This chapter should be looked at in conjunction with Chapter 4, where additional justification is given for the rationale behind the newer of these therapies.
In this chapter we review the efficacy of contemporary procedures used in the treatment of mood disorders, including brain stimulation (electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and vagal nerve stimulation (VNS)) and neurosurgical interventions. We focus our review on methodologically sound randomized controlled trials (RCTs), i.e. a prospective comparison of the procedure to either placebo (sham treatment) or an alternative therapy, with random assignment of consecutive patients (rigorously diagnosed) to the treatment groups, and with blinded objective assessment of outcome using sound statistical analyses.
Brain stimulation procedures
Electroconvulsive therapy (ECT)
In ECT, a brief electrical stimulus is applied through the scalp of a patient under general anesthesia, with the goal of inducing a generalized cerebral seizure. Electroconvulsive therapy is a safe medical procedure due in large part to several important medical modifications in the procedure (use of oxygen, anticholinergic premedication where indicated, anesthesia, and muscle relaxation), and recent improvements in technique (e.g., brief pulse stimulus waveform, appropriate stimulus dosage, appropriate stimulus electrode placement, and quantitative seizure monitoring), all of which have lessened cognitive side effects and improved efficacy. Since its inception in 1938, the efficacy of ECT in mood disorders has been documented by an extensive clinical experience and by numerous open and comparative trials (APA, 2001; Abrams, 2002).