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An experimental depression treatment uses electric currents to bring relief

An experimental depression treatment uses electric currents to bring relief

Eleanor Cole, Ph.D., demonstrates the treatment on trial participant Deirdre Lehman in May 2019 at the Stanford Brain Stimulation Lab.
Steve Fisch for Stanford Medicine

After 40 years of fighting debilitating depression, Emma was on the brink.

“I was suicidal,” said Emma, a 59-year-old Bay Area resident. NPR is not using her full name at her request because of the stigma of mental illness. “I was going to die.”

Over the years, Emma sat through hours of talk therapy and tried numerous anti-depression medications “to have a semblance of normalcy.” And yet she was consumed by relentless fatigue, insomnia and chronic nausea.

Depression is the world’s leading cause of disability, partly because treatment options often result in numerous side effects or patients do not respond at all. And there are many people who never seek treatment because mental illness can carry heavy stigma and discrimination. Studies show untreated depression can lead to suicide.

Three years ago, Emma’s psychiatrist urged her to enroll in a study at Stanford University School of Medicine designed for people who had run out of options. On her first day, scientists took an MRI scan to determine the best possible location to deliver electrical pulses to her brain. Then for a 10 minute block every hour for 10 hours a day for five consecutive days, Emma sat in a chair while a magnetic field stimulated her brain.

At the end of the first day, an unfamiliar calm settled over Emma. Even when her partner picked her up to drive home, she stayed relaxed. “I’m usually hysterical,” she said. “All the time I’m grabbing things. I’m yelling, you know, ‘Did you see those lights?’ And while I rode home that first night I just looked out the window and I enjoyed the ride.”

The remedy was a new type of repetitive transcranial magnetic stimulation (rTMS) called “Stanford neuromodulation therapy.” By adding imaging technology to the treatment and upping the dose of rTMS, scientists have developed an approach that’s more effective and works more than eight times faster than the current approved treatment.

A coil placed on top of Emma’s head created a magnetic field that sent electric pulses through her skull to tickle the surface of her brain. She says it felt like a woodpecker tapping on her skull every 15 seconds. The electrical current is directed at the prefrontal cortex, which is the part of the brain that plans, dreams and controls our emotions.

“It’s an area thought to be underactive in depression,” said Nolan Williams, a psychiatrist and rTMS researcher at Stanford. “We send a signal for the system to not only turn on, but to stay on and remember to stay on.”

Williams says pumping up the prefrontal cortex helps turn down other areas of the brain that stimulate fear and anxiety. That’s the basic premise of rTMS: Electrical impulses are used to balance out erratic brain activity. As a result, people feel less depressed and more in control. All of this holds true in the new treatment — it just works faster.

A recent randomized control trial, published in The American Journal of Psychiatry, shows impressive results are possible in five days of treatment or less. Almost 80% of patients crossed into remission — meaning they were symptom-free within a month. This is compared to about 13% of people who received the placebo treatment.

For the control group, the researchers disguised the treatment with a magnetic coil that mimicked the actual treatment. Neither the scientist administering the procedure nor the patients knew if they were receiving the real or sham treatment. Patients did not report any serious side effects. The most common complaint was a light headache.

Stanford’s new delivery system may even outperform electroconvulsive therapy, which is the most popular form of brain stimulation for depression, but while quicker, it requires general anesthesia.

“This study not only showed some of the best remission rates we’ve ever seen in depression,” said Shan Siddiqi, a Harvard psychiatrist not connected to the study, “but also managed to do that in people who had already failed multiple other treatments.”

Siddiqi also said the study’s small sample size, which is only 29 patients, is not cause for concern.

“Often, a clinical trial will be terminated early [according to pre-specified criteria] because the treatment is so effective that it would be unethical to continue giving people placebo,” said Siddiqi. “That’s what happened here. They’d originally planned to recruit a much larger sample, but the interim analysis was definitive.”

Nolan Williams demonstrates the magnetic brain stimulation therapy he and his colleagues developed, on Deirdre Lehman, a participant in a previous study of the treatment.

Steve Fisch for Stanford Medicine

Mark George, a psychiatrist and neurologist at the Medical University of South Carolina, agrees. He points to other similarly sized trials for depression treatments like ketamine, a version of which is now FDA-approved.

He says the new rTMS approach could be a game changer because it’s both more precise and kicks in faster than older versions. George pioneered an rTMS treatment that was approved by the federal Food and Drug Administration for depression in 2008. Studies show that it produces a near total loss of symptoms in about a third of patients; another third feel somewhat better and another third do not respond at all. But the main problem with the original treatment is that it takes six weeks, which is a long time for a patient in the midst of a crisis.

“This study shows that you can speed it all up and that you can add treatments in a given day and it works,” said George.

The shorter treatment will increase access for a lot of people who cannot get six weeks off work or cover child care for that long.

“The more exciting applications, however, are due to the rapidity,” said George. “These people [the patients] got unsuicidal and undepressed within a week. Those patients are just clogging up our emergency rooms, our psych hospitals. And we really don’t have good treatments for acute suicidality.”

After 45 years of depression and numerous failed attempts to medicate his illness, Tommy Van Brocklin, a civil engineer, says he didn’t see a way out.

“The past couple of years I just started crying a lot,” he said. “I was just a real emotional wreck.”

So last September, Van Brocklin flew across the country from his home in Tennessee to Stanford, where he underwent the new rTMS treatment for a single five-day treatment. Almost immediately he started feeling more optimistic and sleeping longer and deeper.

“I wake up now and I want to come to work, whereas before I’d rather stick a sharp stick in my eye,” said Van Brocklin. “I have not had any depressed days since my treatment.”

He is hopeful the changes stick. More larger studies are needed to verify how long the new rTMS treatment will last.

At least for Emma, the woman who received Stanford’s treatment three years ago in a similar study, the results are holding. She says she still has ups and downs but “it’s an entirely different me dealing with it.”

She says the regimen rewired her from the inside out. “It saved my life, and I’ll be forever grateful,” said Emma over the phone, her voice cracking with emotion. “It saved my life.”

Stanford’s neuromodulation therapy could be widely available by the end of this year — that’s when scientists are hoping FDA clearance comes through. The technology is licensed to Magnus Medical, a startup with plans to commercialize it.

Williams, the lead researcher at Stanford, says he’s optimistic insurance companies will eventually cover the new delivery model because it works in a matter of days, so it’s likely more cost-effective than a conventional 6 week rTMS regimen. Major insurance companies and Medicare currently cover rTMS, though some plans require patients to demonstrate that they’ve exhausted other treatment options.

The next step is studying how rTMS may improve other mental health disorders like addiction and traumatic brain injury.

“This study is hopefully just the tip of the iceberg,” said Siddiqi. “I think we’re finally on the verge of a paradigm shift in how we think about psychiatric treatment, where we’ll supplement the conventional chemical imbalance and psychological conflict models with a new brain circuit model.”

In other words, electricity in the form of rTMS could become one of the vital tools used to help people with mental illness.

Blog author: npr.org

Treating Depressions with TMS

Treating Depressions with TMS

Transcranial Magnetic Stimulation or TMS, is a non-invasive, and effective treatment for depression without the multiple side effects caused by medication treatment. Hear from a patient who says it changed her life. Call the Central California TMS Center for more information.
Medication-free Interventions for Depression

Medication-free Interventions for Depression


Medication-free Interventions for Depression

These treatments have been proven to be effective for mood disorders and are backed by scientific research:



1. Exercise

The last thing a depressed person wants to do is exercise but it is well known that regular physical activity elevates the mood and provides a sense of well being. This is done in part by increasing certain brain neurotransmitters and in part by modulating stress response.





2. Bright Light Therapy (BLT)

This refers to the use of bright light to treat symptoms of depression. Sleep disturbance is a core symptom of depression and of other mood disorders. BLT helps regulate the circadian rhythm, It triggers and increases the amplitude of melatonin production as well as higher serotonin levels. Sleep regulation helps the depressed person start to feel better.






4. Behavioral activation Therapy (BAT)

This behavioral component of CBT has been found to be a “stand alone” treatment for depression and it is highly effective.It guides the person to understand that their emotions are the result of their actions. It helps the depressed person to identify activities that add meaning to their life, like reading, listening to music, volunteering, visiting with friends and family, etc. The person is told to do these things without waiting for their mood to get better.





6. Transcranial Magnetic Stimulation (TMS)

During TMS treatment a large magnetic coil is held against the scalp on the Left Prefrontal Region of the brain. This area is near what is thought to be the “mood center”. Without pain, magnetic pulsations pass through the skull to stimulate the nerve cells. TMS helps normalize the activity of brain circuits involved in depression. The treatment is not invasive and there is no need for an anesthetic. In October, 2008 the US Food and Drug Administration cleared the first TMS device for the treatment of Major Depression




3.Cognitive Behavioral Therapy (CBT)

This is a type of “talk” therapy but also a “do” therapy relying in the delegation of “tasks” to the patient. It focuses on changing negative thought patterns, on learning to redefine problems and on finding new ways to approach them





5. Mindfulness Training

People are told to pay attention in a particular way: to do it on purpose, in the present moment, and without judging. They are thought to bring their mind to mundane objects or activities in everyday life. You practice mindfulness by eating mindfully, walking mindfully, “observing” your breathing, connecting with your senses, resting between actions, listening attentively with mind and heart and “getting lost” in doing what you love.


The Biology of Mental health

The Biology of Mental health

mental health clinical depression fresno

It has been established with certainty that regular exercise (aerobic or anaerobic) is beneficial to one’s overall health. This is especially true if combined with a regimen that includes a balanced diet with plenty of fruit ,nuts and vegetables.
Lately, there has been a series of studies linking physical exercise to improvement of mood and mental health. It has been known for a long time that Tai Chi exercises and Yoga movements and poses improve balancing, muscle strength and flexibility with the concomitant benefit of an improvement of anxiety and depression. More recently the understanding of the relationship of multiple internal body systems with the brain has shown there are specific benefits from physical exercise to achieve and maintain better mental
health. One of the benefits comes from the “neutralization” of stress during physical exercise. This effect is related to a better autonomic nervous system regulation of the heart function as well as modulation of the body’s inflammatory response (HPA axis). Major depression and anxiety by virtue of their pro-inflammatory status cause to endothelial dysfunction that ultimately lead to “arterial stiffness”. The association between depression and cardiovascular disease is bi-directional. Both entities share common pathophysiology. Following a myocardial infarction the presence of depression has a cumulative effect on morbidity and mortality. At Central California TMS Centers in California and in Guatemala we emphasize lifestyle modifications as part of a comprehensive treatment plan. These key changes include: to achieve a BMI 25% or under, exercise regularly, do yoga or Tai Chi, smoking cessation, reduce alcohol intake, modify or better manage stressful conditions, change diet to one low in carbohydrates, with plenty of vegetables, nuts and fruits.

In despair from major depression, I turned to a last resort: Magnets

In despair from major depression, I turned to a last resort: Magnets

For most of my 46 years, I have battled mild to severe depression and anxiety. Mood disorders run like a sticky red tape through my family, so it wasn’t a surprise that I needed a psychiatrist’s care starting as a young child. He helped me push on through middle and high school.

But when I went to college – away from my support system – I started thinking about suicide. Hearing this, a campus psychiatrist had me hospitalized, which only increased my despair. I attempted suicide and was institutionalized even longer.

With time and intensive therapy, along with an early form of antidepressant called a tricyclic, I managed to pull myself back into life. I finished college, worked in journalism, got married, had three children.

However, my depression never entirely left me alone. Dysthymia, a persistent, mild depression that insidiously eats away at self esteem, meant I couldn’t feel sustained pleasure or pride in the accomplishments for which I had fought so hard.

But that was nothing compared with what happened a few months ago. Without warning, I slid back down into the dark hole of severe depression, complete with thoughts of suicide.

Major depression strikes both sexes, but is more common in women, in part, it is thought, due to hormonal differences. Its incidence is on the rise, but it already is the leading cause of disease burden – a measure of both health and financial impact — in women worldwide, according to the World Health Organization.

As my case illustrates, major depression affects the entire family. My husband and in-laws took care of the children. Friends brought dinners. And I dragged myself through the days, desperate to stay out of the hospital, leaning on my psychoanalyst and the psychiatrist who prescribed my medications.

It wasn’t enough.

After many grueling weeks, my psychiatrist suggested that I consider transcranial magnetic stimulation (TMS) – a treatment I had never heard of.

‘Like an electronic woodpecker’

TMS is a noninvasive treatment administered by a physician in an outpatient setting daily for approximately six weeks. A magnetic coil that produces pulsing energy is placed on selected parts of the scalp, carefully set to the level of energy needed to stimulate a patient’s brain cells. You remain lying down, wearing earplugs because the machine makes a loud clicking sound like an MRI. In my experience, TMS feels like an electronic woodpecker hammering on my head. But oddly enough, it isn’t painful, and I sometimes even drift off to sleep during treatment.

The magnetic stimulation has been shown to change neuron activity in parts of the brain involved in mood regulation. Estimates for the success of TMS in patients who haven’t been helped by medication or other therapies vary between 50 percent and 75 percent.

It sounded so promising – and I was so desperate – that I quickly scheduled an appointment with John O’Reardon, a Voorhees psychiatrist who has long seen patients close to giving up.

During our 1½-hour consultation, O’Reardon confirmed my severe depression, accompanied by high anxiety levels. He thought I might not be on the right combination of psychiatric medicines but also recognized I was in no condition for the agonizing process of recalibrating them. Since age 18, I’ve tried roughly 15 different drugs, without lasting success.

My experience is not uncommon. Statistics about the efficacy of antidepressants vary and indicate that those with moderate to severe depression benefit the most. Studies of adults with moderate to severe depression showed that about 40 to 60 out of 100 people who took an antidepressant noticed an improvement in their symptoms within six to eight weeks, though research also indicates that some of this gain may be due to a placebo effect.

Putting any major shifts in my medications on hold, O’Reardon recommended a full course of TMS, which the Food and Drug Administration approved in 2008 for the treatment of depression and migraines. I live in Bala Cynwyd but chose to drive every day to see O’Reardon because of his 21 years of experience, first at the University of Pennsylvania in a clinical research setting and now in private practice. I also took heart in his telling me that although I might feel “hopeless,” I was not a “hopeless case.”

“The amount of patients who have severe, what we call treatment-resistant depression, is about four million at any one time in the U.S.,” O’Reardon said later in an interview. “These are patients who do not respond to medications, who may not respond to therapy, and really need something else. And for those patients, in particular, TMS is very useful.”

The treatments stimulate connections of nerves or neurons called circuits to restore their normal activity.

“These circuits are disabled, or if you like, off-line in depression,” O’Reardon said. “And because they’re not working as normal, the patient has many things like depressed mood, low energy, poor sleep, and can, of course, even feel suicidal. By stimulating these circuits with magnetic energy, we can restore them to normal activity.”

A typical course of TMS is five days a week for a total of 30 to 36 sessions. The treatment is very safe and, unlike psychiatric medications, has few side effects. The most serious issue is a risk of seizure in about one out of every 1,000 patients. People can drive themselves to and from appointments and conduct normal conversation during treatments.

Expanding TMS’s reach

Approximately 1,000 TMS centers have popped up across the country since 2008. Clinicians around the world are studying TMS to treat conditions from post-traumatic stress disorder to autism spectrum disorder.

Deborah Kim and Susan Rushing, psychiatrists who jointly run TMS Associates of Pennsylvania in Haverford, do what is known as deep TMS.

“Really, the main difference is that it works on a larger part of the brain so it gets more of the circuit that we think is involved in depression,” said Kim, who is also an associate clinical professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania. “This is as close as we can get without doing deep brain stimulation,” she said of the surgical procedure used most often to help address some symptoms of Parkinson’s disease.

She notes that TMS is especially useful for treating depression in women who don’t want to use medication while pregnant or nursing.

Yvette Sheline, director of the Center for Neuromodulation in Depression and Stress at Perelman, and her colleague Desmond Oathes are researching using MRIs of people’s brains to better pinpoint where the magnetic energy should be applied to maximize benefits. Showing brain activity on an MRI while the device is in use enables “the correct target to be identified at the outset and keeps the stimulation on target during treatment,” Sheline said.

Roy Hamilton, a Penn neurologist, is looking at TMS for improving language development and motor skills after brain injuries such as stroke. “Plenty of patients who’ve been through physical therapy still have pretty dense motor deficits,” Hamilton said, adding that a goal of his research is to “accelerate the course of recovery and to extend the overall level of recovery.”

O’Reardon has used TMS “off-label” to help people with obsessive-compulsive disorder, post-traumatic stress disorder, auditory hallucinations caused by schizophrenia, and chronic pain.

Up out of the hole

I had 30 sessions at $300 a pop, which I paid for out-of-pocket and then submitted to my insurance company – after receiving prior authorization – for out-of-network reimbursement.

The sensation over time was like climbing up a staircase out of the hole, back into my daily life. I began working and parenting again and ultimately feeling brighter, more hopeful, and more resilient than I had in as long as I could remember.

“Some people really just feel like a light is turned on in a way that it never felt like when they were on medications,” Kim said. “The world looks colorful again.”

O’Reardon and I are now discussing how to maintain my gains, most likely through once or twice monthly session of TMS for the indefinite future. He will also continue to manage my medications.

As remarkable as my recovery feels, what may be more astonishing to me is discovering that depression may no longer be a life sentence for me.

“I had never had somebody tell me before that I could get fully well,” I recently told O’Reardon. “That was really an eye-opener when I came in here, and you talked about remission.”

“I think it speaks to some degree to under-treatment in the community – that [depression is] not always treated intensely enough, and then I guess maybe people don’t think about it the way we should think about it: as a reversible illness,” O’Reardon said.

“We should be treating depression more like treating hypertension or diabetes. If you had the right tools, you should be able to reverse things fully and get back to a normal balance. Now we don’t always achieve that, but you’ve got to start with that goal in mind.”

Source For The Inquirer

Postural exercises improve depression

Postural exercises improve depression

At the American Psychiatric Association meeting in May,2018 Dr. Martin Furman from the University of Maimonides, Buenos Aires, Argentina, presented a randomized study showing marked improvements in depressive symptoms after a series of postural exercises.Two set of exercises, one minute each were repeated 4 times a day every day for 12 weeks. One type was “equilibrium exercise”, raising both arms and flexing one lower limb and then the other. Each flex was maintained for 15 seconds. In the other type of exercise the patient was asked to hold a pencil between the teeth and “smile” for 1 minute. The results were impressive, Reductions in the Ham-D 17 and the Beck Depression inventory scales were significant. Tai Chi exercises emphasize equilibrium and are known to help with depression and significantly reduce anxiety. Yoga posturing combined with verbal expressions of gratitude also have shown benefits for stress, anxiety and depression.Exercise in general improve mood in a variety of circumstances. Dr. Furman has been working with Dr. Tomas Ortiz-Alonzo a psychiatrist from the University Complutense of Madrid. Dr. Ortiz-Alonzo has pioneered this type of investigation for the past several years. According to Dr. Furman, “feedback of the muscular and facial skin afferents has been associated with modulation of neural activity within the central circuit of emotions”