October 29, 2018

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 […]

Dr. Edgar Castillo

October 29, 2018

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."

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