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3 Brain-Stimulating Therapies for Depression That Can Work

ECT, TMS and vagus nerve stimulation are making a difference for some patients


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Almost one-third of Americans have been diagnosed with depression at some point in their lives, according to a 2023 Gallup poll. Recovery rates are mixed, according to the Centers for Medicare & Medicaid Services. Among those who seek treatment, about 30 percent get completely better and another 20 percent find at least some relief with the help of medications, conventional talk therapy plus physical activity.

It’s the remaining 50 percent, though, that psychiatrists really worry about. For people with so-called treatment-resistant depression, life can be a living hell.

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“Symptoms of chronic depression are quite disabling and people with them are at high risk for hurting themselves or suicide,” says Irving M. Reti, M.D., professor of psychiatry and neuroscience and director of the Electroconvulsive Therapy Service at the Johns Hopkins Hospital. Rates of suicide in the United States are highest among people age 75 and older, research shows

Yet there is hope. Although many people don’t respond to initial treatment, “we still help a great number of people, even those with the most resistant, most refractory depression,” says Alan F. Schatzberg, M.D., professor of psychiatry and behavioral sciences at Stanford University School of Medicine.

The approaches used after other therapies fail may evoke visions of distressing movie scenes or bad trips, but they are bringing relief to a surprising number of people.

Electroconvulsive therapy, or ECT

Introduced in a cruder form in the 1930s, ECT conjures up disturbing images of people shaking violently as jolts of electricity bombard their brain. (Remember One Flew Over the Cuckoo’s Nest?) Today the treatment has evolved to be mostly safe — and more effective.

“ECT is the gold standard for treatment-resistant depression,” Reti says. “Some studies show response rates as high as 80 to 85 percent.”

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The treatment appears to be particularly effective among older adults who may experience relief more rapidly. “As people get older, their depression is less likely to respond to treatment, but ECT works quite well in this population,” says Mark George, M.D., professor of psychiatry, radiology and neurosciences and the director of the Brain Stimulation Lab at the Medical University of South Carolina in Charleston. He’s one of the early developers of today’s brain-stimulation therapies.

During ECT, electric currents pass through key parts of a patient’s brain, including the frontal lobe, which is involved with mood regulation. The goal is to induce a small seizure that “resets the activity in the brain,” George says.

To prevent pain and injury, patients are given general anesthesia and muscle relaxants. It usually takes two or three weekly treatments over three or four weeks for them to feel better.

The downsides: Many patients relapse after about six months and need repeat treatments. ECT is also associated with short-term memory loss. “We do our best to minimize that with the electrical settings that we use nowadays,” Reti says. “Still, it can be a significant side effect for some patients.”

ECT also causes surges in blood pressure, which may be problematic for some older people. “We particularly worry about delirium in older patients," which can result from the seizure, Reti adds. “That puts them at risk of a fall during the weeks they are receiving ECT, which can be dangerous.” Luckily only about 6 percent of patients experience high blood pressure as a result and fewer experience delirium.

If you or someone you care about is considering suicide, call, text or chat the 988 Suicide & Crisis Lifeline.

Transcranial magnetic stimulation, or TMS

With TMS, a coil that generates a magnetic field is placed on a patient’s head, sending electric pulses to the prefrontal cortex, the brain region associated with planning and regulation of emotion. How it works isn’t completely understood, but it’s thought to activate regions of the brain that become muffled as a result of the depression. 

The Food and Drug Administration approved TMS for treatment-resistant depression in 2008. But interest has surged more recently due to new treatment protocols that are better at boosting mood in less time.  With conventional TMS, patients receive treatment once a day, five days a week, over four to six weeks. With the new protocols, researchers are administering more electrical pulses per session and more sessions in a day over five days total. “People have a rapid improvement in mood over that period,” Reti says. For one of the new protocols, approved by the FDA in 2022, almost 80 percent of patients experienced relief from their symptoms, with older people as likely to benefit from the treatment as younger ones. 

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When compared with electroconvulsive therapy, TMS holds several advantages. “TMS is nonconvulsive, there is no anesthesia or memory loss involved and no cognitive side effects,” Reti says. That may make it more appealing to older adults. Side effects most often seen with TMS, such as scalp pain and headaches, are generally mild. More serious side effects, such as seizures and hearing loss, are very rare.  

“This is a real game changer,” says George, who conducted some of the studies that led to FDA approval.

Vagus nerve stimulation, or VNS

Like other brain stimulation techniques, this therapy — approved by the FDA for chronic or recurrent depression in 2005—is also getting renewed interest for recurrent and treatment-resistant depression. It involves implanting a device in the chest that emits electrical pulses through a wire to the vagus nerve in the neck.

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“The vagus nerve is an information superhighway that takes information from your body and goes into your brain,” George says. “Sending a signal up that nerve into the base of the brain causes the release of chemicals that seem to have an antidepressant and mood-regulating effect.” The treatment has up to a 67 percent positive response rate. Some patients experience relief for up to five years.  

After its 2005 approval, Medicare and private insurers chose not to cover vagus nerve stimulation and interest waned. However, positive data on its effectiveness has accumulated, George says, and Medicare and medical device companies are conducting a new study on it. Results are expected next year.

“If that research is positive, then Medicare would pay for VNS for any chronic, recurrent or treatment-resistant depressed patient,” he says.

Having to live with a device implanted in the chest is a significant drawback for this approach. But unlike with other brain stimulation therapies, the mood changes are long lasting, says George, adding: “We have better treatments now than we have ever had before.”

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