Chapter 10: Brain Stimulation Therapies

Chapter 10: Brain Stimulation Therapies

Nonpharmacological treatments for certain mental health disorders.

Types of Brain Stimulation Therapies

• Electroconvulsive Therapy (ECT)

• Repetitive Transcranial Magnetic Stimulation (rTMS)

• Vagus Nerve Stimulation (VNS)

• Deep Brain Stimulation (DBS)

Electroconvulsive Therapy

Uses electrical current to induce brief seizure activity while client is anesthetized.

Mechanism unclear; may enhance effects of neurotransmitters (serotonin, dopamine, norepinephrine).

Electroconvulsive Therapy Indications / Contraindications

Major Depressive Disorder

• Not responsive to medication.

• When other treatments carry higher risk.

• Suicidal/homicidal with need for rapid response.

• With psychotic features.

Schizophrenia Spectrum Disorders

• Schizophrenia with catatonia.

• Schizoaffective disorder.

Acute Manic Episodes

• Bipolar disorder with rapid cycling (≥4 episodes/year).

• Unresponsive to lithium or antipsychotics.

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Relative risks:

• Cardiovascular disorders: Recent MI, hypertension, heart failure, arrhythmias.

• Cerebrovascular disorders: Stroke history, brain tumor, hematoma → ↑ ICP during treatment.

Not effective for:

• Substance use disorders

• Personality disorders

• Dysphoric disorder

Electroconvulsive Therapy Considerations

Procedural Care

• Course: 2–3 times/week for 6–12 treatments (for depression).

• Consent: Provider obtains informed consent; if involuntary, can be from next of kin or court.

• Pre-procedure workup: Chest X-ray, blood work, ECG. Discontinue benzodiazepines.

• Medication management:

  • 30 min prior: IM atropine sulfate or glycopyrrolate to ↓ secretions & prevent bradycardia (vagal stimulation).

  • At procedure: Short-acting anesthetic (etomidate or propofol) IV bolus.

  • Muscle relaxant (succinylcholine) to paralyze muscles & ↓ injury risk; requires breathing assistance.

• Control severe hypertension before procedure.

• Monitor/treat cardiac dysrhythmias or hypertension before procedure.

• Nurse monitors vitals & mental status before/after.

• Provide teaching; address misconceptions.

• IV line maintained until recovery.

• Electrodes applied for EEG monitoring.

• 100% oxygen given during/after until spontaneous respirations return.

• Continuous cardiac monitoring during procedure.

• Clients usually alert ~15 min post-procedure.

Electroconvulsive Therapy Complications

Memory loss & confusion

• Short-term memory loss, confusion, disorientation → hours post-procedure.

• Retrograde amnesia (loss of memory before procedure) can last weeks.

• Permanent memory loss is controversial; most recover.

• Actions: Frequent orientation, safe environment, assist with hygiene.

Reactions to anesthesia

• Action: Continuous monitoring during and after procedure.

Cardiovascular changes

• Action: Monitor vitals and cardiac rhythm regularly.

Relapse of depression

• Not a cure; ongoing medication or maintenance may ↓ relapse risk.

A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching?

a

“It is common to treat depression with ECT before trying medications.”

b

“I can have my depression cured if I receive a series of ECT treatments.”

c

“I should receive ECT once a week for 6 weeks.”

d

“I will receive a muscle relaxant to protect me from injury during ECT.”

d “I will receive a muscle relaxant to protect me from injury during ECT.”

A muscle relaxant (succinylcholine) is administered to reduce the risk for injury during induced seizure activity.

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ECT is indicated for clients who have major depressive disorder and who are not responsive to pharmacological treatment.

The typical course of ECT treatment is two to three times a week for a total of six to 12 treatments.

ECT does not cure depression. However, it can reduce the incidence and severity of relapse.

A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect?

Select all that apply.

a

Hypotension

b

Paralytic ileus

c

Memory loss

d

Polyuria

e

Confusion

c Memory loss

d Polyuria

Transient short-term memory loss is an expected finding immediately following ECT.

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Paralytic ileus – Not a typical side effect of ECT; more often associated with postoperative abdominal surgery or bowel obstruction.

Polyuria – Not expected after ECT; urinary incontinence may occur during the seizure, but persistent increased urine output is not a common finding.

A nurse is leading a peer group discussion about the indications for ECT. Which of the following indications should the nurse include in the discussion?

a

Borderline personality disorder

b

Acute withdrawal related to a substance use disorder

c

Bipolar disorder with rapid cycling

d

Dysphoric disorder

c Bipolar disorder with rapid cycling

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ECT has not been found to be effective for the treatment of personality disorders, the treatment of substance use disorders, or dysphoric disorder.

Repetitive Transcranial Magnetic Stimulation (rTMS)

Noninvasive therapy using magnetic pulsations (MRI strength) to stimulate the cerebral cortex.

Repetitive Transcranial Magnetic Stimulation (rTMS) Indications / Contraindications

FDA-approved for major depressive disorder unresponsive to medication.

Similar to ECT but does not cause seizure activity.

Repetitive Transcranial Magnetic Stimulation (rTMS) Considerations

Typically prescribed daily for 4–6 weeks.

Outpatient procedure; lasts 30–40 minutes.

Noninvasive electromagnet placed on scalp; client remains alert.

Possible sensations: tapping/knocking on head, scalp skin contraction, jaw tightening.

Often combined with psychotherapy for better depression treatment outcomes.

Repetitive Transcranial Magnetic Stimulation (rTMS) Complications

Mild discomfort/tingling at site, headaches.

Use low-frequency in clients with seizure history.

Monitor for lightheadedness after procedure.

Seizures are rare but possible.

Contraindicated with cochlear implants, brain stimulators, or metallic implants in/near head.

A charge nurse is discussing rTMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? 

a

“RTMS is indicated for clients who have schizophrenia spectrum disorders.”

b

“I will provide postanesthesia care following rTMS.”

c

“RTMS treatments usually last 5 to 10 minutes.”

d

“I will schedule the client for rTMS treatments 3 to 5 times a week for the first several weeks.”

d “I will schedule the client for rTMS treatments 3 to 5 times a week for the first several weeks.”

RTMS is commonly prescribed 3 to 5 times a week for the first four to six weeks. RTMS is indicated for the treatment of major depressive disorder that is not responsive to pharmacological treatment.

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ECT is indicated for the treatment of schizophrenia spectrum disorders.

The rTMS procedure lasts 30 to 40 min.

Postanesthesia care is not necessary after rTMS because the client does not receive anesthesia and is alert during the procedure.

Vagus Nerve Stimulation (VNS)

Electrical stimulation through the nerve to the brain via a surgically implanted chest device (similar to a pacemaker).

Believed to ↑ neurotransmitter levels and enhance antidepressant effects.

Vagus Nerve Stimulation (VNS) Indications / Contraindications

FDA-approved for depression resistant to medication and/or ECT.

Research ongoing for anxiety disorders, obesity, pain.

Vagus Nerve Stimulation (VNS) Considerations

Outpatient surgical procedure

Device delivers programmed pulsations every 5 min for 30 sec.

Antidepressant effects take several weeks.

Client can turn off device with a special external magnet.

Obtain informed consent.

(Same as DBS)

Vagus Nerve Stimulation (VNS) Complications

Voice changes due to nerve proximity to larynx/pharynx.

Hoarseness, throat/neck pain, coughing (often improve over time).

Possible dyspnea, especially with exertion; may need to turn device off during exercise or prolonged speaking.

A nurse is planning care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects?

Select all that apply.

a

Voice changes

b

Seizure activity

c

Disorientation

d

Cough

e

Neck pain

a Voice changes

d Cough

e Neck pain

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When planning care for a client following surgical implantation of a VNS device, the nurse should monitor for the following adverse effects which include: voice changes are a common adverse effect of VNS due to the proximity of the implanted lead on the vagus nerve to the larynx and pharynx.

Coughing and neck pain are potential adverse effect of VNS. However, neck pain usually subsides with time.

Deep Brain Stimulation (DBS)

Surgically implants electrodes into underactive brain regions to stimulate them and improve function (e.g., in depression).

Increases neurotransmitter levels, enhancing antidepressant effects.

More invasive than VNS; reserved for treatment-resistant cases.

Requires standard postoperative care.

Deep Brain Stimulation (DBS) Indications / Contraindications

FDA-approved for Parkinson’s disease and treatment-resistant obsessive-compulsive disorder (OCD).

Deep Brain Stimulation (DBS) Considerations

Outpatient surgical procedure.

Device delivers pulsations every 5 min for 30 sec.

Antidepressant effects take several weeks.

Can be turned off with special external magnet.

Obtain informed consent.

(Same as VNS)

Deep Brain Stimulation (DBS) Complications

Pulse generator implantation → risk of infection.

Possible hypomania without bipolar history.

Other risks: headaches, seizures, stroke, confusion.

Brain Stimulation Therapies (Table)

Therapy	Definition	Indications	Key Considerations	Complications
Electroconvulsive Therapy (ECT)	Electrical current induces brief seizure under anesthesia; may ↑ serotonin, dopamine, norepinephrine.	- Major depressive disorder (nonresponsive, urgent, psychotic) - Schizophrenia spectrum disorders (catatonia, schizoaffective) - Acute mania (rapid cycling, med-resistant)	- 2–3x/week, 6–12 sessions - Informed consent required - Pre-workup: CXR, blood work, ECG; stop benzodiazepines - Meds: Atropine/glycopyrrolate → anesthetic → succinylcholine - Continuous monitoring; oxygen; EEG	- Memory loss/confusion - Anesthesia reactions - Cardiovascular changes - Possible relapse without maintenance
Repetitive Transcranial Magnetic Stimulation (rTMS)	Noninvasive magnetic pulses stimulate cerebral cortex; no seizure activity.	- Major depressive disorder unresponsive to meds	- Daily sessions for 4–6 wks; outpatient - 30–40 min sessions; client awake - Sensations: tapping, scalp contraction, jaw tightening - Often combined with psychotherapy	- Mild scalp discomfort, tingling, headache - Rare seizures - Contraindicated with certain metal implants
Vagus Nerve Stimulation (VNS)	Implanted chest device sends electrical pulses via vagus nerve to brain; boosts neurotransmitters.	- Depression resistant to meds/ECT - Being studied for anxiety, obesity, pain	- Outpatient surgery - Pulses every 5 min for 30 sec; effects in weeks - Can turn off with magnet - Informed consent required	- Voice changes, hoarseness, throat/neck pain, cough - Dyspnea with exertion/speaking
Deep Brain Stimulation (DBS)	Surgically implanted electrodes stimulate underactive brain regions; ↑ neurotransmitters.	- Parkinson’s disease - Treatment-resistant OCD	- More invasive; for severe, treatment-resistant cases - Outpatient surgery - Pulses every 5 min for 30 sec; effects in weeks - Can turn off with magnet - Informed consent & post-op care	- Infection risk (pulse generator) - Hypomania possible - Headaches, seizures, stroke, confusion