Neuromodulation Options Are Growing, But ECT and TMS Remain the Go-To for Clinical Care

In a session that provided more abbreviations than attendees likely could keep track of (TNS, VNS, CES, DBS, and more), Linda Carpenter, M.D., and Andrew Leuchter, M.D., said that neuromodulation therapies are poised to become the next big thing for treatment-resistant depression (TRD) and other psychiatric disorders.

As of today, however, clinicians and patients should be aware that the only evidence-based neuromodulation options for TRD are transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT). The good news is that both are highly effective, said Leuchter, a distinguished professor of psychiatry and associate director at UCLA’s Semel Institute for Neuroscience and Human Behavior. So, which one is right for your patient?

In terms of pure efficacy, ECT appears the more reliable treatment option, Leuchter said. A pair of meta-analyses conducted some years back showed that about 50% of people with TRD treated with ECT achieve remission, compared with about 34% of those given TMS.

Leuchter noted that retrospective studies include data from the early years of TMS when the magnetic coil properties and stimulation parameters were still being tweaked. More recent data from next-generation machines using updated protocols suggest that TMS may be comparable to ECT. Leuchter added that some research has found that — even factoring in older TMS data — the two treatment modalities are equally effective for individuals with nonpsychotic depression.

The differences come down to protocols, so patient concerns such as time or side effects are key considerations when choosing between the two treatments.

• ECT requires anesthesia, TMS does not. “If you enjoy the thought of getting treatment while watching Netflix, then TMS is perfect,” Leuchter said. “However, some people do find the TMS process uncomfortable.”


• Individual TMS sessions are briefer than ECT sessions. The inducement of therapeutic seizures using ECT takes only a few minutes, but preparation and recovery from anesthesia push the total time of a session to about an hour or more. TMS takes about 30 minutes, but it is basically an in-and-out process.


• More sessions are needed with TMS. Though protocols vary, a typical ECT course involves 8 to 12 sessions, two to three a week. TMS courses may require up to 30 sessions, as often as five a week.


• ECT can produce transient memory problems. “This is the main reason patients gravitate to TMS,” Leuchter said, so the potential impact on memory should be carefully discussed when considering neuromodulation.

Carpenter, a professor of psychiatry and human behavior at Brown University, said two other neuromodulation devices are cleared by the FDA for depression, but said each comes with an asterisk that ranks them way below TMS or ECT in treatment discussions.

The first are cranio-electrotherapy stimulation (CES) devices; these are cellphone-sized stimulators that deliver low-energy electric currents to the brain via two electrodes attached to the temples or earlobes. Though requiring a prescription, they can be used by patients at home. Carpenter cautioned that some CES devices were marketed before the FDA assumed oversight of medical devices and were given grandfathered clearance. As a result, manufacturers of any new CES device need to prove only that they are similar to the older devices; they can get cleared via the 510k pathway without rigorous research.

“To be fair, ECT was grandfathered as well,” Carpenter said, but added that in the intervening years there have been robust data supporting ECT as a therapy.

The second technology cleared for TRD is vagus nerve stimulation (VNS). This approach requires some minimally invasive surgery in the neck and chest to implant electrodes and a tiny battery pack near the vagus nerve. Clinical data from open-label studies show that VNS can improve depressive symptoms, Carpenter said. Since there are no supporting data from randomized clinical trials, insurance companies do not reimburse for VNS treatment.

Given the costs and surgery required, Carpenter does not advocate VNS for routine use of unipolar treatment-resistant depression. She noted, however, that VNS is also cleared for bipolar depression, so there may be more potential for VNS in this population since there are fewer options for treatment-resistant bipolar depression. ■

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