Transcranial magnetic stimulation in psychiatry. Biological non-drug treatments for depression

Transcranial magnetic stimulation is new technique activation of brain cells without external interference using an alternating magnetic field.
Using this method, the excitability of neurons in the cerebral cortex, the location of motor and non-motor functions in the brain, as well as the consistency of the functioning of different areas of the brain are studied.

Studies using the method of transcranial magnetic stimulation were carried out in medical universities Harvard, Michigan, New York, Berlin.

Diagnosis using TMS

After the influence of single magnetic stimuli on brain cells, the response of the studied cells to stimulation is obtained and, accordingly, conclusions are drawn about the state of functioning motor pathways conduction system of the central nervous system, the possibility of initiation and occurrence of processes of excitation and inhibition, the state nervous system generally.

One of the most promising lines of development of the TMS method is mapping the human brain. This is very important for assessing the distribution of functions in the cerebral cortex and the possibilities of its control, which provides the potential for the development of new techniques and methods for the rehabilitation of the nervous system.

TMS allows you to determine the boundaries of the location of various brain functions with maximum accuracy. This is the localization in the cerebral cortex of the centers of speech and vision, the motor center responsible for the work skeletal muscles, parts of the brain that provide the functions of thinking and memory.

Treatment with TMS technique

For treatment, brain cells are exposed to magnetic impulses in a certain rhythm, which improves the transmission of electrical impulses from neuron to neuron. As a result, brain processes are activated during asthenia and depression and, conversely, they slow down during anxiety and panic.

The effect of TMS on nerve cells is similar to the effect of antidepressants - the body’s production of endorphin (the so-called “happiness hormone”) and serotonin increases.

The results of this influence are:

• reduction of instability of the autonomic nervous system;
• improving the processes of falling asleep and staying asleep;
• mood improves;
• anxiety level decreases;
• blood pressure levels return to normal;
• muscle tension decreases;
• stress resistance increases;
• the level of fear decreases;
• memory improves;
• a person’s energy and activity increases.

Each short single pulse carries energy that is transferred nerve cells. This energy is not enough for the normal functioning of the nervous system modern man in conditions of constant psycho-emotional stress. When this energy is transferred, the conduction system of the brain and spinal cord after its defeat during strokes and injuries, the level of tone and strength of the muscles of the limbs increases, sensitivity increases and pain decreases.
In the video there is a lecture on the method of transcranial magnetic stimulation:

Indications for TMS

1. Discirculatory encephalopathy of the second and third degrees.
2. Headaches of various origins, including migraines and tension headaches.
3. Depression, astheno-neurotic syndrome, anxiety and panic conditions.
4. Vegetative-vascular dysfunction (including panic attacks).
5. Acute disorder cerebral circulation ischemic or hemorrhagic origin.
6. Consequences of strokes - post-stroke pain syndrome(so-called thalamic pain), post-stroke hemiparesis (at least three months after the stroke).
7. Speech disorders - Wernicke's aphasia, Broca's aphasia.
8. Neuralgia, neuritis, trigeminal and facial nerves(the fastest and most complete rehabilitation, pain reduction, restoration of sensitivity and facial expressions).
9. Rehabilitation after injuries and neurosurgical interventions on the brain and spinal cord, as well as restoration of the peripheral nervous system.
10. Various lesions of the spinal cord -, etc.
11. Fibromyalgia of various origins.
12. Neuropathic pain, including unspecified origin.
13. Writer's cramp.
14. Tinnitus (noise and ringing in the ears).
15. Various pathologies and syndromes in children - spasticity in cerebral palsy, autism, attention deficit hyperactivity disorder, encephalopathies of various etiologies with delayed speech development.

About the use of the TMS method in rehabilitation after stroke:

Contraindications to TMS

1. Pregnancy.
2. Cerebral aneurysms and surgical interventions on this occasion.
3. History of epilepsy, seizures and fainting.
4. Presence of a pacemaker or other implanted electronic implants.
5. The presence of large metal objects in the patient’s body; metal dentures are allowed.

Carrying out the TMS procedure

The procedure of transcranial magnetic stimulation must be performed by a doctor - a neurologist or a doctor of another specialty who has the appropriate knowledge, experience and necessary preparation. The TMS procedure can be performed on an outpatient basis, without hospitalization of the patient.

Preparation

• refusal to drink alcohol, take strong drugs, and smoke;
• refusal to play sports;
• carrying out studies that the doctor may prescribe before the TMS procedure.

TMS procedure

The patient is in a sitting position. An electromagnetic coil (coil) is applied to a certain area of ​​the body (head, neck, lower back, legs or arms), which generates electromagnetic pulses for a certain period of time. The usual duration of the procedure is about 30 – 40 minutes.
The sensations during the procedure are similar to “current slipping”; they should in no case be painful. Required level pulse radiation is determined by the specialist performing the procedure.

Complications of TMS

The TMS procedure has no consequences. The procedure is painless, there are no risks of deterioration in health. Typically, all patients tolerate the TMS procedure well.

The TMS technique is used to treat patients with various diseases and lesions of the nervous system in medical center Evexia. Highly qualified specialists provide examination of the patient, formation of an individual treatment protocol and rehabilitation course using this innovative method.

Today, transcranial magnetic stimulation (TMS) is a non-invasive method that can induce hyperpolarization or depolarization in brain neurons. Transcranial magnetic stimulation in psychiatry is based on the use of the principles of electromagnetic induction. The goal is to create weak electrical currents using rapidly changing magnetic fields. This results in some activity in certain parts of the brain with minimal discomfort to the patient and the ability to study brain function. Scientists conduct clinical trials TMS as a treatment for psychiatric and neurological diseases.

Particular attention was paid to strokes, migraines, hallucinations, depression, tinnitus, and other problems. Inductive brain stimulation was first used in the twentieth century. Successful research began in 1985. Anthony Barker and his colleagues carried nerve impulses from the motor cortex to the spinal cord, and there was also accompanying stimulation of muscle contractions. The discomfort from the procedure was reduced by using magnets, which replaced the effect of direct electric current on the brain. At the same time, the researchers obtained an image of the cerebral cortex and its connections. Nowadays, active study of the effects of TMS parts on the brain continues.

Depending on the stimulation mode used, the effect of TMS is divided into two types. Single pulses are released, or paired TMS pulses used lead to the depolarization of neurons that are located in the stimulation zone of the cerebral cortex. This entails spreading the potential for impact. When applied to the primary motor cortex, a muscle activity called a motor evoked potential is produced, which can be recorded on electromyography. If the impact is on occipital part, then patients may perceive “phosphenes,” that is, light flashes. It should be noted that if the effect is applied to other areas of the cortex, the patient does not experience noticeable sensations.

When performing TMS of the brain, peripheral nerves, it is possible to track the state of the motor cortex. At the same time, a quantitative assessment is made of the degree of involvement of various parts of motor peripheral axons and motor corticospinal tracts in pathological process. It is worth emphasizing that the nature of the existing process disturbance is not specific, and such changes can occur in pathologies of various forms. Based on this, it is believed that the indication for this procedure is pyramidal syndrome, and its etiology does not matter. As practice has shown, TMS is used for various lesions nervous system such as multiple sclerosis, vascular disease, tumors of the spinal cord, brain, hereditary and degenerative diseases.

There are certain contraindications for TMS. The procedure is not performed if the patient has a pacemaker or there is a suspicion of an aneurysm. cerebral vessels. Pregnancy is also a contraindication. The method is used with caution in patients, since an attack may occur under the influence of TMS. In most cases, experts are inclined to believe that the procedure is safe, although there are cases where it causes induced seizures and fainting. The medical literature provides examples of several such cases. Such seizures are associated with single pulses and TMS.

Scientific studies have revealed that in some cases predisposing factors were influential. These are brain lesions, some medicines, not in last place and genetic predisposition. In 2009, an international consensus discussed TMS and concluded that, theoretically and in practice, the risk of seizures associated with transcranial magnetic stimulation is very low. In addition to a seizure, in some cases there may be fainting, moderate headaches, or certain local discomfort, psychiatric symptoms.

Based on multiple studies, it can be argued that the use of this method in the treatment of mental and neurological diseases gives positive result. Publications and reviews on this topic indicate that the technique has proven itself to be effective in influencing certain types of depression, taking into account certain conditions. There is evidence that transcranial magnetic stimulation reduces the intensity of chronic pain through changes in neural brain activity. Other areas of research involve the rehabilitation of disabled people, as well as patients with motor aphasia after a stroke. This also applies to patients with negative symptoms for, for Parkinson's disease, and so on.

Many researchers question whether this method can be tested for the placebo effect. This is extremely difficult to do, since during a controlled trial the subjects often experienced painful sensations in the back area, cramps, headache that are directly related to the intervention. This causes a change in glucose metabolism, in turn, knocking down the levels. Another complicating circumstance is that subjective assessment patient improvement. Today this issue is of extreme complexity and importance, and remains open. When asked about the clinical use of the method, experts conditionally divide TMS into medicinal purposes and diagnostic.

Especially those that included pronounced, it was suggested to use periodic transcranial magnetic stimulation(TMS). It was assumed that with the help of a rapid alternative change of magnetic fields, it is possible to non-invasively stimulate individual areas of the cerebral cortex (Barker A. et al., 1985). However, it turned out that during TMS the changes induced by changing magnetic fields electric field spread to a depth of no more than 2 cm, so this treatment method can only affect the superficial zones of the cerebral cortex.

In the first studies devoted to the use of TMS for , fairly large areas of the bilateral prefrontal and parietal cortex were stimulated.

In addition to low-frequency TMS (1 Hz), it was proposed to use high-frequency stimulation (20 Hz). Psychiatrists noted that with a high frequency of TMS, seizures may occur. Subsequently, a special treatment method was developed, slightly different from the original TMS - magnetic convulsive therapy(MST). It turned out that MCT in its effect is like a “local ECT”, capable of causing seizures due to a focal effect on certain brain structures.

To monitor the effectiveness of rTMS when irritating the motor cortex, it is important to record the muscle response potential, noticeable by the contraction of individual muscle groups.

Currently, a relatively large number of research results have been published on the effectiveness of subconvulsive TMS for mania, obsessive-compulsive disorder, and post-traumatic stress syndrome. stress disorder and (George M. et al., 1999).

In an open study by V. Geller et al. (1997) demonstrated that in 60% of patients with “chronic schizophrenia,” a transient positive effect can be obtained even after a single TMS session. More positive results were obtained by M. Feinsod et al. (1998) with narrow-local brain stimulation with stimuli with a frequency of 1 Hz during a two-week course of therapy. However, the improvement in the patients' condition mainly concerned anxiety and irritability and did not affect the actual symptoms of schizophrenia.

Some recent studies have noted the effectiveness of repeated transcranial magnetic stimulation (TMS) in treatment-resistant hallucinations or in cases of schizophrenia where negative symptoms were expressed (Wobrock T. et al., 2006). Hoffman et al. (1999) reported successful application TMS (1 Hz) with pinpoint stimulation of the left temporo-parietal cortex in patients with persistent auditory hallucinations. Therapeutic effect V in this case explained by the fact that weak low-frequency stimulation of certain areas of the brain can extinguish the focus of excitation in those areas of the cortex that are presumably involved in the pathological process in the presence of auditory hallucinations (Chen R. et al., 1997). Some authors report a decrease in severity auditory hallucinations already 4 days after rTMS, some patients experienced a delayed positive effect, which was noticed 2 months after the TMS course (Poulet E. et al., 2005).

Carefully controlled studies, however, have previously shown that the effect of TMS in the treatment of schizophrenia is not statistically significantly different from the effect of placebo therapy (Klein E. et al., 1999).

In 1999, Z. Nahas reported a case of reduction negative symptoms after exposure to high-frequency TMS (20 Hz) on the left dorsolateral prefrontal area. The effectiveness of high-frequency TMS in relation to catatonia (Grisary N. et al., 1998) and relief of psychotic symptoms (Rollnik J. et al., 2000) has also been reported.

Recent studies, including longitudinal studies, have indicated the effectiveness of high-frequency TMS in relation to not only the reduction of negative but also depressive symptoms of schizophrenia, but an increase in the positive symptoms of the disease was also noted. It was emphasized that the weakening of the severity of signs of depression does not correlate with the degree of reduction of negative symptoms (Hajak G. et al., 2004).

The use of TMS for the treatment of patients with schizophrenia is currently not recommended by most specialists, due to the insufficiently studied effectiveness of this method.

Psychiatrist, psychotherapist of the highest category,

Mental Health Clinic

Annotation.

This medical technology“Treatment of Depression Using Rhythmic Magnetic Stimulation” contains a description of a method for treating depression. The technology contains: a description of the method of rhythmic transcranial magnetic stimulation (rTMS), a description of the necessary material and technical equipment, indications and contraindications for this method treatment, possible complications and measures for their prevention; the effectiveness of the method is shown. Recommended for psychiatrists, psychotherapists, neurologists, and can be used in medical institutions.

Applicant:

State Educational Institution of Higher Professional Education Moscow Medical Academy named after. THEM. Sechenov. 119991, Moscow, st. Trubetskaya, 8, building 1

1) Artemenko A.R. - Ph.D., senior Researcher Department of Pathology of the Autonomic Nervous System, Research Center of the State Educational Institution of Higher Professional Education, Moscow medical academy them. THEM. Sechenov;
2) Nikitin S.S. - Doctor of Medical Sciences, Leading Researcher, Department of Motor Neuron Pathology, Research Institute general pathology and pathophysiology of the Russian Academy of Medical Sciences;
3) Antipova O.S. - Candidate of Medical Sciences, Senior Researcher, Department of Disorders affective spectrum Federal State Institution of the Moscow Research Institute of Psychiatry of Roszdrav.

Reviewers:

Kurenkov A.L. - Doctor of Medical Sciences, Leading Researcher of the Department rehabilitation treatment children with cerebral palsy Science Center children's health RAMS;
Romasenko L.V. - Doctor of Medical Sciences, Professor, Head of the Department psychosomatic disorders FGU State Scientific Institution of Social and Forensic Psychiatry named after. V.P. Serbian Roszdrav.

INTRODUCTION

Transcranial magnetic stimulation (TMS) is widely accepted diagnostic method, used in neurology, neurosurgery, psychiatry and urology. The discovery of the effect of TMS on mood led to new era using rhythmic TMS (rTMS) as a therapeutic method, and first of all, for depression.
Efficiency and safety of the rTMS method in treatment various types depression have been convincingly demonstrated in numerous publications scientific research in recent years, including the results of 25 randomized placebo-controlled clinical trials, which included approximately 800 patients suffering from major depressive episodes and data from meta-analytic reviews.
It is generally accepted that high-frequency rTMS (> 1 Hz) has an antidepressant effect when exposed to the projection area of ​​the left prefrontal cortex and low-frequency rTMS (< 1 Гц) - при воздействии на область проекции правой префронтальной коры. Однако, наиболее wide application V clinical practice found the use of high-frequency rTMS.
An average of 50% of patients receiving rTMS treatment have been shown to experience clinical improvement, with a reduction in depressive symptoms of 50% or more. The most authoritative is a multicenter study of 301 patients with unipolar depression, the results of which confirmed a statistically significant effect of high-frequency rTMS on the left prefrontal cortex.

INDICATIONS FOR USE OF MEDICAL TECHNOLOGY

1. For depressive episodes mild degree severity rTMS is used as monotherapy.
2. For moderate and severe depressive episodes without psychotic symptoms or suicidal risk, rTMS is used as an adjuvant method in addition to psychopharmacotherapy.
3. Ineffectiveness or low effectiveness of previous courses of treatment for depression.
4. Side effects drug therapy depression that violates the patient’s compliance with treatment.
5. Contraindications to standard treatment depression (to pharmacotherapy, electroconvulsive therapy or other non-pharmacological methods of treating depression).
6. Special cases: elderly age, high risk heavy side effects drug treatment, Patients, professional activity which require a good concentration of attention, which makes it difficult to select pharmacological treatment(pilots, dispatchers, drivers, students during training and others).
7. Combination of depression with chronic pain syndromes.
8. Patient's desire (preference).

Most often, rTMS is used for primary depressive episodes and for repeated depressive episodes as part of recurrent depressive disorder. As a rule, rTMS is used at the stage of active (relieving) treatment of depression. After completing the rTMS course, the achieved improvement in condition and the process of establishing and maintaining remission is carried out using antidepressants and mood stabilizers.

CONTRAINDICATIONS TO THE USE OF MEDICAL TECHNOLOGY

Absolute contraindications:

1. The presence of implanted magnetizable devices (plates, screws, shunts, intracranial ferromagnets, etc.). If there is a certificate of magnetic inertness of the device, TMS can be performed.
2. The presence of a heart pacemaker or any other electronic devices that control body functions.
3. Pregnancy.

Relative contraindications:

1. Epilepsy.
2. Traumatic brain injuries in the acute period.
3. Acute and chronic somatic diseases in the stage of decompensation.
4. Bipolar depression.

MATERIAL AND TECHNICAL SUPPORT FOR MEDICAL TECHNOLOGY

1. with accessories (double coil in the form of a number 8), manufactured by Tonika Elektronik A/S, Denmark. Registration certificate Federal service for supervision in the field of healthcare and social development No. FZS 2008/03099 dated December 4, 2008, validity period is unlimited. The product, by order of Roszdravnadzor dated December 4, 2008 No. 9685-Pr/08, is permitted for import, sale and use in the Russian Federation.
2. Keypoint electromyograph with accessories (standard cutaneous recording electrodes), manufactured by Alpine Biomed ApS, Denmark. Registration certificate of the Federal Service for Surveillance in Healthcare and Social Development No. FZS 2009/04288 dated May 13, 2009, unlimited validity. By order of Roszdravnadzor dated May 13, 2009 No. 3561-Pr/09, the product is permitted for import, sale and use in the Russian Federation.

DESCRIPTION OF MEDICAL TECHNOLOGY

Therapeutic rTMS is carried out in a state of relaxed wakefulness, with the patient sitting in a comfortable chair. During the therapeutic rTMS procedure, the patient's head must be gently fixed to the headrest of the chair, and the stimulating coil must be placed on a rigid holder. This avoids possible deviations focus of magnetic stimulation during the session.

Before performing therapeutic rTMS, it is necessary to determine the threshold for recording the evoked motor response (EMR) in accordance with the recommendations of the International Federation of Clinical Neurophysiology. To do this, standard output cutaneous EMG electrodes are installed in the projection of the motor point m. abductor pollicis brevis on the right. TMS begins when the coil is displaced 5-7 cm lateral to the vertex on the contralateral side in relation to the recording electrodes. By presenting a supramaximal magnetic stimulus, the optimal point of MEP generation of maximum amplitude is determined. Then, by stepwise reducing the stimulus intensity, the MEP threshold is determined. The MEP threshold is considered to be the intensity of the magnetic stimulus at which MEP is recorded with an amplitude (from peak to peak) of at least 50 μV [Nikitin, Kurenkov, 2006].

All patients selected for treatment with rTMS must undergo a clinical-psychopathological examination by a psychiatrist with mandatory assessment on psychometric scales (preferably the Hamilton Depression Rating Scale (HDRS-17) (Appendix 1) or, less commonly, the Beck Depression Rating Scale (Appendix 2)). The criterion for response to rTMS treatment should be a decrease in scores on the Hamilton Depression Scale by 50% or more compared to the state before treatment.

The patient must be informed about the rTMS procedure and must sign an informed consent for treatment (Appendix 3).

During therapeutic rTMS, the stimulating coil is placed over the area of ​​the left dorsolateral prefrontal cortex, located 5 cm anterior to the point upon stimulation of which the maximum amplitude MEP is recorded in the contralateral target muscle (in this case, the m. abductor pollicis brevis) (Appendix 4).

Parameters of therapeutic rTMS:

• Stimulation frequency - 10 Hz;
• The duration of the pack is 8 seconds;

The course of treatment consists of 10 rTMS treatment sessions. It is advisable to conduct each treatment session at the same time once a day for 2 weeks, taking into account no more than 5 treatment sessions per week.

POSSIBLE COMPLICATIONS WHEN USING MEDICAL TECHNOLOGY AND WAYS TO ELIMINATE THEM

When performing therapeutic rTMS using the parameters recommended in this technology, no complications are observed.
The only one undesirable effect is possible development transient mild to moderate headache on the day of the rTMS procedure. Typically, the headache goes away on its own within a few hours and does not require additional treatment.

EFFECTIVENESS OF USING MEDICAL TECHNOLOGY

Purpose of the study: to evaluate the effectiveness and safety of rTMS as monotherapy for the active (reversing) treatment of a depressive episode of mild to moderate severity. The total size of the study sample: 30 people. The study was conducted in the Department of Pathology of the Autonomic Nervous System of the Research Center of the State Educational Institution of Higher Professional Education of the Moscow Medical Academy named after. THEM. Sechenov and Academic clinic neurology and dentistry "Cecile+".

Inclusion criteria:

1. mild to moderate primary depressive episode without somatic symptoms;
2. recurrent depressive episode of mild or moderate severity without somatic symptoms as part of a recurrent depressive disorder;
3. availability of voluntary informed consent to participate in the study and conduct therapy using the rTMS procedure;
4. Age from 18 to 60 years.

The diagnosis was established in accordance with the International Classification of Diseases, 10th revision (ICD-10).

Exclusion criteria:

1. severe depression with/without psychotic symptoms;
2. suicidal thoughts or attempts;
3. affective disorders of the bipolar spectrum;
4. personality disorders;
5. schizophrenia spectrum disorders;
6. alcoholism, drug addiction;
7. mild and moderate cognitive impairment, dementia;
8. pregnancy;
9. epilepsy;
10. the presence of implants, intracranial ferromagnets;
11. somatic and neurological diseases in the stage of decompensation.

Research methods:

1. Clinical-psychopathological and clinical-anamnestic method using a semi-structured clinical interview.
2. Clinical, neurological and general somatic testing.
3. Psychometric scales: Hamilton Depression Rating Scale (HDRS-17) and Beck Depression Rating Scale (full versions are provided in the appendix).
4. Clinical and statistical method.

Statistical analysis of the results was carried out using the computer program Statistica 6.0 for Windows. To determine average values ​​and standard deviations Descriptive statistics methods were used. The significance of group differences for populations was assessed using the Wilcoxon W test for paired samples. Differences were considered significant at p<0,05. Все показатели приведены в формате среднее значение ± стандартное отклонение.

The total course of treatment consisted of 10 rTMS treatment sessions, 5 treatment sessions per week. The duration of the rTMS course was 2 weeks.

Therapeutic rTMS was performed in the left dorsolateral prefrontal cortex. The following parameters of therapeutic rTMS were used:

Stimulus intensity - 110% of the VMO threshold;
Stimulation frequency - 10 Hz;
The duration of the pack is 8 seconds;
The interval between packs is 52 seconds;
The number of packs in a treatment session is 20;
The duration of the treatment session is 1200 seconds.

The results were assessed immediately after completion of treatment, 1 and 2 weeks after the end of the course of therapeutic rTMS by:

• dynamics of clinical and psychopathological manifestations;
• dynamics of the level of depression on the Beck scale;
• dynamics of the level of depression on the Hamilton scale (HDRS-17).

The course of therapeutic rTMS led to the following changes in the main parameters used to evaluate the effectiveness:

It was found that, against the background of rTMS monotherapy, by the end of the 2nd week of therapy there was a decrease in the level of both situationally determined and pointless anxious and melancholy reactions. The representation and severity of dysphoric and asthenic-like manifestations also decreased. Patients concentrated attention more easily, tolerated daily stress better, there was some revival of the need-motivational sphere, anhedonic symptoms were smoothed out, and self-report improved. In 30% of cases, sleep returned to normal and appetite was restored. The indicated dynamics can be regarded as the presence of clinical response to the procedure in 83.3% of cases (in 25 out of 30 patients). The achieved effect was maintained 1 and 2 weeks after completion of the course in 20 and 17 patients, respectively.

An assessment of the dynamics of the level of depression on the Beck scale demonstrated that it decreased from 22.8±4.3 points before the start of therapy to 12.5±4.9 points (p<0,001) непосредственно по завершении лечения; до 12,0±4,8 баллов (p<0,001) через 1 неделю после окончания курса и до 11,5±4,5 баллов (p<0,001) через 2 недели после окончания курса лечебной рТМС (приложение 5).

The initial level of depression on the Hamilton Rating Scale (HDRS-17) decreased from 18.9±3.9 points to 11.7±4.4 points (p<0,001) непосредственно после завершения лечения, до 10,2±4,5 баллов (p<0,001) через 1 неделю и до 10,2±4,6 баллов (p<0,001) через 2 недели после окончания курса лечебной рТМС (приложение 5).

The number of responders was assessed using a standard approach: a decrease in the level of depression on the Hamilton Scale by 50% or more compared with baseline values. It was revealed that the proportion of responders was 50%, 55% and 50% immediately after treatment, after 1 and 2 weeks, respectively (Appendix 6).

During the course of rTMS treatment and the entire follow-up period, no complications were noted. Adverse events included a short-term mild diffuse headache that occurred on the day of the procedure. Headaches were observed in 4 patients (13.3%), were transient, and did not require additional treatment.

In addition to pharmacological and psychotherapeutic treatment of depression, other methods have been proposed for its treatment.

Such methods of treating depression, often effectively combined with pharmacotherapy and psychotherapy, include: intravenous laser irradiation of blood, magnetic stimulation (transcranial low-frequency alternating magnetic field therapy, right-sided pair-polarization therapy), extracorporeal detoxification (plasmapheresis), periodic normobaric hypoxia, craniocerebral hypothermia, light treatment, sleep deprivation, dietary therapy (including its fasting options), balneotherapy (warm baths have been used for a long time to alleviate the condition of a depressed person), massage and physical therapy (breathing exercises and physical activity help weaken).

Among biological methods of treating depression, electroconvulsive therapy occupies a special place.

Intravenous laser irradiation of blood

According to the recommendations of domestic scientists, intravenous laser irradiation of blood should be carried out using a low-intensity helium-neon device (FALM-1). The wavelength of laser irradiation is 0.63 microns. The radiation power at the output of the light guide is 8 mW. Session duration - 15 minutes, course of therapy - 8-12 sessions. It was noted that after laser therapy while taking psychopharmacological drugs, the severity of depressive symptoms in 60% of people suffering from depression is almost halved. Patients with manifestations of apathy and melancholy are especially sensitive to laser therapy; a less clear effect is observed in complex depressive syndromes, including symptoms of depersonalization, obsessive states and hypochondria. Laser therapy is ineffective for anxiety and depression. It should be borne in mind that the effect of laser therapy as a non-drug treatment method, as well as of treatment with antidepressants, may be delayed and appear some time after completion of the course of treatment. Currently, there are various modernizations of laser therapy. An example is a differentiated method of low-intensity magnetic laser therapy. This method of treatment includes an individual stage program of a course of combined laser exposure, which consists of venous irradiation of the tissue with continuous red light (0.63 μm) and transcutaneous irradiation with pulsed infrared light (0.89 μm) of projections of a number of biologically active zones and organs using standard magnetic attachments. Laser irradiation usually does not cause side effects or complications.

Extracorporeal detoxification

Extracorporeal detoxification as a biological non-drug treatment for depression is used in combination therapy for resistant depression and can be combined with transfusion of fresh frozen plasma or albumin to normalize protein metabolism. To do this, 2-3 plasmapheresis procedures are usually performed.

Electroconvulsive therapy

Currently, one of the most effective non-drug methods of treating depression is electroconvulsive therapy, which is used both as an independent method of treatment and in combination with other methods of therapy (Nelson A.I., 2002).

Electroshock therapy methods have been used since ancient Greece. In the temples of Asclepius, depression was treated with electric snakes. In the Middle Ages, it was believed that a strong shock to a patient could bring him out of a state of depression.

Treatment of depression with electric shock was recommended by Hill in 1814 (commotions electriques) (Kempinski A., 2002). Particular interest in this method of treating depression was noted in the early forties of the twentieth century. Electroconvulsive therapy is now generally recognized to be highly effective in treating depression.

It is difficult to overestimate the importance of electroconvulsive therapy for those patients for whom pharmacological treatment is contraindicated (pregnancy, certain somatic diseases, etc.), as well as if it is necessary to overcome depression resistant to other types of therapy.

Typically, to obtain a therapeutic effect from electroconvulsive therapy, about 8-10 shock discharges are required at a frequency of 3 sessions per week.

Subject to monitoring the condition of patients, it is possible that they can be treated with ECT on an outpatient basis or as a day treatment for depression in a hospital.

Complications of electroconvulsive therapy include spinal injury and circulatory disorders, states of confusion after convulsive attacks, as well as periods of anterograde and retrograde memory impairment have been reported. The latter can persist for a month after the end of ECT. ECT causes a temporary rise in blood pressure (often to quite high levels) and increases the heart rate.

Relative contraindications to ECT include coronary heart disease and arrhythmias, as well as some location of the brain tumor.

Most patients are afraid of this method of therapy, so the importance of professional psychotherapeutic work with the patient, as well as its subsequent support during the ECT therapy itself, should be emphasized.

Magnetic stimulation

Repeated transcranial magnetic stimulation (TMS) was proposed for the non-drug treatment of depression in 1985 (Barcer A., ​​et al., 1985). This method of treating depression, as well as vagal nerve stimulation, currently represent new methods of treating depressive spectrum disorders.

Low-frequency transcranial magnetic stimulation has been proposed as an alternative treatment for depression to electroconvulsive therapy where stimuli do not reach the seizure threshold.

Compared to electroconvulsive therapy, this treatment method has an important advantage: a more precise effect on those brain structures that are involved in the pathogenesis of depression (the hippocampal region). In addition, with TMS there are no cognitive impairments that occur after ECT. However, if the effect of TMS and ECT treatment is approximately equal in the treatment of mild or moderate depression, then in the case of severe depression ECT may become a more preferable method (Grunhaus L., et al. 1998).

Studies have shown that TMS induces changes in beta-adrenergic receptors similar to those that occur after ECT and has a positive effect on astroglial tissue in the brain.

TMS has proven effective not only in the treatment of depression, but also in the treatment of schizophrenia, obsessive-compulsive disorder, and post-traumatic stress disorder (George M., et al., 1999). However, it was noted that the positive effect of TMS in the treatment of depression is observed only in 50% of cases. In addition, most patients experienced frequent relapses of depression after several months of remission following TMS. The combination of high-frequency and low-frequency magnetic stimulation appears to be more preferable for the quality of remission and its duration.

From the point of view of the pathogenesis of depression, the method of cyclic transcranial magnetic stimulation seems promising, since weak magnetic fields can reduce circadian rhythms (Mosolov S.N., 2002). Currently, this method of therapy is used to overcome treatment-resistant depression.

The first TMS studies proved the superiority of fast stimulation over slow stimulation, however, the number of such studies was quite limited and the area of ​​influence was not precisely localized. Recent studies show a higher effectiveness of low-frequency magnetic stimulation compared to high-frequency (Klein E., et al., 1999).

Typically, magnetic stimulation is carried out using a unilateral technique: on the projection of the left dorsolateral prefrontal region (high frequency or fast stimulation -< 10 Hz), реже осуществляется стимуляция правой префронтальной области. При низкочастотной магнитной стимуляции воздействуют на селективный участок антеролатеральной префронтальной коры левого полушария.

A course of low-frequency magnetic stimulation for non-drug treatment of depression is 10 sessions, with an average duration of 30 minutes. Sessions are held every other day; stimulation parameters - 1.6 T/1 Hz. The therapeutic effect is noticeable after the first therapy session and most often manifests itself as calming, reducing the severity of anxiety, and restoring sleep. This method is of interest due to the rapid development of effect and the absence of complications. As noted above, unlike ECT, TMS does not require the use of anesthesia.

Vagal stimulation

Vagal stimulation for the non-drug treatment of depression was proposed in 1994 (Harden C., et al., 1994). When conducting vagal stimulation, areas of the lateral and orbital regions of the anterior parts of the brain, as well as the parabrachial nuclei of the nerve and the locus ceruleus region are affected. The impact on the last part of the brain ensures that this method influences the functional activity of the thalamus and hypothalamus.

After the use of vagal stimulation, an increase in the content of biogenic amines in the limbic region of the brain was noted (Ben-Menachem E., et al., 1995)

Sleep deprivation

A relatively gentle non-drug treatment for depression is sleep deprivation, which was actively developed in the early 70s of the twentieth century. Three types of sleep deprivation were used: total, partial and selective. Total sleep deprivation involves being awake for 36-40 hours, partial sleep deprivation means sleeping from 5 pm to 1 am, then staying awake until the next evening or sleeping from 9 pm to 1 hour 30 minutes then staying awake until the next evening - sleep duration 4, 5 hours and selective sleep deprivation, focused on selective deprivation of only REM sleep. For the treatment of depression with symptoms of melancholy, the combination of total sleep deprivation with light therapy at night turned out to be most effective. It should be noted that with complete sleep deprivation, lethargy and drowsiness are more often observed. In most cases, sleep deprivation is carried out two days later on the third; the therapeutic course includes an average of 5 sessions.

Sleep deprivation, both partial and complete, changes the structure of sleep, lengthens the latency period and reduces the duration of rapid eye movement (REM) sleep. As a rule, an improvement in mood in patients is observed after just one sleepless night, however, this effect is usually short-lived and lasts about three days. Improvement in mood occurs gradually, expressed in the form of a feeling of general relief, a decrease in the feeling of lethargy, apathy, and the disappearance of experiences of mental pain and bitterness.

In prognostic terms, the relationship between the change in the mood of a depressed patient after the first and second sleepless night is important.

The mechanism of the therapeutic effect of sleep deprivation is difficult to reduce only to the simple elimination of one of the phases of sleep or the resynchronization of a time-shifted circadian rhythm. Probably one of the mechanisms for improving the condition of a depressed patient after sleep deprivation is the activation of adrenergic structures.

Light treatment

Non-drug treatment of depression has been tried for more than twenty years using light, hoping to normalize human biological rhythms altered by the disease. Natural ways to treat depression include taking a temporary vacation in the winter to places where there is more daylight and longer hours. In addition, prolonged exposure to the street on sunny days helps overcome depression. Light therapy or phototherapy is most indicated for seasonal mood disorder, especially if episodes of worsening depression occur in the winter or spring seasons. According to some authors, with a course of light therapy from three to fourteen days, the effectiveness of this method reaches 60-70%.

It has been experimentally proven that changes in biological rhythms occur when the patient is illuminated with a light source of increased intensity. Attempts have been made to prevent seasonal exacerbation of affective psychosis by “lengthening the daytime period” using artificial lighting and sleep deprivation.

It is assumed that bright and intense light has a multifaceted effect on the centers of circadian rhythms: suppression of the secretion of the pineal gland hormone melatonin, changes in the concentration of cortisol and adrenocorticotropic hormone, increased synthesis of catecholamines, normalization of the function of the autonomic system. Most experts associate the positive effect of light therapy with an increase in the regulatory function of the cerebral cortex, as well as with the normalization of the activity of the autonomic system.

During light treatment, the patient stays daily, preferably in the morning, for several hours (less than half an hour) in a brightly lit room or next to an intense light source specially designed for this purpose.

It was previously believed that to obtain a therapeutic effect, a room illumination of at least 2600 and no more than 8000 lux was required. Such illumination was achieved by using incandescent lamps located on the ceiling of the chamber at a height of about 2.5 meters. Typically about 30 200 W incandescent lamps were used. It was noted that the effectiveness of light treatment increases when the therapeutic room is painted white or green, as well as when the patient’s body is exposed to the maximum (more than 25%).

Before starting light therapy, the patient is carefully examined, usually paying attention to the state of the autonomic system and indicators of the cardiovascular system.

Long therapy sessions were recommended - from 1.5 to 3 hours, with a total number of sessions - 15, however, it was emphasized that these numbers, as well as the time of the therapy session, should be determined based on the characteristics of the clinical picture of depression. Currently, 30 minute phototherapy sessions are recommended.

Some researchers recommend light treatment at any time of the day, both daily and with two- to three-day breaks. Phototherapy sessions are especially effective in the morning, immediately after waking up.

During the therapy session, patients, who are asked only to keep their eyes closed, are free to move around the room. To avoid getting used to the light, once every 3 minutes. should be looked at periodically for 1 second. on the lamps.

After a therapeutic session, there may be an increase in blood pressure, less often a decrease, probably due to the thermal effect, the body temperature usually increases. Quite often, patients report slight drowsiness. Changes in the R-R interval on the ECG can be a reliable predictor of the effectiveness of light therapy. In some cases, the therapeutic effect is possible both during the session and 2-3 days after its completion.

The most common complications of phototherapy are: insomnia, increased fatigue, irritability, headaches. These complications usually occur in people who try to work hard during light therapy.

It is interesting to note the sensitivity to light therapy in patients with symptoms of anxiety. Patients with symptoms of melancholy and apathy respond to this type of therapy to a lesser extent. Speaking about the mechanism of the therapeutic effect of this therapy, we should emphasize the thermal effect of light. General contraindications to light treatment are cancer and eye pathology.

Currently, special table-top and stationary devices have been developed for non-drug treatment of depression using light. Full spectrum lamps are more effective because they produce light that is close to natural light. To ensure that the patient does not suffer from light treatment, special filters are used that block ultraviolet rays and thereby protect the patient’s retina from intense radiation (prevention of cataracts).

Recent studies have shown that the effectiveness of light exposure is determined by three characteristics: intensity, spectrum and exposure time. In connection with the above, phototherapy techniques are being developed to enrich the light flux with long-wave ultraviolet radiation, which has a biologically active effect. This technique involves using a full-spectrum light source, since it is as close to natural light as possible.

Modern achievements of phototherapy include “artificial dawn” (a special electric lamp at the patient’s bedside that intensifies its illumination before dawn).

Biofeedback

Non-drug treatment methods include biofeedback, which by and large refers to psychotherapeutic methods of treating depression. To carry out this method of treatment, special psychophysiological equipment is used, which implies the possibility of printing various psychophysiological indicators: bioelectric activity of the brain, muscles, heart, galvanic skin response, etc. 20-25 sessions of therapy are carried out, based on the use of biofeedback and aimed at increasing power of alpha waves in the left occipital region. Most patients experienced a 50% reduction in the severity of depressive symptoms.

Therapeutic massage and breathing exercises

Auxiliary methods for treating depression include breathing exercises, therapeutic massage (especially if the onset of depression is triggered by mental trauma) and meditation.

Such breathing on the seashore, in a pine forest, is useful, since such breathing increases the amount of oxygen. The massage is usually performed for 30 minutes and its therapeutic effect is associated with a decrease in stress hormones in the blood. In addition, massage relieves internal tension and normalizes sleep.

Homeopathy

From the point of view of representatives of homeopathy - an alternative medical system based on the principle of “like can be cured by like” and using microdoses of drugs, homeopathy can heal depression, however, there is no scientific evidence of the effectiveness of this non-drug treatment method. A variant of a method of treating depression close to homeopathy is the use of flower remedies.

Phytotherapy

Among natural medicines for the treatment of depression, St. John's wort (Negrustin) is used, however, their effect in the treatment of depression is very insignificant. S-adenosyl-L-methionine (SAM-e) is undergoing clinical trials.

Diet food

The effectiveness of dietary nutrition as a non-drug treatment for depression has also not been confirmed by scientific research. However, it is generally accepted that the diet of a patient with depression must necessarily include complex carbohydrates, which naturally contribute to an increase in the production of serotonin by brain neurons, the deficiency of which during depression (especially with symptoms of anxiety) is well known. Complex carbohydrates are found in legumes and whole grains. An increase in the production of norepinephrine and dopamine - neurotransmitters, the concentration of which is reduced in depression with symptoms of apathy, is promoted by a diet high in protein (beef, poultry, fish, nuts, eggs). At the same time, there is an opposite point of view about the inadmissibility of a high protein content in food that should be consumed when suffering from depression. It is recommended to exclude sugar, alcohol, caffeine, convenience foods and canned food. Foods high in saturated fatty acids are undesirable.