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CANMAT Depression Guidelines (2016) > Section IV. Neurostimulation Treatment > Flashcards

Section IV. Neurostimulation Treatment Flashcards

1
Q

What are the six types of neural stimulation?

A

Transcranial direct current stimulation
Repetitive transcranial magnetic stimulation
Electroconvulsive therapy
Magnetic seizure therapy
Vagus nerve stimulation
Deep brain stimulation

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2
Q

For neurostimulation, what acute treatments for MDD are first line?

A

rTMS
ECT (in some clinical situations)

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3
Q

For neurostimulation, what acute treatments for MDD are 2nd line?

A

ECT

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4
Q

For neurostimulation, what acute treatments for MDD are 3rd line?

A

tDCS
VNS

** both level 3 evidence

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5
Q

For neurostimulation, what acute treatments for MDD are 3rd line?

A

tDCS
VNS

** both level 3 evidence

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6
Q

What level evidence is there for rTMS for maintenance therapy for MDD?

A

Level 3

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7
Q

What level evidence is there for ECT for maintenance therapy for MDD?

A

Level 1

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8
Q

For tDCS, what are the two types of stimulation?

A

Anodal stimulation [increases cortical excitability through depolarization]

Cathodal stimulation [decreases cortical excitability through hyperpolarization

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9
Q

What is the target for tDCS?

A

NMDA receptor

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10
Q

Location of tDCS stimulation?

A

Over left dorsal lateral prefrontal cortex

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11
Q

frequency of tDCS treatment?

A

30 minutes per day for two weeks to see antidepressant effect

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12
Q

advantages of tDCS [5]

A
  1. easy to use
  2. Low-cost
  3. Portability/could use at home
  4. Combine with other treatments
  5. Low potential for adverse side effects`
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13
Q

Side effects of tDCS?

A
  • redness of skin at site
  • itching / burning
  • tingling
  • H/A
  • blurred vision
  • ringing in ears
  • illuminated vision
  • mild euphoria
  • reduced concentration
  • insomnia
  • anxiety
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14
Q

What is the overall recommendation for transcranial direct current stimulation [tDCS]?

A

3rd line treatment for MDD, level 2 evidence for acute efficacy with inconsistent results if good for monotherapy or combo therapy

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15
Q

what are the overall recommendations for rTMS?

A

1st line for patients who have failed at least 1 antidepressant (** rTMS often added to a pre-existing antidepressant regime)
Level 1 acute efficacy
Level 3 evidence for maintenance
Level 1 for safety and tolerability

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16
Q

what is rTMS?

A

Magnetic fields
Electrical currents into neural tissue
Noninvasive
Inductor coil on scalp (placed with MRI guidance)
No anesthesia

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17
Q

Frequency of rTMS?

A

Five days per week, however, three times weekly is also effective but with slower improvement

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18
Q

how many sessions to maximize effect of rTMS?

A

26-28

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19
Q

how many sessions are required to declare treatment failure of rTMS?

A

20 sessions

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20
Q

What is the intensity, frequency, and site for rTMS?

A

Stimulate at 110 to 120% of resting motor threshold [70 to 80% for theta-burst stimulation]

Level 1 evidence

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21
Q

how do you determine stimulus intensity for rTMS?

A

Stimulus intensity is based on each patient resting motor threshold [RMT] which is the minimum intensity needed to elicit muscle twitches at relaxed upper or lower extremities by visual inspection or electromyography [EMG]

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22
Q

what is the most common intensity for rTMS?

A

110% RMT, however, other trials have used 120% RMT

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23
Q

what is defined as high frequency for rTMS?

A

High frequency is 5 to 20 Hz which is excitatory

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24
Q

what is defined as low frequency for rTMS?

A

Currency is one to 5 Hz which is inhibitory

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25
Q

what is theta burst stimulation [TBS]?

A

Delivered at lower intensity [70 to 80% of motor threshold]
One to three minutes of stimulation

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26
Q

how effective is our team SS antidepressant therapy for MDD?

A
  • 1st line treatment for MDD
  • Often prescribed in those with TR MDD
  • Good efficacy found with high frequency left DLPFC
  • Good efficacy found with low frequency right DLPFC
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27
Q

True/ False – Bilateral stimulation has shown superiority over unilateral

A

FALSE

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28
Q

Without maintenance therapy, what is the percent chance relapse at 6 months?

A

77% relapse at 6 mos

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29
Q

Which is more effective for patients with MDD with psychosis? ECT or rTMS

A

ECT

30
Q

Adverse side effects associated with rTMS:

A

Scalp pain
Transient headaches

31
Q

Are there absolute contraindications for rTMS? If so, what are they?

A
  1. Cannot use HIGH-frequency rTMS w seizure history
    ** seizure induction is very low with rTMS (0.01 to 0.1%)
  2. Patient cannot have metallic hardware anywhere in their head [cochlear implant, brain stimulator, aneurism clips]
32
Q

What are the relative contraindications of rTMS?

A
  1. Cardiac pacemaker
  2. Implantable defibrillator
  3. History of epilepsy
  4. Presence of brain lesion [vascular, traumatic, neoplastic, infectious, or metabolic]
33
Q

What are the clinical indications for ECT [9]?

A
  1. Acute SI
  2. Psychotic features
  3. TR depression
  4. Repeated medication intolerance
  5. Catatonic features
  6. Prior favourable responses to ECT
  7. Rapidly deteriorating physical status
  8. During pregnancy
  9. Patient preference
34
Q

What are the relative contraindications [7]?

A
  1. Space occupying cerebral lesion
  2. Increased intracranial pressure
  3. Recent MRI
  4. Recent three roll hemorrhage
  5. Unstable vascular aneurysm
  6. Pheochromocytoma
  7. Class 4 or 5 anaesthesia risk
35
Q

Why is ECT 2nd line treatment for MDD?

A

Because of adverse side effects

36
Q

What is the MOA for ECT?

A

unknown - but might increase brain derived neurotrophic factor

37
Q

what are the 4 options for electrode placement?

A

Bilateral
Bitemporal
Bifrontal
Right Unilateral

38
Q

What electrode placement is recommended as first line for treatment using ECT for MDD?

A

Bifrontal
Right Unilateral

39
Q

Why is bitemporal electrode placement 2nd line?

A

Because of higher rates of short term cognitive adverse effects

40
Q

What is the treatment session and frequency for ECT?

A

Between six and 15 sessions deliver 2 to 3 times per week

41
Q

What is the max number of treatments recommended per week?

A

3

42
Q

What is the response rate for ECT as an acute treatment for MDD?

A

70 to 80%

43
Q

is the strongest predictor of non-response to ECT?

A

Resistance to previous treatments

44
Q

which demographics present entire response rates to ECT?

A

Older patients
Patients with psychotic features
Patients with shorter depression episode duration
Patients with less depression severity

45
Q

When are relapse rates following acute course of ECT highest?

A

Relapse rates highest 6 months post ECT

46
Q

By how much do medications reduce relapse in conjunction with maintenance ECT?

A

Medications reduce relapse rates by almost half

47
Q

With regard to medications in conjunction with maintenance ECT, what antidepressant should you try?

A

No evidence to support a specific antidepressant
Recommended to use antidepressant that has not been tried before ECT
Consider nortriptyline plus lithium
Consider venlafaxine plus lithium

48
Q

what is a common schedule for maintenance ECT?

A

Weekly x4 weeks
Then bi-weekly x8 weeks
Then q. monthly

49
Q

What is the mortality rate with ECT?

A

Less than one death per 73,440 treatments

50
Q

what types of cognitive impairment are most commonly reported with ECT?

A

Transient disorientation [partially due to post active confusion and effects of general anesthesia]
Retrograde amnesia
Anterograde amnesia

51
Q

what is retrograde amnesia?

A

Retrograde amnesia - difficulty recalling information learned before ECT, such as autobiographical memories

52
Q

what is anterograde amnesia?

A

Difficulty in retaining learn information after ECT

53
Q

What electrode placement leads to worsened cognitive impairment post-ECT?

A

Bitemporal

54
Q

What electrode placement leads to the least cognitive impairment post-ECT?

A

Ultra Brief Pulse RUL

55
Q

What is cognitive impairment with ECT high correlated with?

A

persistent depressive symptoms

56
Q

What are the risks of using Li+ with ECT?

A

May increase cognitive SEs, encephalopathy, and spontaneous seizures

57
Q

What are the risks of using benzos and/ or anticonvulsants with ECT?

A

May raise seizure threshold and decrease seizure efficacy

58
Q

Which anticonvulsant might be least problematic with ECT

A

lamotrigine

59
Q

Describe magnetic seizure therapy (MST)

A
  • noninvasive
  • induces an electromagnetic field in the brain to elicit generalized tonic clonic seizures
60
Q

Where is the MST coil placed?

A

at the vertex, directly onto the skull

61
Q

What is the general frequency of stimulation for MST?

A

100 Hz

62
Q

What is the duration of MST stimulation?

A

10 sec

63
Q

What level evidence is there for MST to replace ECT?

A

level 3

64
Q

Describe vagus nerve stimulation (VNS)

A
  • neurostimulation device originally approved for Tx of drug resistent epilepsy
  • implantable pulse generator underneath skin
  • electrode placed in vagus nerve
65
Q

Stimulation of the vagus nerve stimulates:

A

nucleus tractus solitarius

66
Q

What is VNS used to treat?

A

chronic depression
recurrent depressoin
Adults who have MDD who have failed 4+ adequate antidepressant trials

67
Q

What is the overall recommendation for VNS in MDD?

A

3rd line acute tx with level 3 evidence

68
Q

Adverse effects of VNS?

A

voice alteration
dysnpea
pain
increased cough

69
Q

Describe DBS

A
  • invasive neurosurgical procedure with an internal electrode that is connected to an IPG implanted in the chest below right clavicle
70
Q

Indications for DBS?

A
  • movement disorders (Parkinson’s)
  • “difficult to treat” psychiatric disorders
  • TR depression
71
Q

Adverse effects of DBS?

A
  • risks from surgical implantation (IC hemorrhage, wound infection)
  • psychosis
  • hypomania
  • blurred vision
  • stabismus

CANMAT Depression Guidelines (2016) (9 decks)

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