Somatic Treatments Flashcards
Bright Light Therapy
Indication: Depression (after a failed medication trial); OCD; Migraine HAs
Procedure: Five days per week, 30-40min per session for four weeks, then 3 for a week, 2 for a week, then one final treatment in the third week following. Maintenance reported at 1-2 treatments per month. Three forms: deep TMS, “express” TMS (uses intermittent theta burst stimulation (iTBS) to reduce TMS session to three minutes), and repetitive TMS (rTMS; most common)
Pre-TMS Workup: None required; standard physical examination. Benzodiazepines and anticonvulsant discontinuation resulted in improved outcomes.
Mechanism: Production of a magnetic field that modulates the activity of the neurons in the cortical brain regions targeted by the coil. High-frequency TMS increases cortical activity (used in the left dorsolateral prefrontal cortex, thought to be underactive in depression). Low-frequency TMS inhibits cortical activity (used in the right dorsolateral prefrontal cortex).
Advantages: Response rate of 60% (after treatment and at 12-months; no need for anesthesia; does not need MD staff to supervise administration.
Contraindicated Patients: Increased risk of seizure; implanted metallic hardware (i.e., pacemakers, cochlear implants; aneurism clips); patients who cannot commit to the 6-8 week treatment course.
ADEs: Scalp discomfort (like a “woodpecker”) (esp. high-frequency TMS); SERIOUS: seizures, hearing loss.
Off-Label: Post-stroke depression; Parkinson’s Disease; Alzheimer’s Disease; PTSD; Chronic Pain
Electroconvulsive Therapy (ECT)
Indication: Severe depression; Catatonia
Procedure: Done under anesthesia; Electric stimulus through temporal area to induce seizure (bilateral; right unilateral; or bifrontal leads); seizures last 30-60s; Treatments given 3x/week; response seen after 1-2 weeks; average number of treatments is 7-10; Maintenance weekly for a month, then monthly for at least six months (relapse is common without maintenance treatments); may require anticholinergic to reduce secretions and a beta-blocker to reduce tachycardia
Pre-ECT Workup: No absolute contraindications; Standard physical; no specific labs; Lithium should be lowered to minimize cognitive effects; Benzodiazepines and anticonvulsants should be held the night before the procedure to not inhibit the seizure.
Mechanism: Unknown effect generalized seizures have on depression; thought to be by increasing monoamine neurotransmission.
Advantages: High remission rate (70-90%); Can be administered during pregnancy; Elderly have an improved response rate.
ADEs: Acute confusion directly after the treatment (for about half an hour); memory loss during the treatment phase); tension headaches; nausea; jaw pain; SERIOUS: anesthesia complications; long-term memory loss (reduces with unilateral lead placement, but lowers efficacy rate)
Off-Label: Psychotic Depression; Severe Schizophrenia; Suicidality; Neuroleptic Malignant Syndrome
Transcranial Magnetic Stimulation (TMS)
Indication: Depression (after a failed medication trial); OCD; Migraine HAs
Procedure: Five days per week, 30-40min per session for four weeks, then 3 for a week, 2 for a week, then one final treatment in the third week following. Maintenance reported at 1-2 treatments per month. Three forms: deep TMS, “express” TMS (uses intermittent theta burst stimulation (iTBS) to reduce TMS session to three minutes), and repetitive TMS (rTMS; most common) – patients should do one hour of activity before session
Pre-TMS Workup: None required; standard physical examination. Benzodiazepines and anticonvulsant discontinuation resulted in improved outcomes.
Mechanism: Production of a magnetic field that modulates the activity of the neurons in the cortical brain regions targeted by the coil. High-frequency TMS increases cortical activity (used in the left dorsolateral prefrontal cortex, thought to be underactive in depression). Low-frequency TMS inhibits cortical activity (used in the right dorsolateral prefrontal cortex).
Advantages: Response rate of 60% (after treatment and at 12-months; no need for anesthesia; does not need MD staff to supervise administration.
Contraindicated Patients: Increased risk of seizure; implanted metallic hardware (i.e., pacemakers, cochlear implants; aneurism clips); patients who cannot commit to the 6-8 week treatment course.
ADEs: Scalp discomfort (like a “woodpecker”) (esp. high-frequency TMS); SERIOUS: seizures, hearing loss.
Off-Label: Post-stroke depression; Parkinson’s Disease; Alzheimer’s Disease; PTSD; Chronic Pain
