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Chapter 27. Nonpharmacological Somatic Treatments

Mark S. George, M.D.; Ziad H. Nahas, M.D., M.S.C.R.; Jeffrey J. Borckardt, Ph.D.; Berry Anderson, B.S.N., R.N.; Milton J. Foust, M.D.
DOI: 10.1176/appi.books.9781585623402.338825

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Excerpt

Psychiatry is now developing a third realm of treatment modalities, complementing the well-established realms of psychopharmacology (medications) and psychotherapy. Various names are used to describe these treatments—ranging from "neuromodulation" to "brain stimulation techniques" to the hard-to-understand and cumbersome "nonpharmacological somatic treatments." As a class, these methods involve focal electrical brain stimulation of some sort and vary widely in their invasiveness and methods of delivery. Table 27–1 lists the current methods. In this chapter we review only those treatments that are U.S. Food and Drug Administration (FDA) approved for treatment of traditionally defined psychiatric disorders, such as electroconvulsive therapy (ECT) and vagus nerve stimulation (VNS), or treatments that have substantial Class I randomized controlled trial (RCT) data supporting their use, such as transcranial magnetic stimulation (TMS). These techniques are also being used in traditionally defined neurological disorders (e.g., deep brain stimulation [DBS] in dystonia or Parkinson's disease). We will mention their uses where appropriate, but a complete review of these treatments is found in the references listed in "Suggested Readings."

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FIGURE 27–1. Transcranial magnetic stimulation (TMS).TMS works by first passing a powerful electrical current through a coil, which creates a transient magnetic field. The current passes unimpeded through the skull, causing electrical current to flow in neurons.Source. Reprinted from George MS: "Stimulating the Brain." Scientific American 289:66–73, 2003. Copyright 2003, Bryan Christie Design, Maplewood, New Jersey. Used with permission.

FIGURE 27–2. Significant secondary effects of TMS (direct cortical stimulation), as seen on interleaved TMS/BOLD fMRI.Interleaved transcranial magnetic stimulation (TMS)/blood oxygen level–dependent (BOLD) functional magnetic resonance imaging (fMRI) reveals that left prefrontal TMS produces deeper transsynaptic effects. Shown are images from different slices of a common brain, where results from 14 medication-free depressed patients have been pooled. The areas in red are regions that have more blood flow when TMS is applied over the prefrontal cortex than when it is off. Note that although TMS directly stimulates only the left prefrontal cortex, there is also increased activity in many limbic and paralimbic regions connected to the frontal cortex.Source. Reprinted from Li X, Nahas Z, Kozel FA, et al.: "Acute Left Prefrontal Transcranial Magnetic Stimulation in Depressed Patients Is Associated With Immediately Increased Activity in Prefrontal Cortical as Well as Subcortical Regions." Biological Psychiatry 55:882–890, 2004. Copyright 2004, Society of Biological Psychiatry. Used with permission.

FIGURE 27–3. Vagus nerve anatomy.Drawing depicts the brain split sagittally. Note that vagus nerve afferents enter the brain stem and then travel to the locus coeruleus, as well as to other important mood- and anxiety-regulating regions.Source. Reprinted from George MS, Sackeim HA, Rush AJ, et al.: "Vagus Nerve Stimulation: A New Tool for Brain Research and Therapy." Biological Psychiatry 47:287–295, 2000. Copyright 2000, Society of Biological Psychiatry. Used with permission.

FIGURE 27–4. Dosing and delivery of vagus nerve stimulation (VNS).Nurse Berry Anderson, left, holds the programming PDA, which is connected to an infrared wand positioned over the left chest wall of research assistant Lauren Forster (not an actual VNS patient). The VNS patient holds the wand over the generator, which is typically implanted in the left chest wall and connected by a wire to the lead wrapped under the vagus nerve in the left neck. The treating clinician can then adjust the VNS device stimulation parameters.Source. Photo courtesy of Dr. Mark George, Medical University of South Carolina (MUSC) Brain Stimulation Laboratory.

FIGURE 27–5. Vagus nerve stimulation (VNS) efferents in the brain.Shown are images from representative slices of a common brain, where results from nine depressed patients have been pooled. Top row: The activated areas (displayed in color) are regions showing increased blood flow while the device was actively delivering stimulation, compared with the few seconds before, when it was silent. Note the activation in the hypothalamus, orbitofrontal and prefrontal cortex, and insula. Bottom row: The colored areas are the brain regions activated when subjects heard a tone (largely auditory cortex). VNS activates the "gut-sensory" system.Source. Reprinted from Lomarev M, Denslow S, Nahas Z, et al: "Vagus Nerve Stimulation (VNS) Synchronized BOLD fMRI Suggests That VNS in Depressed Adults Has Frequency/Dose Dependent Effects." Journal of Psychiatric Research 36:219–227, 2002. Copyright 2002, Elsevier LTD. Used with permission.
Table Reference Number
TABLE 27–1. Overview of somatic nonpharmacological treatments
Table Reference Number

The brain is fundamentally an electrochemical organ, where electrical impulses serve as the basis for information flow and then cause neurotransmitter release.

Electrical stimulation of the brain can theoretically cause focal neuropsychopharmacological changes without the side effects of systemic medications.

Brain stimulation therapies as a class share several common concepts and principles and can be understood by identifying which procedures produce seizures on purpose (ECT, MST, focal electrical alternating current seizure therapy [FEAST]) and which do not (TMS, VNS, DBS).

ECT is our most effective treatment for acute major depression.

TMS is an exciting research tool.

Repeated daily prefrontal TMS has acute antidepressant effects similar to those of medications or ECT, with few side effects.

VNS is FDA approved for the treatment of epilepsy and treatment-resistant depression.

VNS is best reserved for patients with a long history of depression (chronic) who cannot be given most other treatment options.

More research on the fundamental neurobiological effects of brain electrical stimulation will help these new techniques continue to improve and evolve.

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Sample questions:
1.
Electroconvulsive therapy (ECT) is the prototype for nonpharmacological somatic treatments in psychiatry. Which of the following statements regarding the clinical use of ECT is true?
2.
Which of the following statements regarding transcranial magnetic stimulation (TMS) is true?
3.
Transcranial magnetic stimulation (TMS) may have a role in the treatment of anxiety disorders, particularly obsessive-compulsive disorder (OCD). Which of the following statements regarding the treatment of OCD with TMS is true?
NOTE:
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