212 CHAPTER 6
Brain Stimulation
Not all patients with depression are helped by medication or by other com-
monly employed treatments, such as cognitive-behavior therapy (CBT). Elec-
troconvulsive therapy (ECT; see Chapter 4) may be used when a patient’s
symptoms are severe and he or she (1) cannot take medication because of side
effects or other medical reasons, (2) has a psychotic depression (depression
with psychotic features) that does not respond to medication (Fink, 2001), or
(3) has severe depression that has not improved signifi cantly with either medi-
cation or psychotherapy (Lam et al., 1999). Unfortunately, some people receiv-
ing ECT suffer memory loss for events that occurred during a brief period of
time before the procedure (Kho, VanVreeswijk, & Murre, 2006).
ECT for depression is usually administered 2 to 3 times a week over sev-
eral weeks, for a total of 6 to 12 sessions (Shapira et al., 1998; Vieweg &
Shawcross,1998). Depressive symptoms lessen a few weeks after the treat-
ment begins, although scientists don’t yet understand exactly how ECT pro-
vides relief (Pagnin et al., 2004).
Unfortunately, depressed patients who hadn’t responded to antidepres-
sants commonly relapse after receiving ECT: At least half of these patients
experience another episode of depression over the following 2 years (Gagne et
al., 2000; Sackheim et al., 2001). To minimize the risk of a relapse, patients
usually begin taking antidepressant medication after ECT ends. Some research
suggests that relapse may be best prevented by beginning antidepressant med-
icationduringthe course of ECT—rather than afterward—and by continuing
ECT at a maintenance level (weekly sessions tapering to monthly sessions) for
several months after the standard course of treatment is completed (Gagne
et al., 2000).
Some patients with depression might benefit from transcranial magnetic
stimulation (TMS; see Chapter 4), which involves sending high-intensity mag-
netic pulses through the brain. In some encouraging studies, about half of the de-
pressed patients who did not improve with medication were treated successfully
enough with TMS that they did not have to receive ECT (Epstein et al., 1998;
Figiel et al., 1998; Klein et al., 1999). TMS is easier to administer and causes
fewer side effects than ECT. However, unlike ECT, researchers have yet to estab-
lish defi nitive guidelines for TMS that govern critical features of the treatment,
such as the positioning of the coils that deliver magnetic pulses and how often
the treatment should be administered (Holtzheimer & Avery, 2005). In 2008, the
Federal Drug Administration approved TMS as a treatment for depression to be
used after medication treatments have failed.Targeting Psychological Factors
Biomedical treatments are not the only ones available for depression. A variety
of treatments are designed to alter psychological factors—changing the patient’s
behaviors, thoughts, and feelings.Behavioral Methods
Behavioral methods focus on identifying depressive behaviors and then changing
them. For instance, being socially isolated and avoiding daily activities can lead
to depressive thoughts and feelings or can help maintain them (Emmelkamp,
1994). Changing these depressive behaviors can, in turn, increase the opportu-
nities to receive positive reinforcement (Lewinsohn, 1974). Specifi c techniques
to change depressive behaviors, collectively referred to as behavioral activation
(Gortner et al., 1998), include self-monitoring, scheduling daily activities that
lead to pleasure or a sense of mastery, and identifying and decreasing avoidant
behaviors. Behavioral activation may also include problem solving—identifying
obstacles that interfere with achieving a goal and then developing solutions toEighty percent of all ECT treatment is given for
depression (Sackheim et al., 1995).Will & Deni McIntyre/Photo Researchers