Different types of therapy exist for severe depression

Dear Dr. Roach: I am an ex-medical/surgical nurse. I have a daughter-in-law who was treated for depression with magnetic therapy. My psychiatric exposure in the 1950s was with electroshock therapy and insulin shock therapy. Can you explain how the new magnetic therapy works for depression, compared with the other two treatments?

P.S. Is electroshock therapy still being used?

N.P. Electroconvulsive therapy (ECT) is still used for treatment of drug-resistant severe depression. However, despite decades of use, the exact mechanism of how it works is not understood. ECT does increase neurotransmitters such as dopamine, serotonin and norepinephrine (as do some medications). ECT also releases hormones such as prolactin, thyroid-stimulating hormone and endogenous endorphins, and it has anti-seizure properties as well.

A newer theory is that ECT increases the ability of the body to respond to brain atrophy that is often caused by long-standing depression. I have hardly ever seen it used. Of nearly a million people treated for depression in a 2014 study, only 1/4 of 1% were treated with ECT. Still, I have seen remarkable success with this treatment, which works far faster than medication. Meanwhile, insulin shock therapy was first tried in the 1930s, but was discredited in the 1960s.

Transcranial magnetic stimulation (TMS) is a new treatment that has been shown to be relatively safe. The major serious side-effect is seizures, although these are uncommon. It might also cause headache and temporary hearing loss.

Unfortunately, I can’t tell you exactly how TMS works, either. The strong magnetic field of the TMS machine (very similar to an MRI machine) rapidly alternates, generating electrical currents in the brain — both on the surface of the brain and the deep brain in some cases. TMS is in some ways similar to ECT.

TMS and ECT are appropriate to consider if medications are ineffective or can’t be used and when psychotherapy (the other mainstay of depression treatment) can’t be accessed. Unfortunately, this is a common problem.

Dear Dr. Roach: I read your recent column about medications for gastroesophageal reflux disease (GERD) in people with Barrett’s. What about surgical procedures, such as the Nissen fundoplication or the LINX procedure? I want to end my GERD symptoms and stop taking daily meds. D.C.

Surgical treatments in people with Barrett’s esophagus are controversial, and the manufacturer of the LINX devices recommends against the device in people with Barrett’s.

People with GERD who have not been treated effectively with medicine, or those with persistent symptoms who don’t want a lifetime of medications, can be considered for surgical therapy. The LINX procedure uses a ring of magnets to keep the sphincter at the bottom of the esophagus closed most of the time, but it opens when food is being swallowed.

The choice of procedure is always made after a careful discussion with a surgeon, including the possibility that meds may still be required.