While I have been caring for patients over 30 years, I have seen many advances and breakthroughs. Most of my work has been with depressive, bipolar and anxiety disorders. As a professor of psychiatry, I have taught many residents and medical students. I have had the occasion more than once to say, “if a new treatment seems to work for everything, it probably works for nothing!” But for this new treatment I am reserving such a judgment as I see it helping so many patients in so many ways. The treatment is called transcranial magnetic stimulation usually referred to as TMS. This is a procedure where pulses of magnetism are applied to the brain in very specific locations and dosages. This leads to changes in the nerve cells in these areas which can be modulated to treat depression and, in all likelihood, many other conditions. TMS was approved by the FDA in 2008 for depressed patients who had failed a trial of an antidepressant. There have been various refinements of the equipment since then. As doctors have used TMS over this time they have also gained insight into the correct intensity of treatments and number of treatments needed to remove depressive features.
It has been used primarily for the patient with difficult to treat depression. These are patients who either do not respond to antidepressants or if they respond it is with a heavy side effect burden. Sometimes they cannot tolerate antidepressants or antidepressant medication is dangerous when combined with certain other nonpsychiatric medications (Heart Disease, Renal Disease, Liver Disease, etc.) or potentially harmful if administered to people with a multitude of medical conditions. Interestingly, although not an issue for older adults, this treatment may be helpful for many young women wanting to become pregnant. Currently they may choose not to become pregnant in order to avoid exposure to antidepressant or anti-bipolar medications potentially dangerous to the fetus. They and their doctors may feel they should proceed with the pregnancy knowing they can use TMS to get better and stay better throughout this time.
Many people confuse TMS with ECT. While ECT remains a potent treatment for depression it is fraught with difficulties which simply do not exist with TMS. A patient with TMS does not need to receive any type of anesthesia, do not undergo a seizure, he or she can drive themselves to the office before and after the procedure, and we have not found any significant confusion or memory disorders associated with the treatment. There is a slight rise in the chances of possibly inducing a seizure, but this remains quite infrequent and remote. TMS is simply a good choice in many cases where ECT would not be considered the next therapeutics step. We physicians always make judgments according to a risk-benefit equation. With the risk of ECT being rather high, we reserve it for those patients in whom we need a particular benefit because of the severity or lack of positive outcome of their depressive disorders with other treatments.
In an initial TMS session a physician calibrates an individual’s brain to decide exactly where and what intensity of magnetic pulses to use. The patient sits comfortably in what appears to be a dentist chair and generally receives treatment sessions lasting about 45 minutes. Most patients need four or five sessions per week for four or five weeks. So the treatment does not work quickly, but it works fairly reliably for patients who otherwise do not seem to respond to other treatment options. It is my experience with the population of older adults with depression that many simply are told to accept the fact that they remain at least partially depressed. So, if someone is in the position to make the commitment of time and effort, we now have a treatment which has the potential to completely change their lives for the better.
Generally speaking, all treatments for depression work best when the outcome is maximized through the use of many different combinations of treatment modalities. So, while doing TMS we may still use some antidepressant medication, psychotherapy, light therapy or just common-sense advice on how people would best lead their lives. While people are receiving their TMS they can watch TV, read a book or talk to the technicians who are constantly with them during the procedure. As the potential for positive outcome is high and the risk of negative collateral effects are low, we physicians should have a low threshold for adding TMS to the treatment of patients with depression who do not otherwise show a full response. The ultimate goal in treating a patient with depression is not only to get them not sad and have a positive attitude about life, but to allow them to do the real things they need to do in order to have satisfaction. This may relate to sexual/romantic activities, hobbies or work experience. Certainly anything that can be done to lead people to be more independent in their lives is considered a desired outcome. The changes in depression seen with the use of TMS will translate into a better quality of life.
There is interestingly a role for TMS in the treatment of psychiatric disorders other than depression. Being that this is a fairly new procedure, we are only now gaining a significant research database concerning the use of TMS in these disorders. What we are seeing is quite promising. We’re seeing some positive outcomes in the area of bipolar disorder, posttraumatic stress disorder, dementia, obsessive-compulsive disorder, autism spectrum disorders and attention deficit disorder. In all these areas further investigation is needed to firmly establish the role of TMS. As we use it for these disorders we begin to refine the intensity of magnetism needed and the precise target areas to be stimulated.
In dementia, for which the older adult population has increased risk, having a safe and nonpharmacologic treatment is of obvious benefit. Developing data is suggesting positive use of TMS in Alzheimer’s disease. Also, many older adults considered to have dementia really suffer from what we call pseudo-dementia, a memory problems secondary to the residual effects of partially treated depression. Once depressive treatment is brought into remission, we may see a sustained improvement in memory. Overall TMS has shown great promise in this area which needs to be more firmly established through continued rigorous research.
I myself am particularly interested in the treatment of obsessive-compulsive disorder. This is because in most cases of severe obsessive-compulsive disorder even with the best of treatments patients rarely show full remission. The gold standard for the treatment of obsessive-compulsive disorder has been the use of pharmacotherapy and cognitive behavioral psychotherapy. The pharmacotherapy employed is often through the use of multiple medications at high doses. We often have to accept a tradeoff between obsessive-compulsive symptoms and the undesired side effects of the medication treatment. I’m now hopeful that the adjunctive use of TMS will lead to a fuller recovery, or at least allow treatments which minimize side effects as it allows utilizing fewer and lower dosages of medicines.
So, is the future now? I believe it is, in that we have a totally new type of treatment for a host of well recognized psychiatric syndromes. The data concerning its use in treatment of depression is well-established. As we use TMS for other disorders we are gaining knowledge as to the limits of its use. Overall, I can say there is great promise. So, since my involvement in studying and treating with TMS I no longer say in my lectures “if something seems to work for everything it probably works for nothing.” I will now say that “the newer treatments like TMS appear to work for many conditions and our task is to establish sound data on the use of this treatment for many different conditions.” There is every reason to have renewed hope!
You may reach Dr. Deltito by calling (203) 434-2997.
