[Neuromodulation as the fourth pillar in the treatment of depression : A position paper of the German Center for Mental Health].

Abstract

Background: Depressive disorders are associated with a high burden of disease; a substantial proportion of patients show insufficient response despite guideline-based pharmacotherapy and psychotherapy, particularly in treatment-resistant depression (TRD). Neuromodulation has become established as a fourth pillar in the treatment of depression and includes electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS), transcranial electrical stimulation (tES), magnetic seizure therapy (MST), deep brain stimulation (DBS) and neurofeedback (NF). Despite partly well-established efficacy, these interventions remain insufficiently integrated into routine clinical care. The aim of this paper is to summarize the current evidence and to analyze key barriers to implementation.

Material and methods: Narrative review of clinical studies, meta-analyses, and care data on efficacy, safety and cognitive tolerability.

Results: The strongest evidence for both acute and maintenance treatment of severe depressive disorders is for ECT; rTMS is effective and cognitively well tolerated and VNS can represent an additive long-term option in TRD. For tES, small and heterogeneous effects have been reported, MST and DBS remain experimental and for NF consistent evidence of efficacy is lacking. Key barriers include partly heterogeneous protocols, insufficient funding structures, particularly in the outpatient setting and the absence of standardized qualification requirements.

Conclusion: Neuromodulation should be systematically integrated into staged-care models. Standardized protocols and registry-based research are needed to enable the structured and sustainable implementation of neuromodulatory interventions in clinical care.