Brain stimulation therapies involve activating or touching the brain directly with electricity, magnets, or implants to treat depression and other disorders. First developed in 1938, electroconvulsive therapy (ECT) for years had a poor reputation with many negative depictions in popular culture. ECT is usually considered only after a patient's illness has not improved after other treatment options, such as antidepressant medication or psychotherapy, are tried. Before ECT is administered, a person is sedated with general anesthesia and given a medication called a muscle relaxant to prevent movement during the procedure. Scientists are unsure how the treatment works to relieve depression, but it appears to produce many changes in the chemistry and functioning of the brain.
A typical course of ECT is administered about three times a week until the patient's depression lifts (usually within six to 12 treatments). The most common side effects associated with ECT are headache, upset stomach, and muscle aches. Research has found that memory problems seem to be more associated with the traditional type of ECT called bilateral ECT, in which the electrodes are placed on both sides of the head. Vagus nerve stimulation (VNS) works through a device implanted under the skin that sends electrical pulses through the left vagus nerve, half of a prominent pair of nerves that run from the brainstem through the neck and down to each side of the chest and abdomen. A device called a pulse generator, about the size of a stopwatch, is surgically implanted in the upper left side of the chest.
Typically, electrical pulses that last about 30 seconds are sent about every five minutes from the generator to the vagus nerve. The device also can be temporarily deactivated by placing a magnet over the chest where the pulse generator is implanted. Repetitive transcranial magnetic stimulation (rTMS) uses a magnet instead of an electrical current to activate the brain.
In October 2008, rTMS was approved for use by the FDA as a treatment for major depression for patients who have not responded to at least one antidepressant medication. Unlike ECT, in which electrical stimulation is more generalized, rTMS can be targeted to a specific site in the brain.
Not all scientists agree on the best way to position the magnet on the patient's head or give the electromagnetic pulses.
Deep brain stimulation (DBS) was first developed as a treatment for Parkinson's disease to reduce tremor, stiffness, walking problems and uncontrollable movements.
DBS has only recently been studied as a treatment for depression or obsessive compulsive disorder (OCD). After the electrodes are implanted and the patient provides feedback about the placement of the electrodes, the patient is put under general anesthesia. Because the procedure is still experimental, other side effects that are not yet identified may be possible. Brain stimulation therapies hold promise for treating certain mental disorders that do not respond to more conventional treatments. Other researchers are studying how the brain responds to VNS by using imaging techniques such as PET scans. 1 Kellner CH, Knapp RG, Petrides G, Rummans TA, Husain MM, Rasmussen K, Mueller M, Berstein HJ, O-Connor K, Smith G, Biggs M, Bailine SH, Malur C, Yim E, McClintock S, Sampson S, Fink M. 5 George MS, Sackeim HA, Rush AH, Marangell LB, Nahas Z, Husain MM, Lisanby S, Burt T, Goldman J, Ballenger JC. 8 Janicak PG, O-Reardon JP, Sampson SM, Husain MM, Lisanby SH, Rado JT, Heart KL, Demitrack MA. 11 Mayberg HS, Lozano AM, Voon V, McNeely HE, Seminowicz D, Hamani C, Schwalb JM, Kennedy SH. 12Greenberg BD, Malone DA, Friehs GM, Rezai AR, Kubu CS, Malloy PF, Salloway SP, Okun MS, Goodman WK, Rasmussen SA.
The National Institute of Mental Health (NIMH) is part of the National Institutes of Health (NIH), a component of the U.S.
Electroconvulsive therapy is the most researched stimulation therapy and has the longest history of use. However, the procedure has improved significantly since its initial use and is safe and effective. It is most often used to treat severe, treatment-resistant depression, but occasionally it is used to treat other mental disorders, such as bipolar disorder or schizophrenia.


An anesthesiologist monitors breathing, heart rate and blood pressure during the entire procedure, which is conducted by a trained physician. Because the patient is under anesthesia and has taken a muscle relaxant, the patient's body shows no signs of seizure, nor does he or she feel any pain, other than the discomfort associated with inserting an IV.
After that, maintenance ECT treatment is sometimes needed to reduce the chance that symptoms will return.
Some people may experience memory problems, especially of memories around the time of the treatment.
Unilateral ECT, in which the electrodes are placed on just one side of the head—typically the right side because it is opposite the brain's learning and memory areas—appears less likely to cause memory problems and therefore is preferred by many doctors. The vagus nerves carry messages from the brain to the body's major organs like the heart, lungs and intestines, and to areas of the brain that control mood, sleep, and other functions. However, it became evident that it also had effects on mood, especially depressive symptoms. Food and Drug Administration (FDA) approved VNS for use in treating major depression in certain circumstances—if the illness has lasted two years or more, if it is severe or recurrent, and if the depression has not eased after trying at least four other treatments. Connected to the pulse generator is a lead wire, which is guided under the skin up to the neck, where it is attached to the left-side vagus nerve. The duration and frequency of the pulses may vary depending on how the generator is programmed. A person may want to deactivate it if side effects become intolerable, or before engaging in strenuous activity or exercise because it may interfere with breathing. There may be complications such as infection from the implant surgery, or the device may come loose, move around or malfunction, which may require additional surgery to correct. First developed in 1985, rTMS has been studied as a possible treatment for depression, psychosis and other disorders since the mid-1990's. It is also used in countries such as in Canada and Israel as a treatment for depression for patients who have not responded to medications and who might otherwise be considered for ECT.
Scientists believe that focusing on a specific spot in the brain reduces the chance for the type of side effects that are associated with ECT. An electromagnetic coil is held against the forehead near an area of the brain that is thought to be involved in mood regulation. They also do not yet know if rTMS works best when given as a single treatment or combined with medication. Like rTMS, it uses a magnetic pulse instead of electricity to stimulate a precise target in the brain. Studies on both animals and humans have found that MST produces fewer memory side effects, shorter seizures, and allows for a shorter recovery time than ECT.9,10 However, its effect on treatment-resistant depression is not yet established. In DBS, a pair of electrodes is implanted in the brain and controlled by a generator that is implanted in the chest. The head is shaved and then attached with screws to a sturdy frame that prevents the head from moving during the surgery. From there, the surgeon threads a slender tube down into the brain to place electrodes on each side of a specific part of the brain. The electrodes are then attached to wires that are run inside the body from the head down to the chest, where a pair of battery-operated generators are implanted. Finally, although DBS as a depression treatment is still very new, researchers are beginning to conduct studies with people to determine its effectiveness and safety in treating depression, OCD and other mental disorders. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from CORE. Transcranial magnetic stimulation in the treatment of depression: a double-blind placebo-controlled trial. Double-blind controlled investigation of bilateral prefrontal transcranial magnetic stimulation for the treatment of resistant major depression. Transcranial magnetic stimulation in the treatment of major depressive disorder: a comprehensive summary of safety experience from acute exposure, extended exposure, and during reintroduction treatment. Safety and feasibility of magnetic seizure therapy (MST) in major depression: randomized within-subject comparison with electroconvulsive therapy.
Differential effects of high-dose magnetic seizure therapy and electroconvulsive shock on cognitive function.
Three-year outcomes in deep brain stimulation for highly resistant obsessive compulsive disorder.


Other stimulation therapies discussed here — vagus nerve stimulation, repetitive transcranial magnetic stimulation, magnetic seizure therapy, and deep brain stimulation—are newer, more experimental methods.
ECT maintenance treatment varies depending on the needs of the individual, and may range from one session per week to one session every few months. People may also have trouble remembering information learned shortly after the procedure, but this difficulty usually disappears over the days and weeks following the end of an ECT course. Using brain scans, scientists found that the device affected areas of the brain that are also involved in mood regulation. Despite FDA approval, VNS remains a controversial treatment for depression because results of studies testing its effectiveness in treating major depression have been mixed. More research, including a large NIMH-funded trial, is underway to determine the safest and most effective use of rTMS.
So far, very little research has been conducted to test DBS for depression treatment, but the few studies that have been conducted show that the treatment may be promising. From here, electrical pulses are continuously delivered over the wires to the electrodes in the brain.
For example, researchers continue to look for ways to reduce the side effects of ECT while retaining the benefits.
Through the electrodes, an electric current passes through the brain, causing a seizure that lasts generally less than one minute. Frequently, a person who underwent ECT will take antidepressant medication or a mood stabilizing medication as well.
The pulse generator, which operates continuously, is powered by a battery that lasts around 10 years, after which it must be replaced.
The magnetic pulse easily passes through the skull, and causes small electrical currents that stimulate nerve cells in the targeted brain region.
It is also possible that the procedure could cause a seizure, although documented incidences of this are uncommon. This area has been found to be overactive in depression and other mood disorders.11 In the case of OCD, the electrodes are placed in a different part of the brain believed to be associated with the disorder. Although it is unclear exactly how the device works to reduce depression or OCD, scientists believe that the pulses help to "reset" the area of the brain that is malfunctioning so that it works normally again.
Normally, a person does not feel any sensation in the body as the device works, but it may cause coughing or the voice may become hoarse while the nerve is being stimulated.
And because this type of pulse generally does not reach further than two inches into the brain, scientists can select which parts of the brain will be affected and which will not be.
A recent large-scale study on the safety of rTMS found that most side effects, such as headaches or scalp discomfort, were mild or moderate, and no seizures occurred.8 Because the treatment is new, however, long-term side effects are unknown. Therefore, like ECT, the patient must be anesthetized and given a muscle relaxant to prevent movement. Patients are awake during the procedure to provide the surgeon with feedback, but they feel no pain because the head is numbed with a local anesthetic. The magnetic field is about the same strength as that of a magnetic resonance imaging (MRI) scan. The goal of MST is to retain the effectiveness of ECT while reducing the cognitive side effects usually associated with it.
Generally, the person will feel a slight knocking or tapping on the head as the pulses are administered.
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