cost … about $15,000 now. If the device does not work, it has to be removed through another surgical procedure. The risks to patients are not trivial and the benefits are not proven.
CBS CARES: But there are two completed VNS studies and the FDA seems at least potentially supportive of the procedure. Aren't you being cynical about a potentially exciting breakthrough in new treatment for depression?
DR. FINK: No, I am not being a cynic. I personally believe that there's just too little science here. I think it is clearly driven as a marketing operation. Benjamin Franklin experimented with electrostatic charges when he was in France in the late 18th Century and offered treatments to people who were ill without scientific proof. I see VNS in the same order.
CBS CARES: Well, you have said that the placebo effect can make depressed patients feel better and that this might explain any benefits of VNS. By that reasoning, how do you know that the benefits of ECT are not also due to the placebo factor?
DR. FINK: That is a wonderful question! The reason we know ECT works is because there have been many trials of "sham" ECT compared to real ECT in severely ill patients. In "sham" ECT, we do everything but induce the actual seizures. There is no question that it is the seizure which causes the benefits of ECT. It has been repeatedly demonstrated that ECT is the equivalent, and often superior, to the chemical agents in antidepressant drugs. If CBS viewers or readers of your website are interested, an excellent review of the evidence for "sham" versus "real" ECT is the report of the UK ECT Review Group headed by Dr. John Geddes, an Oxford University scientist, in Lancet, a British medical journal (The Lancet 2003; 361:799-808.)
CBS CARES: How do you evaluate the success/efficacy of ECT?
DR. FINK: We interview the family and patient extensively. Feedback such as "I slept and ate last night for the first time" or "I don't feel depressed right now, doctor" or "I feel great!" are significant.
CBS CARES: Couldn't these responses from which you conclude success sometimes be driven by a patient's desire to appear better and avoid the discomfort of another round of ECT? … like the person who was asked why he kept banging his head against a brick wall and said, "because it feels so good when I stop!" ?
DR. FINK: About 1978, the American Psychiatric Association Task Force on ECT answered that question. They asked, "do patients volunteer for ECT when they relapse?" The answer is that they do volunteer. And as I said, there are too many well-conducted trials comparing "sham" ECT against real ECT. The scientific basis for efficacy of ECT is rock solid. The experience may sound terrible, but with anesthesia and muscle relaxants, it is not much worse than a visit to the dentist.
CBS CARES: By what percentage does ECT reduce suicides?
DR. FINK: In more than 95 percent of patients, treatment reduces suicide intent to zero. This doesn't mean that people are cured, of course, and that there is no future risk of suicide. But ECT is the single most effective treatment for major depression, melancholia and catatonia. In fact, while there is no cure for severe depression, ECT does cure catatonia itself. The May issue of the American Journal of Psychiatry (2005; 162:977-982) has a report on an ECT study in which I participated -it shows that the data on ECT reducing suicide intent are compelling.
CBS CARES: Can you give us a specific example of how ECT that you personally administered was effective?
DR. FINK: Well, for example, I had a patient who told me: "Dr Fink. I am the son of God. I hate you and am going to punish you!" After a few treatments, he said "Dr Fink, you're a really nice guy". I asked him who his father was and he gave me the name of his actual father. So, after ECT, delusions go, sleep returns, appetite and sexual libido come back.
CBS CARES: Can antidepressants be used in conjunction with ECT and, if so, do they boost or sustain the benefits of ECT?
DR. FINK: There is no definitive published study that compares ECT combined with antidepressants versus ECT and placebo. One reason is that with the older antidepressants, the tricyclics, there were heart attack risks. So, you didn't want to combine the risks of a cardiac event with ECT with the risks of a heart attack due to the tricyclics. Dr. Nelson, when at Yale, reported that patients treated with tricyclics plus ECT needed fewer ECT and had fewer relapses. But this was not a controlled study. Currently, university scientists at Columbia, Pittsburgh and Iowa Universities are being funded by NIMH in a trial combining the antidepressant "Effexor" with ECT to determine whether there is heightened efficacy.
CBS CARES: How widely is ECT available to patients in the US?
DR. FINK: Not as much as it should be. It is a puzzle to me that ECT, which is a highly effective treatment for severe depression when other treatments have failed and a remarkably safe treatment may not be accessible to patients. ECT is just not available in many hospitals that treat psychiatric patients and I think it should be. It is wrong that such an effective option for seriously ill patients should be stigmatized through misinformation. ECT is very different from Vagus Nerve Stimulation and TMS (transcranial magnetic stimulation) for which there is not strong enough evidence of efficacy in seriously ill patients to be offered as a substitute.
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