The Specialist:
The director of the adult psychopharmacology program at Mount Sinai, Dr. Dan Iosifescu is a psychiatrist who specializes in difficult-to-treat mood and anxiety disorders. He is a 15-year veteran of the field.
Who’s at risk:
Using magnets to induce activity in parts of the brain might sound like space-age medicine. But doctors are already using this futuristic technology to combat some types of depression.
“Transcranial Magnetic Stimulation (TMS) is a non-invasive way of stimulating specific areas of the brain and, in the process of doing that, helping to correct or improve certain brain functions,” reports Iosifescu. “It’s been six years since the FDA approved the first generation of TMS devices for treating severe major depressive disorder and now a newer form, Deep Transcranial Magnetic Stimulation, has been approved to help people with major depressive disorder who have failed multiple medications — patients with what we call treatment-refractory or treatment-resistant depression.”
True to its name, Deep Transcranial Magnetic Stimulation is able to activate deep regions of the brain.
“Deep TMS utilizes a special magnetic coil to create a magnetic field that goes much deeper into the brain than previous technologies could,” Iosifescu says. “Going deep into the brain allows us to stimulate areas involved in the management of emotions.”
In any given year, major depressive disorder will affect almost 15 million American adults. One estimate is that as many as a quarter of women and 10% of men of will experience the disorder at some point in their lives. “Major depressive disorder causes a series of severe and disabling symptoms that must last for at least two weeks, but typically last much longer,” Iosifescu says. “These symptoms include depressed mood, the inability to experience pleasure, disrupted sleep, whether excessively long or short, changes in appetite, which can increase or decrease, extreme self-criticism, fatigue, feeling very slowed down or low energy, and suicidal ideation.”
Who is a candidate for TMS? “Typically, TMS isn’t a first line of treatment,” Iosifescu says. “It’s recommended for patients who experience major depressive disorder and have not experienced improvement with other antidepressant treatments.”
Doctors cannot always predict how an individual patient will respond to treatment. But there are certain factors associated with higher degrees of treatment resistance. “Patients who have other medical or psychiatric problems tend to be more treatment-resistant,” Iosifescu says. “For instance, if you have depression and other forms of anxiety or substance abuse or other medical problems like diabetes or cardiovascular disease.”
Women are almost three times more likely than men to have depression, though gender doesn’t seem to be a factor in who develops hard-to-treat depression.
Signs and symptoms:
Difficult-to-treat depression presents with the same set of symptoms as more treatable cases of major depressive disorder. “The only thing that distinguishes treatment-resistant major depressive disorder is that the person continues to experience symptoms months later, despite ongoing treatment,” says Iosifescu. “Right now, we can’t predict upfront who will respond to treatment and who won’t. We have to try different treatments in order to identify a patient’s depression as treatment-resistant.”
Traditional treatment:
Most patients with major depressive disorder can find relief by taking an antidepressant medication and/or psychotherapy. “About one-third of patients try one antidepressant medication and then another without getting better-this is the population we call treatment -resistant,” Iosifescu says. “These are the patients who are candidates to receive TMS in addition to pharmacological and talk therapy.”
TMS is delivered during daily sessions at the doctor’s office. “The patient spends 30 minutes or more with the machine and does these sessions five days a week for at least a month,” Iosifescu says. “As a result, this treatment is both logistically cumbersome and relatively expensive, though researchers are working to make it easier.”
The magnetic fields that stimulate the brain are delivered by a helmet-like device.
“We tailor the intensity of the treatment to the individual patient, based on how much energy is needed to make the thumb muscles move involuntarily,” Iosifescu says. “Then we move the coil to stimulate the area of the brain that controls mood and depression. There’s a programmed sequence of stimuli for about 25 minutes.” Most patients start to feel better after four to six weeks, and then can continue TMS at a lower intensity as a maintenance treatment.
Which raises the question: does TMS hurt? “Most people don’t find it painful, but some do develop mild headaches that can be treated with Tylenol,” Iosifescu says. “During the treatment, you can feel a knocking on your head. Generally, most people get used to it.”
Research breakthroughs:
Researchers are pressing forward to make TMS technology cheaper and easier. “There’s very active research into milder forms of TMS that could lead to take-home devices,” Iosifescu says. “Studies have been published, but nothing has been FDA-approved yet. But we hope that take-home devices would allow many more patients to benefit from TMS.”
Questions for your doctor:
If you’ve been diagnosed with major depressive disorder and are not completely satisfied with the results of your regimen, then ask, “Should I be considered a treatment-resistant patient?” You can follow up with, “Are other options like TMS reasonable for me?” If you do meet with a TMS doctor, the first question is, “Am I the kind of patient who can be helped by TMS?” The second is, “What side effects can I expect?” Most patients tolerate the treatment well. “A lot of patients who are treatment-resistant are feeling hopeless and miserable,” Iosifescu says. “Only recently do we have other alternatives for these patients, and there is hope for very legitimate benefit from TMS.”
What you can do:
Get informed. For vetted and updated information online, try the Clinical TMS Society (clinicaltmssociety.org/), whose website includes a handy “find a provider” search engine, and Mount Sinai (mountsinai.org).
Assess your risk. TMS carries a very small risk of seizures, so people who have a past history of seizures or who drink a lot of alcohol may not be good candidates for this treatment.
See an expert. Ask your primary care physician or psychiatrist for a referral. “A good rule of thumb is that you want to talk with a group of doctors who are very familiar with treatment-resistant depression and all the different options, including TMS but not only TMS,” Iosifescu says.
By the numbers:
— The FDA approved Deep Transcranial Magnetic Stimulation for the treatment of major depressive disorder in 2013.
— Almost 15 million American adults experience major depressive disorder in a given year; that’s just under 7% of the adult population.
— Women are twice as likely as men to experience major depressive disorder.
— The median age of onset is 32.
Source: The Depression and Bipolar Support Alliance.
