23. Somatic Therapies

Question 1

Describe: Modern Electroconvulsive Therapy (1)

Answer 1

• induction of a generalized seizure using an electrical pulse through scalp electrodes while the patient is under general anesthesia with a muscle relaxant

Question 2

Name considerations for Electroconvulsive Therapy (4)

Answer 2

• unilateral vs. bilateral electrode placement
• pulse rate
• energy
• number, and spacing of treatments

Question 3

Name indications for Electroconvulsive Therapy (6)

Answer 3

• depression: poor response to antidepressant (unipolar, bipolar I, bipolar II), psychotic features, catatonic features, when medications may be unsafe or rapid response is needed (i.e. cachexia, severe dehydration, frail elderly, high suicide risk)
• catatonia: refractory, severe, or life-threatening
• schizophrenia: acute symptoms with poor response to antipsychotics, catatonia, history of NMS
• mania: refractory, severe or life-threatening situation
• personal or family history of good response to ECT
• inconclusive evidence for OCD

Question 4

Name adverse effects for Electroconvulsive Therapy (4)

Answer 4

• risk of anesthesia (equal to risk of ECT)
• memory loss (may be retrograde and/or anterograde, tends to resolve by 6-9 mo, permanent impairment controversial)
• headaches
• myalgias

Question 5

Between unilateral and bilateral, which causes less memory loss?

Answer 5

Unilateral ECT causes less memory loss than bilateral but may not be as effective

Question 6

Name contraindications of ECT (5)

Answer 6

• no absolute contraindications
• relative contraindications:
  
  • increased intracranial pressure
  • recent (<4 wk) hemorrhagic stroke
  • recent (<2 wk) MI
  • requires special monitoring

Question 7

Describe: Repetitive Transcranial Magnetic Stimulation (rTMS) (1)

Answer 7

noninvasive production of focal electrical currents in select brain circuits using magnetic induction

Question 8

Describe: Repetitive Transcranial Magnetic Stimulation (rTMS) (1)

Question 9

Name indications: Repetitive Transcranial Magnetic Stimulation (rTMS) (3)

Answer 9

• strong evidence for treatment-resistant depression
• pain disorders
• possibly efficacious for anxiety disorders, eating disorders, substance use disorders

Question 10

Name adverse effects: Repetitive Transcranial Magnetic Stimulation (rTMS) (6)

Answer 10

• common
  
  • transient local discomfort
  • hearing issues
  • ccognitive changes
• rare
  
  • seizure
  • syncope
  • mania induction

Question 11

Describe: Magnetic Seizure Therapy (Experimental) (2)

Answer 11

• generalized seizure induction using strong magnetic current
• early studies demonstrate efficacy for depression as well as anxiety, with reduced memory effects vs. ECT

Question 12

Name: Neurosurgical Treatments (3)

Answer 12

• Ablative/Lesion Procedures
• Deep Brain Stimulation (Experimental)
• Vagus Nerve Stimulation

Question 13

Describe: Ablative/Lesion Procedures (2)

Answer 13

• used for MDD or OCD unresponsive to all other forms of treatment; efficacy ranges from 25-75% depending on procedure
• adverse effects: related to lesion location and size, high risk of suicide in those who are not helped by surgery

Question 14

Describe: Deep Brain Stimulation (Experimental) (2)

Answer 14

• placement of small electrode leads in specific brain areas to alter neuronal signaling, usually for MDD unresponsive to all other forms of treatment
• response rates (>50% symptom reduction) of 40-70%, adverse effects related to surgical risks and poor treatment response

Question 15

Describe: Vagus Nerve Stimulation (2)

Answer 15

• direct, intermittent electrical stimulation of left cervical vagus nerve via implanted pulse generator
• used for chronic, recurrent MDD with poor response to previous therapy and ECT; slow onset, approximately 30% response rate after 1 yr

Question 16

Describe: Phototherapy (Light Box Therapy) (2)

Answer 16

• bright light source exposure (usually 10,000 lux) for 30-60 min; best if done daily in the morning
• proposed mechanisms: reverses pathological alterations in circadian rhythm through action on suprachiasmatic nucleus

Question 17

Name indications: Phototherapy (Light Box Therapy) (3)

Answer 17

• seasonal affective disorder (SAD)
• non-seasonal depression (as augmentation)
• some sleep disorders

Question 18

Name adverse effects: Phototherapy (Light Box Therapy) (2)

Answer 18

• mania induction
• reaction with photosensitizing drug or photosensitive eye or skin conditions

Question 19

Describe: Aerobic Exercise as therapy (3)

Answer 19

• moderate-intense aerobic exercise is associated with acute increased release of serotonin, phenethylamine, brain-derived neurotrophic factor, endogenous opioids, and cannabinoids (likely this combination is what contributes to the “runner’s high”)
• long term increases grey matter in multiple areas, as well as improvements in cognition, memory, and stress tolerance
• may be helpful in PTSD, schizophrenia

Question 20

Name indications: Aerobic Exercise as therapy (3)

Answer 20

• monotherapy for mild-moderate MDD
• adjunctive therapy for moderate-severe MDD
• research suggests 30 min of supervised moderate-intensity exercise at least 3 times weekly for a minimum of 9 wk is as effective as psychotherapy or antidepressant medications