Vagus Nerve Stimulation

[Ouchterlony]

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I wonder if anyone has any thoughts on the FDA-approved Cyberonics VNS treatment modality for depression? Will psychiatrists in future be able to bill for the procedure of monitoring/ checking/ modifying the VNS voltage? How will this work? Will this be a referral to a neurosurgeon for implantation and then to a neurologist for maintenance?
Thoughts?
Ouchterlony

 

[yeti00]

I've read some very sparse literature on it for treatment of refractory epilepsy, but I can't seem to find anything on it--in a peer-reviewed journal anyway--for the treatment of depression.

I'm generally pretty skeptical of "experimental" psych treatments...

😕

 

[PublicHealth]

I've read some very sparse literature on it for treatment of refractory epilepsy, but I can't seem to find anything on it--in a peer-reviewed journal anyway--for the treatment of depression.

I'm generally pretty skeptical of "experimental" psych treatments...

😕

Most of psychiatry (and medicine for that matter) is experimental. Not all patients respond similarly to the same drug(s), psychotherapy is sometimes more effective than drugs and vice versa, certain therapeutic cocktails/combinations work better than others, doses vary, etc. That's why it's called practicing medicine.

Don't forget that medicine (yes, this includes psychiatry) is continuously evolving, with new "experimental" treatments, including vagal nerve stim, transcranial magnetic stim, etc., being evaluated all the time. Regardless of what types of therapies are available, there's always the possibility that better therapies are possible, even if peer-reviewed literature does not yet support them. Just ask this guy about his work on angiogenesis: http://www.pbs.org/wgbh/nova/cancer/folkman.html

 

[yeti00]

PublicHealth,

No doubt that medicine is a field that is always evolving, in fact, someday I hope to advance the knowledge that we have about psychiatry by research. But, there is a distinction between advancing the field and descending into quackery. Respected scientists have been known to do both. I appreciate that you mention Dr. Folkman's "war," it is a story that I am familiar with. But we also cannot forget the two Nobel prizes in psychiatry were given for (1) Malaria fever therapy and (2) frontal lobotomy. Since the pathophysiology of mental disorders is still largely uncertain or unproved, it is dangerous to subscribe to treatments that have an uncertain effect on the brain and body.

The past "experimental" treatments of psychiatry litter our history, some of which did more harm than good. What about insulin coma? Hystorectomy? Hydrotherapy? ECT is a rare example of something that we have developed that works and that we can administer without side effects for specific disorders (now, not necessarily the past). In psychiatry, we often jump headlong into treatment about which we know little (with a mixed bag as a result).

That's why I said that I was open to reading literature about vagal nerve stimulation, but with the disclaimer that I was "skeptical" and my header a ?

 

[PublicHealth]

PublicHealth,

No doubt that medicine is a field that is always evolving, in fact, someday I hope to advance the knowledge that we have about psychiatry by research. But, there is a distinction between advancing the field and descending into quackery. Respected scientists have been known to do both. I appreciate that you mention Dr. Folkman's "war," it is a story that I am familiar with. But we also cannot forget the two Nobel prizes in psychiatry were given for (1) Malaria fever therapy and (2) frontal lobotomy. Since the pathophysiology of mental disorders is still largely uncertain or unproved, it is dangerous to subscribe to treatments that have an uncertain effect on the brain and body.

The past "experimental" treatments of psychiatry litter our history, some of which did more harm than good. What about insulin coma? Hystorectomy? Hydrotherapy? ECT is a rare example of something that we have developed that works and that we can administer without side effects for specific disorders (now, not necessarily the past). In psychiatry, we often jump headlong into treatment about which we know little (with a mixed bag as a result).

That's why I said that I was open to reading literature about vagal nerve stimulation, but with the disclaimer that I was "skeptical" and my header a ?

Science can be viewed as a dialectic between the 'Mad Scientist' and the 'Concerned Clinician.' The Mad Scientist is the anarchist of the pair, often engaging in unruly experimentation that may border on quackery, and that often distracts him from more pragmatic activities. The Concerned Clinician is the fascist of the pair, often trying to extract an organized thesis from the Mad Scientist in the hope of determining its merits and ability to withstand scientific scrutiny for it is the Concerned Clinician who seeks standardization, formalization, and external validation. Alternating between these positions is a perpetual, tug-of-war-type process that ultimately yields useful, safe, and effective, and sometimes dangerous and ineffective medical and psychiatric therapies. Historically, psychiatry has been more affected by this pushing and pulling, probably because psychiatric illnesses are endlessly complex, and likely a product of some dizzying combination of somatogenic, neurogenic, and psychogenic factors.

In other words, if medicine is to survive and evolve, we will need both the Mad Scientist and Concerned Clinician. Most new ideas, irrespective of how revolutionary or farcical they may eventually become, are initially met with skepticism, doubt, and occassionally even ridicule. Sure, some forms of quackery have and will continue to emerge, and yes, maybe even some will enter into mainstream practice. But let's say that some therapy that has not withstood scientific scrutiny helps someone, just one patient, would it not be worth it?

P.S. Nobel prizes are not awarded in psychiatry.

 

[yeti00]

P.S. Nobel prizes are not awarded in psychiatry.

P.S. They are in Physiology or Medicine

Julius Wagner-Jaregg, 1927 prize "for his discovery of the therapeutic value of malaria inoculation in the treatment of dementia paralytica"

Egas Moniz, 1949 prize "for his discovery of the therapeutic value of leucotomy in certain psychoses"

 

[yeti00]

But let's say that some therapy that has not withstood scientific scrutiny helps someone, just one patient, would it not be worth it?

PublicHealth,

You miss the entire point of both my posts. Step back and look at the big picture.

I hope we can have both researchers and clinicians in psychiatry who advance the field and help as many patients as possible. But "helping patients" isn't a license for sloppy science... that, by and large, harms all patients in the end. That's why I gave the examples of previous psychiatry treatments.

The ideal is to try therapies in a research setting with rational methods that inform clinical practice. Each therapy comes with it's own set of risks and benefits, and baseless enthusiasm can ignore the risks while touting the benefits. Any good scientist--clinician or researcher--is trained to be skeptical. And as a doctor and a psychiatrist, you have to be a little bit "mad scientist" and "concerned clinician" in order to be the best to your patients as possible; critical thinking is a hallmark of medicine.

Again, I'm open to experimental therapies and treatments, but I need more than just claims to back them up.

 

[PublicHealth]

But we also cannot forget the two Nobel prizes in psychiatry were given for (1) Malaria fever therapy and (2) frontal lobotomy. Since the pathophysiology of mental disorders is still largely uncertain or unproved, it is dangerous to subscribe to treatments that have an uncertain effect on the brain and body.

"Moniz had an idea that some forms of mental illness were caused by an abnormal sort of stickiness in nerve cells, causing neural impulses to get stuck and the patient to repeatedly experience the same pathological ideas. There was no empiric evidence for his theory, but Moniz pressed on."

Source:
http://www.pbs.org/wgbh/aso/databank/entries/dh35lo.html

Following the story above, some may even say that Moniz himself was a 'Mad Scientist.'

 

[yeti00]

Yup, he was a mad scientist, and lead psychiatry down a road that hurt a lot of patients and their families.

'In the words of Jeffrey Schwartz, a research psychiatrist at UCLA:

"We as a profession had one generation of humility after the era of lobotomy, but it's gone. We're now back to a point where the elite of our society believe that the most sophisticated way to treat mental illness is with drugs, magnetic fields, a knife or radiation beam."'

http://www.psychosurgery.org/

 

[PublicHealth]

Again, I'm open to experimental therapies and treatments, but I need more than just claims to back them up.

While you wait for results of randomized, double-blind clinical trials to appear in the New England Journal of Medicine, rest assured that thousands of peoples' lives are being improved each day by quacks such as neurofeedback practitioners, EMDR specialists, chiropractors, and traditional osteopaths. Who knows why it works. Most of medicine is placebo effect anyway.

 

[PublicHealth]

Yup, he was a mad scientist, and lead psychiatry down a road that hurt a lot of patients and their families.

'In the words of Jeffrey Schwartz, a research psychiatrist at UCLA:

"We as a profession had one generation of humility after the era of lobotomy, but it's gone. We're now back to a point where the elite of our society believe that the most sophisticated way to treat mental illness is with drugs, magnetic fields, a knife or radiation beam."'

http://www.psychosurgery.org/

With the financial backing of pharmaceutical companies ("elite of our society"), psychiatrists now use psychoactive drugs to "lobotomize" patients from the inside. Oh, and "the elite" also suggest using a knife to treat mental illness, quite a step away from psychosurgery.

Educate yourself:
http://www.iop.kcl.ac.uk/iopweb/departments/home/default.aspx?locator=528

 

[PublicHealth]

I've read some very sparse literature on it for treatment of refractory epilepsy, but I can't seem to find anything on it--in a peer-reviewed journal anyway--for the treatment of depression.

I'm generally pretty skeptical of "experimental" psych treatments...

😕

While they're not ALL "peer-reviewed" journal, I found over 280 articles on vagal nerve stimulation and depression. Here's a sample:

CNS Spectr. 2003 Jul;8(7):515-21.

Beyond the treatment of epilepsy: new applications of vagus nerve stimulation in psychiatry.

Kosel M, Schlaepfer TE.

Department of Psychiatry, University Hospital, Bern, Switzerland.

Vagus nerve stimulation (VNS) in humans generally refers to stimulation of the left vagus nerve at the cervical level VNS is an established treatment largely devoid of severe side effect for medically refractory partial onset seizures and has been used in more than 16,000 patients. Over the past 5 years, applications in other neuropsychiatric disorders have been investigated with a special emphasis on depression. Recent data from an open-label, multi-center pilot study involving 60 patients suggest a potential clinical usefulness in the acute and maintenance treatment of drug-resistant depressive disorder. The perspective of VNS as along-term treatment with the advantage of assured compliance makes it an interesting technique to potentially treat drug-resistant depression. However, definite therapeutic effects of clinical significance remain to be confirmed in large placebo-controlled trial. Results of clinical pilot studies involving patients suffering from obesity and Alzheimer's disease indicate that VNS might induce weight loss and improve cognition. Besides its clinical usefulness, VNS can be used as a research tool, allowing neurophysiologic investigations of the parasympathetic system and its interactions with other parts of the central nervous system.
Emerging targets for the treatment of depressive disorder.



J Psychosom Res. 2003 May;54(5):475-82.

The effects of vagus nerve stimulation on sleep EEG in depression: a preliminary report.

Armitage R, Husain M, Hoffmann R, Rush AJ.

Department of Psychiatry, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9070, USA. [email protected]

OBJECTIVE: The present study evaluated the effects of vagus nerve stimulation (VNS) on sleep in seven treatment-resistant depressed outpatients. METHODS: Sleep studies were conducted in the laboratory at baseline and 10-12 weeks after VNS implantation while the concomitant psychotropic medication regimen was unchanged. Standard sleep macroarchitecture based on visual stage and assessment of ultradian sleep electroencephalographic (EEG) rhythms were measured on all nights. RESULTS: An overall significant treatment effect on sleep macroarchitecture was obtained by MANOVA. Decreased awake time, decreased Stage 1 sleep and increased Stage 2 sleep were evident post-VNS, although univariate analyses did not reach significance. In addition, the strength or amplitude of ultradian sleep EEG rhythms more than doubled on VNS and was restored to within normal range. CONCLUSION: VNS improved the clinical symptoms of depression and sleep architecture. Results suggest that treatment-resistant depressed patients have dampened sleep EEG rhythms that are restored to near-normal amplitudes with VNS treatment.

 

[PublicHealth]

Neurosurg Clin N Am. 2003 Apr;14(2):275-82.

Cervical vagus nerve stimulation for treatment-resistant depression.

Carpenter LL, Friehs GM, Price LH.

Department of Psychiatry, Brown University Medical School, Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906, USA. [email protected]

Therapeutic brain stimulation through left cervical VNS now has established safety and efficacy as a long-term adjunct treatment for medication-resistant epilepsy. There is considerable evidence from both animal and human studies that the vagus nerve carries afferent signals to limbic and higher cortical brain regions, providing a rationale for its possible role in the treatment of psychiatric disorders. Open-label studies in patients with treatment-resistant depression have produced promising results, especially when response rates at longer term (1 year and 2 years) follow-up time points are considered. Short-term (10 weeks) treatment with VNS failed to demonstrate statistical superiority over sham treatment in a recently completed double-blind study, so antidepressant efficacy has not yet been established. Longer term data on VNS in depressed patients as well as further information regarding the possible dose-response relation will help to determine the place of VNS in the armament of therapeutic modalities available for major depression.



Macritchie KA, Young AH.

Department of Psychiatry, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK. [email protected]

New agents offering novel mechanisms of action are required in the treatment of depressive disorder. Established agents targeting monoamine systems are unsatisfactory because of full and partial treatment resistance, delay in the onset of their effect and the occurrence of side effects. The monoamine hypothesis of depression is now recognised to provide an incomplete explanation of the pathophysiology of depression. New theories have recently developed and new targets for treatment have emerged. We briefly review some important candidate systems and therapeutic targets in depression: the hypothalamic-pituitary-adrenal axis (HPA) and the glucocorticoid and corticotrophin-releasing factor receptors, synaptic plasticity and neurotrophins and the N-methyl-D-aspartate (NMDA) receptor. The putative role of the neuropeptides substance P and neuropeptide Y, the nicotinic system and the potential therapeutic benefits of cannabinoids are also reviewed. Vagal nerve stimulation (VNS) and transcranial magnetic stimulation, serendipitous advances in treatment, are discussed briefly.



Crit Rev Neurobiol. 1999;13(4):317-56.

A noradrenergic and serotonergic hypothesis of the linkage between epilepsy and affective disorders.

Jobe PC, Dailey JW, Wernicke JF.

Department of Biomedical and Therapeutic Sciences, University of Illinois College of Medicine-Peoria, 61656, USA.

Noradrenergic and/or serotonergic deficits, as well as other abnormalities, may contribute to predisposition to some epilepsies and depressions. Evidence for this hypothesis stems from several sources. Epidemiological investigations are intriguing but incomplete. Pharmacological studies show that noradrenergic and/or serotonergic transmission are both anticonvulsant and antidepressant. Therapeutically pertinent investigations show that antidepressant drugs have anticonvulsant properties, whereas antiepileptic drugs are effective in the management of affective disorders. Additional investigations demonstrate that seizures, whether spontaneously occurring or therapeutically induced, protect against depression. Through studies of innate pathophysiology, noradrenergic and serotonergic deficits have been identified in individuals with depression and in animal models of epilepsy, as well as in some humans with epilepsy. Vagal nerve stimulation, a treatment already known to be effective in the epilepsies, is presently under investigation for effectiveness in affective disorder. New evidence suggests that vagal nerve stimulation exerts at least some of its therapeutic effects through its capacity to increase noradrenergic and serotonergic transmission. Finally, emerging evidence supports the concept that some genetic mammalian models of the human epilepsies exhibit analogous manifestations of depression.

 

[yeti00]

now was that so hard?

I wasn't being facetious when I said I was interested in learning more.