Transcranial Magnetic Stimulation Offers Hope for Patients with Intractable Depression
NeuroStar Transcranial Magnetic Stimulation (TMS) Therapy, an FDA-approved, nonpharmacologic method of neuromodulation, lifts depression in a number of people for whom medical management has failed.
Photo: Martha St. John, MD, FAPA, uses the Neurostar TMS Therapy System.
Although the FDA approved the NeuroStar TMS Therapy System in 2008, only about 12,000 patients have received treatment so far, though one in 10 people in the United States takes antidepressant medications.
“This therapy slid under the radar,” says Martha St. John, MD, FAPA, who practices at Progressive Psychiatry TMS Center. “Many psychiatrists, not to mention primary care providers, do not understand TMS’ utility and where it fits into the treatment algorithm.”
Major depression takes a large toll on patients in the United States, accounting for $34 billion in absenteeism and other workplace costs, increasing mortality rates in people with other illnesses, and greater likelihood that people will commit suicide.
Unfortunately, depression remains untreatable in many cases. Only about half of patients respond well to the first antidepressant they try; after that, success rates decline to 25–30 percent with the second medication and even lower with subsequent prescriptions. TMS offers an effective alternative.
“It is exciting to offer a treatment that is so novel and actually works for a population of people suffering from major depression who do not benefit from traditional medical management.”
— Martha St. John, MD, FAPA, psychiatrist practicing at Progressive Psychiatry TMS Center
In a large-scale study by Neuronetics, NeuroStar’s manufacturer, 62 percent of patients with treatment-resistant depression experienced relief from their depression after completing TMS therapy, with 41 percent of those experiencing total remission. These numbers remained stable and even improved over time, with 68 percent of patients enjoying greater freedom from symptoms and 45 percent of those experiencing remission 12 months following completion of therapy.
“When I investigated NeuroStar TMS Therapy, I was very attracted to it as a way to benefit my patients,” Dr. St. John says. “There is a tremendous need to expand our options for treating depression. With efficacy exceeding what we can expect from medication in most cases and minimal side effects, TMS looked extremely promising.”
The Science of TMS
TMS uses electromagnetic induction to depolarize neurons in the dorsolateral prefrontal cortex (DLPFC). An electrical current passed through a coil generates a magnetic field, and a current generated in the opposite direction transforms the magnetic field into an electrical field within the DLPFC. The electrical field causes nearby neurons to release neurotransmitters, such as dopamine, norepinephrine and serotonin.
“One way to put the neural circuits back in balance is chemically with medication,” explains Dr. St. John. “Alternatively, because the brain is basically a large circuit, we can activate the outside 2 to 3 cm of the prefrontal cortex magnetically, then utilize the brain’s natural circuitry to stimulate more distal regions, such as the anterior cingulate cortex and amygdala.”
The process continues during and between sessions, which typically last about 40 minutes and are repeated regularly from four to six weeks, for an average of 30 sessions.
Side effects of TMS are quite rare, but this therapy does have the potential to produce mania in people with bipolar disorder. The only contraindication to TMS therapy is presence of an implanted metallic device within 30 cm of the treatment coil. It is not recommended for patients who have seizure disorders, are pregnant or are very elderly.
The patient experience reflects the simplicity of this noninvasive technology. After a first session to establish dosing, patients come daily for a month to a month and a half, spending just over half an hour sitting comfortably for treatment. They do not need sedation or protective equipment, apart from earplugs, and they are able to drive themselves home after each session. They may experience a headache or scalp discomfort.
All of her patients express gratitude for the opportunity to receive TMS therapy, Dr. St. John says.
“Every patient would do it again or recommend it to someone else,” she says. “We have had an overwhelmingly positive response.”
The high rate of anecdotal satisfaction echoes the experience of other clinicians and their patients, Dr. St. John adds.
“An NIMH [National Institute of Mental Health] study confirmed that about 30 percent of patients with medication-resistant depression achieve remission with TMS, but experientially, it’s higher,” she says. “Psychiatrists believe this is because, while patients were withdrawn from their medications before undergoing TMS for research purposes, the common practice is to use TMS as augmentation to medications, rather than replacement. We commonly obtain much better results than are published.”
Make the Connection
Dr. St. John practices at Progressive Psychiatry TMS Center.
The longer depression lasts, the less likely it is to respond to treatment. Dr. St. John encourages referring primary care physicians, counselors and others who have patients struggling with depression to consider early referrals.
“We would like to help patients early in their illness ,” she says. “Patients who have tried one to three antidepressant medications at a reasonable dosage and duration but have not had a good response or have experienced intolerable side effects are good candidates for TMS.”
Patients who come to Dr. St. John’s practice, Progressive Psychiatry TMS Center, will find an experienced staff ready to assist them in obtaining insurance coverage for their treatment. In fact, Texas’ Medicare contractor, Novitas, has covered TMS since December 2013.
“Depression is a pervasive illness, affecting 14 million people in the United States,” Dr. St. John says. “We all know someone or treat someone whose life has been touched by it. Unfortunately, a lot of patients are receiving inadequate treatment. We need to treat depressed patients more aggressively. NeuroStar provides hope even for treatment-resistant patients. When TMS is considered earlier in the treatment algorithm, it allows patients to improve their quality of life much sooner.”
To refer a patient to Progressive Psychiatry TMS Center, visit www.doctorstjohn.com or call 281-987-5036.
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1 comment for “Transcranial Magnetic Stimulation Offers Hope for Patients with Intractable Depression”
Posted Wednesday, March 26, 2014 at 1:47:23 PM
To Whom It May Concern:
As a very, very long-term support person and mental health advocate/activist for my spouse I would like to address an important point missing from this and similar articles.
While this treatment option has also been FDA approved as was VNS (Vagus Nerve Stimulation) Therapy what you all seem to omit and not address and what is most important to the patient and/or his/her support persons is the fact that CMS (Centers for Medicare and Medicaid Services) has not approved national coverage. At best TMS is covered by Medicare/Medicaid and private health insurance carriers on a spotty basis. In the case of VNS, although this treatment option was FDA approved in 2005, it was declined by CMS on May 4, 2007.
I should know as I have been battling CMS and the private health insurance carriers to at the very least cover the original study subjects for VNS Therapy and all those who obtained implants on or prior to May 4, 2007. This has been an egregious, immoral and discriminatory oversight on the part of government to allow these patients to be implanted with medical devices and then refuse medical coverage for these seriously ill patients who responded and obtained efficacy from this treatment option. It has been a major struggle on my part to make any advances and one which the various medical associations and physicians should join forces to overcome.
So what good is VNS at a cost of about $58,000 or TMS at a cost of about $10,000 to $15,000 out-of-pocket to the patient if the health insurance companies and Medicare/Medicaid will not pay and the patient cannot afford the therapy?
You folks want a story to write about? I’ll give you a story to write about; available FDA approved treatments denied by CMS and the health insurance industry that patients cannot afford.