Most people experience full benefit within two weeks to two months with titration to full dose as indicated. The most common side effects associated with SSRIs and SNRIs are headache, nausea, sleeplessness or drowsiness, diarrhea or constipation, anxiety or agitation, dry mouth, tremors, heavy sweating, and sexual problems (Jones, 2023). Patients should be educated about the risks, signs, and symptoms of serotonin syndrome, a potentially serious complication resulting from high-dose therapeutic medication usage, drug interactions, or intentional overdose (Simon & Keenaghan, 2023). Brain Stimulation Therapies Brain stimulation therapies are FDA-approved treatments for serious mental illnesses like depression. Generally, a second-line treatment, utilized after nonresponse to trial(s) or medication and/or psychotherapy, the research and options for brain stimulation therapies are growing. Brain stimulation therapies act on the electricity of the brain, either activating or inhibiting. Stimulation occurs internally or externally, with electrodes implanted into the brain or attached to the external scalp. FDA-approved therapies include electroconvulsive therapy, repetitive transcranial magnetic stimulation, and vagus nerve stimulation. FDA experimental therapies that require additional research include magnetic seizure therapy and deep brain stimulation (National Institute of Mental Health, 2023). Electroconvulsive Therapy Electroconvulsive therapy (ECT) is considered a viable and effective treatment option for people experiencing major depressive disorder, with an estimated response rate of 80% (American Psychiatric Association, 2023). Advances in ECT have evolved the treatment to reduce cognitive side effects and maximize therapeutic benefits (Park et al., 2021). Used as a treatment option for people experiencing treatment-resistant depression and some subtypes of depression (Park et al., 2021), ECT induces grand mal seizures and was the treatment of choice before the development of antipsychotic medication (Park et al., 2021). The exact mechanism of action is unknown; however, possible mechanisms include the role of neurotransmitters (serotonin, dopamine, GABA) as well as mechanisms within the fields of neurophysiology, neuro-immunology, and neurogenesis (Park et al., 2021). The response is often rapid and dramatic, with the speed of remission being life- saving for many experiencing a life-threatening depression (American Psychiatric Association, 2023). The use of ECT as a treatment modality is often limited to clients with severe psychosis, depression, bipolar disorder, or schizophrenia, in which there are life-threatening behaviors such as catatonia or suicidality (American Psychiatric Association, 2023). Electroconvulsive therapy is considered a beneficial treatment when used in combination with antipsychotic medication; however, the decision to implement this
modality must be made on an individual, case-by-case basis (National Institute of Mental Health, 2023). The most common short-term side effects are headaches, nausea, muscle aches, confusion, disorientation, and memory loss. Typically, these side effects are temporary and abate quickly (National Institute of Mental Health, 2023; American Psychiatric Association, 2023). Updated guidance on the use of ECT with people suffering from depression (Park et al., 2021) recommended: 1. Maintenance of ECT therapy alone or in combination with psychiatric medication reduced the risk of relapses and recurrences over pharmacotherapy alone (Park et al., 2021). 2. Although there is no absolute definition, “treatment- resistant depression” (TRD) is commonly defined as depression that does not respond or remit to treatment with two or more antidepressants used for sufficient trials, including duration and dose (Gaynes et al., 2020). Response rates for people with TRD are greater for ECT than antidepressant medication, 50-60% to 17%. 3. As the response to ECT is often rapid and dramatic, ECT is helpful when a rapid reduction of symptoms or suicidal ideation is indicated. The long-term impact of ECT on suicidality is unconfirmed (Park et al., 2021). 4. ECT was found to be efficacious for geriatric people with severe depression, with a shorter time to remission and generally well-tolerated side effects. Cognitive side effects were restricted and not permanent, with overall improved cognitive functioning correlating with symptom remission (Park et al., 2021). 5. The use of ECT is supported for the treatment of both unipolar and bipolar depression (Park et al., 2021). 6. Based on limited available studies, ECT shows benefits with treatment of “psychotic depression,” depression co-occurring with symptoms such as hallucinations or delusions (Park et al., 2021). Those with psychotic depression experience a higher risk of suicide, higher rates of recurrence and mortality, and decreased quality of life (Gournellis et al., 2018). 7. Perinatal depression (depression during pregnancy, postpartum depression, or both) affects between 10- 20% of United States women (Payne, 2020). Bauman et al. (2020) data found the prevalence rate for postpartum depression to be 13.2%, with rates ranging between states (9.7% in Illinois to 23.5% in Mississippi). ECT is noted to be a relatively safe and viable treatment option for pregnant and postpartum women. CIH Modalities See Table 5 for the American Psychological Association’s “Guideline for the Treatment of Depression” (2019, p. 15).
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