Delving into the history of treatments for mental illness can be depressing. Rather than developing ever-more-potent therapies, psychiatrists and others in the mental-health industry seem merely to recycle old ones. Consider, for example, therapies that stimulate the brain with electricity. In 1901, H. Lewis Jones, a physician, stated in the Journal of Mental Science:
"The employment of electricity in medicine has passed through many vicissitudes, being at one time recognized and employed at the hospitals, and again being neglected, and left for the most part in the hands of ignorant persons, who continue to perpetrate the grossest impositions in the name of electricity. As each fresh important discovery in electric science has been reached, men’s minds have been turned anew to the subject, and interest in its therapeutic properties has been stimulated. Then after extravagant hopes and promises of cure, there have followed failures, which have thrown the employment of this agent into disrepute, to be again after time revived and brought into popular favor."
Jones’s concerns could apply to our era, when electro-cures for mental illness have once again been "brought into popular favor." Below I briefly review the evidence—or lack thereof--for five electrotherapies: transcranial magnetic stimulation, cranial electrotherapy stimulation, vagus-nerve stimulation, deep-brain stimulation and electroconvulsive therapy.
Research on electro-cures is often tainted by conflicts of interest. So I rely on assessments by the National Institute of Mental Health and the Cochrane Collaboration, which provide relatively objective assessments of the clinical literature. My hope is to provoke closer scrutiny of electro-therapies by other journalists and consumers.
Transcranial Magnetic Stimulation, TMS (also called rTMS, “r” standing for “repetitive”)
TMS involves stimulating the brain with an electromagnetic coil. The firm Neurnetics claims that more than 650 physicians have treated more than 25,000 patients for depression with its NeuroStar device; the recommended treatment consists of five 37-minute sessions a week for up to six weeks. Celebrity physician Dr. Mehmet Oz says TMS could be “the controversial therapy to pull your brain out of the darkness.” A 2014 article in The Journal of Clinical Psychiatry reported benefits from TMS, but the study was not controlled, and 11 of the 12 authors have ties to Neuronetics and/other other vendors and three work for the firm. Here’s the NIMH overview of TMS: “Clinical trials studying the effectiveness of rTMS reveal mixed results. When compared to a placebo or inactive (sham) treatment, some studies have found that rTMS is more effective in treating patients with major depression. But other studies have found no difference in response compared to inactive treatment.” A 2009 Cochrane review of TMS for depression looked at 16 studies, only 14 of which were “in a suitable form for quantitative analysis.” Cochrane concludes that “there is no strong evidence for benefit from using transcranial magnetic stimulation to treat depression, although the small sample sizes do not exclude the possibility of benefit.”
Cranial Electrotherapy Stimulation, CES
CES is similar to TMS but stimulates the brain with electric current rather than magnetic pulses. CES has attracted attention due to aggressive marketing by Fisher Wallace Laboratories of the Fisher Wallace Stimulator, which has received positive coverage from CBS, Fox News, Huffington Post and other outlets. The firm’s main marketing strategy is claiming that its CES device, which costs $699 and can be used at home, is cheaper and safer than other electro-cures. The company claims that “more than 20 published studies prove the safety and effectiveness of the Fisher Wallace Stimulator” for treating depression and anxiety. Cochrane carried out a review in 2014 and found “no high quality clinical trials comparing CES with sham CES in people with acute depression. Currently, there is insufficient evidence to support the use of CES in treatment of acute depression.” (See also a report on the Fisher Wallace Stimulator by one of my science writing students, Julia Vance: http://horgansciseminar.blogspot.com/2015/02/fisher-wallace-stimulator-too-good-to.html.)
Vagus-Nerve Stimulation, VNS
Unlike TMS and CES, vagus-nerve stimulation is an invasive treatment developed originally for epilepsy. It consists of stimulating the vagus nerve, a major neural conduit that runs from the brain down through the neck, with electrodes connected to a pacemaker-type device implanted in the chest. Here’s how the NIMH sums up the evidence for VNS treatment of depression: “In 2005, the U.S. Food and Drug Administration (FDA) approved VNS for use in treating major depression in certain circumstances—if the illness has lasted two years or more, if it is severe or recurrent, and if the depression has not eased after trying at least four other treatments. Despite FDA approval, VNS remains a controversial treatment for depression because results of studies testing its effectiveness in treating major depression have been mixed.”
Deep-Brain Stimulation, DBS
Of all the electro-cures, DBS is arguably the riskiest and most invasive, because it involves implanting electrodes deep into the brain to treat severe depression and other ailments. DBS has helped treat Parkinson’s and other motion disorders, and the NIMH provides a relatively upbeat assessment of DBS for depression: “So far, very little research has been conducted to test DBS for depression treatment, but the few studies that have been conducted show that the treatment may be promising.” The NIMH needs to update its listing. The major DBS researcher is Helen Mayberg, who recently described her research in Scientific American and in 2006 was lauded for her “incredible” results in a 2006 profile in The New York Times Magazine. As I reported last year, a major clinical trial of the DBS technique pioneered by Mayberg was recently halted because it failed a "futility analysis," which considers whether an experimental treatment has a reasonable chance of improving upon current treatments. See also this followup post, in which a DBS subject talks about the pain it inflicted on him.
Electroconvulsive Therapy, ECT
Of all the electro-cures, electroconvulsive therapy, also called ECT or “shock treatment,” has the best track record. Pioneered in the 1930s, ECT involves inducing seizures in anesthetized patients by administering electricity to the brain through external electrodes. The NIMH notes that ECT “for years had a poor reputation with many negative depictions in popular culture. However, the procedure has improved significantly since its initial use and is safe and effective.” In my 1999 book The Undiscovered Mind, I reported that ECT can provide short-term relief for many severely depressed patients, but relapse rates are high. Not much has changed, according to a 2013 study in Nature: “Relapse rates following ECT are disappointingly high and appear to have increased over time. In patients treated with continuation pharmacotherapy, the main focus of our investigation, relapse was highest in the first 6 months, plateauing afterwards. In present day clinical practice, nearly 40% of ECT responders can be expected to relapse in the first 6 months and roughly 50% by the end of first year.”
The persistence of electro-cures exposes the inadequacies of the primary method of treating mental illness—psychopharmacology—as well as psychotherapy. As I have pointed out previously (see Further Reading) there is evidence that antidepressants and other medications—while they provide short-term relief for many patients--may over the long run and in the aggregate do more harm than good.
More than a century after the era of Sigmund Freud and William James, science still has not found compelling theories of or potent treatments for mental illness. When, if ever, will that situation change?
Post-script: My review is not comprehensive. It excludes, for example, transcranial direct current stimulation, tDCS, which was described in a recent report in The New Yorker.
Addendum: I’d like to thank Walter Brown, professor of psychiatry at Brown University, with whom I did a Q&A in 2013, for drawing my attention to the growing popularity of electro-cures (which he reviewed in 2006) and providing me with information on the trend. He recently emailed that he is “increasingly concerned about the promotion of transcranial magnetic stimulation as a treatment for depression. The studies available, some of which are sponsored by the device manufacturer, are either uncontrolled or show little effect and what effect shows up is more than likely placebo. Yet this procedure is being aggressively promoted.” Brown sent me the above-cited 2014 article on TMS in The Journal of Clinical Psychiatry and pointed out the authors’ conflicts of interest.
I’d also like to thank David Healy, who is professor of psychiatry at Bangor University, founder of RxISK.org, an organization that provides information on drugs’ side effects, and author of the 2012 book Pharmageddon. He sent me the 1901 article by H. Lewis Jones, "The Use of General Electrification as a Means of Treatment in Certain Forms of Mental Disease.” Healy emphasizes that ECT can be beneficial for a certain subset of severely depressed patients. “ECT is a treatment for melancholia (depression with a motor component) rather than depression (anxiety-nerves). If it’s just depression then a high relapse rate doesn't offer much. If you have pulled a person out of profound melancholia--when nothing else will--and they relapse later, that's a different matter.”