If you have not responded successfully to one or more conventional talk therapies or medication options, our experts – upon a careful and comprehensive evaluation — may prescribe one of the following treatments:
- Deep Transcranial Magnetic Stimulation (TMS). This is a noninvasive method of treatment that uses pulsating magnetic fields that go unobstructed through the skin and skull to harmlessly target the prefrontal cortex of the brain, where mood is supposed to be regulated (but in TRD patients it is not). This is done to stimulate these nerve cells in the brain to help improve mood regulation and lessen symptoms of depression. TMS is an outpatient, office-based treatment method that involves one 20 to 30-minute session every weekday or so for a total of 30 to 36 sessions during the course of five to six weeks. You can drive yourself to and from each treatment without any disruption to your daily activity. Side effects are minimal and most people experience improvement after four to six weeks of treatment.
- Ketamine Intra Nasal Therapy (KINT). Used mostly as an anesthetic or analgesic (pain reliever) by anesthesiologists, at lower doses, ketamine (also known as esketamine when given in nasal spray form) has been shown to rapidly and effectively reduce and relieve symptoms of treatment resistant depression that may or may not be accompanied by anxiety. This outpatient office-based treatment method has two phases: an induction phase (the amount of time required for your body to acclimate to ketamine in it) and a maintenance phase. During the first phase, ketamine is administered in the office intranasally twice weekly for four weeks (weeks 1 to 4) for a total of eight treatments. At the end of week four, the individual is evaluated to determine the need for continued treatment in the maintenance phase. During the maintenance phase, ketamine is continued once weekly for four more weeks (weeks 5 to 8. Then, from week 9 onwards it is given every 2 weeks or continued once weekly. The dose frequency is individualized to the lowest frequency needed to maintain the best response to this therapy. Each treatment is monitored in our office for 120 minutes. The most common side effects include dissociation, dizziness, nausea, sedation and blood pressure elevation. Most of these side effects are short lived and resolve during the 120 minutes observation period.
- Vagal Nerve Stimulation (VNS). A pacemaker-like stimulator is placed by a surgeon under the skin of the chest wall under the left clavicle (collarbone) and programmed by our psychiatrist to send mild electrical signals along the left vagus nerve in the neck to the brainstem, and from here to certain areas of the brain that affect mood symptoms and can relieve symptoms of depression. VNS is not a rapid treatment for depression. While it may take several months for a treatment response to occur, whenever it's necessary, we can change the settings on the device (essentially changing the dose of the stimulation) in the office with a programming wand. Usually, the device is set to go off at regular intervals and one can also turn it off using a special magnet. Possible side effects from VNS include temporary hoarseness, cough, or shortness of breath, however such side effects usually only occur during the 30 seconds that the stimulator is on. Like any operation, the implantation procedure poses some risks, including infection, and as with pacemakers, eventually, one will need surgery to replace the battery when it wears out (7 to 8 years).
- Electroconvulsive Therapy (ECT). The most effective treatment for depression, ECT can also be used to treat catatonia and other forms of mental illness, particularly when symptoms have not responded to other treatments. ECT can be given to hospitalized patients or on an outpatient basis. Most people will need 6 to 12 treatments, which are initially given 2 to 3 times a week, but the exact number will be individualized based on the person's needs and response. Some people benefit from additional maintenance treatments to keep symptoms from returning. Before beginning ECT, a person will be evaluated carefully to see if ECT is likely to be helpful and to fit the treatment approach to their medical and psychiatric needs. As part of this evaluation, the Stony Brook ECT Service team, led by Laura Fochtmann, MD, will ask for information from the mental health professional who is currently providing treatment. During each ECT treatment, an ECT nurse will prepare the patient for the treatment. Next, an anesthesiologist gives an anesthetic medication and a muscle relaxing medication. Once the patient is asleep, the psychiatrist gives a very brief electrical stimulation through electrodes placed on the patient’s head. This creates a short seizure, which produces the beneficial effects of ECT. As with any procedure that involves anesthesia, there is a very rare risk of breathing or heart problems. Consequently, the patient’s heart rate, blood pressure, and oxygenation are monitored closely throughout the treatment, which takes 5-10 minutes. Additional monitoring takes place for about an hour, until the patient is ready to leave the recovery area. Many people will experience confusion, problems with concentration, or temporary gaps in memory around the time of the treatment. These usually resolve within two weeks of stopping ECT, but less commonly, memory gaps can persist or affect memories that are further in the past. Other side effects include headache, nausea, or muscle aches, which are temporary and can be treated with medications. Our ECT team encourages patients and families to ask, at any point, if they have questions about side effects or other aspects of the ECT treatment.
Emerging Therapies
We're excited about our plans to incorporate these emerging therapies into our program in the near future.
- Psilocybin – This naturally forming compound in mildly potent psychedelic mushrooms recently earned the distinction of "Breatkthrough Therapy" designation for major depressive disorder by the Food and Drug Administration (FDA). Psilocybin offers the potential for significant improvements over existing therapies for severe depression and anxiety. It has been shown to produce noticeable changes in a person's consciousness that can contribute to long-term remission of depressive symptoms. (source: https://www.healtheuropa.eu/clinical-trials-fda-marks-psilocybin-for-depression-treatment/95377/ )
- Yoga / Hot Yoga – Yoga, and specifically Bikram, or hot yoga has been shown to positively contribute to a person’s sense of optimism, quality of life, and cognitive function by helping to reduce the neuroendocrine stress response in the brain. Depending on a person’s individual situation, we recommend it as an adjunct to other treatments for severe or treatment resistant depression. Our referral program to yoga studios offering Bikram is currently on hold due to COVID-19.