This document provides information on various brain stimulation therapies, including electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), transcranial magnetic stimulation (TMS), and deep brain stimulation (DBS). It discusses the history, procedures, indications, side effects, and mechanisms of action for each therapy. ECT involves inducing seizures with electricity to treat conditions like depression. VNS uses electrical pulses to the vagus nerve to treat epilepsy and depression. TMS uses magnetic pulses to target specific brain regions without surgery. These non-pharmacological therapies can be effective options for treating neuropsychiatric illnesses.

1. Dr.S.Santhosh Goud
Chairperson Dr.D.Ragadeepthi

2.  Brain stimulation therapies involve activating
or touching the brain directly with electricity,
magnets, or implants to treat neuro psychiatric
illness
 Other names- neuromodulation/non-
pharmacological somatic therapies
 16th century seizure induction in psychiatric
conditions
 1785 therapeutic use of seizure induction
inLondon Medical Journal
 Father of electrotherapy-G.B.C Duchenne

3.  ELECTRO CONVULSIVE THERAPY
 VAGUS NERVE STIMULATION
 TRANSCRANIAL MAGNETIC
STIMULATION
 DEEP BRAIN STIMULATION
 MISCELLANEOUS

4. S.no. Year Procedure Introduced by
1 1934 Chemical convulsive therapy Von Meduna
2 1938 Electro convulsive therapy Cerlette&Bini
3 1940 Curare modified therapy Bennet
4 1945 Oxygenation during ect Holovachka
5 1949 Unilateral non dominant ect Goldman
6 1952 Succinylcholine-modified ect Holmberg&Thesleff
7 1942 Ect in india Brig.E.A.Bennet
8 1979 FDA approval for Depression

5.  The aim of ECT -to induce generalised
cerebral seizure activity with an electrical dose
that is sufficiently above the seizure threshold
to maximize the clinical efficacy of treatment,
but not so high that it needlessly contributes to
the cognitive effects of treatment

6.  Electrical aspects
Parameter Brief Pulse wave Sine wave
Current
amplitude
0.8A 0.6A
Voltage 160V 120V
Frequency 100PPS 50Hz
Width 1msec
Duration 1sec 0.5sec
Impedence 200ohm 200ohm
Energy 12.8J 36J
charge 80mC 300mC

7. Electrode placement
 Unilateral vs Bilateral
 Bi temporal
 Bi frontal
 Unilateral(d’Elia RUL)
Frequency of treatment
 Thrice or twice a week
 Matelzky’s multiple monitored ECTs-2 or more
ECTs per treatment session, at a frequency of 2 or more
sessions per week
Regressive ECTs-repeated ECTs to produce vegetative state

8. Stimulus aspects
 Threshold stimulus-lowest stimulus at which
seizure is produced
 Effectiveness with supra threshold
stimulus(150%)
 Threshold is increased with number of ECT
sessions

9.  Determining the stimulus strength
 Based on age,sex,anesthetic dosage and
concomitant medication
 Trial method
 Fixed high charge for all patients

10. EEG changes-electro cerebral silence
Neurochemical changes-
 Upregulation of 5-HT receptors
 Decreased DA autoregulation
 Increased opiods in brain
 Increased GABA
 Increased CSF Acetylcholine
Action on second messangers
Neuro endocrine changes HPA axis
Blood Brain Barrier permeability
Increased expression of growth factors

11.  Informed consent
 Pre-ect investigations
 Pre anesthetic precautions
 NBM for 6 hours prior
 Void urine
 Not to apply hair oil,remove hair pins
 Remove jewellery,contact lens,hearing aids,
dentures
 Establish venous and airway access

12. Pre medication,anesthesia and muscle relaxant
 Atropine 0.3-0.6mg/i.m 30-45 mins before
 Methohexitol(0.75-
1.0mg/kg)/thiopentone(2.5mg/kg)Profopol(1.
5mg/kg)
 Scoline with in a minute of anesthetic
agent(0.5-1mg/kg)
 Oxygenation(100% 5L/min) through out the
procedure

13. Unmodified ECT
 With out prior muscle relaxant
 Common in India, Japan and Nigeria
 Union health ministry recommended to ban
direct ECT in mental health care bill 2013
 Benzodiazepine-modified ECT

14.  Duration of seizure
 Atleast 25 sec(15secs of motor seizures(30-60sec
optimal)
 Monitering
 Seizures(motor seizure duration 30% shorter
than EEG seizure)
 Ecg
 vitals

15.  Missed seizures-25-100% increase in dose with
proper oxygenation and a 20-40second
delay(max 4/session)
 Abortive seizures-restimulation after a 60-90
seconds delay
 Prolonged seizures-more than 120secs(>90secs
of motor seizures)
 Terminate by giving iv anesthetic/Benzo with
adequate ventilation

16.  ECT emergent delirium-give iv
benzo/haloperidol
 Prolonged confusion ->1 hour
 Reduce ect sessions/stop ECT/Switch to
unilateral ECT
 Headache-analgesics, bodyache-curare
 Prolonged apnoea –assisted respiration for 1
hour; Rarely fresh plasma transfusion

17.  The major risks of ECT are those of brief
general anesthesia.
 There are virtually no absolute health
contraindications precluding its use where
warranted (Potter & Rudorfer, 1993; Rudorfer
et al., 1997).

18.  The most common adverse effects are
confusion and memory loss for events
surrounding the period of ECT treatment.
 The confusion and disorientation seen upon
awakening after ECT typically clear within an
hour.
 Mortality 1 per 10,000

19. Contraindications
 Only relative contraindications
 Raised ICT
 Recent MI(<3 months) > 6 months not aCI
 Unstable vascular aneurysm
 Retinal detachment
 Pheochromocytoma
 Anesthetic risk
 Cardiac pacemaker is not a contraindication
 Thyroid dysfunction should be corrected

20. Indications
 Major depressive disorder with
Suicidal attempt
Severe suicidal plans
Severe illness refusing food/fluids
Stupor
Psychomotor retardation
psychosis

21.  ECT may be considered as a second- or third-
line treatment of a depressive illness that has
not adequately responded to antidepressant
drug treatment and where social recovery has
not been achieved (e.g. an inability to return to
work).
 70% efficacy in MDD

22. Mania
 The treatment of choice for mania is a mood-
stabilising drug plus antipsychotic drug.
 ECT may be considered for severe mania
associated with:
life-threatening physical exhaustion
treatment resistance (i.e. mania that has not
responded to the treatment of choice).

23.  A combination of ECT and a moderate dose of
a neuroleptic is extremely effective in rapidly
aborting an acute episode of mania
 ECT can be recommended for any manic
patient,irrespective of the severity or the
duration of the illness (Sikdar et al 1994)

24. Acute schizophrenia
 The treatment of choice for acute schizophrenia
is antipsychotic drug treatment. ECT may be
considered as a fourth-line option, that is, for
patients with schizophrenia for whom
clozapine has already proven ineffective or
intolerable
 Effective in 10% cases

25. Catatonia
 Catatonia is a syndrome that may complicate
several psychiatric and medical conditions. The
treatment of choice is a benzodiazepine
drug;most experience is with lorazepam.
 ECT may be indicated when treatment with
lorazepam has been ineffective.

26.  Delusional disorder
Other neuropsychiatric conditions
 PD and movement disorders
 Intractable seizures
 NMS
 Hypopituitarism
 Delirium

27.  There is no evidence to indicate what number
of sessions of ECT gains the best response.
Neither is there any evidence to support the
practice of giving two extra ECT sessions after
the patient is considered to be well enough to
discontinue ECT.
 Frequency 3 times weekly/Twice weekly
 Total 6-12 or more when needed
 No response with 6 sessions-stop ect

28. ECT in elderly patients with depression
 Electroconvulsive therapy is a highly effective
treatment for major depressive disorder in the
elderly, perhaps even more so than in younger
age groups (Benbow, 1987; Devenand &
Kruger, 1994).
 It is also effective and well tolerated in the old-
old(Tew et al, 1999).

29.  Older people tend to have higher seizure
thresholds
 Older patients may be more susceptible to
confusion after ECT
 Cognitive function should be assessed at least
24 hours following ECT
 If confusion proves to be a problem,
consideration should be given to switching
from bilateral to unilateral ECT

30.  There is no significant difference in the
cognitive outcome of elderly patients with
depression treated with ECT or tricyclic
antidepressant medication
 ECT can be given to patients with dementia
and depression without ill effect but they may
be at increased risk of post-ECT delirium

31.  ECT in pregnancy the recommended (Heath &
Yonkers, 2001):
 Obstetric consultation before referral for ECT
 Routine fetal heart monitoring before and after
each individual treatment when gestational age
is beyond the first trimester(obstetric
consultation may suggest earlier monitoring in
high-risk pregnancies)
 case-by-case consideration of intubation,
because of the risk of regurgitation, particularly
beyond the first trimester.

32. ECT in children and adolescents
 No studies only case reports
 Differ in opinions
 Safe in 15-17
 Case report in 8 year child with successful
resolution of depression
 Risk benefit ratio

33.  There is evidence that ECT can cause persistent
or permanent memory loss (Squire et al,
1981;Weiner et al, 1986; McElhiney et al, 1995;
Sobin et al, 1995), which is difficult to
distinguish from that caused by illness.
 Deficits are usually in recall of both
autobiographical memory and public
information(knowledge of events in the world)

34. ECT and Psychotropics
 No isssues with any anti depressant
 Antipsychotics except clozapine are safe
 Reduce anti epileptic dose if possible(only for
mania)
 Reduce benzodiazepine dose(or shift to non
benzo anxiolytic/for sleep add low dose CPZ)
 Lithium???

35.  Focal electrically adminstered seizure
therapy(FEAST)-Spellman,2009
 Uses direct current/monophasic pulses
 Different electrode configuration
 Unidirectional stimulation
 Focal seizures in prefrontal cortex with
secondary generalization
 Few side effects

37.  Primarily developed for seizure disorder(1997
FDA approval)
 In 2005 approved for MDD
 Response rate 30%
 Approved for chronic use only>2yrs

38.  Vagus nerve is a mixed nerve
 Afferents had connection with NTS and many
other vital centers
 Zabara(1992) discovered anti convulsant action
of VNS in experimental seizures(pentylene
tetrazole) in dogs
 His hypothesis VNS prevents or controls motor
and autonomic components of epilepsy
 Action on mid brain centers
 Regulation of NE and GABA

39. A device called a pulse generator, about the size
of a pocket watch, is surgically implanted in
the upper left side of the chest. (left had few
cardiac efferents so low risk of arrhythmias)
 Connected to the pulse generator is a lead wire,
which is guided under the skin up to the neck,
where it is attached to the left-sided vagus
nerve.
 VNS generator can be controlled by personal
computer or digital infra red wand

40.  Typically, electrical pulses that last about 30
seconds are sent about every five minutes from
the generator to the vagus nerve
 The vagus nerve, in turn, delivers those signals
to the brain.
 The pulse generator, which operates
continuously, is powered by a battery that lasts
around 10 years, after which it must be
replaced.

41.  The device also can be temporarily deactivated
by placing a magnet over the chest where the
pulse generator is implanted. A person may
want to deactivate it if side effects become
intolerable, or before engaging in strenuous
activity or exercise because it may interfere
with breathing. The device reactivates when
the magnet is removed.

42.  VNS is indicated for the adjunctive long-term
treatment of chronic (more than 2 years) or
recurrent depression for patients 18 years of
age or older who are experiencing a major
depressive episode and have not had an
adequate response to four or more adequate
antidepressant treatments

43. Side effects
 Infection
 Voice changes or hoarseness(SLN&RLN
stimulation)
 Cough or sore throat
 Neck pain
 Discomfort or tingling in the area where the
device is implanted
 Breathing problems, especially during exercise
 Difficulty swallowing, dyspepsia

44. Other uses
 Anxiety disorders
 Migraine
 Alzheimer's disease
 Fibromyalgia
 Tinnitus
 Obesity
 Lennox-gastaut syndrome
 Multiple sclerosis

45. Thompson 1910

46. Barker, 1984
Cadwell
DantecMagstim
Common rTMS machines

47.  Repetitive transcranial magnetic stimulation
(rTMS) uses a magnet instead of an electrical
current to activate the brain.
 Typical rTMS session lasts 30 to 60 minutes and
does not require anesthesia.

48.  An electromagnetic coil is held against the target
area of the brain that is thought to be involved in
deserved function. Then, short electromagnetic
pulses are administered through the coil.
 The magnetic pulse easily passes through the skull,
and causes small electrical currents that stimulate
nerve cells in the targeted brain region. And
because this type of pulse generally does not reach
further than two inches into the brain, scientists
can select which parts of the brain will be affected
and which will not be.
 Generally, the person will feel a slight knocking or
tapping on the head as the pulses are administered

49. 1. Non invasive procedure
2. Fewer cognitive side effects
3. Patient can drive in and drive out
4. No risk of anesthesia
5. No stigma
6. Less risk for clinician

50. Low frequency rTMS
 < 1 Hz. frequency stimulation
 Low frequency stimulation for
long duration, induces long
lasting inhibition of neuronal
excitation called as Long term
depression (LTD)
 Reduces cerebral metabolism
 Reduction in cerebral blood flow
 Application on Lt. PFC causes
deterioration of mood
High Frequency rTMS
 > 1 Hz frequency stimulation
 High frequency stimulation for
short duration, induces long
lasting increase of neuronal
excitation called as Long term
Potentiation (LTP)
 Increases cerebral metabolism
 Increase in cerebral blood flow
 Application on Lt. PFC causes
elevation of mood

51.  Protocol A
 low frequency stimulation (1 Hz)
 Used for auditory hallucinations on left temporo
parietal region at 90% of MT
 Protocol B
 High frequency stimulation ( 2Hz)
 Used for anxiety disorders, somatisation disorder,
OCD, moderate depressive disorder on left prefrontal
region at 110% of MT
 Protocol C
 High frequency stimulation(3Hz)
 Used for severe depression on left prefrontal region at
110% of MT

52.  TMS diagnostic uses-to measure activity and
function of specific brain circuits in humans.
 measuring the connection between the
primary motor cortex and a muscle to evaluate
damage from stroke, multiple sclerosis,
amyotrophic lateral sclerosis, movement
disorders, motor neuron disease and injuries
and other disorders affecting the facial and
other cranial nerves and the spinal cord.

53.  The use of single-pulse TMS was approved by
the FDA for use in migraine
 For neuropathic pain, for which there is high-
frequency (HF) repetitive TMS (rTMS) appears
effective
 For loss of function caused by stroke LF-rTMS
of the corresponding brain region has probable
efficacy

54.  For treatment-resistant major depressive
disorder, HF-rTMS of the left dorsolateral
prefrontal cortex(DLPFC) appears effective and
low-frequency (LF) rTMS of the right DLPFC
has probable efficacy.
 For negative symptoms of schizophrenia, HF-
rTMS of the left DLPFC has probable efficacy
 Hoffman used daily LF-rTMS over temporal
lobes to treat hallucinations

55. Areas of research
 Rehabilitation of aphasia and motor disability
after stroke
 Anxiety disorders,obsessive-compulsive
disorder, schizophrenia,substance
abuse,addiction, and posttraumatic stress
disorder (PTSD)
 Amyotrophic lateral sclerosis, multiple
sclerosis,epilepsy,Alzheimer's disease,
Parkinson's disease, Tinnitus

56. Side effects
 The muscles of the scalp, jaw or face may contract
or tingle during the procedure.
 Mild headache or brief light headedness
 Possibility of seizure(1 in 1000 patients or 1 in
30,000 treatments)
 Transient induction of hypomania, transient
cognitive changes
 Transient hearing loss, transient impairment of
working memory,
 Induced currents in electrical circuits in implanted
devices

57.  Contraindications
Patients with any type of non-removable metal
in their heads (with the exception of braces or
dental fillings), or within twelve inches of the
coil should not receive rTMS

59.  Deep brain stimulation (DBS) was first
developed as a treatment for Parkinson's
disease to reduce tremor, stiffness, walking
problems and uncontrollable
movements(Limousin 1995)
 Internal globus pallidus & Sub thalamic
nucleus are the target areas

60.  In DBS, a pair of electrodes is implanted in the
brain and controlled by a generator that is
implanted in the chest. Stimulation is
continuous and its frequency and level is
customized to the individual.
 DBS has only recently been studied as a
treatment for depression or obsessive
compulsive disorder
 No FDA approval for depression

61.  DBS requires brain surgery. The head is shaved
and then attached with screws to a sturdy
frame that prevents the head from moving
during the surgery. Scans of the head and brain
using MRI are taken. The surgeon uses these
images as guides during the surgery. Patients
are awake during the procedure to provide the
surgeon with feedback, but they feel no pain
because the head is numbed with a local
anesthetic

62.  Once ready for surgery, two holes are drilled into the
head. From there, the surgeon threads a slender tube
down into the brain to place electrodes on each side of
a specific part of the brain.
 In the case of depression, the part of the brain targeted
is called Area 25(Rostral anterior cingulate). This area
has been found to be overactive in depression and
other mood disorders.
 Another approach bilateral high frequency stimulation
of nucleas accumbens
 In the case of OCD, the electrodes are placed at anterior
limb of internal capsule ,bilaterally (Greenberg)

63.  After the electrodes are implanted and the
patient provides feedback about the placement
of the electrodes, the patient is put under
general anesthesia.
 The electrodes are then attached to wires that
are run inside the body from the head down to
the chest, where a pair of battery-operated
generators are implanted.
 From here, electrical pulses are continuously
delivered over the wires to the electrodes in the
brain.

64. Epidural cortical stimulation
 Based on principle of cortical regulation of sub
cortical ,limbic regions
 Shown good results
Other indications of DBS
 Tourette’s disorder
 Substance use
 Obesity
 schizophrenia

65. Side effects
• Bleeding in the brain or stroke
• Infection
• Disorientation or confusion
• Unwanted mood changes
• Movement disorders
• Lightheadedness
• Trouble sleeping

67.  Magnetic seizure therapy (MST) borrows certain
aspects from both ECT and rTMS.
 Like rTMS, it uses a magnetic pulse instead of
electricity to stimulate a precise target in the brain.
However, unlike rTMS, MST aims to induce a
seizure like ECT. So the pulse is given at a higher
frequency than that used in rTMS(100Hz,2T)
 Therefore, like ECT, the patient must be
anesthetized and given a muscle relaxant to
prevent movement.
 The goal of MST is to retain the effectiveness of
ECT while reducing the cognitive side effects
usually associated with it.
 It is currently being investigated for the treatment
of treatment-resistant depression (TRD),
schizophrenia and obsessive-compulsive disorder

68.  Application of constant weak(<
1mA) for 20mins through scalp
electrodes
 Induces subthreshold changes in
membrane potential thus alters the
cortical excitability
 Most research for neuro
rehabilitation(post stroke aphasia
rehabilitation)
 Studies in pain and depression
 Burns over scalp is the only side
effect if current >2mA

69. THANK YOU FRIENDS