When treatments such as medication and therapy aren’t able to relieve the symptoms of depression or another mental health condition, there are other options available. A psychiatrist might suggest electroconvulsive therapy (ECT) or other forms of brain stimulation. Brain stimulation therapies involve stimulating the brain directly with electricity, magnets or implants.
Electroconvulsive Therapy (ECT)
ECT is a non-invasive medical treatment that is most often used with individuals who have a serious mental illness, such as major depression or bipolar disorder. It’s performed under anesthesia and involves using small electric currents to trigger a brief, controlled seizure in the brain. ECT appears to create changes in brain chemistry that can quickly improve certain mental health symptoms.
Although ECT is effective, it’s under used as a treatment option. This is possibly due to factors such as stigma and misinformation, lack of availability, or concerns over side effects. The reality of treatment with ECT is very different than it was decades ago, when it was in the early stages of development. As with any treatment approach, the goal is to provide the highest benefit with the least amount of risk, and ECT has since emerged as a safe and effective option.
Treatment with ECT occurs in a series, usually a couple of times a week. People are asleep during the procedure and wake up about 5-10 minutes after it has finished. They are able to resume normal activity in about an hour. Some people receive occasional ''maintenance ECT" treatments after they complete their initial series. Between 70 and 90% of individuals who receive ECT treatment report an improvement in their depression.
Side effects of ECT are usually mild and may include:
- Headaches, muscle soreness, or nausea
- Short-term memory loss (may occur during treatment and tends to be brief)
- Longer-term memory loss (rarely permanent)
Find out more about ECT and hear personal stories from those who have used this treatment option.
Transcranial Magnetic Stimulation (TMS)
TMS is a non-invasive treatment that uses magnetic fields to stimulate nerve cells in the brain. TMS is safe and effective, and is used to treat a range of mental and physical health conditions, including depression, obsessive compulsive disorder, PTSD, pain and substance use disorders, and others. This can be particularly important for individuals who have not benefitted from other treatments. For example, 30-64% of patients report an improvement in symptoms of depression.
During TMS, an electromagnetic coil is placed on a person’s scalp near their forehead. Short magnetic pulses are painlessly directed into an area of the brain that controls moods. The doctor performing the treatment will determine the amount of magnetic energy needed during the first treatment session. TMS treatments usually last between 40-60 minutes. TMS does not require the use of anesthesia and person remains awake during treatment. Like ECT, several sessions occur over a period of weeks. Rapidly administered pulses are called repetitive TMS (rTMS), and can provide longer lasting changes in brain activity. You may see treatment referred to interchangeably as TMS or rTMS.
There are few reported side effects of TMS, which are usually mild and diminish over the course of treatment. The most commonly reported side effect is headache. Less commonly, people report scalp pain or facial twitching. The most serious risk of TMS is seizures, however current evidence suggests the risk of seizures is very rare (about 0.03%), with no evidence of permanent damage.
Other Brain Stimulation Therapies
ECT and TMS are the most widely used brain stimulation therapies, but there are two other options available: Vagus Nerve Stimulation and Deep Brain Stimulation [VNS and DBS]. Research continues to accumulate, offering insight to these treatment options.
Vagus Nerve Stimulation (VNS)
The vagus nerve carries messages between your brain and other areas of your body, controlling important functions such as heart rate, digestion, immune response, and moods. Treatment with VNS involves the use of a pulse generator, about the size of a stopwatch, that’s placed in the upper left side of the chest to stimulate the vagus nerve.
VNS alters nerve activity in the body by sending mild electrical pulses through the vagus nerve to the brainstem. This pulse is then sent throughout the brain to change the way brain cells function, much like a pacemaker. VNS has been used for decades to treat seizure disorders, as well as for treatment-resistant depression.
Historically, VNS for treatment-resistant depression wasn't covered by insurance providers, making this treatment option out of reach for most people. However, in 2019 the Center for Medicare and Medicaid Services began allowing coverage for participants through a randomized controlled trial in 100 study sites across the US.
Stimulation usually occurs without the person feeling it, but it can sometimes cause tingling in the skin, mild cough, voice changes, or hoarseness when stimulation is active. Side effects that are troubling can be addressed with a change to stimulation settings.
More studies are needed on the effectiveness of VNS for treatment-resistant depression, given that other forms of stimulation such as TMS and ECT have provided more supporting research on their effectiveness. However, current VNS study results appear promising, with estimates ranging from a 50-70% response rate.
A non-invasive version of VNS is also being investigated, known as transcutaneous auricular VNS, or taVNS. One such device has already been approved by the FDA for treating migraine and cluster headaches. Another version of taVNS has received a Breakthrough Device Designation by the FDA for the treatment of PTSD.
Deep Brain Stimulation (DBS)
Deep brain stimulation (DBS) is used to treat symptoms of movement disorders, such as tremors associated with Parkinson’s disease, and conditions like dystonia and treatment-resistant epilepsy. DBS is also used to treat severe obsessive-compulsive disorder (OCD) that hasn’t responded to traditional treatment. Although DBS is used less frequently for OCD, studies indicate that it can be effective for debilitating symptoms.
More recently, DBS is being studied as a potential treatment for Tourette’s syndrome, as well as for psychiatric conditions such as treatment-resistant depression associated with major depression and bipolar disorder. More information is needed on its effectiveness for these conditions, though studies involving severe and highly treatment-resistant depression have been encouraging. A promising area of research focuses on the use of DBS to target specific symptoms and brain circuits to develop unique, patient-tailored treatments. This approach has in part led to improvements in effectiveness for treating other conditions, including OCD.
DBS involves one or more tiny wires, or electrodes, that are surgically placed in the brain. These electrodes are connected to a very small pulse generator that is placed in the chest. There are possible side effects from surgery, or from the stimulation itself. Surgical side effects may include infection, headache, confusion, or hardware complications. Side effects related to stimulation may include numbness or tingling, tightness in facial or arm muscles, speech problems, unwanted mood changes, or lightheadedness. Once the device is ready to be used for stimulation, treatment providers work with individuals to establish device settings, and make further adjustments. This process can take weeks or up to a few months, and is designed to help find the best stimulation level for symptom relief, as well as for reducing any side effects that are experienced.