Neurostimulatory, neuromodulatory and neurosurgical treatments in psychiatry

Electroconvulsive therapy (ECT) is the most effective treatment for depression, with a remission rate of approximately 50% with standard brief-pulse ECT. It is recommended for treatment-resistant depression, where there is patient preference and/or a previous good response, for rapid improvement of life-threatening episodes of severe depression, and for severe or prolonged mania and catatonia. It is a medically safe procedure, and the major risks are related to anaesthesia. Cognitive adverse effects can be minimized by using right unilateral electrode placement and ultra-brief pulse width (<0.5 ms) stimuli. Most adverse effects usually resolve within a few weeks after the course of treatment, although retrograde amnesia can persist with some forms of ECT. Repetitive transcranial magnetic stimulation has been approved by the UK National Institute for Health and Care Excellence for use in depression, but is much less effective than ECT. Other methods of brain stimulation include vagus nerve stimulation, transcranial direct current stimulation and deep brain stimulation. Neurosurgery for mental disorders is only available in specialized centres and under highly regulated conditions, but can benefit some patients.