Somatic Treatments and Neuromodulation in Psychiatry

Brain stimulation, neuromodulation, and other physical therapies have played a relatively small but continuous role in the treatment of mental health conditions since the mid-twentieth century. For many years, the mainstay of nonpharmacological physical treatments was electroconvulsive therapy (ECT). The safety and application of ECT has improved substantially over recent decades and continues to have a significant role, especially in the treatment of patients with severe and treatment-resistant major depressive disorder (MDD). The range of physical and neuromodulation treatments for mental health conditions, however, is relatively rapidly expanding at the moment. Repetitive transcranial magnetic stimulation (rTMS) – characterized by its safety and efficacy – is fast becoming a core part of the treatment of MDD and its use is expanding into other disorders such as obsessive-compulsive disorder (OCD). There is also emerging evidence for the potential use of other forms of non-invasive brain stimulation such as transcranial direct current stimulation (tDCS) and cranial electrical stimulation (CES). Additionally, there are an increasing range of approaches under active investigation including novel seizure therapy approaches such as magnetic seizure therapy (MST). In addition, there are several forms of brain stimulation that require a surgical procedure for implantation. Vagal nerve stimulation (VNS) appears to have a slow acting but persistent benefit in some patients with treatment-resistant MDD, and deep brain stimulation has an emerging role in the management of some patients with severe OCD. Beyond neuromodulation, an increasing range of research studies have been conducted investigating the use of forms of biofeedback, especially as it might pertain to the treatment of attention deficit hyperactivity disorder (ADHD) and there is modest but consistent evidence supporting the use of bright light therapy in seasonal affective disorder and also potentially in MDD. Physical therapies, including those utilizing brain stimulation methods, clearly have an important and growing role to play as the third tier of therapeutic interventions alongside pharmacotherapy and psychotherapy in the management of patients with mental health problems.