By Emma Suttle, D.Ac, AP
A lecture called Holistic Treatments in Depression, given by Dr. Heather Luing at the Holistic Lifestyle Expo in June of this year, featured a review of holistic and evidence-based treatments for depression that do not rely on conventional pharmaceuticals.
Dr. Luing is board certified in general forensic psychiatry and addiction medicine and specializes in alternative and cutting-edge depression treatments. She is also co-founder of the Florida Center for TMS.
In her lecture, Dr. Luing discussed a wide range of treatment options for depression and explained that, ultimately, the goal of these new treatments is increased neuroplasticity. Treatments aim to increase the connections of neurons and their pathways in the brain because people with depression have weakened synaptic connections or lower synaptic density. These weakened connections lead to many different symptoms associated with depression—such as poor emotional regulation, negative thinking, anhedonia (the inability to experience pleasure in things that are usually enjoyable), and problems with memory and executive functioning.
What Is Interventional Psychiatry?
Interventional psychiatry is a relatively new branch of psychiatry that represents a shift in thinking. Instead of thinking about the brain in terms of chemicals, interventional psychiatry thinks of the brain in terms of electrical pathways and circuits, leading to a different approach to treatments.
Interventional psychiatry uses neuro technologies and other interventions to treat the underlying problems in the brain without using chemicals. These interventions aim to help the brain recover its normal and natural functioning.
1. TMS–Transcranial Magnetic Stimulation
TMS, or transcranial magnetic stimulation, is a non-invasive (does not break the skin or physically enter the body), non-drug treatment that uses magnetic pulses to stimulate parts of the brain that are underactive in depression. When the magnetic pulses enter the brain, they turn into electrical energy—stimulating specific regions of the brain known to affect mood and depression.
TMS is non-invasive because it does not involve surgery or cutting the skin—rather, it is a device—simply placed either on or against the head.
How It Works
An electromagnetic coil is placed against the head that sends magnetic pulses that stimulate brain activity. As these magnetic pulses move into the brain, they produce tiny electrical currents that activate cells within the brain—causing them to rewire—a process known as neuroplasticity. TMS is also thought to release neurotransmitters like dopamine, serotonin, and norepinephrine, although the precise mechanism of action is still unclear.
According to Dr. Luing, people are awake during TMS treatments, there are minimal side effects, and no downtime—so people can function normally during and after treatments. The transmission of the magnetic pulses is also painless.
TMS is not new and has been approved by the U.S. Food and Drug Administration (FDA) since 2008 for treatment-resistant depression (TRD). It has also been used for obsessive-compulsive disorder, smoking cessation, and other conditions.
TMS treatments are five days per week for 6-8 weeks and generally last less than 20 minutes. Treatments are covered by most health insurance companies, Medicare, and the Veteran’s Association, so for those who have not had success with other treatments for their depression, TMS may be a good option.
TMS is usually used for people who have not had success with medications or other treatments for their depression. Still, because a referral is not necessary, anyone with an interest can seek out TMS treatment.
According to the Mayo Clinic, TMS is considered safe and well tolerated, however, there can be some mild to moderate side effects that decrease over time. Those side effects may include scalp discomfort and pain, headaches, tingling, spasms or twitching of facial muscles, and feeling lightheaded.
Less common side effects like seizures, occur in fewer than 1 percent of TMS-treated people according to a study published in 2020.
TMS has also resulted in beneficial effects for a range of conditions including post-traumatic stress disorder, schizophrenia, and addiction, according to a study posted by MIT.
2. ECT–Electroconvulsive Therapy
According to Dr. Luing, ECT, or electroconvulsive therapy, was always the gold standard as far as interventional treatments. Although ECT might conjure images like the ones out of the 1975 film “One Flew Over the Cuckoo’s Nest,” Dr. Luing says that ECT has come a long way since its development in the 1930s and there have been big strides in how it is used in clinical practice today.
She explains that ECT is now used with general anesthesia and muscle relaxants. The procedure is very short, and the anesthesia only lasts about five minutes.
Unlike what you see in the movies, Dr. Luing says it’s not a violent procedure—patients are essentially asleep—and most of the time, they’re not moving.
How It Works
In ECT treatment, after the patient undergoes general anesthesia, a small amount of electrical current is passed through the brain causing a seizure that affects the entire brain, including the regions that control mood, appetite, and sleep.
Doctors believe that the seizure causes the brain to “rewire” itself which leads to an improvement in symptoms of depression.
Although the precise way that ECT works is not fully understood, The American Psychiatric Association states that ECT produces substantial improvement in approximately 80 percent of patients.
One risk associated with ECT therapy is retrograde amnesia—a memory loss of events leading up to the treatment and of the treatment itself. ETC can also cause difficulty in learning new things. Both risks are generally temporary and resolve within a couple of months according to the American Psychiatric Association. There are however some patients who experience permanent memory loss and other cognitive side effects due to ECT treatment.
1. Deep Brain Stimulation (DBS)
Deep brain stimulation in its present incarnation, has been around since the 1980s and involves surgery to permanently place electrodes into specific regions of the brain. It uses a device implanted under the skin on the chest to deliver continuous electrical stimulation to parts of the brain to help regulate mood and ease severe symptoms of depression.
Deep brain stimulation works like a pacemaker—only it’s used in the brain instead of the heart. The device is connected to the electrodes in the brain via wires that are placed under the skin. The amount and strength of stimulation is regulated by the person using an external remote control. Stimulation of the brain is usually continuous, occurring 24 hours a day.
DBS has traditionally been used for people with movement disorders like Parkinson’s Disease, essential tremor, and dystonia (a relatively uncommon movement disorder), although it is also used to treat other neurological conditions.
Deep brain stimulation is generally reserved for patients with severe or treatment-resistant depression (TRD) who have not had success with other treatments like antidepressants, therapy, ECT, or other less invasive treatments. Deep brain stimulation may be indicated for those who are at risk of suicide or who have suicidal ideation.
Although deep brain stimulation is not yet approved for depression by the FDA, in July 2022, it did receive breakthrough status, which will be used to explore the use of deep brain stimulation for managing severe depression. Breakthrough status is given by the FDA to expedite the review of technologies that can improve the lives of people with life-threatening or debilitating conditions.
How It Works
The proposed mechanism of action of DBS is that it corrects connectivity dysfunctions associated with clinical impairment, including those in patients with depression. DBS not only modulates the brain activity of the stimulated area, but distant regions through connected circuitry, according to a narrative review published in 2022.
Deep brain stimulation does come with risks, which include the risks associated with surgery and anesthesia.
According to the American Association of Neurological Surgeons, risks of deep brain stimulation may include:
- 1 percent risk of brain hemorrhage, including stroke.
- Device malfunction.
- Lack of benefit for certain symptoms.
- Worsening mental or emotional status.
Vagus Nerve Stimulation (VNS)
The concept of stimulating the vagus nerve to modify activity in the brain is not new and has been studied for more than a century. It wasn’t until the 1980s that methods became available to efficiently stimulate the vagus nerve in animals and humans, according to an article in Nature.
Dr. Luing explains that despite getting FDA approval in 2005, vagus nerve stimulation was not added to Medicare’s list of covered services. Since most insurance companies follow Medicare, despite being FDA-approved, vagus nerve stimulation has not been readily available for patients. She says this will likely change soon as a large nationwide study is underway—called the Recover Trial—the study is looking at using VNS for depression, and the results will be shared with Medicare.
The American Association of Neurological Surgeons explains vagus nerve stimulation this way:
“The vagus nerve is one of 12 pairs of cranial nerves that originate in the brain and is part of the autonomic nervous system, which controls involuntary body functions. The nerve passes through the neck as it travels between the chest and abdomen and the lower part of the brain. It is connected to motor functions in the voice box, diaphragm, stomach and heart and sensory functions in the ears and tongue. It is connected to both motor and sensory functions in the sinuses and esophagus.”
“Vagus nerve stimulation (VNS) sends regular, mild pulses of electrical energy to the brain via the vagus nerve, through a device that is similar to a pacemaker. There is no physical involvement of the brain in this surgery and patients cannot generally feel the pulses. It is important to keep in mind that VNS is a treatment option limited to select individuals with epilepsy or treatment-resistant depression.”
How It Works
VNS uses a small device called a vagus nerve stimulator. The device is about the size of a quarter and is placed under the skin (thus considered an “invasive” therapy), right below the collarbone. The device is connected to leads that are threaded along the vagus nerve in the neck. The device sends mild, continuous impulses to the vagus nerve in the neck, which leads up into the brain, specifically into areas affected by depression.
The proposed mechanism of action of VNS includes alteration of epinephrine release by projections of solitary tract to locus coeruleus in the medulla oblongata, and elevation of gamma-aminobutyric acid levels in the brain stem, according to an article in Neurostimulation: Principles and Practice.
According to the American Association of Neurological Surgeons, the risks associated with vagus nerve stimulation are :
- Increased coughing.
- Changes in voice/speech.
- General pain.
- Throat or neck pain.
- Throat or larynx spasms.
- Muscle movements or twitching related to the stimulation.
- Nausea or vomiting.
- Impaired sense of touch.
- Prickling or tingling of the skin.
Of these, hoarseness, coughing, throat tickling, and shortness of breath are the most common and are usually temporary.
Holistic Treatments Support Depression Treatment
In her lecture, Dr. Luing said she thinks the first step for not only treating depression—but preventing it—is to go back to a holistic approach.
She says that she speaks to her patients about diet, exercise, mindfulness, meditation, and sleep.
Eating an inflammatory diet, she says, has been linked with depressive symptoms, so avoiding inflammatory foods is something people can do to help themselves.
“Omega fatty acids can be very helpful for brain health, as well as micronutrients and vitamins, like vitamin C, and E, selenium, that help with oxidative stress. Nutrients like folate are also linked to developing neurotransmitters that are needed in the brain,” she says.
A sedentary lifestyle is a risk factor for depression, and aerobic exercise can significantly improve depressive symptoms. The intensity of the exercise is less important than frequency, so keeping your body moving and staying active is good for the brain and can help alleviate symptoms of depression.
Dr. Luing says she thinks about mindfulness and meditation as exercises the brain needs for good health, saying it’s true that focused mental activity can have physical effects on the brain.
Lastly, is sleep, which she says is very important for brain health. She explains that it’s now known that there is a bidirectional effect between sleep and depression—meaning that if you start having severe insomnia—it can be a risk factor for depression, even if you have never been depressed before.
Dr. Luing says CBT-I is a free app that you can download onto your phone to help you sleep. It is a type of cognitive behavioral therapy that is equally or more effective than medications without side effects, making it an excellent option for those struggling to sleep well.
As for what other factors are important for recovery if you are struggling with depression, Dr. Luing says:
“I think hope is really essential for recovery. You know, I always tell patients, hope is always there, even when you feel like you’ve tried everything. There are new things on the horizon, and there’s always hope for a better future.”
Note: If you or someone you know is suffering from depression, there are several free, confidential helplines, available 24 hours a day that you can call or text for support. If you are suffering, please reach out and get help. You are not alone.