Types of Brain Stimulation Therapies: A Clinical Overview

Electroconvulsive therapy (ECT)

• Mechanism: ECT uses electrical currents passed through the brain to purposefully trigger a small seizure. The process causes brain chemistry changes that help alter functional connectivity and gene expression, while also potentially enhancing neuroplasticity.
• Invasiveness: ECT is noninvasive because it does not involve incisions or implants, though patients receive the treatment under a short-acting general anesthesia.
• What it treats: ECT treats catatonia or a severe major depressive episode associated with major depressive disorder (MDD) or bipolar disorder.
• FDA status: ECT is an FDA-authorized treatment for catatonia or a severe major depressive episode in patients ages 13 years or older who are treatment-resistant and require a rapid response. It’s administered with FDA-cleared devices.
• Evidence: Today, it’s considered one of the most effective treatments for severe depression and for treatment-resistant cases, in which patients don’t adequately respond to first-line treatments such as selective serotonin reuptake inhibitors medication (SSRIs) or psychotherapy.

Vagus nerve stimulation (VNS)

• Mechanism: The vagus nerve is the longest cranial nerve, connecting the brain with various organs. VNS uses an implantable device to regularly stimulate the vagus nerve in the neck, sending electrical impulses to the brain that help change how neurons function, improve blood flow, alter chaotic electrical patterns to prevent seizures, and stimulate the cortex.
• Invasiveness: VNS is invasive because it requires the implantation of a device under the skin of the chest while the patient is under general or local anesthesia. However, some noninvasive options are emerging.
• What it treats: VNS treats partial seizures and treatment-resistant depression. It’s also used for ischemic stroke rehabilitation.
• FDA status: VNS is an FDA-approved treatment for epilepsy in patients ages 4 and older, for treatment-resistant depression in patients ages 18 or older, and for stroke rehabilitation.
• Evidence: VNS has been FDA-approved for epilepsy since 1997 with robust evidence. Research is mixed on the benefits of VNS for depression, with some studies indicating that symptom improvement can take months and it does not provide relief for all patients.

Deep brain stimulation (DBS)

• Mechanism: DBS involves the placement of electrodes next to deep brain structures. The electrodes connect via wire to a pulse generator implanted in the chest. The pulse generator, controlled by a computer, tells the electrodes when to fire to stimulate the brain. Stimulation may block abnormal activity.
• Invasiveness: DBS is invasive because it requires the implantation of electrodes in the brain and the pulse generator in the chest wall, while the patient is under general anesthesia.
• What it treats: DBS treats essential tremor, dystonia, Parkinson’s disease, and treatment-resistant obsessive-compulsive disorder (OCD). It’s also used to treat some psychiatric conditions.
• FDA status: DBS is FDA-approved to treat essential tremor, dystonia, and Parkinson’s disease, generally in patients ages 18 years or older. It’salso authorized under the FDA’s Humanitarian Device Exemption for treatment-resistant OCD.
• Evidence: DBS is a well-established treatment for movement disorders and for refractory OCD. For psychiatric conditions, the evidence is growing but still emerging.

Magnetic seizure therapy (MST)

• Mechanism: MST involves placing a specialized electromagnetic coil on the scalp to deliver rapid, high-frequency magnetic pulses to induce a localized seizure to help reset neural circuitry and brain chemistry. It’s being studied as an alternative to ECT.
• Invasiveness: MST is noninvasive because it doesn’t require incisions or implantation, though patients are under general anesthesia during the procedure.
• What it treats: MST is used to treat treatment-resistant depression in MDD and bipolar disorder.
• FDA status: MST does not have approval or clearance and is considered an investigational approach.
• Evidence: Some research suggests MST may ease symptoms of treatment-resistant depression, but evidence remains limited.

Transcranial magnetic stimulation (TMS)

• Mechanism: TMS involves two types: standard TMS (rTMS) and Deep TMS. Each works in its own way to treat the targeted condition. While rTMS relies on a standard figure-8-shaped device to convey electromagnetic pulses to the brain, Deep TMS relies on patented H-Coil technology to transmit electromagnetic pulses from within a specially designed helmet. The electromagnetic pulses reach wider and deeper swaths of the brain, avoiding the targeting issues of rTMS.
• Invasiveness: Both types are noninvasive because they do not require incisions or implants; they also do not require the patient to be under anesthesia.
• What it treats: First-Gen TMS is used to treat MDD, OCD, and migraine. It’s also used to support smoking cessation. Deep TMS is used to treat MDD and OCD, and to support smoking cessation.
• FDA status: Standard TMS devices have FDA clearance, though indications vary by device. Deep TMS is FDA-cleared to treat MDD, including the reduction of comorbid anxiety symptoms, together commonly referred to as anxious depression, as well as OCD and smoking cessation.
• Evidence: For both rTMS and Deep TMS, randomized, placebo-controlled clinical trials support these treatments for authorized uses.

Other types of brain stimulation therapy are still emerging, including transcranial direct current stimulation (tDCS), transcranial alternating current stimulation (tACS), and temporal interference (TD).

Is your patient a candidate for brain stimulation therapy?

If you’re a provider, you might be exploring how to best investigate whether your patient is a candidate for brain stimulation therapy. Sam Zand, DO, founder and chief psychiatrist at Anywhere Clinic,  provides some insight.

“Start with the whole person: their diagnosis, symptom severity, previous treatments, daily functioning, and goals,” he says.

A thorough assessment for a deep brain stimulation modality includes screening for any contraindications.

“We also need to understand practical barriers, such as transportation and scheduling,” he adds. “And a treatment plan has to fit the patient’s life.”

Talking to patients about brain stimulation options

Once you’ve assessed a patient for contraindications and any barriers, you’re ready to talk to them about a specific brain stimulation therapy that might be right for them.

“Start by asking what the patient has learned about the treatment and what concerns them,” Dr. Zand says. “Walk them through the experience.”

He shares the example of TMS. “Let them know they remain awake, wear hearing protection, feel a light tapping on the scalp, and can drive home after treatment,” he says. “Explain possible discomfort or headaches and the rare risk of seizure.”

Sharing the specifics of a treatment, such as TMS, is crucial. “A conventional course often involves weekday visits for four to six weeks, sometimes followed by a taper; session length and the overall schedule depend on the protocol,” Dr. Zand says. “Discuss travel time, work, childcare, and coverage.”

He also likes to share realistic expectations for a modality. Again, he uses TMS as an example. “Improvement may take several weeks, and some people won’t respond,” he notes. “Ask what getting better would look like in everyday life, and track that alongside symptom scores.

Finally, walk patients through any lifestyle changes that may be useful. “I also encourage patients to connect treatment with sleep, movement, meaningful relationships, and psychological support,” he explains. “Our goal is to help someone feel better and build a life that supports staying well.”

Decoding what your patient is asking for

In some cases, your patient may ask for a therapy they’ve heard or read about, sometimes using a different name for it because the terms for various brain stimulation therapies can get confusing. Below are some colloquial terms you might hear and the therapies they likely refer to.