Brain stimulation deserves more attention in depression care. In a letter to The Lancet, Roel Mocking, Odile van den Heuvel and colleagues from the European College of Neuropsychopharmacology (ECNP) Neuromodulation Network warn against a cycle of underuse. A major depression review omitted these treatments because they are used less often. The current paper argues that such omissions may reinforce underuse. Barriers include limited access, insufficient training, referral problems, reimbursement and stigma.

What role can Brain Stimulation play in depression care?

Brain stimulation influences brain activity with electrical or magnetic stimulation. Guidelines recommend electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS). ECT can be lifesaving in severe depression; rTMS is less invasive. Vagus nerve stimulation has a selective role in longstanding, difficult-to-treat depression. Deep brain stimulation (DBS) can be effective even in extremely treatment resistant depression. Drawing on existing evidence, the letter calls for brain stimulation to be considered when indicated. It can be combined with psychological treatment, medication and lifestyle interventions to help patients engage more effectively in their care.

What needs to change?

The practical message is to discuss ECT and rTMS when indicated and combine them with other care where appropriate. Better training, clear referral routes, improved access and adequate reimbursement could help reduce underuse, alongside efforts to address stigma. Research should address implementation barriers as well as treatment effects. Educational materials and influential reviews should reflect the evidence and cover options such as ECT, rTMS, VNS and DBS.

Roel J. T. Mocking, Monika Klírová, Nils Opel, Tiago da Silva Costa, Maria Semkovska, Leif Oltedal, Odile A. van den Heuvel, Jonathan Repple, on behalf of the ECNP Neuromodulation Network. Underuse of neuromodulation in depression care. The Lancet, 408, 1552-1553