Gemeinsamkeiten und Unterschiede der therapeutischen transkraniellen Magnetstimulation und der Elektrokrampftherapie

Zusammenfassung

Die Elektrokrampftherapie (EKT) ist ein etabliertes Verfahren zur Behandlung von therapieresistenten Depressionen, während die transkranielle Magnetstimulation (TMS) über dem präfrontalen Kortex zurzeit als experimentelle Behandlungsform dieser Erkrankung gilt. Beide Therapieverfahren, die EKT und die TMS, induzieren intrakortikal ein elektrisches Feld. Dieses Feld führt zu einer neuronalen Depolarisation unter der Spule und zu Fernwirkungen via Projektionen zum anterioren Cingulum und ventralen Striatum sowie anderen tiefer gelegenen Hirnstrukturen. Ein wesentlicher Unterschied ist das subkonvulsive Prinzip der TMS, während die EKT per definitionem einen generalisierten Krampfanfall induziert und somit eine Narkose und Muskelrelaxation benötigt. Die TMS-induzierten Effekte auf den Hypothalamus und Hirnstamm sind im Vergleich zur EKT wesentlich schwächer ausgeprägt, was eventuell die geringere antidepressive Wirksamkeit begründen könnte. Die TMS verursacht andererseits weder passagere noch anhaltende kognitive Nebenwirkungen, sodass die Akzeptanz der TMS bei den Patienten entsprechend hoch ist. Die TMS ist kostengünstiger und kann ambulant durchgeführt werden. Größere Multicenter-Studien könnten helfen, die antidepressive Wirksamkeit dieser subkonvulsiven Technik zu beweisen und das alte Dogma der EKT-Forschung, nur generalisierte Krampfanfälle seien wirksam, zu überwinden.

Summary

Electroconvulsive therapy (ECT) is proven to be a highly effective antidepressant therapy, whereas at this time prefrontal therapeutic transcranial magnetic stimulation (TMS) should be considered as an experimental treatment for major depression. Both induce an intracortical electric field. The TMS acts subconvulsive by a localised depolarisation of a set of neurones which project to limbic structures like the anterior cingulum and ventral striatum, involved in affective processes. The ECT by definition induces a generalized seizure, therefore requiring a short anesthesia with muscle relaxation. The TMS-effects on the hypothalamus and brainstem are less pronounced than in ECT or electroconvulsive shock (ECS) in the animal models. This lack of autonomous and consistent hormonal effects of TMS to the prefrontal cortex may be responsible for its minor therapeutic effect especially in psychotic depression compared to the right unilateral ECT and bilateral ECT. TMS, however, does not induce any temporary or persistent cognitive side effects, rendering this technique highly acceptable to patients and psychiatrists. Multi-center studies of the antidepressive TMS-effects may help to overcome the old ECT-dogma that there is no clinical benefit without a sufficient generalized seizure.

Schlüsselwörter

Transkranielle Magnetstimulation - Elektrokrampftherapie - Wirkmodelle - psychotische Depression - kognitive Nebenwirkungen - »magnetic seizure therapy«

Keywords

Transcranial magnetic stimulation - electroconvulsive therapy - electroconvulsive shock - psychotic depression - cognitive side effects - models of action - magnetic seizure therapy

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