What Is Non-Medication Depression Treatment?

-Is treating depression with medication a thing of the past?

      Non-medication depression treatment is an attempt to use unconventional means to treat the symptoms of depression. The first line of treatment for depression is normally a combination of anti-depressant drugs and psychological counseling. The use of anti-depressant drugs is often times ineffective (1) for people with depression especially for those that are suffering from mild to moderate depression (2). The risk of side effects from medication versus the results often drive people to pursue alternative forms of treatment because they carry less risk of experiencing these side effects, as well as because the use of traditional medication treatment for depression proved ineffective. There are many different alternative treatment options for people suffering with symptoms of depression, a change in habits (exercise, sleep, diet), psychological counseling, herbal supplements, and the use of medical devices (Trans-cranial magnetic stimulation, Electroconvulsive therapy).

The Shortcomings of Anti-Depressants

     Anti-depressant are the most commonly used form of treatment for depression but they have a number of short comings. Including, side effects, lack of remission, lack of efficacy, and delayed onset of action. The side effects of anti-depressant drugs for some are not tolerable and patients will discontinue their use. Only about 30% to 40% of people that take anti-depressant drugs to treat their depression achieve full remission from symptoms. This means that more than half of people that pursue that form of treatment have a partial response or no response to that treatment. These drugs do not begin to produce measurable effects until the patient has been taking them for 10 days to 3 weeks. During this time their symptoms are essentially going untreated and they are at greater risk of suicide, hospitalization, and psychological impairment.

Side Effects

The 4 commonly prescribed classes of antidepressant drugs are selective serotonin reuptake inhibitors (SSRIs), atypical antidepressants, tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs).

SSRIs common side effects-  nausea, insomnia, dizziness, weight gain, tremors, sweating, anxiety, decreased sex drive, drowsiness, dry mouth, diarrhea, and headaches.

Atypical antidepressant’s common side effects- nausea, blurred vision, weight gain, sleepiness, nervousness, dry mouth, and fatigue.

TCAs common side effects-  blurred vision, dry mouth, constipation, weight gain, low blood pressure, rash, hives, and increased heart rate. TCAs also have withdrawal symptoms when their use is abruptly discontinued.

MAOIs common side effects- dizziness, insomnia, weight gain, headaches, sexual dysfunction, and drowsiness. MAOIs also have very serious interactions with certain foods, drinks, and other drugs which can lead to extremely high blood pressure.

Side effects are a common reason that people discontinue use of anti-depressant drugs. The amount of discomfort that is experienced when taking these drugs is the number one reason for non-compliance. In a study conducted in 1994, 32% of patients within the study discontinued the use of anti-depressants within 6 weeks due to the severity of the side effects.(3)

Treatment Resistant Depression

       In some cases the use of traditional anti-depressants to treat depression is found to not adequately alleviate symptoms or fails to work entirely. When a primary care doctor finds a patient to be unaffected by the first course of medication they will often either increase the dose or add another medication which is known as combination therapy. When a patient is found to have not responded to 2 or more courses of medication then their depression is known as Treatment resistant depression (TRD). TRD is actually quite common. Only about 49% of all people treated with anti-depressant drugs achieve full remission. Meaning that nearly half of all people that seek treatment for depression are either only partially effected or entirely unaffected by the most common form of treatment for depression.

      There are a number of different options outside of medication for patients with TRD. Electroconvulsive therapy (ECT) is a treatment that uses electrically induced seizures to treat depression. In cases of people that have TRD it is found to be about 50% effective but approximately half of those people have depressive episodes within the next year.(4) ECT is an informed consent procedure and has many debated adverse effects. Its most common side effects are memory loss and confusion. Vagus nerve stimulation (VNS) is the use of an implant to deliver electrical impulses to the Vagus nerve. Due to the fact that it is an implant it is an invasive procedure. In addition to that research on VNS’s efficacy in treating TRD is limited. It is FDA approved for that purpose but in the only randomized controlled trial conducted the implant failed to outperform the control in treating TRD.(5) Trans cranial magnetic stimulation (TMS) is a procedure that uses magnetic fields to generate electric current in regions of the brain. The process was approved by the FDA in 2008 for the treatment of depression.

Transcranial Magnetic Stimulation Results in Treatment Resistant Depression

The FDA approved Transcranial magnetic stimulation (TMS) as a procedure for treating treatment resistant depression (TRD) in 2008. This treatment was approved as long it was for someone that had been unaffected by at least one traditional anti-depressant medication. There are over 35 randomized controlled clinical trials that support the fact that TMS is an effective treatment for depression. Most studies concluded that the rate and magnitude of effect that TMS has on patients is comparable to that of anti-depressant medication, despite the fact that all participants in the studies were resistant to said medications. Some of the evidence that supports TMS as efficacious in cases of TRD was conducted by the NIMH in 2010. What was found was that 14% of those treated with TMS achieved remission within the 6 week initial treatment and 30% achieved complete remission who took part in the open ended treatments that started after the clinical trial ended. In a large sample (307 participants) longitudinal study conducted by brown university researchers collected data about patients that had received TMS for TRD. What they found at the end of a year was that 68% of participants symptoms improved and that 45% experienced complete remission.(6)

What the Medical Community is Saying

There have been more than 60 randomized controlled studies on the effect that TMS has on depression since its FDA approval in 2008. The results of these studies have produced mixed views on the efficacy of TMS in treating depression. At least 35 of these studies suggest that stimulation of the left dorsolateral prefrontal cortex with TMS will cause a decrease in symptoms of depression at a rate that is comparable to current medications.(7) This also does not take into account the fact that the people in these studies had treatment resistant depression. However, many studies also do not find a statistically significant variation between the placebo procedure and the actual one. In cases where patients have an extremely high resistance to treatment and a long history of treatment for depression this is even more pronounced. In two studies conducted on the efficacy of TMS as an add on to conventional medication treatment for depression found that there was not a significant improvement in mood compared to those who did not receive TMS. The most commonly stated issues with most of this research on TMS is that the studies had small sample sizes and that test blinding was inaccurate. Meaning that the number of participants may be too few to obtain accurate results. (8) In the largest study (199 participants) that was conducted on TMS’s effect on depression it was concluded that its positive effects on the symptoms of depression were statistically significant. (9) It seems that the jury is still out on TMS and that more research must be conducted to solidify it as the answer to treatment resistant depression.

What’s Coming Next for TMS

TMS is a relatively new procedure for the treatment of depression unlike Electroconvulsive therapy. we do not have nearly 100 years of clinical trials and real world application to gauge its effectiveness. But because of TMS’s status as a FDA approved treatment for depression the data that is needed to prove or disprove its efficacy is quickly being generated. As it becomes a more common treatment for depression the issue of having to small sample sizes in trials will cease to be a problem. Due to the nature of TMS the area of the brain that it affects is highly focused. With more research it is hoped that the area that is most effective for treating different kinds of neurological conditions will be identified. With a more focused application of electrical stimulation to areas that are directly responsible for mood it is believed that TMS can be made more effective for those that are suffering from depression. The goal for TMS is that it will be a viable alternative to a lifetime of taking medication which has a low rate of effectiveness and considerable side effects.

Will TMS Work For You?

Medication and psychological counseling are the first line of treatment for most people suffering from depression. Many times this treatment does not work whether it is due to failure of the drug to produce positive results or because the side effects of the drugs are intolerable to the patient. When a patient has exhausted that course of treatment then TMS would be an option they could pursue. Current evidence points to the fact that people who are less resistant to traditional treatment of depression do have better results than those who are more resistant. This does not mean that those people should not attempt a course of treatment. Although not conclusive some trials of patients receiving TMS while also taking anti-depressant drugs concurrently experienced lessened results. In addition, patients that did not have bipolar or psychotic tendencies had better results. People who have any kind of non-removable metal (excluding dental devices) in their head, neck or face should not pursue TMS. This is because the electromagnets used in the treatment could cause these objects to move or heat up potentially causing serious injury. Those who have a history of seizures should not pursue treatment because the treatment could exacerbate that condition.