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Brain Stimulation Therapy: Psychiatry Services

Symptoms of treatment-resistant mood disorders that do not improve with standard medication and talk therapy can often be relieved using brain stimulation treatments.i Brain stimulation therapies involve activating or inhibiting specific brain areas with a mild electrical current or a magnetic field.ii Several FDA-approved brain stimulation therapies are shown to be effective in treating a range of conditions including major depression, bipolar disorder, obsessive-compulsive disorder, schizophrenia, and nicotine/tobacco addiction.iii

Treatment-resistant depression is one of the most common mental illnesses that can be treated with brain stimulation. It's estimated that about 21 million adults (approximately 8% of all US adults) experienced one or more major depressive episodes in 2020.iv While many people manage their depression effectively with antidepressant medications and talk therapy, others find that standard care only provides temporary or partial relief.

Brain stimulation can also be helpful for treatment-resistant bipolar disorder (cyclical mood swings between depression and mania or agitation) and obsessive-compulsive disorder (anxiety with repetitive, intrusive thoughts and behaviors).v,vi

While symptoms vary based on your specific diagnosis and unique characteristics, common signs of a treatment-resistant mental health condition include having symptoms that:

  • Continue despite treatment
  • Return after treatment resolved them for a period time
  • Prevent you from functioning in daily life (eg, eating, bathing, working, studying, socializing)
  • Frighten or disturb you (eg, seeing or hearing things that are not there)
  • Include thoughts of harming yourself or others

If you notice any of these signs, please make an appointment to talk to a mental health professional.

The Brain Stimulation team at the MUSC Institute of Psychiatry are experts in identifying and managing hard-to-treat mental health conditions. They will talk to you about your options and goals, and work with other specialists across MUSC to design the best treatment plan for you.

Usually, managing treatment-resistant mental health conditions with brain stimulation calls for combining it with other traditional therapies such as medication and one-on-one or group psychotherapy (talk therapy). Your personalized treatment plan will be customized to fit your individual condition, symptoms, general health, goals, and lifestyle.

Your treatment options may also include the possibility of receiving a unique, new therapy through one of our clinical trials. Participating in clinical trials allows the Brain Stimulation Service at MUSC Health to offer our patients treatments that are not available at other medical centers.

The Institute of Psychiatry at MUSC Health is a national leader in brain stimulation therapy. Our team published the first use of Transcranial Magnetic Stimulation (TMS) for depression and performed the nation’s first Vagus Nerve Stimulation (VNS) implant for depression, first Epidural Prefrontal Cortical Stimulation (EpCS), and one of the first Focal Electrically-Administered Seizure Therapies (FEAST).

As the only comprehensive Brain Stimulation Service in South Carolina, our highly trained specialists give you access to the latest mental health treatment innovations, including clinical trials, advanced surgical techniques, and family - and patient-centered support services. You are in good hands with our nationally top-ranked experts in clinical care and academic research.

Common Questions

Brain stimulation therapy may be used when standard treatments such as medication and psychotherapy (talk therapy) can’t relieve the most severe symptoms of a mental health condition. There are several types of brain stimulation therapies which all involve directly activating or inhibiting certain areas of your brain using implanted electrodes or an external magnetic field. They work by disrupting abnormal nerve signals that are thought to cause mental health dysfunction. Some types of brain stimulation therapy, like electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS), are administered externally in several clinic visits over a period of a few weeks. Other types, like deep brain stimulation (DBS) and vagus nerve stimulation (VNS), require surgery to implant devices that provide continuous pulses of electrical stimulation. Although these therapies are not as common as medications and psychotherapy, they are often effective in treating mental disorders that have not responded to standard care.viii

There are several stimulation therapies available:

  • Electroconvulsive therapy (ECT) has been used the longest and is the best studied brain stimulation treatment. It is used for severe depression, bipolar disorder, and schizophrenia, and on a case-by-case basis to help people at risk for suicide or with catatonia (disconnection from the outside world). In ECT, the person is put under general anesthesia to avoid any discomfort and electrodes are placed on the head in precise locations. A low-voltage current passes through the brain and causes a brief (less than 1 minute) seizure. It is not painful, and the person wakes up about 10 minutes later. Within an hour, most people can go back to their normal daily activities.ix
  • Repetitive transcranial magnetic stimulation (rTMS) uses a electromagnetic field instead of electrical current to stimulate targeted brain areas. It has been studied as a treatment for depression, psychosis, anxiety, and other difficult-to-treat mental health conditions. Because it is more specifically targeted and does not require anesthesia, rTMS has fewer side effects than ECT. While the person is awake, an electromagnetic coil is placed against their forehead over brain areas responsible for mood regulation. Short pulses of electromagnetic energy pass into the brain up to a depth of about 2 inches, stimulating nerve cells to reorganize and stabilize their functioning. Patients feel only a mild tapping or knocking in their head from the pulses and can return to normal activities after.x
  • Vagus nerve stimulation (VNS) has long been used to treat epileptic seizures and is now being used in treatment-resistant depression. In VNS, the person undergoes surgery to implant a device under the skin of their chest that sends electrical pulses to one side of the vagus nerve. Because this large nerve carries messages to areas of the brain that regulate mood and sleep among other things, it is implicated in depression, anxiety, and other mental health conditions. Studies indicate that applying electrical pulses to the left vagus nerve has a positive impact on levels of brain chemicals that affect mood (eg, serotonin, norepinephrine, GABA, and glutamate). Most people feel nothing when the device delivers a pulse which usually occurs once every five minutes. The battery in the pulse-generator lasts about 10 years, and then needs to be replaced.xi
  • Deep brain stimulation (DBS) is a newer therapy for treating severe depression or obsessive-compulsive disorder. In DBS, the person undergoes open brain surgery to implant 2 electrodes inside their skull and 2 electrical pulse generators in their chest. Surgeons use MRI images and feedback from the person (who is numbed but awake for the first part of the procedure) to guide the brain implant placements. What specific brain areas are targeted for stimulation depend on the condition being treated. Once the brain implants are placed, the person is put under general anesthesia to wire the electrodes in their brain to the pulse generators in their chest. Once in place, the targeted brain areas receive continuous electrical pulses which are believed to help stabilize those areas, allowing them to function more normally. The level and frequency of electrical impulses are tailored to the individual.xii

Electroconvulsive therapy (ECT) was discovered in the 1930s and was the first brain stimulation therapy used to treat severe depression.xiii However, in the following decades the best stimulation methods to reduce side effects were not known and, for that reason, ECT was a controversial therapy for many years. Now that ECT has been thoroughly studied and new techniques have been developed, its efficacy and safety are well-established for relieving symptoms of treatment-resistant depression and other mental health conditions. In addition, other brain stimulation techniques including repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS) are also now used to help people with hard-to-treat mental health conditions. Because the brain is an electrochemical organ, these therapies treat challenging mental health conditions by directly modifying neuronal circuit signals without affecting other systems of the body the way medications do. Ongoing research into these and other brain stimulation techniques are advancing our ability to reduce the burden of mental illness on individuals and their families. It is important to understand that brain stimulation therapies are not first-line treatments and are often combined with medication and psychotherapy (talk therapy) after other treatments have failed.

Yes, brain stimulation has been used to treat severe depression for over 70 years. While electroconvulsive therapy (ECT) has been used for the longest time and is the most well-studied technique, other brain stimulation therapies including repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS) are also used to treat severe depression. It is important to understand that brain stimulation therapies are not considered first-line treatments and are reserved for particular patients with treatment-resistant and recurrent mental health conditions.xiv

Brain stimulation therapies such as electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS) are non-invasive and, typically, are not painful. In the case of ECT, the patient is anesthetized to minimize any discomfort during the induced seizure. Although vagus nerve stimulation (VNS) requires implanting a stimulation device under the skin of the chest, the patient is anesthetized during the procedure and does not feel anything afterwards when the implanted device emits electrical pulses. These brain stimulation procedures may produce temporary side effects that are largely mild to moderate including headache, short-term memory loss, tingling, muscle soreness, and, for VNS, hoarse voice or temporary discomfort at the site of the implant. Deep brain stimulation (DBS) can be more painful and have more side effects because it requires an open brain surgery to implant electro-stimulation devices inside the brain and chest. However, after the procedure, patients do not feel anything when the implanted pulse-generators stimulates their brain. Side effects of DBS can include bleeding in the brain, stroke, infection, confusion, negative mood changes, movement disorders, dizziness, and sleep disturbance.xv

Treatment and Support

The Brain Stimulation Clinic at the MUSC Institute of Psychiatry provides the highest quality, state-of-the-art treatments. Our specialists and nurse navigators will work with you to come up with a comprehensive, individualized treatment plan that may include the following:

Electroconvulsive Therapy (ECT)

  • ECT is an effective therapy for treatment-resistant mood disorders. The Brain Stimulation team at MUSC Health use the latest equipment and the most effective techniques to improve efficacy and reduce side effects.
    • Patients receive anesthesia and a muscle relaxant.
    • Our state-of-the-art, ultra-brief pulse unilateral ECT sends low-voltage current to one side of the brain, reducing memory side effects seen with older versions of ECT.
    • The procedure takes a few minutes.
    • Patients generally go home within an hour.
  • Typically, about 10 treatments over 3 to 4 weeks are needed.
  • Maintenance treatments are based on individual response. Some people do not need them at all. Others may need a maintenance ECT treatment once weekly, monthly, or annually.
  • Each person responds differently. About 75 percent of severely depressed patients, on average, find ECT improves their condition.

Repeated Transcranial Magnetic Stimulation (rTMS)

  • rTMS is a non-invasive procedure that is FDA-approved for treatment-resistant depression, obsessive-compulsive disorder (OCD), and tobacco/nicotine addiction (smoking cessation). The MUSC Brain Stimulation Clinic is the first in South Carolina to provide this treatment to people with OCD and those wanting to stop smoking or using tobacco/nicotine.
  • rTMS for Depression
    • rTMS has similar results to ECT, but does not require patients to be under anesthesia, so you can read or listen to music during the 20-minute procedure.
    • The rTMS device directly stimulates brain areas involved in mood regulation.
    • Magnetic pulses delivered are the same strength as for an MRI (magnetic resonance image).
    • rTMS has fewer side effects than ECT and the most common one is scalp irritation.
    • Typically, there are 6 weeks of daily treatment with some people needing periodic maintenance treatments afterward based on their individual response.
    • Real world studies find that rTMS significantly improves treatment-resistant depression in about 83 percent and leads to remission in 62 percent of people who are treated for 6 weeks.
  • rTMS for Obsessive-Compulsive-Disorder (OCD)
    • rTMS is an effective treatment for the 40 percent of people with OCD who do not respond to standard therapy.
    • rTMS acts directly on the brain networks involved in OCD.
    • Typically, there are 29 daily treatments that are done over several weeks.
    • During a session, before rTMS begins, the person’s OCD circuitry is activated for about 5 minutes by exposing them to things that trigger their obsessions or compulsions.
    • The rTMS magnetic field then can stimulate the active regions to reduce OCD symptoms.
    • Studies find a treatment response rate of 57.9 percent after 29 sessions, with even better responses in people treated over longer times.
    • rTMS works differently than other OCD treatments such as medication, which means that people who do not get relief from other therapies may still respond to rTMS.
  • rTMS for Tobacco/Nicotine Addiction (Smoking Cessation)
    • rTMS is an effective treatment for addiction to tobacco/nicotine and can help people stop smoking – a leading cause of death and chronic disease.
    • rTMS treats nicotine addiction by directly affecting the brain’s craving and reward systems to help people control the urge to smoke cigarettes or use other tobacco/nicotine products.
    • Studies find that 28 percent of people who received rTMS over 6 weeks quit smoking for more than a month afterwards, and those who did not quit, smoked fewer cigarettes after treatment.

Deep Brain Stimulation (DBS)

  • DBS is a surgical therapy that is effective in treating obsessive-compulsive disorder (OCD).
  • In DBS, electrodes are implanted directly into specifically targeted brain areas during an open brain surgery.
  • Battery-powered electrical impulse generators are implanted in the chest and connected to the brain electrodes by tiny wires which provide pulses of stimulation to the targeted brain areas.
  • These electrical signals interfere with OCD brain activity to reduce symptoms.
  • Because it requires an open surgery, DBS has more potential risks and side-effects than less invasive therapies, but it can be highly effective in reducing symptoms of treatment-resistant OCD. So, it’s important to consider the unique risks and benefits for each person.
    DBS has been used to treat the symptoms of Parkinson’s disease since 1987 and now has a humanitarian device exemption for treating severe OCD.

Consultations

The Brain Stimulation team at MUSC provides consultation for individuals referred by their provider and individuals seeking help for themselves for difficult-to-treat mental health conditions. We can help you determine the most appropriate next-steps when standard treatment options have not been effective and symptoms continue interfering with daily life.

Our team of world-renowned specialists can assist in determining whether someone is eligible for brain stimulation therapy. To schedule a consultation for yourself or, if you are a physician – for one of your patients, please call Monday through Friday between 8:00 a.m. 4:30 p.m.

Learn more about our consultation process.

Research

Our team of Brain Stimulation specialists are constantly striving to improve treatment options and outcomes for you. By using team science, our doctors and scientists collaborate to look at new ways to solve problems and advance mental health treatment.

Clinical Trials

As South Carolina’s largest and most comprehensive mental healthcare provider, the Institute of Psychiatry at MUSC Health offers you clinical trials and treatments that aren’t available anywhere else in the state. These opportunities provide you with access to the latest medications, therapies, and surgical techniques that can improve your outcomes. Learn more about clinical trials at the Brain Stimulation Clinic and see our current clinical trials here.

References

iNational Institute for Mental Health (NIMH). Brain Stimulation Therapies.

iiNational Institute for Mental Health (NIMH). Brain Stimulation Therapies.

iiiWani A, Trevino K, Marnell P, Husain MM. Advances in brain stimulation for depression. Ann Clin Psychiatry. 2013;25(3):217-224.

ivNational Alliance on Mental Illness (NAMI). Depression.

vGraat I, van Rooijen G, Mocking R, et al. Is deep brain stimulation effective and safe for patients with obsessive compulsive disorder and comorbid bipolar disorder? J Affect Disord. 2020;264:69-75. doi:10.1016/j.jad.2019.11.152.

viGippert SM, Switala C, Bewernick BH, et al. Deep brain stimulation for bipolar disorder-review and outlook. CNS Spectr. 2017;22(3):254-257. doi:10.1017/S1092852915000577.

viiNational Alliance on Mental Illness (NAMI). ECT, TMS and Other Brain Stimulation Therapies.

viiiNational Institute for Mental Health (NIMH). Brain Stimulation Therapies.

ixNational Institute for Mental Health (NIMH). Brain Stimulation Therapies.

xNational Institute for Mental Health (NIMH). Brain Stimulation Therapies.

xiNational Institute for Mental Health (NIMH). Brain Stimulation Therapies.

xiiNational Institute for Mental Health (NIMH). Brain Stimulation Therapies.

xiiiSadowsky, J. Electroconvulsive Therapy: A History of Controversy, but Also of Help. Scientific American: The Conversation. January 13, 2017.

xivNational Institute for Mental Health (NIMH). Brain Stimulation Therapies.

xvNational Institute for Mental Health (NIMH). Brain Stimulation Therapies.