A Burst of Therapeutic Magnetic Pulses to the Brain

Can Repeated Exposure to an Electromagnet Help Cure Persistent Depression?

The Ravages of Severe Depression

Laura comes across to just about everyone she meets as amicable, gracious, and bearing a kindly, approachable disposition. She is soft-spoken, measured, and thoughtful. Ours was a chance meeting. The year was 2015. We struck up a casual conversation on all things mundane. A casual conversation held at a food truck near the MedStar Hospital Behavioral Health Clinic, a block away from the Johns Hopkins University Homewood campus. I frequented the truck after my Introduction to Literary Studies class. Greek food menus have a way of stimulating conversation with the right people.

            After getting acquainted, Laura confided that she was attending the intensive outpatient program at the clinic. It entailed a daylong series of patient meetings, dialog, and activities that, according to Laura, bordered on monotony. The program was highly selective. To qualify, the patient’s symptoms should have had a stranglehold on their daily living. Also, the treatments—both medication and counseling—should have proven inadequate against the onslaught of the symptoms. This last bit was the most troubling: Laura had clinical depression that was unresponsive to medication.

            We lost touch when the program ended, only to meet at an administrative office at the Johns Hopkins Hospital a year later. I worked there and was running an errand then. My pleasure at the reacquaintance was tempered. Laura did not recall who I was. “I’m sorry if I knew you before; I had electroconvulsive therapy and sort of lost some of my recollection,” she said. Laura, who requested to be identified by pseudonym, was oblivious as to who I was. Our entire acquaintance had been pulverized by shock treatments to the brain, with electroconvulsive therapy (ECT) to thank for it. Daniel Glass, a psychotherapist at Sasco River Center, says, “ECT has long-term effects like memory loss and emotional blunting.”

Fortunately, new treatments are emerging that don’t turn your brain into a palimpsest. Some of these circumvent the need for measures like anesthesia because they are virtually painless. They bypass more than that. Problems such as memory loss evident in ECT are now avoidable rather than inevitable. And this is paramount. Persistent depression lingers in a segment of the population. About 40 percent of depressed individuals do not respond to their initial round of antidepressant medication. A considerable proportion may not respond to the second or the third. Now more than ever, effective alternative treatments for persistent

A Crippling Desensitization

Electroconvulsive Therapy (ECT): A Shock to Remember

The first treatment for major depression is typically pharmacotherapy—by prescribing antidepressants. Prozac, Lexapro, and Wellbutrin are antidepressant prescriptions as ubiquitous or recognizable as fashion brands. Some individuals respond to this intervention; some do not. Some require taking concurrent prescriptions. Then there are some that do not respond adequately to any form of pharmacological intervention. Some whose symptoms are not abated by varied dosages or combinations of antidepressants. Some like Laura who initially spent months suffering sordid symptoms—profound sadness, diminished interest in almost every activity, deflated mood and energy, and poor concentration. Whatever minuscule hope she bore in her treatment regimen fizzled away.

In light of these “failures,” her psychiatrist recommended ECT, which worked but has turned out to be a temporary fix. She has undergone two separate ECT treatment sessions thus far. The symptoms disappear for a year and some months, but eventually recur. And pray do not forget that pesky annoyance—every time they induce those electrical seizures, she is liable to lose most of her recent memory. “Electroconvulsive therapy involves administering electric shocks to the head to induce electric seizures in the brain,” says Dr. Reti. “The electrodes are placed globally all over the scalp or bilaterally [on either temple above each cheek].” Dr. Reti explains that each ECT session requires administering the patient with anesthesia and a muscle relaxant. ECT changes neuron firing patterns, effecting mood changes. However, since the same firing patterns normally code for, or store memories, the electric shocks disrupt these patterns, leading to memory loss.

Transcranial Magnetic Stimulation (TMS)

TMS was approved for the treatment of major depression by the FDA in 2008, about 68 years after the advent of ECT. A form of TMS called repetitive transcranial magnetic stimulation (rTMS) is employed for this purpose. rTMS differs from TMS in that the former involves an extended session of delivering repeated pulses to a targeted brain region, with sessions conducted over several visits. The latter administers a few pulses and is mainly used for imaging the brain and investigating its function. “The procedure runs for 20 to 40 minutes depending on the number of pulses to be delivered,” says Tibbs. “Typically, 2,000 to 5,000 pulses are administered.” Patient visits may span months at a time. “Every brain has a mind of its own,” says Dr. John O’Reardon, a psychiatrist specializing in persistent depression, in explaining how long rTMS treatment typically takes. “Early responders improve significantly in the first ten sessions, making up 30 percent [of the treated population],” he adds. He also mentions that “middle responders” take 10-20 sessions while “late responders” may need at least 20 sessions to witness effects and improvement. “But there is still a good reason to keep going, for [up to] 30 to 36 sessions,” he says.

rTMS treatment involves targeting the dorsolateral prefrontal cortex (DLPFC), which is the left upper portion of the front of the brain. The prefrontal cortex was described by the character Hannibal (Lecter) in his eponymous film as the “seat of good manners.” This region controls aspects of working memory—the ability to maintain and alter information without continuous input, along with planning and focus—functions impaired in major depression. “Neuropsychiatrists observed in studies that depression reduced activity in the neocortex,” says Dr. Reti. The neocortex, which includes the DLPFC, is the part of the brain responsible for complex cognition, including working memory that suffers deficits in depression. A train of rTMS pulses alters electrical current and responsiveness to nerve cell tracts in the DLPFC, modulating any deficits inherent in depression. “rTMS pulses to the prefrontal cortex [DLPFC] can counter the decreased activity associated with depression,” Dr. Reti adds.

Who Qualifies?

Giga Hertz of Magnetic Impingemenr

            Major depression is a mood disorder that affects a substantial number of the populace and is one of the more prevalent forms of mental illness. The American Psychiatric Association placed its annual prevalence at around seven percent in 2013. This number astounds me: 7 out of every 100 Americans are at risk for developing depression at least once in their lifetime. Worse still, one need not inherit a genetic predisposition to fall prey to it. Social and occupational stressors are enough to cause depression. Laura made the statistic—she was one of the 7 out of 100 liable to get it. Injury accompanied insult. She had recurrent, severe depression. She had known of profound sadness and desolation for months at a time, quite a few times. Antidepressants hadn’t helped. Psychiatrists resorted to one of several final resorts, in her case electroconvulsive therapy. Recovery came at a price. An itemized price.

Who then qualifies for rTMS treatment? Dr. Reti says that the FDA prefers it for patients who do not respond or are intolerant to at least one trial of an antidepressant, adding, “Typically the patients coming in are much more resistant than simply failing one trial.” Glass mentions that there are different diagnostic measures to rate the severity and persistence of depressive symptoms. These include using the Beck’s Depression Inventory II (a rating scale used to measure how severe depressive symptoms are). Also, the mental health professional assesses the quality of the patient’s daily life. A history of unimpactful drug therapy usually makes for a strong case.

rTMS has become a beneficial and prolific treatment for persistent depression over the years. "I would recommend rTMS over ECT. It requires no anesthesia and has virtually no side effects,” says Dr. O’Reardon. rTMS appears just as effective as ECT without any of the latter’s drawbacks. The only noted adverse effects from rTMS include a slight headache reported by very few treated individuals. There have also been reports few and far between of infrequent cases of fainting, not enough to fit a pattern. Most individuals have an uneventful, routine treatment experience. Dr. O’Reardon adds that the treatment is covered by over 90 percent of health insurance companies. One thing’s for sure: Laura would have probably qualified for rTMS therapy since she qualified for a more stringent ECT treatment. And she would more than likely have remembered who I was.

But rTMS wasn’t a viable choice for Laura when she was mulling her treatment options. The year was 2015. rTMS therapy had been FDA approved and in use for seven years. And yet health insurance companies still considered it an experimental treatment regimen. Perhaps as a cautionary measure. Or perhaps as a loophole to circumvent covering a costly procedure. Either way, Laura would have had to foot an obnoxiously expensive medical bill to receive rTMS treatment. Seven years later, she reflects on the road not taken. No, the road she was barred from taking. Perhaps it is mercy to be deprived of the memory of desolation. Perhaps it is mercy that she does not remember being unable to choose rTMS to treat her depression.

The health insurance companies’ reluctance to cover health costs for emerging technologies is rampant, almost self-serving, and detrimental to all covered ill persons. It doesn’t stop at mental health; even breakthrough cancer therapies take time to have their costs covered. Terminal patients are sometimes denied longevity, or even an extension on living by a few months or even weeks because of this obstinacy. And Laura received shocks to her brain, and her memory banks were wiped clean because of that same obstinacy. Because she needed urgent, optimal treatment three years too soon. Dr. O’Reardon mentions another FDA-approved treatment, Vagus Nerve Stimulation, where an implanted stimulator periodically excites a nerve that feeds into the brain. It’s very promising, showing improvements in 50 percent of treated individuals. But the health insurance companies haven’t approved it yet. Their claim: ‘it’s largely experimental.’

An Uneasy Conclusion

Laura is doing fine, all things considered. She still doesn’t recall who I am, but it is a comfort that I’m listed in her phone’s contacts. She still loves Greek food. Thankfully that aspect of her was left intact. Propriety dictates that I do not indulge, but I sometimes wonder if she would still qualify for rTMS treatment at the outset. It’s bound to be a sour conversation topic, especially with a stranger. But why lament? She has braved induced seizures and rebuilt parts of her reality from the ground up. A true story of pluck and mettle.