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Brain Stimulation in Psychiatric Treatment

Edited by Sarah H. Lisanby, M.D. Arlington, Va., American Psychiatric Publishing, 2004, 153 pp., $34.95 (paper).

Ever since man found ways to control electrical and magnetic fields, these skills have been part of medical experimentation (1, 2). The French revolutionary Jean-Paul Marat published a treatise on medical uses of electricity in 1783 (3). Reports that electric shocks to the head of mentally ill patients elicited facial grimacing and prolonged insomnia that ameliorated psychoses and melancholia appeared in 1804 (4). Experiments with static electricity were showpieces for Benjamin Franklin in French drawing rooms in the late 18th century (5). Recently, the new technologies of transcranial magnetic stimulation (and its offshoot, magnetic seizure therapy), deep brain stimulation, and vagus nerve stimulation have captured psychiatric attention.

This paperback describes each technique and the results of clinical trials in psychiatric patients. The authors conclude,

However, definite therapeutic effects of clinical significance remain to be demonstrated [for transcranial magnetic stimulation]. (p. 1)

DBS [deep brain stimulation] is an established therapy for movement disorders. It is an investigational treatment of other neurological conditions and of neuropsychiatric illnesses. (p. 62)

The efficacy of VNS [vagus nerve stimulation] is uncertain....In psychiatry, we are unlikely to recommend VNS...for a "quick fix." (p. 136)

These nonseizure methods are offered as replacements for ECT by researchers who seek "a means of reducing the cognitive side effects of ECT...[because] its use is limited by cognitive and other side effects" (p. 69). Other nonseizure methods, such as sham ECT, electrosleep, EEG alpha enhancement, low-voltage direct-current bifrontal stimulation, isoflurane anesthesia-induced EEG silence, and light therapy, were proffered as ECT replacements, and each has been found wanting. These new methods are also not equal to the challenge.

A risk of transcranial magnetic stimulation is eliciting of a grand mal seizure. After the failure to demonstrate its psychiatric benefits, the researchers now exploit this risk as a clinical technique. They offer magnetically induced grand mal seizures, hoping that the benefits will match those of ECT with lesser effects on memory. This hope, however, is inconsistent with the 70 years of experimentation with convulsive therapy. Seizures have been induced with intramuscular camphor or insulin, intravenous pentylenetetrazol, the inhalant flurothyl, and electrically. When full grand mal seizures are induced by any method, the behavioral effects are demonstrable, as are accompanying transient memory effects. An extensive experience with the asymmetric and partial seizures induced with unilateral electrode placement found seizures with lesser cognitive effects to have lesser clinical benefits (6). Among stimulation techniques, ECT dominates clinical practice today, not for any specific benefit or lesser risk associated with electricity but for ease of use, least expense, and least discomfort to patients. Magnetic seizure therapy may, in time, emulate ECT, but it is improbable that it will be as easy and as inexpensive as electrical inductions.

Transcranial magnetic stimulation, deep brain stimulation, and magnetic seizure therapy are not yet approved for clinical use by the U.S. Food and Drug Administration. Vagus nerve stimulation is approved for intractable epilepsy. It requires the surgical implantation of a stimulator in the chest wall with leads that snake up to the vagus nerve in the neck. Stimulation impairs speech, and the risks of surgery are not to be passed over lightly. The Wall Street investors and their consultant researchers who are supporting this treatment should be required to demonstrate a remarkable efficacy in specifically defined populations before it is approved for clinical use in psychiatry. The mentally ill may not be able to properly make fully informed judgments of the benefits, risks, and expense of this procedure, which, once implanted, requires another surgical procedure for its removal.

Four years ago, the American Psychiatric Press summarized the first experiences with transcranial magnetic stimulation (7). The publisher’s current report offers no new evidence of clinical utility. The reviews in this volume offer little hope that these brain stimulation techniques are replacements for ECT. Readers will find little reason to alter their clinical practice. These experiments are not based on a theory of brain and behavior but are offered for the same reason that explorers climb Mount Everest. In this context, it is useful to recall that convulsive therapy was developed on the basis of neuroscience data and not as an empirical adventure (8).

References

1. Bertucci P, Pancaldi G (eds): Electric Bodies: Episodes in the History of Medical Electricity. Bologna, Italy, University of Bologna, 2001
2. Crook HE: High Frequency Currents; Their Production, Physical Properties, Physiological Effects, and Therapeutic Uses. New York, William Wood Co, 1909
3. Marat J-P: Mémoire sur l’électricité médicale. Paris, NT Méquignon, 1783
4. Brazier MAB: A History of Neurophysiology in the 17th and 18th Centuries. New York, Raven Press, 1984
5. Franklin B: Experiments and Observations on Electricity. London, David Henry, 1769
6. Abrams R: Electroconvulsive Therapy, 4th ed. New York, Oxford University Press, 2002
7. George MS, Belmaker RH: Transcranial Magnetic Stimulation in Neuropsychiatry. Washington, DC, American Psychiatric Press, 2000
8. Fink M: Induced seizures as psychiatric therapy: Ladislas Meduna’s contributions in modern neuroscience. J ECT 2004; 20:133–136[Medline]

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