Brain Stimulation in Psychiatry
Brain stimulation spans our oldest to our newest treatment modalities in psychiatry. From the introduction of convulsive therapy in the 1930s, to the growing list of novel investigational treatments (e.g., transcranial magnetic stimulation (TMS), magnetic seizure therapy (MST), transcranial direct current polarization (tDCS), vagus nerve stimulation (VNS), deep brain stimulation (DBS), and epidural cortical stimulation), brain stimulation now comprises a unique family of therapeutic interventions that act via electromagnetic stimulation of the brain. These interventions differ in their degree of invasiveness, focality, efficacy, side effects, and mechanisms of action. Two (electroconvulsive therapy (ECT) and VNS) are currently U.S. Food and Drug Administration (FDA) approved, while the others are at various stages of clinical testing and FDA review. Collectively, these modalities have provided valuable information regarding basic brain functions and the pathophysiology of psychiatric illness. They also offer hope to patients who are experiencing severe psychiatric disorders that have failed to respond to conventional psychotherapy or psychopharmcology. This chapter reviews each brain stimulation modality, discussing its history, mechanisms of action, side effects, role in basic studies of pathophysiology, evidence for clinical efficacy, current status in treatment algorithms, patient selection, dosing, and future directions. As new brain stimulation techniques gain FDA approval and enter the realm of clinical practice, the field will be in the position to assess the ultimate clinical role of these modalities, and their proper place in treatment algorithms with respect to the original brain stimulation treatment in psychiatry-ECT. © 2008 John Wiley & Sons, Ltd.
