Table 1:
Neuromodulation Treatments for Major Depression
| Treatment | Primary Advantages | Primary Disadvantages | Comments |
|---|---|---|---|
| Food and Drug Administration Approved Treatments | |||
| Electroconvulsive Therapy (ECT) | Excellent database in geriatric treatment resistant depression (TRD), continuation and maintenance treatment. ECT is the "gold standard" for the treatment of the most severely ill patients including patients with psychotic depression. | Potential for cognitive and cardiac side effects; significant costs to providing an appropriate medical setting for ECT; the social stigma related to the treatment | ECT techniques continue to evolve. For example, ultrabrief right unilateral ECT has been shown to limit the cognitive side effects of ECT while maintaining efficacy in depression. |
| Transcranial Magnetic Stimulation (TMS) | No discernable cognitive or cardiac side effects; good data in the elderly to maintain efficacy with specific treatment modifications (e.g., increasing the intensity and number of pulses) | 6 weeks of daily treatments may present practical problems; Insurance coverage often limits modifications to the TMS protocol. | TMS technique will need to be refined (increased intensity and/or pulses) to be effective in the most treatment resistant geriatric patients. |
| Vagus Nerve Stimulation (VNS) | Evidence that VNS is an effective long-term treatment for chronic depression with no apparent cognitive or cardiac side effects; evidence that VNS may be effective in patients who have failed a trial of ECT. | Surgical procedure and efficacy may take months to become apparent; insurance coverage is difficult to obtain; limited data in the elderly | Centers for Medicare and Medicaid Services (CMS) will cover VNS when provided under the CMS-approved Coverage Evidenced Development plan. |
| Investigational Treatments | |||
| Magnetic Seizure Therapy (MST) | More focal stimulation than ECT that may provide the efficacy of ECT with fewer cognitive side effects | Involves anesthesia and the medical setting for ECT; limited data particularly in the elderly | More focal brain stimulation may provide a therapeutic effect without significant cognitive side effects |
| Focal Electrically Administered Seizure Therapy (FEAST) | More focal stimulation and the potential to decrease cognitive side effects with similar efficacy to ECT | Involves anesthesia and medical setting for ECT; limited data in the elderly | This is a similar approach to MST |
| Transcutaneous Vagal Nerve Stimulation (tVNS) | Noninvasive form of VNS which has been shown to be safe and well tolerated | Limited data in the elderly and TRD | This approach may have the advantages of VNS with a less invasive procedure |
| Transcranial Direct Current Stimulation (tDCS) | Preliminary data supports tDCS in the treatment of depression; safe, low cost and easy accessibility | Limited data in the elderly and TRD | Has a number of potential advantages for the elderly if shown to be effective |
| Deep Brain Stimulation (DBS) | Published data shows that TRD patients, even patients who have not responded to ECT, respond to DBS. | Invasive surgical procedure; may take months to show response. | Data in Parkinson's disease may be useful in determining safety in geriatric TRD patients |