Tricyclic Antidepressants (TCA) Overview

About Tricyclic Antidepressants
Tricyclic antidepressants (TCAs) are an old class of antidepressive drugs, much older than Prozac and other SSRIs. The first TCA imipramine was discovered back in the 1950s, when psychopharmacology was still a new science. The name "tricyclic" comes from their molecular structure which contains three rings of atoms.


The TCAs are effective antidepressants, but because they tend to cause more side effects than newer drugs, they are rarely used to treat depression any more. They are, however, still commonly used in the treatment of chronic pain, sleep disorders and some other conditions, usually in doses much smaller than would be used for depression.


The SSRIs are fairly selective for serotonin, as their name, selective serotonin reuptake inhibitors, implies. TCAs on the other hand are far from selective. They increase brain levels of serotonin, but also norepinephrine (noradrenaline). In addition they block histamine receptors, muscarinic acetylcholine receptors and alpha adrenergic receptors and have some other actions.


How TCAs work
Tricyclic antidepressants (TCAs) inhibit the reabsorption (reuptake) of serotonin and norepinephrine by brain cells. To a lesser extent, TCAs also inhibit reabsorption of dopamine. These antidepressants also block other cell receptors, which accounts for many of their side effects. TCAs are called tricyclic because of their chemical structure. They were among the earliest antidepressants developed and remained the first line of treatment for depression before newer antidepressants arrived.


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Antidepressants, in general, may also work by playing a neuroprotective role in how they relieve anxiety and depression. It's thought that antidepressants may increase the effects of brain receptors that help nerve cells keep sensitivity to glutamate — an organic compound of a nonessential amino acid — in check. This increased support of nerve cells lowers glutamate sensitivity, providing protection against the glutamate overwhelming and exciting key brain areas related to anxiety and depression.


Therapeutic effects of antidepressants may vary in people, due in part to each person's genetic makeup. It's thought that people's sensitivity to antidepressant effects, especially selective serotonin reuptake inhibitor effects, can vary depending on:
  • How each person's serotonin reuptake receptor function works

  • His or her alleles — the parts of chromosomes that determine inherited characteristics, such as height and hair color, which combine to make each person unique



Antidepressant medications are often the first treatment choice for adults with moderate or severe depression, sometimes along with psychotherapy. Although antidepressants may not cure depression, they can help you achieve remission — the disappearance or nearly complete reduction of depression symptoms.


TCA and Clinical Depression
For many years the TCAs were the first choice for pharmacological treatment of clinical depression. Although they are still considered to be highly effective, they have been increasingly replaced by the SSRIs and other newer antidepressants. Notably, however, a recent Cochrane review of the efficacy of the SSRIs concluded that they were only slightly more effective than placebo for the treatment of people with depression. Other indications of SSRIs were not tested. Newer antidepressants are thought to have fewer and less intense side effects and are also thought to be less likely to result in injury or death if used in a suicide attempt, as the doses required for clinical treatment and potentially lethal overdose are far wider in comparison.


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Nonetheless, the TCAs are still occasionally used for treatment-resistant depression that has failed to respond to therapy with newer antidepressants. They are not considered addictive and are somewhat preferable to the monoamine oxidase inhibitors (MAOIs). The side effects of the TCAs usually come to prominence before the therapeutic benefits against depression and/or anxiety do, and for this reason, they may potentially be somewhat dangerous, as volition can be increased, possibly giving the patient a greater desire to attempt or commit suicide.


TCAs approved to treat depression
Here are the TCAs approved by the Food and Drug Administration specifically to treat depression, with their generic, or chemical, names followed by available brand names in parentheses:
  • Amitriptyline

  • Amoxapine

  • Desipramine (Norpramin)

  • Doxepin (Sinequan)

  • Imipramine (Tofranil, Tofranil-PM)

  • Nortriptyline (Pamelor)

  • Protriptyline (Vivactil)

  • Trimipramine (Surmontil)

Some of these medications come in forms that must be injected or as oral solutions that must be mixed with liquids, such as water or juice.
Some of these medications may also be used to treat conditions other than depression.


Side effects of TCA
The most common side effects of tricyclic antidepressants, and ways to deal with them are as follows:
  • Dry mouth -it is helpful to drink sips of water; chew sugarless gum; brush teeth daily. Or use saliva substitutes, which come in liquid and tablet forms and are available without a prescription.

  • Constipation -bran cereals, prunes, fruit, and vegetables should be in the diet.

  • Bladder problems -emptying the bladder completely may be difficult, and the urine stream may not be as strong as usual. Older men with enlarged prostate conditions may be at particular risk for this problem. The doctor should be notified if there is any pain.

  • Sexual problems -sexual functioning may be impaired; if this is worrisome, it should be discussed with the doctor.

  • Blurred vision -this is usually temporary and will not necessitate new glasses. Glaucoma patients should report any change in vision to the doctor.

  • Dizziness -rising from the bed or chair slowly is helpful.

  • Drowsiness as a daytime problem - this usually passes soon. A person who feels drowsy or sedated should not drive or operate heavy equipment. The more sedating antidepressants are generally taken at bedtime to help sleep and to minimize daytime drowsiness.

  • Increased heart rate -pulse rate is often elevated. Older patients should have an electrocardiogram (EKG) before beginning tricyclic treatment.

  • Increased sensitivity to sunlight. Even brief exposure to sun can cause severe sunburn or a rash. While being treated with this tricyclic antidepressants, avoid being in direct sunlight, especially between 10A.M. and 3 P.M.; wear a hat and tightly woven clothing that covers the arms and legs; use a sunscreen with a skin protection factor (SPF) of at least 15; protect the lips with a sun block lipstick; and do not use tanning beds, tanning booths, or sunlamps.

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Special conditions
People with certain medical conditions or who are taking certain other medicines can have problems if they take tricyclic antidepressants. Before taking these drugs, be sure to let the physician know about any of these conditions:
-        ALLERGIES. Anyone who has had unusual reactions to tricyclic antidepressants or to carbamazepine (Tegretol), maprotiline (Ludiomil), ortrazodone (Desyrel) in the past should let his or her physician know before taking tricyclic antidepressants. The physician should also be told about anyallergies to foods, dyes, preservatives, or other substances.
-        PREGNANCY. Problems have been reported in babies whose mothers took tricyclic antidepressants just before delivery. Women who are pregnant or who may become pregnant should check with their physicians about the safety of using tricyclic antidepressants.
-        BREASTFEEDING. Tricyclic antidepressants pass into breast milk and may cause drowsiness in nursing babies whose mothers take the drugs. Women who are breastfeeding should check with their physicians before using tricyclic antidepressants.
-        DIABETES. Tricyclic antidepressants may affect blood sugar levels. Diabetic patients who notice changes in blood or urine test results while taking this medicine should check with their physicians


Suicidal feelings and TCAs
In some cases, antidepressants may be associated with worsening symptoms of depression or suicidal thoughts or behavior in those ages 18 to 24. These symptoms likely occur in the first one to two months of treatment or when you change your dosage. Be sure to talk to your doctor about any changes in your symptoms. You may need more careful monitoring when beginning treatment or changing dosage, or you may need to stop the medication if your symptoms worsen. Adults age 65 and older taking antidepressants have a decreased risk of suicidal thoughts.


Work with your doctor or a mental health provider to nix your irritability, sadness or guilt and boost your mood with tricyclics. Feel good again.


Recommended dosage
The recommended dosage depends on many factors, including the patient's age, weight, general health and symptoms. The type of tricyclic antidepressant and its strength also must be considered. Check with the physician who prescribed the drug or the pharmacist who filled the prescription for the correct dosage.


Always take tricyclic antidepressants exactly as directed. Never take larger or more frequent doses, and do not take the drug for longer than directed. Do not stop taking the medicine just because it does not seem to be working. Several weeks may be needed for its effects to be felt. Visit the physician as often as recommended so that the physician can check to see if the drug is working and to note for side effects.


Do not stop taking this medicine suddenly after taking it for several weeks or more. Gradually tapering the dose may be necessary to reduce the chance of withdrawal symptoms.


Taking this medicine with food may prevent upset stomach.


Sources and Additional Information:

Acupuncture Depression Treatment

Acupuncture is a centuries (if not millennia) old practice of Chinese medicine. It is truly an art form and an incredible way to heal just about everything that ails you. There is research going on into the effectiveness of acupuncture on depressed patients as a way to augment or replace chemical therapies.



It is believed that acupuncture can be at least as good as and maybe better than drug therapies and even psychotherapy regimens. The studies that are surfacing are properly and scientifically controlled studies that use placebo, drug and talk therapy treatments in comparison to people with similar types of depression. The researchers are finding that the acupuncture depression treatment is so effective that doctors are beginning to recommend their patients consider this as an alternative depression therapy.



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How Chinese Medicine Views Depression

In contrast, Traditional Chinese Medicine (TCM) does not recognize depression as a particular illness per se, but it aims to treat the specific symptoms that are unique to the individual using a variety of techniques such as acupuncture, Chinese herbs, tui-na massage, and energetic exercises to restore imbalances found in the body.



Based on a holistic approach, acupuncture consists of fine needles inserted along various points in the body, with the purpose of stimulating the body's flow of energy and functionality, known as Qi. Though acupuncture has been traditionally taught as a preventive form of health care, it has also been proven effective in the treatment of pain and chronic conditions.



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Acupuncture Depression Treatment

As with other types of acupuncture treatments, acupuncture depression treatment rebalances the life forces in the body using ancient Chinese medical techniques. These types of therapies have been employed in eastern medicine for many, many years so it is a wonder they took so long to find their way to the west.



Acupuncture depression treatment addresses the many problems that come along with depression and works to eliminate the symptoms of depression as well as the illness itself. Many depressed people suffer from chronic pain, fatigue, insomnia, mood disorders and emotional upheaval; acupuncture depression treatment treats all of these problems at the same time as treating the overall depression.



Understanding Acupuncture Depression Treatment

The treatment works because it releases endorphins in to the central nervous system which are ‘feel good’ hormones which increase energy and rebalance the emotional imbalances that lead to mental imbalances which result in depression. It kick starts the process of realigning the mental processes and begins a positive cycle to combat the negative, depressive cycle.



Initially, acupuncture depression treatment is not enough to treat depression on its own, it is a catalyst. It helps other treatments take hold easily and work better on the depression. Eventually, you are able to decrease any medication or other therapy and use acupuncture as your primary depression treatment.



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How That Works

Unlike allopathic treatment where each condition or organ system is treated separately, acupuncture considers the entire human body system and its alignment or balance with the environment in examining and treating various conditions. Acupuncture engages a similar methodology in diagnosis, treating, and healing depression.



Acupuncture establishes a concrete link or association between the mind and the body while treating depression; hence this form of treatment becomes much more effective and holistic in treating depression.



Most physical problems have a corresponding mental or physical cause or imbalance and the opposite is also true, mental problems and complaints do have physical causes and reasons. Therefore, acupuncture is one of the best forms of treatments to employ in diagnosing and treating depression.



The premise on which acupuncture and depression treatment works is to bring about a balance in energy flow with no disruptions or blockages and to bring about a harmonious relationship between the mind, body, intellect, and environment.



Depression, according to Traditional Chinese Medicine (TCM) and acupuncture, is a representation of blocked energy or imbalance between the yin and yang poles of energy. This is something which is made used of in acupuncture and depression treatment.



Imbalance in the yin and yang energy can manifest in different forms and by examining the physical body, posture, gait, texture of the skin, vision, voice, tongue, pulse etc., an astute and well-experienced acupuncturist will be able to make an accurate assessment of the problem and extent of depression.



Acupuncturists will also record a detailed history of the patient and his or her symptoms from the patient. This will be followed by evaluating the extent of imbalance present in the fortitude, mettle, energy, blood, fluids, and organs of the patient.



Acupuncture describes the presence of 14 main channels in the human body through which the life force or qi (chi) flows. These channels run through all parts of the body and are interconnected. Externally there are close to 400 acupoints or key points that can provide access to these channels of energy. Each key point is associated with one or more functions hence by inserting needles into these key points, the acupuncturist is releasing energies that are stagnating or blocked and helping it to move freely.



Energy that is blocked at a particular point will result in depriving a certain organ or channel of energy thereby starving it of the vital force. By releasing energy that is blocked, these organs or channels will be flush with fresh energy and will no longer be deficient of energy.



During acupuncture and depression treatment, people suffering from depression often claim that their experience of acupuncture treatment was soothing, relaxing, and energizing. Needles employed in treatment are extremely fine, thin, and sterile making it a safe and painless procedure. Any experience of soreness or stretching sensation during acupuncture for depression treatment is a strong indication of the needle connecting with the qi or energy. During the procedure, patients are made to feel relaxed and comfortable and draped appropriately.



Patients often describe the acupuncture and depression treatment experience as coming out of deep meditation. The precise acupuncture treatment for depression could include a history and physical examination, followed by vital statistics, and acupuncture treatment. Patient is generally requested to lie on his or her stomach followed by a brief acupuncture session to key points on the back.



These points could include the lung point to release any sorrow that the patient is withholding and not letting go. The heart point to heal the lack of happiness, liver points to cure anger or depression, and kidney points to heal fear or distress, and the treatment to the back is completed.



For the next part of acupuncture and depression treatment, the patient is then asked to lie on his or her back for treatment of points that enhance the energy flow and balance the spirit. This involves inserting needles in the lower arms, legs, stomach, and head.



Acupuncturists select these points are selected because they are associated with the seven chakras as described in ancient Indian science of yoga.



In addition to this acupuncture needles could be inserted on the exteriors of the ears in an attempt to harmonize the neurotransmitters released by the brain and establish a sense of wellness. Most often times, magnets are placed behind the ears or in the auricular points to extend the treatment.



Thus, acupuncture and depression treatment involves releasing the blocked energies that are stagnating at certain points and depriving other channels and organs from the free flowing life force. Balancing the energy and brining about harmony within the body by accessing the energy channels with the help of needles is the treatment modality employed by acupuncture in treating depression.



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Studies of Acupuncture for Depression

Since the early nineties, studies around the globe have suggested that treating depression with acupuncture has a positive and holistic effect on depressed patients, particularly when used in combination with psychotherapy and herbal treatments.



Psychologist John Allen, from the University of Arizona in Tucson, and Acupuncturist Rosa Schnyer, conducted the very first pilot controlled study on treating depression symptoms with acupuncture in the Western scientific world. In a double blind randomized study, 34 depressed female patients who met the DSM-IV diagnostic criteria were assigned to one of three treatment groups for eight weeks.



The first group received acupuncture treatment specifically tailored to their depression symptoms. The second group received a general acupuncture treatment not specific to depression, and the third group was placed on a waiting list for acupuncture treatment, but received no treatment. The study found that those in the tailored acupuncture treatment experienced a significant reduction in symptoms, compared to those in the non-specific treatment. Moreover, over 50% of the participants no longer met the DSM-IV diagnostic criteria for depression after the study.



The study findings suggest that using acupuncture alone could be as effective as other types of treatments for relieving depression symptoms typically used in Western medicine, such as psychotherapy and drugs. While these results are promising and the United Nations World Health Organization has approved acupuncture as a treatment for depression, further clinical trials with larger samples are deemed necessary to endorse this new hope for relief.



Disadvantages and Side Effects

None known, apart from discomfort from the acupuncture needles. Single-use needles are required.



Insurance Coverage

Depression is now considered an illness like any other that you would receive treatment for from a health practitioner and is covered by medical insurance. Most insurance companies accept acupuncture depression therapy as a normal type of treatment for depression and will cover the expense. Even if your insurance company does not cover acupuncture depression therapy, the cost of treatment is usually quite low and affordable.



Different Patients, Different Results

Just as with any other form of medicine or therapy, acupuncture depression treatment will not work for absolutely everyone. No one understands how or why acupuncture works, but they know that it does.



There is no known physical science explanation behind the treatment but it does work better than most other treatments available. Some people blame it on the placebo effect and others say it is simply ancient medicine that works for a forgotten reason. Simple fact is, it works. This treatment works in people of all ages, from childhood to old age and even works on animals. It is necessary to use any type of therapy for depression under the supervision of a trained professional and not try any form of self treatment.



Many people are incapable of using traditional drug treatments and even herbal depression treatments for a variety of reasons. When people find a treatment that is effective they tend to stick with it, especially if it has few or no ill side effects. Acupuncture depression treatment is one of those few therapies that is easy to stick to because it works and you feel great afterward.



Sources and Additional Information:

Youth Suicide: Risk Factors and Prevention

Facts and Statistics

Teenagers attempt suicide roughly 10 times more frequently than adults, although their fatality rate of 11.1 per 100,000 people is about the same as adults'. This is the third leading cause of death among 15-19 year-olds. For this age group, there were 5,174 motor-vehicle deaths in 1994, compared to 1,948 suicides.



According to U.S. national data released in September 1991, about one million teens (out of about 25 million) attempt suicide each year, of which an estimated 276,000 sustained injuries serious enough to require medical treatment.



Some other estimates (these are total, not per-year) are considerably higher: 3% of elementary-school, 11% of high-school, and 17% of college students. However, "Most were low-lethality attempts for which medical or other attention was not sought. Accordingly, the vast majority of [these] suicide attempts will not be uncovered by investigations dealing solely with clinical or medically identified populations." Thus, estimates or calculations of teenage suicide-attempt rates are particularly unreliable.

About four times more girls than boys make suicide attempts, but boys are much more likely to die: about 11% of (reported) males' attempts were fatal, compared to 0.1% of females', a ratio of more than 100:1. This also gives a ballpark average of about 50 attempts for every fatality in this age group.



This low fatality rate might be taken to mean that most of these adolescents don't want to kill themselves (true) and that there is generally one or more "warning" attempts before a lethal one (not true). In a study from Finland, only 30 percent of male, and 68 percent of female suicides 13 to 22 years old had made a previous (known) suicide bid. This suggests that many of these lethal first-time-attempters intended to die.



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Compared to those of older people, adolescents' suicide-attempt statistics show two significant differences. First the fatality rate for boys is a hundred times that of girls, a much greater gender difference than with any other age group. The immediate reason is clear enough: most teenage girls use relatively low-lethality methods like drugs and wrist cuts, while a substantial number of boys use guns and hanging. The reasons behind these choices are not known.



Second, the fatality rate among adolescents, less than 2%, is much lower than that among the elderly, variously reported to be between 25% and 50%. This may be because the young, however miserable, usually have more reason for optimism about the future than do the old, who are too often without friends, family, job, and health.



Nevertheless, their suicide rate is increasing, and approaching the national average.

This corresponds to about 2000 suicides among 15-19 year-olds per year. While it's true that the suicide rate is substantially higher among old people, suicide is a relatively more frequent cause of death in the young, who have few deaths from illness. That's why it's the third leading cause of death among 15-24 year-olds, but ranks ninth or tenth for those 55-74.



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The reasons for this rise are also in dispute. Besides the usual social rationales (e.g. higher divorce rates), "Some statistics indicate that suicide attempts among younger persons have not increased, but the methods and means they are using are more lethal, making the attempts more successful," says CDC's [centers for Disease Control] Dr. Alexander E. Crosby.



Risk Factors Related to Adolescent and Youth Suicide

Mental health professionals have identified those factors that pose the greatest risk to adolescents and youth suicides. Youths who attempt and commit suicide generally have several risk factors, which are combined with the ready availability of a lethal means and the lack of suitable sources of help.



Social and economic environments

The family is one of the earliest and most significant influences in a young person's development. There have been numerous studies of family troubles associated with youth suicidal behavior, including early parental loss, parental mental health problems, parental abuse and neglect, and a family history of suicide. In addition to chronic family troubles, there are usually precipitant events closer in time to a suicide attempt, many of which involve the family. These precipitants include serious conflicts with family members or divorce of parents, perceived rejection by one's family, and failure of family members to take an adolescent's talk about suicide seriously.



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The school constitutes an important influence on youth. It is therefore not surprising that a history of school problems and the stress of disruptive transitions in school are potential risk conditions for youth suicidal risk behavior, as well as failure, expulsion, and overwhelming pressure to succeed.



Bullying is an extremely serious problem in schools and can result in the victims becoming depressed and suicidal, and even taking their own lives.



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The influence of peers on young people's behavior can sometimes be greater than that of family and school. There is a risk of copycat suicidal behavior in adolescents who have been exposed to a peer's suicide. This contagion effect is most pronounced for vulnerable youths who tend to identify strongly with someone who has committed suicide in their environments or in mass media. Common precipitating events in youth suicidal behavior include rejection from peers, the breakup of a significant relationship, or the loss of a confidant. Furthermore, adolescents and young people who fail to act when confronted with a suicidal peer, by dismissing it as insignificant or failing to inform an adult, can increase the risk of suicide.



Poverty in children and youth heightens the risk conditions for suicide, including school problems and failures, psychiatric disorders, low self-esteem, and substance abuse, all of which can increase vulnerability to suicide and suicidal behavior.



Physical environment

Having immediate and easy access to lethal means to kill oneself increases the risk that a suicide will occur. Firearms are common methods of male suicides in the United States, and young women are increasingly using guns to kill themselves. Having such an instantly lethal method available increases the risk that vulnerable young people may kill themselves impulsively.



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Additional risk factors

The researcher Jerome Motto suggested that the increased use of alcohol and drugs might have been a significant factor related to the rise of youth suicide since the 1970s. According to David Brent, at least one-third of adolescents who kill themselves are intoxicated at the time of their suicide and many more are likely to be under the influence of drugs.



A history of previous suicide attempts and the presence of a psychiatric disorder are among the most important and well-established risk factors for youth suicidal behavior. As many as 10 percent of suicide attempters eventually die in a later suicide attempt. Depression is a major mental health problem associated with suicide. In addition, impulsive behavior, poor problem-solving and coping skills, alcoholism, and homosexual orientation also increase the likelihood of suicidal behavior.



Prevention

No single risk factor alone is sufficient to result in a suicide. Youths who attempt and commit suicide generally have several risk factors that are combined with the ready availability of a lethal means and the lack of suitable sources of help.



Primary prevention consists of actions to prevent suicidal behavior before people develop a high-risk or a suicidal crisis. Most youth and adolescent suicide prevention programs have focused on school-based activities where adolescents receive training in identifying signs of suicide risks and how to best react to suicidal peers. Some programs also identify resources to help with suicide and encourage young people to talk with adults if they feel that they or their friends are feeling suicidal. Young people are specifically encouraged not to keep a "secret" confession of suicidal intentions to themselves. Controversy surrounds the usefulness and effects of school-based suicide prevention programs. Few programs have been the subject of rigorous evaluations and not all programs have had positive results. Research indicates that programs that provide a variety of resources within the school and community, including specially trained teachers, mental health services and counselors, and information and training for parents, may be of more benefit in preventing suicidal behavior.



In addition to school-based programs, many primary prevention approaches have focused on key persons who may come in contact with potentially suicidal youth. These persons, called "gatekeepers," include school staff, child welfare workers, community volunteers, coaches, police, family doctors, and clergy members. Training usually involves information on taking suicide threats seriously and asking specific questions to assess suicide risk, identifying behavior changes that may indicate increased suicide risk, better identification and treatment of depression and other mental health problems, and providing information about resources to help with suicide and other community youth problems.



Emergency Help

If you or someone you know is in immediate danger because of thoughts of suicide

Please call 911

There is help for you. Stay on the phone with the operator and wait for help to arrive.

Do not hesitate to call. Your life is extremely valuable, and people care about you.

Please reach out for help. Never act on your thoughts of suicide. Never… Remember, when you die, you cannot change your mind. And if your attempt fails, you might become physically or mentally impaired for all your remaining life!



Sources and Additional Information:

http://www.cdc.gov/ncipc/dvp/suicide/youthsuicide.htm

Deep Brain Stimulation for Treatment Resistant Depression

Deep brain stimulation (DBS) is an experimental surgical treatment involving the implantation of a medical device that sends electrical impulses to specific parts of the brain. DBS has been approved for treating tremor (a disease where parts of the body, usually the hands, shake when someone is intentionally moving), dystonia (a disorder where muscle contractions cause twisting and repetitive movements or abnormal postures), and Parkinson's Disease. DBS has also shown some promise in helping people with treatment-resistant depression.



The pacemaker or stimulator that controls DBS is placed in specific areas of a person's brain (mapped out ahead of time using imaging technology such as a CT scan or MRI) during a surgical procedure where the patient is anesthetized (i.e., feels no pain), but awake. The device is then calibrated to provide optimal amounts of stimulation for each person. After approximately 3 to 5 years, the brain pacemaker must be replaced, because the batteries wear out across time.



In individuals with treatment resistant depression, the pacemaker is placed in the subgenual cingulate region (SCR or Brodmann's area 25) or the nucleus accumbens (a part of the brain that controls our ability feel pleasure). It is unclear why the treatment works, but the stimulation of these brain regions seems to help with emotional regulation and decreasing depressive thoughts and feelings. Preliminary research results are promising; DBS patients experienced a remission in depression symptoms for 6 months. However, the procedure is still considered experimental; very few people have undergone this type of treatment for depression.



Exactly how deep brain stimulation can affect depression isn't clear. Researchers theorize that certain regions deep within the brain influence mood and depression. They believe that the areas associated with depression may be overactive in certain people. Sending electrical impulses to these areas may "reset" them to normal functioning.



Risks

Any surgical procedure carries risks. Because deep brain stimulation involves brain surgery, the procedure may be especially risky, posing some serious health risks. Also, the brain stimulation itself may cause side effects.



Possible surgical complications

Complications of surgery may include:

  • Bleeding in the brain

  • Stroke

  • Infection

  • Breathing problems

  • Nausea

  • Heart problems

  • Incision scarring



Possible side effects after surgery

Side effects and adverse health problems associated with deep brain stimulation include, but may not be limited to:

  • Bleeding in the brain

  • Seizure

  • Infection

  • Delirium

  • Unwanted mood changes, such as mania and depression

  • Movement disorders

  • Lightheadedness

  • Insomnia

  • Dizziness

  • Device malfunction

  • Temporary tingling in your face or limbs

Also, people who have undergone deep brain stimulation to treat Parkinson's disease have reported a variety of problems, including:

  • Panic attacks

  • Mania

  • Speech difficulty

  • Movement problems

  • Increased suicidal thoughts and behavior

The long-term risks and side effects of deep brain stimulation for depression aren't known.



How you prepare

Because deep brain stimulation is experimental, it's available only through participation in clinical trials. Because of the risks involved, its use is limited to people who have severe, debilitating depression that has not improved with standard treatments.



First, weigh the pros and cons

Deep brain stimulation is a serious and potentially risky procedure because it requires brain surgery. Even if you might be eligible for a clinical trial to test deep brain stimulation, you and your doctors must carefully weigh the pros and cons of the procedure. If your depression prevents you from going about your daily activities or is life-threatening, you may be more willing to face the risks involved with deep brain stimulation. But you still must be screened by a team of medical professionals to make sure deep brain stimulation is a good and safe option for you.



Next, preparing for surgery

Before surgery, you need a medical evaluation with your doctor or neurosurgeon to make sure it's safe for you and a good option in your case. You may need a full physical and psychiatric evaluation. This may include neuropsychological evaluations to determine your level of intellectual and cognitive ability before the procedure so that potential changes can be monitored over time. You also need brain-imaging studies, such as an MRI, before the surgery.



What you can expect

During the surgery

Deep brain stimulation requires two surgical procedures:

  • Surgery on your brain to implant electrodes

  • Surgery on your chest to implant a neurostimulator device

Because the procedure is new and experimental for depression, it may not be performed exactly the same way everywhere. In general, here's how surgery for deep brain stimulation works.



Brain surgery 

For the brain surgery portion, you're given local anesthetics to numb the areas being operated on. You remain awake and alert, however, so that the surgeon can talk to you to make sure the proper areas of your brain are being stimulated.

Your head is placed in a special frame to keep it still during surgery. Two holes are drilled in your skull. Guided by imaging techniques, the surgeon implants electrodes on both sides of your brain. You may undergo testing during the surgery to see how your mood is affected by the stimulation.



Chest surgery

During the second portion of surgery, the surgeon implants the neurostimulator in your chest, near your collarbone. You're put to sleep with general anesthesia for this surgery. Wires from the brain electrodes are placed under your skin and guided down to the battery-operated neurostimulator.



After the procedure

After the surgeries, you may need to take antibiotics to lower the risk of infection. A week or so after the surgeries, the neurostimulator in your chest is activated in your doctor's office. This sends electrical signals to the electrodes in your brain, affecting areas related to mood.



The amount of stimulation is customized to your situation, based on your mood and side effects. Stimulation is generally constant, 24 hours a day. The neurostimulator, which runs on battery power, can be easily programmed from outside your body.



You're given a hand-held magnetic device to use at home. With this, you can temporarily turn off stimulation by holding the magnet over the area of your chest where the neurostimulator is implanted. When you move the magnet away, stimulation restarts.

You must visit your doctor periodically to make sure that the neurostimulator is working correctly and that it hasn't shifted out of position. If necessary, the neurostimulator can be replaced or removed in a simple surgical procedure. The neurostimulator device may need replacement after a few years.



Results

If deep brain stimulation works as hoped, your depression symptoms will improve or go away completely. It may take several months of treatment with deep brain stimulation before you notice any improvements in your depression symptoms, though. And not everyone with chronic depression, especially those who have had depression for years, gets better with deep brain stimulation. Additional research is needed to learn more about how deep brain stimulation works and how safe and effective it is for depression.



St. Jude Medical Study

According to the latest data in a clinical study supported by St. Jude Medical, Inc., deep brain stimulation (DBS) therapy for depression may provide sustainable improvement in depression symptoms among patients with major depressive disorder. Study results was presented at the American Psychiatric Association (APA) meeting in San Francisco.



This study profiles 21 patients with DBS therapy in the area of the brain known as Brodmann Area 25, most of whom have completed one year of post-surgery evaluation. At six months, 62 percent of the patients experienced at least a 40-percent decrease in symptoms of depression as measured by a standardized test called the Hamilton Rating Scale for Depression. Of these patients, 92 percent maintained this improvement at their last follow-up visit (typically at one year). Additionally, 71 percent of all patients in the study exhibited at least a 40-percent decrease in symptoms of depression as measured by the Hamilton scale.



"Typically these patients do not maintain responses to traditional approaches such as medications and electroconvulsive therapy," said Peter Giacobbe, M.D., psychiatrist with the University Health Network in Toronto and presenter of the study results. "We are encouraged that this data indicates DBS therapy may provide sustainable improvement in the quality of life for these patients."



Ongoing at three leading Canadian academic medical centers, the study utilized the St. Jude Medical Libra Deep Brain Stimulation System to deliver stimulation to an area of the brain known as Brodmann Area 25, which appears to become overactive in severely depressed people. The pilot study builds upon the research of Helen Mayberg, M.D., and Andres Lozano, M.D.



Patients in the study had suffered from depression for an average of 20 years, had tried in excess of 12 depression medications and were considered disabled or unable to work at the time of enrollment. At the 12-month evaluation point, eight of the study patients had returned to daily life activities such as school, work and sustaining relationships with family and friends, and two patients were considered to be in remission.



"These results are important as they contribute to the growing body of research about the potential benefits deep brain stimulation may provide this patient population," said Chris Chavez, president of the St. Jude Medical Neuromodulation Division. "We are committed to expanding our research into the field of depression and to completing the BROADEN study to determine whether stimulation of Brodmann Area 25 is clinically significant in treating severely depressed patients who have exhausted other treatment options."



Heidelberg University Hospital Study

A team of neurosurgeons at Heidelberg University Hospital and psychiatrists at the Central Institute of Mental Health, Mannheim have for the first time successfully treated a patient suffering from severe depression by stimulating the habenula, a tiny nerve structure in the brain. The 64-year-old woman, who had suffered from depression since age 18, could not be helped by medication or electroconvulsive therapy. Since the procedure, she is for the first time in years free of symptoms.



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Source: Heidelberg University Hospital.
The habenula is a tiny double structure in the diencephalon. For stimulation two electrodes are implanted. The picture shows the pathway of an electrode in the brain.




Scientific studies have shown that the habenula is hyperactive in depression, the idea was to downregulate this structure by deep brain stimulation. The surgical procedure is based on a hypothesis of how the habenula is involved in depression that was first formulated by Dr. Alexander Sartorius, psychiatrist at the Central Institute for Mental Health.



The success of the procedure was confirmed when the electrode was accidentally switched off: the patient had a bicycle accident which required surgery for which an ECG had to be made as preparation. The brain pacemaker was switched off and was not reactivated for a few days, and the depression promptly returned. A few weeks after reactivation, the patient completely recovered again.



The neurosurgeons in Heidelberg and the psychiatrists in Mannheim now want to build on this positive experience and are planning a clinical study in which the habenula stimulation is to be implemented for severely depressive patients at five psychiatric-neurosurgery centers in Germany. “We aim to show that habenula stimulation has a better success rate than other target areas attempted for depression and that it is also safe to use,” says Dr. Sartorius, Coordinating Investigator of the proposed study.



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Light Therapy for Depression

I have severe pain and trouble walking, I push myself 

to go outside in the sunlight. It makes the whole day 

change and lessons the intensity of pain. 

Of course it's hard for me to just sit there 

so I begin planting or just visiting my flower family. 

It truly works for me.





Marcella Floyd





About Light Therapy

What may be a good treatment for one type of depression may be good for another. Take light therapy for depression, for instance. Doctors have successfully treated seasonal affective disorder (SAD), a mild depression caused by reduced exposure to sunlight in winter months, with light therapy – spending a prescribed amount of time each day in front of artificial light that replicates the spectrum of sunlight. Light therapy may one day be used for general depression, too.



Researchers at the University of North Carolina at Chapel Hill School of Medicine discovered an interesting finding after reviewing 20 studies. “We found light therapy is an effective treatment not only for SAD but other types of depression as well,” says study leader Robert Golden, MD, professor and chairman of psychiatry.



Dr. Golden and his researchers reviewed studies of people aged 18 to 65 with a diagnosed mood disorder. Participants were grouped into four categories: bright light for SAD, bright light for non-seasonal depression, dawn simulation (simulating early dawn with artificial light at lower levels) for SAD and bright light with antidepressants for non-SAD. In every category, participants’ moods improved, with greater improvement found with a combination of antidepressants and light therapy. “The findings [for light therapy] are as strong or as striking” as those for conventional medications used as treatments for depression, according to Dr. Golden.



More studies are needed to provide definitive evidence on the effectiveness of light therapy for depression. Still, Dr. Golden says, “Light therapy may be a reasonable alternative to more established forms of treatment, including medication and psychotherapy.”



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How much light are you getting?

Light therapy can treat more than just winter depression, though that's the main use. Here's why:  the amount of light reaching your eyeball from interior lighting is far less than the amount from the real thing. So unless you are outside much of the day in the winter, you are relying on electric light for your photons (in summer, there is so much light, most people get enough, even if they are indoors during their work hours). The following table shows you just how much less light you receive, indoors versus outdoors (Lux is a standard unit of light flow):



Brightness Values:

-        Candle light at 20 cm       10-15 Lux

-        Street light                       10-20 Lux

-        Normal living room lighting    100 Lux

-        Office fluorescent light    300-500 Lux

-        Halogen lamp                   750 Lux

-        Sunlight, 1 hour before sunset            1000 Lux

-        Daylight, cloudy sky        5000 Lux

-        Daylight, clear sky           10,000 Lux

-        Bright sunlight                 > 20,000 Lux



When to consider light therapy

Light therapy may be a treatment option for you if:

  • You don't want to take medications such as antidepressants

  • You can't tolerate the side effects of antidepressants

  • You've tried antidepressants but they haven't been effective

  • You want an alternative to psychotherapy

  • You're pregnant or breast-feeding and are concerned about the effects of antidepressants on your developing fetus or baby

  • You don't have insurance coverage for mental health services

  • You lack access to mental health services



Conditions light therapy may help

Conditions and problems that may benefit from light therapy include:

  • Seasonal affective disorder

  • Nonseasonal types of depression

  • Obsessive-compulsive disorder

  • Premenstrual dysphoric disorder

  • Postpartum depression

  • Jet lag

  • Certain sleep disorders

  • Shift-work problems

Keep in mind that light therapy hasn't officially been approved by the Food and Drug Administration as a treatment for seasonal affective disorder or other conditions. But many mental health providers consider light therapy the main seasonal affective disorder treatment.



Risks

Risks and side effects associated with light therapy are uncommon but can happen. They can include:

  • Eyestrain

  • Headache

  • Agitation

  • Nausea

  • Vomiting

  • Irritability

  • Fatigue

  • Dry mouth

  • Sleep problems

  • Mania

When side effects do occur, they're usually mild. They may go away on their own within a few days of starting light therapy. You also may be able to manage these problems by reducing treatment time, moving farther from your light box, taking breaks during long sessions, or changing the time of day you use light therapy. Talk to your doctor for additional help and advice, or if your side effects don't go away or get worse.



Who shouldn't use light therapy

Some light boxes don't filter out or shield harmful ultraviolet (UV) light. UV light can cause skin and eye damage. Don't use light therapy without consulting your doctor first if:

  • Your skin is sensitive to light

  • You take medications that react with sunlight, such as certain antibiotics or anti-inflammatories

  • You have an eye condition that makes your eyes vulnerable to light damage

Cautions for bipolar disorder, severe depression

Light therapy may trigger episodes of mania in people with bipolar disorder. Also, although rare, some people, particularly those with severe forms of depression, develop thoughts of suicide after light therapy. Be sure to talk to your doctor or mental health provider before starting light therapy or at any time during treatment if your condition gets worse.



What you can expect

Starting light therapy

The general recommendation for most people with seasonal affective disorder is to begin treatment with light therapy in the early fall, as soon as your symptoms start. Treatment generally continues until spring, when outdoor light alone is sufficient to sustain a good mood and higher energy.



Some people experience seasonal affective disorder in the summer. And others who typically have winter depression may notice symptoms during prolonged periods of cloudy or rainy weather during other seasons. You and your doctor can adjust your light box treatment based on the timing and duration of your symptoms.



For other conditions, talk to your doctor about the best time to begin light therapy.



During light therapy

During light therapy sessions, you sit or work near a light therapy box. To be effective, the light from the light box must enter your eyes indirectly. You can't get the same effect merely by exposing your skin to the light. While your eyes must be open, don't look directly at the light box because the light can damage your eyes.



Light therapy sessions are generally done each morning after you awake. Some light therapy boxes, however, are dawn simulators — they turn on in the morning while you're still asleep and gradually get brighter until you wake up.



Three key elements for effective light therapy

Light therapy is most effective when you have the proper combination of duration, timing and light intensity:

  • Duration. When you first start light therapy, your doctor may recommend treatment for shorter blocks of time, such as 15 minutes. You gradually work up to longer periods. Eventually, your light therapy typically involves daily sessions ranging from 30 minutes to two hours, depending on your light box's intensity.

  • Timing. For most people, light therapy is most effective if used in the morning, after you first wake up, rather than during the evening. Doing light therapy at night can disrupt your sleep. Because light therapy seems to work best in the early morning, you may need to wake up earlier than you normally would to match treatment with your natural biological rhythms. You may find it hard to wake up early, especially if depression leaves you feeling lethargic. Your doctor can help you find a light therapy schedule that works for you.

  • Intensity. The intensity of the light box is recorded in lux, which is a measure of the amount of light you receive at a specific distance from a light source. Light boxes for light therapy usually produce between 2,500 lux and 10,000 lux, with 10,000 lux being typical. In contrast, the lighting in an average living room in the evening is less than 400 lux, while a bright sunny day may register 100,000 lux. The intensity of your light box may also determine how far you sit from it and the length of time you need to use it. The 10,000 lux light boxes usually require 30-minute sessions, while the 2,500 lux light boxes may require 2-hour sessions.

Results

Light therapy probably won't cure seasonal affective disorder, depression or other conditions. But with safe and effective light therapy, your symptoms can get better. You may feel better about yourself and life again, and have more energy.



Light therapy can start to improve symptoms within just a few days. In some cases, though, it can take two or more weeks.

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Light Therapy Development

In the early 1980’s, scientists researching depression noted a consistent pattern of symptoms becoming more severe in many patients during the long winter months, particularly in the northern hemisphere. Significantly these symptoms eased or disappeared completely as the longer summer days returned.



In 1982 The National Institute of Health (NIH) identified winter depression and coined the term, ‘SAD’ for Seasonal Affective Disorder.



The scientists found that 'SAD' was related to an imbalance in the body's natural circadian rhythms. The Circadian rhythm, or the body’s inner clock governs the timing of sleep, hormone production, body temperature, and other biological functions.



In 1984 these pioneering scientists discovered that exposure to bright white light is very effective at treating seasonal affective disorder.



For many years doctors had relegated light therapy to the periphery of credible science. It wasn’t until 2001 that researchers from NIH, Thomas Jefferson Medical University and Apollo Health fully understood how exposure to specialized bright light, stimulates the production of brain chemicals to relieve the symptoms associated with seasonal depression.



Dr. George Brainard’s team at Thomas Jefferson Medical University, identified a photo receptor in the human eye, responsible for reacting to light and controlling the production of melatonin.



They found specifically that light in the range of 447-484 nm (nanometers) is responsible for suppressing melatonin production and shifting circadian rhythms. Indeed, this particular bandwidth of light is up to ten times more effective than other wavelengths. We now know this technology as BLUEWAVE. The light therapy is considered as an effective treatment for body clock corruption as well, helping to the patients fighting sleep disorders.



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Vagus Nerve Stimulation for treating Depression

Vagus nerve stimulation, an effective epilepsy treatment, has produced encouraging preliminary results for patients suffering from "treatment-resistant depression," and a study beginning at University Medical Center of Arizona and a handful of other U.S. sites may verify the promising new therapy. Approximately 18 million Americans suffer from depression, and about 1 million of whom have severe treatment-resistant depression.



FDA Approval

FDA approval for the Vagal Nerve Stimulator (VNS) came July 1997 as adjunctive treatment of complex partial seizures for patients over 12 years old. As with any approved treatment, "off label" use is permitted and epileptologists have already implanted children younger than 12 (three y.o.), and treated patient with other than complex partial seizures (absences, Lennox-Gastuat).



FDA approval for the VNS Therapy System as depression treatment approach was received on July 15, 2005. This device is indicated for the adjunctive long-term treatment of chronic or recurrent depression for patients eighteen years of age or older who are experiencing a major depressive episode and have not had an adequate response to four or more adequate antidepressant treatments.



How VNS works?

There's one vagus nerve on each side of your body. The nerve runs from your brainstem through your neck and down to your chest and abdomen. Information travels through this nerve to and from your central nervous system. The pulse generator sends electrical signals along your vagus nerve up into your brain, where it's hoped that these electrical signals will create a reaction that improves your mood and reduces depression symptoms.



The principal components of the VNS Therapy System are an implantable pulse generator and lead, and an external programming system. The procedure usually lasts about 50 to 90 minutes with the patient under general anesthesia. Sometimes a hospital stay of one night is required. Some surgeons have performed the procedure with local anesthesia and the patient has been discharged the same day.



The study patients are implanted with a NeuroCybernetic Prosthesis (NCP) System, which consists of a battery-powered generator implanted in the chest and a lead attached, at neck level, to the vagus nerve leading to the brain. The device delivers an automatic, periodic electrical stimulation to the vegus nerve. A physician can adjust the intensity, duration and frequency of the stimulation, which may be minimally noticeable by the patient, in follow-up visits.



The Vagus Nerve Stimulation device costs $12,000 and the cost of surgery to implant the device can run as high as $15,000.

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Side Effects

The possible side-effects that have been reported at some time during treatment that were significantly increased, were

  • voice alteration/hoarseness,

  • cough,

  • throat pain,

  • nonspecific pain,

  • dyspnoea,

  • paraesthesia,

  • dyspepsia,

  • vomiting and

  • infection.

However, VNS does not cause the side effects normally associated with depression medications, such as weight gain, loss of sexual function, cognitive impairment and insomnia.



Medical Coverage

In May 2007, US Department of Health and Human Services issued a memo, claiming that there is sufficient evidence to conclude that vagus nerve stimulation is not reasonable and necessary for treatment of resistant depression. Accordingly, it has been issued the following national coverage determination: Vagus nerve stimulation is not covered for treatment resistant depression.



During the surgery

Surgery to implant the vagus nerve stimulation device is done either on an outpatient basis, allowing you go to home that same day, or on an inpatient basis, requiring an overnight stay in the hospital. The surgery usually takes one to two hours. It may be done under local or general anesthesia. The FDA recommends that the surgery be done by a neurosurgeon with expertise in implanting the device.



The surgery doesn't involve your brain. The pulse generator is surgically implanted in the upper left side of your chest. The device is meant to be a permanent implant, but it can be removed if necessary. The pulse generator is about the size of a stopwatch and runs on battery power. A lead wire is connected to the pulse generator. The lead wire is guided under your skin from your chest up to your neck, where it's attached to the left vagus nerve through a second incision.

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After the procedure

The pulse generator is activated during a visit to your doctor's office a few weeks after surgery. The pulse generator can be programmed to deliver electrical impulses to the vagus nerve at various durations, frequencies and currents. Vagus nerve stimulation usually starts at a low level and gradually increases, depending on your symptoms and side effects.



Stimulation typically lasts for 30 seconds and occurs every five minutes. You may have some tingling sensations or slight pain in your neck during episodes of nerve stimulation.

You are given a hand-held magnetic device so that you can control the stimulation yourself at home. This enables you to temporarily turn off the vagus nerve stimulation, which may be necessary when you engage in such activities as public speaking, singing or exercising, or when you're eating if you have swallowing problems.



You must visit your doctor periodically to make sure that the pulse generator is working correctly and that it hasn't shifted out of position.



Maintenance of the Device

The device comes with a programming wand and software, which are used to program the device or turn it off if necessary. You will eventually need surgery to replace the generator when the battery wears out. How quickly the battery wears out depends upon its settings, but on the average it lasts about six years. Replacement of the generator is generally an outpatient procedure under local anesthetic that takes about one hour to complete.



What can you expect?

Vagus Nerve Stimulation hasn't been on the market that long, so long-term studies aren't available. That's why it's extremely important to discuss the pros and cons of VNS Therapy with your psychiatrist and other doctors. As mentioned earlier, the FDA advises that VNS be used only along with traditional depression treatments such as antidepressants and psychotherapy.



It may take several weeks to months before a VNS patient notices improvement in their depression symptoms. And since VNS didn't perform any better than a placebo in clinical trials, it's possible a patient won't experience any improvement at all. In fact, the FDA advises that, in some cases, depression could worsen with VNS therapy. The most common adverse effect (side-effects) associated with VNS is voice alteration or hoarseness, throat pain and cough. Dyspnea and paresthesia are also reported side-effects of Vagus Nerve Stimulation. Vagal nerve stimulation has not been reported to cause cognitive impairment.



One Happy Customer

One news report cites Lauri Sandoval, 42, a participant in the pilot study, who has tried almost every antidepressant available and was set to start electroconvulsive therapy: "I was so desperate and depressed that I wasn't even scared of it, even though it hadn't been studied before."



Lauri had suffered from depression for 30 years and was having trouble holding down a job. It took her three months after receiving the implant to feel the change, and 18 months later, she reported feeling dramatically better: "I used to be a hermit and I tried to pretend that I wasn't depressed. I would stay in bed as long as I could. I would get up to go to work, or to walk my dogs, but after a while that would even be difficult."



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