New Magnetic Depression Treatment Offers Hope, Questions

This small office on the fifth floor of Concord Hospital is designed to make patients relax.
That’s a good thing, because I’ve just learned that psychiatrist Karl Lanocha is going to use me as a model for his explanation of transcranial magnetic stimulation, or TMS.
I’m facing a device that looks like a dentist’s chair – except that instead of a drill, at the top of the chair is a metal skullcap that clamps onto a patient’s head.
In a moment, that head will be mine.
Thechair.wav: E: You’re gonna put me in the chair? Lanocha: We’re going to put you in the chair. E: Oh my, OK. Lanocha: We’re going to find your motor threshold. E: Oh. Lanocha: You’re going to have to sign a waiver, but it’s no big deal. E: OK, all right, I’m happy to do that…fade under
EG2: Using magnetic pulses, Dr. Lanocha is about to search for my left dorso-lateral pre-frontal cortex.
That’s a small area that has a lot to do with regulating mood.
It also governs some movement on the right side of the body.
Lanoka1.wav: We’re going to deliver a few single pulses to your left motor cortex until we find the spot that causes your right thumb to twitch. Once we have found that site, that is our landmark, and we just move forward a little bit and we’re right where we need to be – the left dorso lateral prefrontal cortex.
EG3: When he works with a patient, Dr. Lanoka will make a series of precise measurements in order to find it.
But that’s time consuming, so today, he says, he’s jus t going to wing it.
Thumbsounds.wav: Susan: Put your thumb in hitchhiker position, etc.
Karl: What I’m trying to do is get good contact, is that pressure OK, etc. Click sounds.
EG4: The FDA approved TMS to treat depression last October.
And Concord hospital is one of only three in New England to offer the treatment, and one of a handful around the country.
At first glance, TMS seems like science fiction.
A patient suffering from major depression will come to the hospital for treatment five days a week for four to six weeks.
CLICK SOUNDS UNDER VO
Sitting in this chair, the patient will receive a rapid-fire series of electromagnetic pulses to the brain..
That sounds scary – but as I learned, those loud pulses don’t hurt – they just make me blink.
SOUND: ARE YOU OK< ETC
And after two or three weeks, about half of TMS patients feel better – and slightly more than 30% have a complete remission.
The reasons why patients get better are complex.
To understand how TMS works, you have to understand something about how nerve cells in the brain work.
Our neurons are firing all the time.
You could say, up to a certain point, that a healthy brain is an active brain.
And that’s where depression comes in.
Eric Wasserman is a neuroscientist at the Neurology Institute at the National Institutes of Health.
He performed some of the early research on TMS.
Wasserman1.wav: The idea for using TMS to treat depression came from functional imaging studies that showed that brain activity and blood flow were reduced in the front of the brain in patients with depression.
EG5: In other words, the neurons of depressed patients don’t fire as quickly as the neurons in people who don’t suffer from the disease.
So Wasserman and some of his colleagues wanted to see if they could speed up the firing rate of those neurons by jumpstarting them with magnetic energy.
By the early 1990s, these scientists and other researchers, at places like Beth Israel in Boston, discovered that it worked.
They found that the resulting acceleration in brain activity lifts the mood of some depressed patients.
They didn’t know then – and they still don’t know – exactly why it works.
But they do know that stimulating these neurons causes a brain to release neurotransmitters like serotonin, norepinepherine and dopamine.
Those are the same neurotransmitters that are affected by popular antidepressant medications like Prozac and Zoloft.
And, says NIH researcher Eric Wasserman, stimulating these neurons also may strengthen their connections, perhaps permanently.
Wasserman7.wav: If we are strengthening connections in a pathway – a series of nerve cells that are interconnected and involved in feeling happy, then a strengthening of those connections might enable happiness to occur more easily.
EG6: So does that mean that scientists have discovered which of our nerve cells are responsible for happiness?
Wasserman8.wav: NO. Laughs. I think in a very general way you could infer that the nerve cells or the brain areas that are underactive in depression are somehow involved in not being depressed.
EG7: Once researchers knew that TMS could help some depressed people, it still wasn’t ready for use outside of the research lab.
They still had to answer several very precise questions about how TMS should work.
Karl Lanoka:
Lanokaresearch.wav: How strong should the magnetic pulses be, how rapidly should they be administered, for how long, and over what part of the brain? All of those parameters are very important.
EG8: Then there was that other niggling question: how safe is it to send magnetic pulses into the brain, particularly over a long period of time?
Lanokasafety.wav: It seemed to be pretty safe. Just about the only thing that anybody complained about was minor scalp irritation at the stimulus site. But every once in a while, somebody had a seizure. It didn’t happen very often, only one in 10,000, but the fact that it happened at all was bad news.
EG9: By 1997, researchers had figured out how strongly and rapidly they should deliver the pulses and to what part of the brain.
And, Dr. Lanoka says, they’d also figured out how to avoid creating seizures.
He says no patient has had a seizure since 2000, and that the treatment is completely safe.
But TMS isn’t for everyone suffering from depression.
The relatively small clinical trials have proved its efficacy for patients who have tried – and failed – with one course of antidepressant medication.
But lots of patients give up on antidepressant medications early on, because they don’t like the side effects.
The company says it doesn’t know yet whether it works for patients who have tried more than one course of medication – at the proper dose, that is.
Another problem is that the treatment is so new insurance doesn’t yet cover it.
A full course of treatment costs about $8,000.
And there’s no telling – yet -- whether the positive effect of treatment is permanent or whether a patient might need to repeat this expensive treatment more than once.
Psychiatrist Mark Demitrack is the chief medical officer at Neuronetics, the machine’s manufacturer.
Demitrack4.wav: Keep in mind that all antidepressant treatments, TMS included, that we have today, are not curative. We don’t understand the cause of depression so we’re not in a position to design curative treatments in the way we do with some other medical illnesses.
EG10: In other words all of today’s depression treatments, including TMS, can only manage depression’s symptoms.
So to maintain a stable mood after finishing the TMS treatment, most patients take an antidepressant drug.
But some may need to come back for more magnetic pulses.
Demitrackrepeat.wav: We know that when some people have returned to their symptoms months after they’ve benefited a short repeat course of TMS will help to restore their symptoms again, bring them out of the depressive episode again at a later point in time.
EG11: The other unanswered question is whether TMS is as effective -- or better than – other antidepressant treatments.
NIH neurologist Eric Wasserman.
Wasserman4.wav: Not much comparison has been made to say standard medication treatments, but in most instances these are patients who have failed one or more trials with medication.
EG12: Still, the new treatment does offer hope to at least some of the country’s 15 million people who suffer from depression.
But Wasserman cautions that it’s not a panacea.
Wasserman11.wav: This may be the pot of gold at the end of the rainbow for some depressed patients who haven’t responded to other things and respond particularly well to TMS, I’ve certainly heard of such patients. However, in general I think it should be regarded as another promising treatment but not necessarily THE treatment.
EG13: What may be at least as promising is the potential that TMS holds to treat other illnesses.
Scientists are investigating the benefits of TMS for rehabilitating stroke victims and for treating schizophrenia, Parkinson’s Diseases, epilepsy, migraine headaches, and even autism.
For NHPR News, I’m Elaine Grant.