Power of a Pulse

A treatment using magnetic force is lifting people from depression.

Photograph by Brandon Dill

Lisa Austin knows about the grief that comes from watching her parents die, and the stress that builds from teaching and counseling high-school students, raising two active children, and enduring debilitating migraines. For a while the 46-year-old resident of Blytheville, Arkansas, managed the sorrow and stress and remained a vivacious, fun-loving woman. “If there was music playing,” she says, “I was the one dancing, I was the one embarrassing my kids. Or on the spur of the moment I was painting a room.”

But in 2013, that upbeat, energetic Lisa began fading. She made it to work, then came home and went through the motions with her family. “I’d put on a face and act silly. But it drained me,” says Austin. Eventually, after quitting the job she loved, she was simply moving from the bed to the couch, where she lay for hours and watched TV. “I had been on an antidepressant since my father died — but it was a band-aid. I was not myself. My kids didn’t know what to think. My husband wanted his wife back. I felt so tired. So absolutely blah. I knew this was different.”

On TV one afternoon, Austin happened to see a news segment about a treatment for depression called transcranial magnetic stimulation, or TMS. The newscaster was interviewing a Memphis psychiatrist, Dr. Leslie Smith, about the treatment, and Austin sat up and took notice. “I would rewind the show and watch it again and again. I’d think, Wow, I’ve got to try this.” When she met Smith for an appointment around Christmas of 2013, “I went in and started bawling. I told him something was wrong. My mother never lay around on the couch all day and neither did I before this. I needed help.”

Within two weeks of TMS treatments — which required a three-hour round-trip drive between Blytheville and Memphis each weekday — she could tell a difference: “The third week was magic — like daylight and dark. I’d initiate things. I’d seek out a girlfriend. I’d go see my kids’ games and enjoy them. I quit taking naps, a biggie for me. I am so grateful for this therapy. I found Lisa again.”

Certainly not every patient responds to TMS as Austin did, but since it was approved by the FDA in 2008, it holds promise for the 19 million Americans who suffer from depression. Smith — who received his medical degree from UT Memphis College of Medicine and his psychiatric training from Dartmouth Medical Center — started offering TMS in 2011 and was the first to bring it to this area, though several other local doctors are now trained in the treatment.

In his office at 5050 Poplar, Smith points to two laptop images of the human brain, specifically the prefrontal cortex. One image shimmers with bright blue areas; the other is barely lit. “This is typical for what people with severely depressed brains look like,” says Smith referring to the latter image. “It’s hard for people to do anything when they’re this limited. Transcranial magnetic stimulation causes the brain to wake up and smell the coffee, so to speak. And we believe it has some regenerating effect.”

First studied in England in the 1980s, high-powered magnetics were used then in mapping the motor cortex of the brain by creating a magnetic field — which is about the same strength as magnetic resonance imaging (MRI). Gradually researchers discovered that directing the magnetic field pulse at targeted areas of the brain could improve symptoms of depression.

“The magnet causes a temporary, very gentle sort of pulse,” explains Smith. “Nervous tissue is exceptionally reactive to that. Treatment-wise we’ve learned we can target pulses at distinct areas that relate to mood regulation and this leads to a cascading effect. It’s kind of like casting sunshine on a garden that’s been slow and sluggish.”

In treating a patient, doctors concentrate on the prefrontal cortex — the outer inch and a half of the brain — specifically the left and center. “That area has important connections to other, deeper structures of the brain. The stimulation seems to help the nervous tissue start working to get stronger and pull people out of depression.” At this point, the FDA has approved TMS for patients who have not responded to a full course of at least one antidepressant medication. “The majority of these patients — those with treatment-resistant depression — have probably tried and failed a minimum of six or seven different [medications],” says Smith. “Or they may have had partial success before it faded away.”

During TMS treatment, a patient sits in a reclining chair, similar to those in dental offices. The first visit — which can take up to two hours — involves mapping and identifying areas of the brain. “Most of the tests are done on the motor strip of the cortex,” says Smith, who uses a wand-like instrument containing a magnetic coil or arc, which is placed against the patient’s forehead. “Every brain is different, so knowing the centerline of the person’s head helps us understand exactly where to target the treatment.” Once the target is established and Smith has graphed out a series of pulses shown on a computer screen next to the chair, TMS begins. The doctor or his assistant remains in the room during each session. “Some patients talk to us or listen to music,” he says. “One man sat and worked a crossword puzzle.” Because no anesthesia is required for TMS, “patients don’t report feeling bad or dopey,” he adds, and they generally return to work or to whatever activity they have planned for the day.

As the pulses issue from the magnetic arc against the patient’s forehead, “it can feel like someone’s tapping on your head with a pencil,” explains Smith, who had the treatment himself so he could better relate to his patients. “It can be less or more intense than that, but I’ve never had anybody not tolerate it. There’s a layer of muscle between your skin and your skull. The magnetic field makes the muscle contract so it feels like somebody’s poking it. Over the course of treatment it’s sort of like getting a charley horse. But as soon as the session is over, it goes away pretty quickly.”

Other minor short-term side effects of TMS, according to the Mayo Clinic, include headache, scalp discomfort, tingling or twitching of facial muscles, and lightheadedness. More serious but rare side effects include seizures and mania; to date no long-term side effects have been reported.

The recommended approach for depression uses repetitive TMS. During each 40-minute session the patient receives 3,000 pulses, five days a week for six weeks for a total of 30 treatments. Patients vary in how soon they respond; some notice improvement within the first two weeks, others not till closer to the end of the treatment. Among Smith’s patients, he says 75 percent report significant improvement. “One out of four do not,” he says, “and that’s discouraging for them and for us. But for those who do get positive results when nothing has helped before — that’s pretty remarkable.”

Smith recommends a patient receive all 30 treatments, “and there’s a growing consensus in the TMS community that we need to go longer than that,” he adds. “If people aren’t responding, we can increase the number of pulses, continue using them on the left side, and add some on the right. I had one patient who showed little signs of getting better. Then she and her family agreed to two more weeks of treatment and she ended up turning the corner. There are always tweaks we can make to ensure the treatments are as effective as possible.”

Noa Eason is one patient hoping a “tweak” might help her. “I’d been taking medications since I was a teenager and they either didn’t work or created side effects,” she says. “I googled alternative treatments and read about TMS and contacted a few doctors and decided to see Dr. Smith.” Though TMS didn’t help her, she says, “it was a good experience, and I still have hope.”

Smith explains that Eason over-responded to the treatment, causing a manic reaction. With changes in parameters or in the locations where treatment is targeted, he explains, “we can help her [dominant] depressive phase without the risk of another over-response.” This intervention would be considered by TMS clinicians in a private forum about difficult cases, he adds: “It isn’t done just randomly but with input from leaders in the field.”

In explaining depression, Smith talks of two types. “I see people who feel disconnected, dead in the water with no wind in their sails. It’s like they are stuck with no energy or motivation. And I see those with the psychically painful aspect of depression,” he continues. “They feel guilty or anxious. They worry and ruminate and have lots of regrets. They may feel like a burden to others. We can apply TMS to both kinds of depression.

“The area we stimulate was identified by researchers who developed this,” Smith continues, “and more research has been done to make the treatment better. We’ve seen experimental protocols to stimulate the right prefrontal cortex, which seems to relieve anxiety symptoms. There’s also a stimulating protocol and a calming protocol, and the Army uses that in calming patients with PTSD [post-traumatic stress disorder]. Understanding the prefrontal cortex is key.”

In early studies of TMS, some critics asked whether it was different from electroconvulsive therapy, also known as electric shock treatment. With ECT, electrodes are placed on the anesthetized patient’s scalp and an electric current is applied. “ECT basically uses a convulsive seizure as a therapeutic element,” says Smith, who says he doesn’t use ECT but has referred patients to doctors who practice it. “When ECT is administered, it’s like you’re having a gigantic electrical storm in your brain. The brain responds by trying to put itself back together,” he says. “But TMS is very different. Instead of a cataclysmic effect, it’s like a gentle massage.”

As for how long its effects can last, Smith tells of attending a conference of the Clinical TMS Society, an international organization with more than 200 members, based in Greenwich, Connecticut. “A researcher spoke on the longevity of TMS now that it’s been out a few years. What’s exciting is that among the people who do have great response, the majority continue to maintain a long-term benefit. Some of my patients have gone more than two years without a setback. About half have achieved remission of all symptoms.” To prevent relapse, Smith continues his highly resistant patients on a simplified mix of medications. And with some who start a decline, he’ll administer a short booster series of TMS sessions.

For the category of patients — about 25 percent — who show improvement but have lingering milder depressive symptoms, “we are able to maintain most of their improvement with less medication,” says Smith. “They have better daily function and connection to everyday life.”

One current drawback to TMS is that many insurance companies don’t yet cover the cost. While significant — $12,000 for the full series of 30 recommended treatments — that cost is comparable and in some cases less than other psychotherapies, but many patients can’t handle the full out-of-pocket expense. On the plus side, Medicare now covers it in Tennessee, and Smith and other practitioners are hopeful that more insurers will add it to their coverage.

Lisa Austin recalls discussing the cost with her husband after learning their insurance wouldn’t pay for it. After nine months of going through the motions of life, she says, “we just bit the bullet and paid for it. I hope eventually these companies will realize how important this treatment can be.”

Meanwhile, TMS appears to hold hope for younger patients with depression and for other problems affecting nervous tissue.

For now, TMS is limited to patients over age 18, but Smith cites an article in the Mayo Clinic newsletter about a study on adolescents with severe depression who had not responded to medication. The 2011 article states that “repetitive transcranial magnetic stimulation is a safe, feasible, and potentially effective therapy for adolescents with treatment-resistant major depressive disorder.” The study’s team leader also states that dosing in previous trials had been variable and less than the adult level and “[we] felt it was important to use the adult treatment parameter to give kids the best chance for treatment benefit.”

Smith believes that “if you treat people with TMS early, before depression has become so ingrained in their brains, they may not end up like those who suffer for years. It could be more potentially healing in the long term.”

Finally, he sees the therapy as a threshold to a whole new way of treating nervous tissue injuries: “For those who have had strokes, it can stimulate the language areas of the brain. And it’s being adapted for people with spinal cord injuries. Right now we’re seeing the tip of the iceberg. I think TMS will be developed in all kinds of beneficial ways. It has the potential to inaugurate a new era of more potent techniques to treat nervous tissue disorders.”

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