When you hear the words “electroconvulsive therapy,” you might picture the scene in One Flew Over the Cuckoo’s Nest where Jack Nicholson’s character, Randle Patrick McMurphy, is subjected to barbaric, unjustified shock treatment as a punishment rather than as a mental health therapy. Cultural depictions like this have attached a stigma to electroconvulsive therapy (ECT) and other brain stimulation treatments, but the reality is quite different. For starters, people getting ECT are sedated—Randle wasn’t—to prevent them from feeling any pain. Instead, ECT and other brain stimulation therapies are used today to relieve the emotional pain that can come with conditions like depression.
It’s estimated that around 30 percent of people with depression don’t respond to typical antidepressants. This is known as treatment-resistant depression, and brain stimulation therapies can be life-changing for people who experience it.
“Brain stimulation therapies involve the application of [electric] energy over specific brain regions to modulate the function of neural circuits,” Joshua Berman, M.D., Ph.D., assistant professor of psychiatry at Columbia University Irving Medical Center, tells SELF. This can help alleviate symptoms of depression or other mental illnesses that aren’t responding to typical treatments, such as bipolar disorder.
The five main types of brain stimulation therapies used to treat mental illness are electroconvulsive therapy, vagus nerve stimulation, deep brain stimulation, repetitive transcranial magnetic stimulation, and magnetic seizure therapy. Let’s explore what they are, how they work, and their potential risks.
Electroconvulsive therapy (ECT)
In addition to severe or treatment-resistant depression, ECT may be used to treat conditions like schizophrenia and bipolar disorder if you’re not responding to treatment or if you need extremely prompt treatment due to suicidal ideation, according to the Mayo Clinic. While many insurers currently cover ECT to treat certain conditions, the FDA proposed changing the classification of ECT devices back in 2015 from class III medical devices to class II medical devices, while also putting certain restrictions on who should use the therapy (due to potential risks, which we'll discuss in a bit). That proposed reclassification is still ongoing.
So, let’s say your medical care team has decided you’re a good candidate for ECT. In each session, you’ll be anesthetized to prevent pain and given a muscle relaxant, the National Institute of Mental Health (NIMH) explains. Then, doctors will expose you to a direct electrical current via electrodes on your scalp. The current triggers a short seizure, usually under a minute long. Again, you shouldn’t feel any discomfort, which might be hard to believe. But that’s the beauty of anesthesia.
Five to 10 minutes later, you’ll wake up and should be able to get back to your usual activities within an hour, according to the NIMH. Although it obviously depends on what your doctor thinks is best, a person receiving ECT will typically get a few treatments a week and may experience less severe depression (or other mental health symptoms) within six to 12 treatments.
“We don't know the exact mechanisms by which ECT works,” Dr. Berman says. One theory holds that the seizures change blood flow in various parts of the brain such as the amygdala, which is linked with your emotions. There’s also evidence that ECT affects neurotransmitters that impact your mood, like serotonin and dopamine, which some antidepressants also target. The difference is that ECT seems to engage the same brain systems as conventional antidepressants more powerfully and possibly more quickly as well, Dr. Berman explains.
The most common side effects someone might experience after ECT are headaches, an upset stomach, muscle aches, and memory loss, the NIMH says. The memory loss might sound alarming, but it’s usually temporary, and it seems to be less severe if the ECT electrodes are on just one side of the head instead of both. This is known as unilateral ECT, and it’s the more modern take on bilateral ECT, the older form of the treatment that is linked with more intense memory issues, the NIMH says.
Vagus nerve stimulation (VNS)
Vagus nerve stimulation was initially developed as a treatment for the seizure disorder epilepsy, and in a happy accident, scientists discovered that it could help with depression as well, the NIMH explains. So, the FDA approved VNS for treatment-resistant depression in 2005.
Although VNS is a brain stimulation treatment, it actually starts outside your head. If you’re getting this kind of therapy, doctors will surgically implant a tool called a pulse generator into the upper left portion of your chest, the NIMH explains. An electrical wire connects the pulse generator to your vagus nerve, which runs from your brain through your neck and into your chest and abdomen. From its command center in your chest, the pulse generator will send bursts of electric currents to your brain every couple of minutes. Pulse generators typically work for around 10 years before they need to be replaced, the NIMH says.
It appears as though VNS can improve issues like severe depression by changing levels of neurotransmitters in your brain including serotonin, norepinephrine, GABA, and glutamate, the NIMH explains. A 2018 study published in The Journal of Clinical Psychiatry analyzed quality of life reports from 599 people with treatment-resistant depression, finding that those who combined VNS with other antidepressant treatments experienced significant improvements in their quality of life, even if their symptoms didn’t disappear completely.
That points to an important fact about VNS: Anyone receiving it will need to continue their other treatments (like taking antidepressants), the NIMH explains. Even so, it can take months to see a difference when using VNS, and the device could shift or malfunction, which may require more surgery.
Doctors don’t know of long-term side effects of VNS, but short-term ones include voice changes, neck pain, a cough or sore throat, discomfort or tingling in the chest, breathing issues (particularly during exercise), and trouble swallowing, according to the NIMH. Your doctor should give you a special magnet you can hold over the pulse generator to stop it temporarily if the side effects are really bothersome, the Mayo Clinic explains.
The NIMH notes that some people’s conditions get worse after they try VNS, not better. It’s not a surefire fix, which is why it’s only recommended for cases in which a person’s depression hasn’t abated after trying at least four other treatments, the NIMH says.
Deep brain stimulation (DBS)
This started as a treatment for Parkinson’s disease, according to the American Association of Neurological Surgeons. Then doctors realized it shows promise for easing depression and obsessive compulsive disorder, too. (DBS is FDA-approved for OCD, but not yet for depression.)
Like VNS, deep brain stimulation uses pulse generators in the chest to send electrical pulses to the brain. Unlike VNS, which delivers stimulation in bursts, DBS involves more continuous stimulation, the NIMH explains, but you should be able to customize the exact frequency with your doctor’s help. DBS also involves surgery to place two electrodes on either side of the brain and two generators in your chest.
If you’re getting DBS, you’ll actually be awake for the brain surgery, which, yes, sounds terrifying. But anesthesia will numb your head, and your brain doesn’t actually feel pain (nerves in other parts of your body transmit pain messages to your brain). Being awake for this part shouldn’t hurt, and it gives your doctors a chance to ask you questions so they can make sure they’re targeting the right areas of your brain.
It seems as though the DBS pulses “reset” the parts of the brain that are causing symptoms, the NIMH explains. For instance, if you have treatment-resistant depression, doctors might target your subgenual cingulate cortex, which is implicated in depression, along with other portions of your brain. If OCD is your issue, they might focus on a part of the brain called the ventral capsule/ventral striatum.
Even though you won’t actively feel pain during the brain surgery to get the DBS device, you can experience related side effects such as infection, confusion, mood changes, movement issues, lightheadedness, trouble sleeping, and in more severe cases, brain bleeding or stroke, the NIMH says. And the stimulation could cause numbness and tingling, muscle tightness in the face or arm, speech and balance issues, lightheadedness, and mood changes, according to the Mayo Clinic.
It’s pretty unfortunate that mood changes are a potential side effect of both brain surgery and stimulation meant to address mood-related mental illnesses. That goes to show that, like the other therapies on this list, deep brain stimulation may be helpful—but isn’t perfect.
Repetitive transcranial magnetic stimulation (rTMS)
In 2008, repetitive transcranial magnetic stimulation (rTMS) was approved by the FDA as a treatment for people with depression who aren’t responding to antidepressants. In August 2018, approval was expanded to include treatment of obsessive compulsive disorder.
A less invasive brain stimulation therapy than the above options, rTMS uses an electromagnetic coil to deliver short electromagnetic pulses to specific areas of the brain for 30 to 60 minutes, the NIMH explains. This is typically administered five times a week for four to six weeks, according to the Mayo Clinic.
If you’re getting this treatment, you’ll be awake during each session and shouldn’t feel any serious pain; the pulses pass seamlessly from the coil through your skull into your brain. You might feel a knocking or tapping sensation as this happens, though.
“[rTMS] is very well-tolerated, and there are no cognitive side-effects such as memory loss associated with it,” Irving Michael Reti, M.B.B.S., M.D., associate professor of psychiatry and behavioral sciences at The Johns Hopkins University and director of the Brain Stimulation Program at The Johns Hopkins Hospital, tells SELF.
Instead, possible side effects include tingling or tightness in the muscles of the scalp, jaw, and face, the NIMH says. You might also feel some discomfort at the stimulation site and a headache during or after the procedure. A much rarer potential side effect is seizures, meaning rTMS may not be appropriate for people at high risk such as those with epilepsy, a history of head injury, or other serious neurologic issues.
A NIMH study of 190 people published in Archives of General Psychiatry in 2010 found that 14 percent of people who got rTMS experienced less intense depression compared with 5 percent who received what was essentially a fake treatment. The second phase of the trial allowed everyone (including those who got the fake treatment) to try rTMS, and around 30 percent of study subjects experienced less intense depressive symptoms. Although it’s a small study, it’s promising.
However, the NIMH notes that doctors still aren’t sure which parts of the brain are best to target and whether rTMS is most effective on its own or when added to a regimen of more conventional treatments, like therapy and medication, so more research is required.
Magnetic seizure therapy (MST)
One of the newest brain stimulation therapies, magnetic seizure therapy (MST) is something of a mix between electroconvulsive therapy and repetitive transcranial magnetic stimulation. Like ECT, MST induces a seizure, but like rTMS, it does so by using magnetic pulses over specific parts of the brain involved with mental illness instead of electrical currents. Since these pulses are more intense than they are with rTMS, if you’re having MST, you’ll need to be anesthetized and given a muscle relaxant as though you were undergoing ECT. As of now, the only known side effects are those that come with anesthesia and seizure induction, the NIMH says.
MST was developed to address remaining concerns about the effects of other brain stimulation therapies on cognition. A 2015 review in Neural Plasticity looked at eight different studies on MST, depression, and bipolar disorder, ultimately finding that 40 to 60 percent of people with treatment-resistant depression responded to MST, 15 to 30 percent experienced significant relief from depressive symptoms, and that this could be helpful in treating bipolar depressive episodes. The review also found that people were able to recover more quickly after receiving MST than receiving ECT and that it didn’t come with the same level of cognitive risk as ECT when it comes to functions such as memory. Although that’s all exciting, experts aren’t yet sure of a standard protocol for how often to administer MST for mental health conditions, the NIMH explains, and it hasn't yet been FDA-approved for that purpose.
Science has only scratched the surface when it comes to the potential of brain stimulation therapies to treat mental illness.
While they may not be a first-line treatment for depression and other psychiatric disorders, they may offer promise when other treatment methods don’t work. If you think you may be a good candidate for one of these treatments, get in touch with a mental health professional who can walk you through which option may be best for you, how much your insurance may be able to help, and what you can expect from your new treatment regimen.