Depression: Vagus Nerve Stimulation (VNS)

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Depression: Vagus Nerve Stimulation (VNS)




Guest:  Dr. Ziad Nahas – Psychiatry & Behavioral Sciences

Host:  Dr. Linda Austin – Psychiatry


Dr. Linda Austin:  I’m Dr. Linda Austin.  I’m interviewing Dr. Ziad Nahas who is Associate Professor of Psychiatry and Director of the Mood Disorders Clinic here at the Medical University of South Carolina.  Dr. Nahas, let’s talk about VNS, vagal nerve stimulation.  What is VNS?


Dr. Ziad Nahas:  Vagus nerve stimulation is, essentially, a brain stimulation technology by which a pacemaker is delivers electrical stimulation to the vagus nerve, a nerve that runs down by the main blood vessels in the neck.  We take advantage of the vagus being primarily a nerve that takes information from the periphery of the body into the brain to then carry on information with the type of stimulation we deliver.  So, ultimately, the effect, although we’re stimulating a rather peripheral nerve, is happening in the brain. 


The device and the technology was first tested in the 90s for treatment of refractory epilepsy and showed that it had a clinically significant effect on regulating the number of seizures and being an adjunctive valuable therapeutic intervention.  And then, shortly after that, in the late 1990s, it got tested for depression.  Actually, the first implant took place here at MUSC.  And since then, there were larger studies and multicenter trials, some equivocal results but, ultimately, an FDA approval.  And it is considered the only brain stimulation technology and the only antidepressant treatment, actually, that is indicated for the treatment of depression.


Dr. Linda Austin:  Who is a good candidate for this treatment?


Dr. Ziad Nahas:  Obviously, because of the nature and the invasiveness, it still requires surgery.  Although it’s not brain surgery, it’s still rather invasive.  One would need to document a substantial level of treatment for depression.  And what we mean by that is that not only at the time you’re being evaluated, you’re severely ill, in terms of the type of symptoms you’re exhibiting, but that you’ve been treated with different treatment that is classically known to be reasonable treatment for depression, at a good enough dose for a long enough period of time, you took some without having too many side effects, and then you still failed.  And, at least in our clinic, we have put the benchmark for different failed antidepressants and a current depressive episode such that we feel that we have enough documentation for the necessity to move forward into a more aggressive treatment.


Dr. Linda Austin:  And, of those patients who by definition are pretty sick people and pretty resistant to treatment, what percentage have at least some response to VNS?


Dr. Ziad Nahas:  Well, with the treatment trials, the results I mention earlier were a little bit equivocal because, at the three-month benchmark, VNS really did not do better than other treatment.  However, at one year, it showed about a 30 percent response.  And when you compare its response to equally severe patients being clinically managed by their psychiatrist, VNS, added to their ongoing treatment, doubled their chances of getting better.  So then, by one year, if you are implanted with the device, you have a one in three chance of getting better. But, it’s two times better than if you were to not get the treatment.


Dr. Linda Austin:  If a patient were interested in getting this treatment, where would they go at MUSC?


Dr. Ziad Nahas:  We have set up the Mood Disorder Clinic primarily to act as a first clinical translation to the new technologies for depressed patients.  So, at MUSC, we have the Mood Disorder Clinic, in which we mainly deal with tertiary referrals and kind of a second opinion evaluation for the treatment of depression, in which we can evaluate patients for their candidacy for vagus nerve stimulation.


The procedure, primarily, requires contacting the scheduling office of the Institute of Psychiatry and formally stating that a patient is interested in a vagus nerve stimulation evaluation.  The person taking that call will then know how to direct them and essentially get them hooked up with our nurse who would primarily do, first, a phone screening, to give them an idea of the approach and the needed documentation.  We try to do a lot of homework because, as we said, this is a rather invasive procedure, and we need to show the necessity to move forward.  And then we ultimately do an evaluation face-to-face. 


The concern, really, lies in the hesitancy by the insurance company to readily pay for the procedure.  This is rather costly.  And because of some of the earlier equivocal results that I mentioned, the insurance companies, in general, have said that this is still experimental despite the fact that is has US FDA approval.  Aside from having clinical evaluation to see if the patient really would benefit from this, there’s also the financial hurdle of either having to consider paying out-of-pocket or going through quite a bureaucratic phenomenon to essentially get the preauthorization required from an insurance carrier.  We have been lucky in getting those, but it’s not an easy route. 


Dr. Linda Austin:  Do you know how much it costs if you pay out-of-pocket?


Dr. Ziad Nahas:  At MUSC, we have a flat rate of $28,000.  That will cover the cost of the surgery evaluation, the surgery itself, and the implanted device.  It does not cover the initial evaluation from the clinical psychiatric stand point, nor the follow-ups for maintaining and monitoring the vagus nerve stimulation throughout.


Dr. Linda Austin:  Thank you so much.


Dr. Ziad Nahas:  You’re welcome.


If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection:  (843) 792-1414.

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