Several new electroconvulsive therapy treatments, while still unproven, are available to patients with mental illness, including veterans.
Too many Americans are seriously depressed, and the mental health profession has been looking for better cures.
Among all Americans, suicide rates have been increasing steadily by 2 percent a year, reaching 30-year highs, according to the Centers for Disease Control and Prevention (CDC). Post 9-11 veterans especially have suffered enormously from depression, post-traumatic stress disorder (PTSD), traumatic brain injury, and anxiety.
Many people have heard of electroconvulsive therapy treatment (ECT), or “shock” therapy. Among the new cures on offer are a number based on electrical gadgets, some applying electricity to the brain in milder doses than ECT. For instance, at the Collateral Damage Project, which aims to provide a four-week on site program in the foothills of the Blue Ridge Mountains in Forest, Va., veterans may receive cranial electrotherapy stimulation (CES), and transcranial direct current stimulation (tDCS), alongside training in neurofeedback as well as brain wave entrainment — all influenced by input from “LoRETA Brain Mapping.” To veterans accustomed to high-tech military equipment, this approach may be attractive or at least not scary.
How much is known about these electroconvulsive therapy treatments? Let’s start with CES: pulses of low-intensity current applied to the earlobes or scalp. The Fisher Wallace Stimulator, which costs $699, can be used at home, and the manufacturer claims that a number of studies demonstrate the safety and effectiveness of the device. When the prestigious Cochrane group reviewed the evidence in 2014, however, researchers found no high quality clinical trials comparing CES against sham CES in people with acute depression. So any benefit could be attributed to the placebo effect. The Food and Drug Administration (FDA) considered holding CES devices to a tougher standard — but received enough comment that it decided to classify them as “moderate to high risk” – meaning that doctors could use them at their discretion. In November 2015, results appeared from a double-blind, sham controlled study backing CES for patients with bipolar disorder — but it involved only seven patients who reported feeling better up to a month later.
With tDCS, patients receive a continuous low current to a particular part of the brain via electrodes on the scalp. The treatment is not FDA-approved, and considered experimental. Its effectiveness remains “unclear,” according to a 2013 review of the data. A 2015 study found that it basically didn’t do anything of relevance to the brain. That fits nicely with the idea that the procedure can sometimes succeed because of a placebo effect — people feel better because they’re hopeful.
Neurofeedback, when you receive real-time feedback on your brain responses, has helped some people, according to an exhaustive review, but remains unproven, expensive, and time-consuming. The benefits may take months to set in and tend not to last.
Brain wave entrainment involves wearing earphones and goggles that stimulate different kinds of brain waves through sound and light. You’ll feel like you’re watching a light show with moody music. A research review found three studies of its effect on mood, none of which reported any benefits.
What about that claim to tailor treatment through brain mapping? There does seem to be early evidence that brain scans can guide treatment on exactly one point — which depressed patients are more likely to benefit from Lexapro and which from cognitive behavioral therapy over three months.
The Veterans Administration reports that the most effective treatment for PTSD is cognitive behavioral therapy, which is also recommended by the American Psychological Association for depression. The electrical devices may be attracting attention because they could be cheaper and faster ECT, which in effect induces mild seizures, does provide short-term relief for many severely depressed people. However, according to a 2013 study in Nature, as many as half of people who respond to ECT relapse by the end of the first year. If you’re severely depressed, the hope of being in the half who continue to feel better is not a small thing. Getting milder currents or flashes of light and sound could also induce hope, for the same reason the Wizard of Oz made Emerald City look green: It’s different. (In the first book by author Frank Baum, the Wizard requires everyone to wear green-tinted glasses.)
August 30, 2017
Christopher Nystuen, MD, MBA