I go through this almost every time I see a new patient. I often hear that this is all they really wanted, “To know what my options are and that I’m not choosing something way out there.”
First off, most treatments for psychiatric brain illnesses are not done with intention to cure, but rather to restore health and increase quality of life. Healthy is not the same as disease free.
This applies to all the treatments listed here.
1. Hospitalization:
Inpatient – 24 hour locked unit, voluntary and involuntary, little psychotherapy, and daily physician care.
Partial Hospital – Day Hospital that runs during business hours such as 9AM-3PM, voluntary only, includes intensive psychotherapy, and weekly physician care.
2. Counselling/Psychotherapy:
Talk therapy and exercises of various forms. May be with physician or nonphysician.
3. Stimulation Therapies, such as:
Deep Brain Stimulation (DBS) requires brain surgery to implant an electrical stimulation device in the specific brain area, controlled by a device implanted in the gut. Effective, but higher risk. Least time consuming for maintenance care.
Transcranial Magnetic Stimulation (TMS) – The patient sits in a chair with a magnet at the head’s surface that uses magnetism to stimulate the brain for treatment, 1 hour a day, 5 days a week for various weeks, according to the patient’s need and funding. Few side-effects. Time consuming. Not as effective as DBS or ECT but comparable to some medications.
Electroconvulsive Therapy – Uses electricity to stimulate the brain, inducing a short seizure for treatment. Considered safe and of low risk. Most effective. Response is speedy. Few, and mostly temporary side effects. Does not enter into the body systems. Less time consuming.
4. Medications:
Chemicals for treatment in the form of pills, liquids, injections, patches, powders, vapors, gases – enter into the body systems causing physical side effects that, as with any treatment, must be weighed against the benefits.
Pills – generally taken daily, which is a challenge to treatment compliance, and activate internal conflict and personal stigmas.
Injections – generally done in a clinical setting, bimonthly or monthly.
5. Aerobic exercise 50+ minutes, 5 days a week.
6. Sleep hygiene.
7. Diet
8. The spirit also needs nurturance.
9. Alternatives – such as over the counter herbals, naturalistic supplements, meditation, spiritual, acupuncture, acupressure, massage, or no treatment.
Questions: What do you think of your options? What do you choose? And why? Please tell us your story.
Did I miss anything?
Self-Care Tip: Get informed about your treatment options.
Dear Doc Sana,
As I come to this forum I do so from a different perspective. That is I come as a very, very long-time support person and mental health advocate/activist for my spouse and others.
“Did I miss anything?” Yes, you did but I’ll address that later on.
After these many years and having learned that which I have I would first point out that your sequence of treatment options are, in my opinion, in an inappropriate order when addressing a patient whether new or one who has been through gamut of treatment options.
I think it is incumbent upon the physician to first discuss the least invasive therapeutic treatment options as mentioned by you but in reverse order such as diet, exercise, sufficient sleep, holistic treatments etc. and on to the various modalities of talk therapy.
Then on to medications whether in conjunction with and/or standalone use of any of the aforementioned treatments.
In the event the previous options are proving to be ineffectual I would then consider moving on to the newer neuro-modulation therapies. As rTMS has recently been FDA approved and apparently exhibits little to no side-effects, as a support person, I would opt for this therapy as it too is least invasive. A major drawback to this therapy is the fact that health insurance coverage for this treatment option is spotty at best and the patient and/or his/her support person should check with the physician whether or not health insurance coverage is available. The initial therapy regimen can run $10,000 to $15,000 out-of-pocket.
What you have omitted to mention and that which I’ll address now is VNS (Vagus Nerve Stimulation) for depression. It is one of the newest neuro-modulation therapies for depression that was FDA approved in 2005 long before rTMS. While the results for my spouse, utilizing VNS, have been nothing short of remarkable it does not work for everyone. But then again what I’ve learned and what many patients come to learn there is no way of knowing in advance who will or will not be a responder to any given treatment and also retain efficacy. I coined a phrase some 50 years ago which is still applicable today, “The Trial and Error Approach to Wellness.” This fact may slowly be changing through research and some of the work of Dr. Helen Mayberg:
Deep Brain Stimulation & Depression: A Decade of Progress with Helen S. Mayberg, M.D.
https://www.youtube.com/watch?v=1MkVk0HnG5A
VNS also has the inherent fact that it requires invasive surgery and potential side-effects from infection etc. A pulse generator is implanted in the abdominal cavity and a lead wire running from the pulse generator to the electrodes wrapped around the left vagal nerve. Some patients respond quickly, as did my spouse, while others may have taken as much as one year. There are other potential side-effects but I’ll leave that up to you and your readers to investigate. Lastly, while the FDA approved the therapy for depression CMS (Centers for Medicare and Medicaid Services) declined reimbursement and in turn the private health insurance carriers followed suit. Therefore anyone seeking this therapy after May 4, 2007 has to pay out-of-pocket. The cost can be upwards of $50,000 to $70,000.
I’ll also point out there are other therapies you’ve not addressed such tDCS (Transcranial Direct Current Stimulation), nVNS (non-invasive Vagus Nerve Stimulation) and several others.
DBS (Deep Brain Stimulation) is somewhat similar to VNS in that a pulse generator is implanted in the abdominal cavity and not the gut (alimentary canal) as you had previously indicated. Only in this case the lead wires affixed to electrodes are inserted into the brain. Potential side-effects are infection, stroke etc. This therapy is still being researched and therefore can only be obtained as a study subject at this time. It has not as of yet been submitted to the FDA for approval of the depression indication.
Then there is ECT which I’ll have to somewhat disagree with your presentation. I’ll also point out when discussing ECT the various treatment applications such as RUL, bi-frontal and bilateral are extremely important from my viewpoint which you did not address. I would leave ECT lower down the list of treatment options unless suicidal ideations were prevalent and overwhelming patient thoughts. After many years Dr. Harold Sackeim finally acknowledged what many patients had experienced and shared with others. That is memory and cognitive side-effects are a potential serious issue:
http://www.nature.com/npp/journal/v32/n1/pdf/1301180a.pdf
Again, who will or will not respond to this treatment is an unknown.
There is also cingulotomy as a treatment option and another permanent option which I do not normally discuss or encourage.
Lastly, I would like to discuss the definition of the word “cure”; “transitive verb to bring an end to an illness, disorder, or injury by medical treatment.”
When one looks up the definition of the word “cure” you’ll note there is no time frame mentioned as my brother was astute to point out to me some time ago. Therefore an individual could be cured for a week, month, year or permentally. I think when discussing serious mood disorders it is more appropriate to discuss in terms of control and/or remission of the illness.
While my spouse has been depression free for almost 14 years I avoid using the term cured knowing how her illness could bite us in the backside if we’re not vigilant, observant and cautious.
Sincerely,
Herb
http://www.vnstherapy-herb.blogspot.com
http://www.vnstherapy.wordpress.com
Good inclusions herb. Yes thanks. Keep on
Long walks, stimulating conversation, fruits and vegetables, hot baths. Pythagoras 2.700 years ago.
Ooo! Yes. I’m en rout to the walk. :). Keep on
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