Neurotherapeutic Interventions for Psychiatric Illness

Abstract

Many patients with mental illness do not respond to common evidence-based treatments such as psychopharmacology and psychotherapy. We increasingly understand these illnesses as disorders of brain circuits, suggesting that otherwise treatment-refractory patients might be helped by direct intervention in those circuits. Non-invasive techniques for circuit intervention include electro-convulsive therapy (ECT) and transcranial magnetic stimulation (TMS). Circuits can also be targeted more directly and focally through neurosurgical intervention, including through vagus nerve stimulation (VNS), ablative neurosurgery (cingulotomy and capsulotomy), cortical brain stimulation (EpCS), or deep brain stimulation (DBS). Each of these approaches has evidence supporting its use in a major psychiatric disorder, although many have yet to demonstrate a strong clinical signal in a randomized controlled trial. New technologies that may aid in that demonstration include non-invasive techniques that can focus energy more precisely in the deep brain and invasive devices that respond in real time to changes in brain activity (closed-loop stimulation). In this article, we review the modalities and evidence base for these neurotherapeutics, with an emphasis on their clinical readiness and relative advantages.