Vagus nerve stimulation is a treatment for depression and seizure disorders that involves the electrical stimulation of the vagus nerve. For vagus nerve stimulation, a generator, wires and electrodes are implanted to deliver electricity to the vagus nerve at predetermined intervals.

In July 2005, vagus nerve stimulation (sometimes called vagal nerve stimulation) was approved by the FDA for the treatment of depression in treatment-resistant patients. To meet the criteria for vagus nerve stimulation therapy (VNS therapy), a patient must:

• Be age 18 or older
• Have treatment-resistant depression
• Have chronic depression that has lasted two or more years
• Have depression that hasn't improved after the use of at least four or more antidepressants or ECT or both

Vagus nerve stimulation (VNS) doesn't guarantee an improvement in depression symptoms. The FDA advises vagus nerve stimulation must be used in addition to traditional depression treatments such as antidepressants.

Does Vagus Nerve Stimulation for Depression Work?

FDA approval was given to VNS therapy based on two studies: one pilot 10-week study with 60 participants and one sham or placebo-controlled 10-week study with 235 participants. In both VNS studies, patients were being treated for severe, refractory depression.¹

• In the pilot study approximately 30.5% of patients responded to treatment and 15.3% remitted
• In the larger study, 15.2% of patients responded to treatment while 10% of patients responded to sham (placebo) treatment
• Patients in both studies were followed and at one year after device activation, positive response rates were approximately 43% in both study groups

FDA approval of VNS continues to be controversial with some professionals indicating the study on which approval was based was flawed.

Vagus Nerve Stimulator Implantation

Surgery to implant the VNS device may be done on an inpatient or outpatient basis. Surgery is typically done under a general anesthetic. A VNS electrical pulse generator (battery-powered) is surgically implanted under the skin in the chest and wires connected to it are guided up and wrapped around the left vagus nerve.

Vagus Nerve Stimulation Side Effects

Side effects for vagus nerve stimulation can come from the implantation surgery, the vagus nerve stimulation itself, or both. Vagus nerve stimulator implantation and VNS therapy are both considered safe but complications can occur. VNS surgery side effects include:

• Pain / scarring at the incision sites
• Infection
• Damage to the vagus nerve
• Breathing problems
• Nausea
• Heart problems
• Vocal cord paralysis, which is usually temporary

VNS therapy side effects tend to occur only when the pulse generator is actually stimulating the vagus nerve. VNS therapy side effects include:

• Voice changes (in over half the people who have the procedure)
• Hoarseness; cough
• Throat or neck pain
• Chest pain or spasms
• Breathing problems, especially during exercise
• Difficulty swallowing
• Tingling or prickling of the skin

VNS Implant Costs

One of the major downsides of vagus nerve stimulation therapy is the cost of implantation and treatment. Not only are there costs to having the VNS device implanted but there are additional costs as the device must be monitored and programmed regularly by a doctor.

The cost of implanting a VNS device is approximately $30,000 and up. Medicaid does not pay for VNS² although some healthcare insurance companies will pay for it on a case-by-case basis.³

More details about vagus nerve stimulation, implantation, costs, insurance coverage and obtaining treatment can be found through the Cyberonics web site: http://depression.cyberonics.com/depression/main.asp

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Deep brain stimulation for depression is a treatment involving the stimulation of neurons through the use of an implanted generator and electrodes. Deep brain stimulation is currently FDA approved for the treatment of:

• Essential tremor (a degenerative neurological disorder)
• Parkinson's disease
• Dystonia (a neurological movement disorder)

Deep brain stimulation for depression and other disorders is currently in clinical trials. For depression, deep brain stimulation uses electricity to stimulate the part of the brain that controls mood.

Deep Brain Stimulation for Depression Procedure

Deep brain stimulation requires the implantation of electrodes in the brain as well as the implantation of an electrical generator in the chest. This involves a two-part surgery.¹

In the first part of the deep brain stimulation implantation procedure, the electrodes are placed in the brain. This is done through two small holes that are drilled into the skull. The patient is awake during the surgery but feels no pain due to the administration of a local anesthetic and because the brain itself has no pain receptors. The patient's responses help guide the electrode placement along with neuroimaging techniques.

In the second part of the surgery, the patient is under general anesthesia; the deep brain stimulator is implanted and the electrodes are connected to it by wires known as leads.The deep brain stimulator is known as a pulse generator and is implanted into the chest. The pulse generator must be surgically replaced when the battery runs out, about every 6-18 months.

Once the deep brain stimulation surgery is complete, the pulse generator is turned on about one week later. Stimulation of the brain is generally constant once the device is turned on.

Deep Brain Stimulation for Depression Side Effects

As implanting a deep brain stimulation device involves two surgeries – including one in the brain – deep brain stimulation can be risky. There are known complications both from the surgery, as well as from the deep brain stimulation itself. Side effects of deep brain stimulation implantation include:

• Bleeding in the brain (hemorrhage)
• Stroke
• Infection
• Speech problems
• Breathing problems
• Nausea
• Heart problems
• Incision scarring

After surgery, deep brain stimulation side effects include:

• Seizure
• Infection
• Unwanted mood changes, such as mania and depression
• Insomnia
• Allergic reaction to the implant
• Slight paralysis
• Jolting or shocking sensation
• Temporary pain and swelling at the implantation site

Cost of Deep Brain Stimulation for Depression

As deep brain stimulation for treatment of depression is not approved, at this time it is only available through clinical trials. When deep brain stimulation is used for other disorders, it can cost up to $150,000 or more.²

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Transcranial magnetic stimulation (TMS) is a noninvasive therapy that uses a rapidly changing magnetic field to stimulate the neurons in the brain. Repetitive transcranial magnetic stimulation (rTMS) refers to the repetitive use of TMS in the treatment of neurological and psychiatric disorders. Repetitive transcranial magnetic stimulation has been tested in the treatment of:¹

• Depression
• Migraines
• Strokes
• Parkinson's disease
• Dystonia
• Tinnitus
• Auditory hallucinations

While rTMS is approved for the treatment of depression in the United States, some doctors are unsure of its efficacy. However, a well-designed placebo-controlled study sponsored by NIH (National Institute of Health) did show remission in 14.1% of depressed patients given rTMS while only 5.1% of those remitted were given inactive (placebo) treatment. This response rate was seen over three weeks of daily weekday treatment (15 treatments total).²

Transcranial Magnetic Stimulation Therapy Procedure

The rTMS therapy procedure is outpatient and doesn't require anesthetic. Patients are awake and have a plastic-encased magnetic coil placed just above the scalp. There may be a tingling or tapping sensation in the scalp during the rTMS procedure. Ear plugs may be worn due to the noise of the magnetic stimulation device. Headaches can occur during and after an rTMS treatment but are generally treated with over-the-counter medication.

The rTMS therapy treatments are about 40 minutes long and a full treatment course is at least 20-30 treatments long over 2-3 weeks.³

Cost of rTMS and Maintenance rTMS

Repetitive transcranial magnetic stimulation therapy costs vary, but an initial course of rTMS may cost $5000 - $7500 or more.

Depending on the severity of the depression, the therapeutic effect may last only a few months. Once symptoms of depression begin to return, additional rTMS called maintenance rTMS is required. Maintenance rTMS requires approximately half the treatments of the initial course and may be needed anywhere from a few months to more than two years after the initial treatment depending on the individual's response to treatment. Maintenance antidepressant medication therapy may also be effective.

More information on rTMS for depression or other illnesses can be found at:

• NeuroStar TMS Therapy in the US: http://www.neurostartms.com/Home.aspx
• MindCare Centers in Canada: http://www.mindcarecentres.com/

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Eye movement desensitization and reprocessing (EMDR) is a type of psychotherapy that focuses on reprocessing the events of a past trauma such as childhood sexual abuse or a serious accident. Past trauma may be related to depression, so some believe EMDR for depression may be effective.

People who have experienced prolonged stress might also find relief using EMDR for their depression. EMDR has been found effective for treatment of long-lasting stress that may be causing depression.This stress may result from such things as growing up with alcoholism or in poverty, or living with mental illness in the family.

EMDR therapy combines multiple techniques from other therapies like:

• Cognitive
• Psychodynamic (talk therapy)
• Interpersonal
• Experiential

EMDR adds physical stimulation to these techniques, typically the movement of the eyes, although other movements can also be used.

How Does EMDR for Depression Work?

EMDR uses a clearly-outlined multi-phased approach involving:

• Discussion of history / current issues
• Creating trust and a safe space
• Focus on the traumatic memory including eye movement and sensation awareness (processing)
• Support and reevaluation

During the processing phase of EMDR therapy, the patient focuses on the traumatic memory for 15-30 seconds while initiating eye movement. After the 30 second interval, the patient talks about how they felt during the interval. These new feelings become the target of the next 15-30 second interval. This process is then repeated many times.

Francine Shapiro, who developed the technique, has stated it works by changing the neurological and physiological associations with the memory, allowing the memory to be processed. Others, however, believe the eye-movement is non-therapeutic and EMDR is an example of desensitization.

Cost of EMDR for Depression

EMDR is typically used in the treatment of post traumatic stress disorder but some practitioners use EMDR for treatment of depression as well.

The number of sessions required to process a traumatic memory varies from three sessions for simple, single traumatic memories to many more for complex trauma. Cost of EMDR varies but can be around $100 / hour with one-and-a-half hours being a common session time.

More information can be found at the EMDR International Association web site: http://www.emdria.org/

Source:

Wikipedia, Eye Movement Desensitization and Reprocessing: http://en.wikipedia.org/wiki/Eye_movement_desensitization_and_reprocessing

There may by a negative link between some types of antidepressants and marijuana. Antidepressants are generally used to treat depressive disorders and research shows that people with depression tend to use illicit drugs more than the average population. Of those who do use drugs, it's likely many with depression also use marijuana. The key, however, is that most people don't report this use to their doctor, so there is less information on antidepressants and marijuana than for other drug interactions.

There are some case reports though involving weed and antidepressants that show some types of antidepressants are negatively affected by marijuana – sometimes dramatically so. Types of antidepressants include:

• Tricyclic antidepressants (TCAs)
• Monoamine oxidase inhibitors (MAOIs)
• Selective serotonin reuptake inhibitors (SSRIs)
• Other (various)

It's also important to note chronic use of more than small amounts of marijuana acts as a depressant and this depressant effect can reduce the efficacy of antidepressants.

TCA and MAOI Antidepressants and Marijuana

Tricyclic antidepressants and marijuana can be a dangerous combination as both drugs can cause tachycardia – an increased heart rate. Tachycardia can be very serious, possibly fatal, and require emergency, medical attention. Tachycardia has been seen even in those who use marijuana regularly.

Tricyclic antidepressants and marijuana have caused:¹

• Tachycardia severe enough to require intensive care
• Extreme restlessness
• Confusion
• Mood swings
• Hallucinations
• Chest and throat pain

MAOI antidepressants and weed may also have adverse interactions. It appears marijuana affects how MAOIs work in the body but the full effect is not known.

Modern Antidepressants and Marijuana

Weed and modern antidepressants such as SSRIs and SNRIs are thought to interact less frequently and less severely than in TCA or MAOI antidepressants. Weed may increase the antidepressant levels in the blood and possibly increase sedation effects. It's important to note though, a significant study has not been done on modern antidepressant and marijuana interactions.²

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All antidepressants carry the warning not to mix them with other medication without medical consultation, and, specifically, not to mix antidepressants and alcohol at all. You should not drink alcohol with antidepressants like both because alcohol can interact badly with the drug and cause negative side effects, and because alcohol can make depression worse.

Depression and Alcohol

Alcohol is known as a "depressant" drug due to its effect on the body. In addition to reducing inhibitions, increasing talkativeness and slowing reaction times, alcohol can also increase depression symptoms both when drinking and afterward.

Alcohol may negatively affect depression by:¹

• Decreasing quality of sleep (decreasing REM sleep)
• Inducing sedation, anger and depression (as alcohol levels are falling)
• Worsening depression symptoms over time (chronic drinking reduces serotonin function – one suspected cause of depression)
• Creating hangover effects such as nausea and vomiting

Antidepressants and Alcohol

Alcohol can also reduce the effectiveness of antidepressants, making you feel more depressed and possibly making your depression harder to treat. In addition to directly making you feel more depressed, taking antidepressants and alcohol together can:²

• Increase drowsiness, particularly when combined with other medications like sleeping or anti-anxiety drugs
• Cause a dangerous spike in blood pressure when monoamine oxidase inhibitor antidepressants and drinking alcohol are combined
• Make you prone to alcohol abuse as those with depression are known to be at a higher risk of drug abuse and dependence
• Increase antidepressant side effects

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While most people with severe depression will take prescription antidepressants, some people with less severe depression may be able to treat their illness with natural antidepressants. Alternatives to antidepressant drugs include:

• Therapy
• Supplements
• Herbs
• Lifestyle changes

People may also want over-the-counter antidepressants to reduce the cost of depression treatment. Generic antidepressants may also be helpful in efforts to save money.

Therapy – an Alternative to Antidepressants

For those with severe depression, therapy is typically combined with antidepressant medication for the treatment of depression. Therapy, though, can be beneficial in and of itself. Psychotherapy can treat depression symptoms in many of the same ways classic antidepressants can. Therapy can:

• Help deal with stressful life events or situations
• Teach tools to better handle stressful situations that may lead to depression
• Address and change depressive thought patterns
• Supply information about depression
• Address any issues that may be underlying the depression such as past traumas

More comprehensive information about Psychotherapy for Depression.

Natural Antidepressants

There are also natural products some people may use to treat depression. These herbs and supplements can be considered over-the-counter antidepressants. It's important to remember though, just because an antidepressant is natural, doesn't mean it won't interact with other medication. Herbs, supplements and all other natural antidepressants should always be used under the care of a doctor.

Natural antidepressants include:

• St. John's Wort – the most well-known herbal antidepressant. St. John's wort has been used as a treatment for depression in Europe although it is not approved for this use in North America. A recent study showed St. John's wort was no better than a placebo in treating moderate depression¹ but research into mild depression is ongoing.
• SAMe – a synthetic form of a chemical found in the body. A form of SAMe is sometimes used as a prescription antidepressant in Europe.²
• Omega-3 fatty acids – this alternative to antidepressants is found in foods like cold water fish, flaxseed, walnuts and soybeans. While supplements are available, the body absorbs omega-3 more easily when it's in food.

These alternatives to antidepressants are not regulated through the FDA, so efficacy may be inconsistent. Some supplements can interact dangerously with critical medications for illnesses like heart disease and seizures and should always be used under medical supervision.

Natural Antidepressants – Lifestyle Changes

Lifestyle and behavioral changes for treating depression can be very effective. Reduction in stress can often help the symptoms of depression. Lifestyle changes are often useful when combined with therapy or other depression treatments.

Lifestyle changes that may act as a natural antidepressant include:

• Exercise
• Healthy diet
• Yoga
• Meditation / guided imagery
• Acupuncture
• Massage therapy

Generic Antidepressants List

If cost is the major concern when selecting a depression treatment, generic antidepressants are often an option. Generic antidepressants are often a fraction of the cost of brand name antidepressants and may be just as effective. Moreover, generic antidepressants have been prescribed for a longer period of time, so their side effects are well-known and documented.

The following generic antidepressants list shows the generic antidepressant name with its alternative brand name in brackets. A list of available, common generic antidepressants includes:

• Bupropion (Wellbutrin)
• Citalopram (Celexa)
• Fluoxetine (Prozac)
• Fluvoxamine (Luvox)
• Mirtazapine (Remeron)
• Paroxetine (Paxil)
• Phenelzine (Nardil)
• Tranylcypromine (Parnate)
• Trazodone (Desyrel)
• Venlafaxine (Effexor)

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Antidepressant side effects are experienced by almost everyone who takes the medication, at least initially.

Antidepressants are medications that have been used since the 1950s to treat depression and other disorders. These medications alter chemicals in the brain like serotonin, dopamine and norepinephrine.

Often the side effects of antidepressants fade over days or weeks as the body adjusts. Some side effects of depression medication, though, can be ongoing and may require stopping or switching antidepressant medication. No antidepressant should ever be stopped without first talking to the prescribing doctor.

First Generation Antidepressant Side Effects

Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) were the first types of antidepressants developed. These medications affect many systems in the body and are more prone to side effects. Side effects of these antidepressants can also be more severe than those seen in newer SSRI or SNRI antidepressants.

All antidepressant side effects should be reported to the prescribing doctor to ensure the symptoms are not indicators of something more serious.

Common first-generation antidepressants side effects include:¹

• Dry mouth – can be treated by chewing gum, sipping water, sucking candy or with over-the-counter dry mouth medications.
• Fatigue, sedation – may be treatable by altering the antidepressant dose or time medication is taken; also by taking a nap or getting more exercise.
• Insomnia – may be treated by improving sleep hygiene, changing when the antidepressant is taken, exercising, or over-the-counter or prescription sleep aids.
• Headache – over-the-counter non-steroidal anti-inflammatory medications (NSAIDS) like ibuprofen (Motrin) may help.
• Nausea – may be helped by taking the medication with food, eating smaller, more frequent meals and drinking plenty of water; over-the-counter nausea medication is also available.
• Dizziness or light-headedness, especially when arising from a sitting or lying position – rising slowly can help; from the bed, try laying on your side, then sitting up, dangling legs before standing; avoid caffeine, tobacco, and alcohol.
• Weight gain – focus on a healthy lifestyle including diet and exercise may help; you can also consult a dietician.
• Sensitivity to sunlight / heat –by staying out of the sun and wearing sunscreen, full sleeves, long pants, and a hat while outside you can avoid feeling ill or getting a rash.
• Constipation – eating high-fiber foods, drinking more water, getting exercise or taking a fiber supplement can help.

Other side effects of depression medication that may need professional help include:

• Tremor
• Unpleasant taste
• Diarrhea
• Weakness
• Anxiety, nervousness, unusual excitement
• Excessive sweating
• Pounding heart
• Swelling of feet and/or lower legs
• Dark urine
• Fever
• Skin rash

Side Effects of Modern Antidepressants

More commonly, people are now prescribed selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs) or similar antidepressants. These medications are generally considered much safer than TCAs or MAOIs. SSRI and SNRI antidepressants tend to have fewer side effects and are much less likely to cause a fatal overdose.

Modern antidepressant side effects include some of those seen in first-generation drugs. Side effects of newer antidepressants also include:

• Anxiety – may be improved through therapy like cognitive behavioral therapy, exercise, relaxation techniques or treated with medication.
• Sexual dysfunction – may be treated with additional medication or by changing medications.
• Menstrual changes – may require changing antidepressants.
• Blurred vision – may be helped with eye drops.
• Serotonin Syndrome - requires lowering serotonin medication dosage.

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Serotonin syndrome is a potentially lethal condition caused by too much serotonin in the body. The cause of serotonin syndrome is typically a drug combination. When taken alone, each drug may raise serotonin by a small amount, but when taken together a medication cocktail can cause serotonin syndrome. Street drugs, like cocaine, can put a person at high risk for serotonin syndrome.

People are more at risk for serotonin syndrome during medication increases or when a new medication is added. Many drugs can cause serotonin syndrome. Some common drugs include:¹

• Antidepressants
• Pain medication
• Lithium
• Anticonvulsants
• Herbal products
• Over-the-counter medication including cold medication
• Street drugs

Signs and Symptoms of Serotonin Syndrome

Serotonin syndrome symptoms can range from mild to severe depending on the drugs taken and the level of serotonin present. While some signs can be unpleasant, others can require intensive treatment in a hospital.

Signs and symptoms of serotonin syndrome include:

• Agitation or restlessness
• Loss of muscle coordination or twitching muscles
• Rapid heart rate and high blood pressure
• Confusion
• Dilated pupils
• Diarrhea
• Headache
• Heavy sweating
• Shivering, goose bumps

While any sign of serotonin syndrome should prompt an immediate call to a doctor, the following severe symptoms should be treated as a medical emergency:

• High fever
• Seizures
• Irregular heartbeat
• Unconsciousness

Most signs and symptoms of serotonin syndrome go away within 24 hours, but some may last longer depending on how long the medication stays in the body. Some antidepressants can cause serotonin syndrome and take weeks to fully clear from the body.

Serotonin Syndrome Treatment

Immediate treatment for serotonin syndrome includes stopping medication and calling the doctor as soon as the condition is suspected. The doctor can then properly diagnose and determine the appropriate treatment, if necessary.

In minor cases, stopping the drug is all that is required and the serotonin syndrome will abate as the medication leaves the system. In more severe cases you may need to be admitted to the hospital for observation or for specific treatments.

Depending on the serotonin syndrome severity, treatments include:

• IV fluids
• Muscle relaxants
• Serotonin-blocking drugs
• Oxygen or breathing tube
• Heart and blood pressure medication

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When considering treatment with antidepressants, weight gain is a concern for many people. Even though weight gain was more common with older antidepressants like tricyclics and monoamine oxidase inhibitors (MAOI), concerns over selective serotonin reuptake inhibitors (SSRIs)and weight still exist. Some people even refuse antidepressant treatment due to the concern over weight gain.

Weight gain while on antidepressants is common but doesn't happen to everyone and some SSRIs are more likely to cause weight gain than others. About 25% of people gain weight on antidepressants. SSRI weight gain can be 10 pounds or more and may be more common after six months of treatment.¹

Preventing Antidepressants Weight Gain

Weight gain on SSRIs may be one reason a person stops taking their antidepressant medication. Not only can weight gain have negative effects on one's health but it can contribute to a more negative self-image. This lower self-esteem may contribute to feelings of depression.

Sometimes a lifting depression causes weight gain rather than the antidepressant itself. The person starts to feel pleasure from eating again and so they eat more than usual. However, a healthy lifestyle including a balanced diet and exercise can prevent this type of antidepressant weight gain.

SSRIs and weight gain may also be linked by changes in appetite and metabolism, however. This may make it very difficult to maintain, or particularly to lose, weight. If ongoing weight gain while on an SSRI medication is a problem, switching to another antidepressant medication may be the best solution.

Specific Antidepressants and Weight Gain

Some antidepressants are more likely to cause weight gain; here is a list of some antidepressants and information on weight gain.²

• Citalopram (Celexa) and weight gain – studies found less than 1% of people reported weight changes on citalopram (Celexa).
• Desvenlafaxine (Pristiq) and weight gain – this antidepressant is considered very low risk for weight gain.
• Duloxetine (Cymbalta) and weight gain – low risk for weight gain; approximately 2% of patients experienced weight loss in studies.
• Escitalopram (Lexapro) and weight gain – this SSRI antidepressant is considered less likely to cause weight gain with only 1% of patients reporting weight gain as a side effect during trials.
• and weight gain – weight gain is very infrequent with sertraline (Zoloft) treatment.
• Venlafaxine (Effexor, Effexor XR ) and weight gain – thought to have little risk of weight gain; in studies, 2%-5% of study patients found weight loss on venlafaxine (Effexor).

The above are SSRI or SNRI (serotonin norepinephrine reuptake inhibitor) type antidepressants which are known to, in general, have less risk of weight gain. Some antidepressant medications more likely to cause weight gain include:³

• Paroxetine (Paxil) – some doctors consider paroxetine (Paxil) to be the "worst offender" in terms of weight gain in modern antidepressants.¹
• Mirtazapine (Remeron) – weight gain with mirtazapine (Remeron) was noted in 7.5% of adult study patients and much higher in pediatrics.
• Tricyclic and MAOI antidepressants – older antidepressants with a much greater chance of weight gain than typical SSRI or SNRI medications.

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