Brain Stimulation: A New Hope for the Treatment of Depression

Do you feel like you have tried everything for your depression? Have you been on several different kinds of medications and tried talk therapy to no avail? You are not alone!

Did you know that approximately 2 out of 10 veterans will suffer from a mental health disorder in the year following their release from service, and that 1 out of 3 people with depression do not improve with the usual kinds of treatments, such as medications or therapy?

But there is a new option available when standard treatments fail.  A team at University Health Network’s Toronto Western Hospital (TWH) is offering a new kind of treatment for treatment-resistant depression.  It’s called repetitive transcranial magnetic stimulation, or rTMS for short.

Approved by Health Canada since 2002, rTMS uses finely focused magnetic fields to strengthen the activity of brain areas that have become underactive in depression - like an exercise program for your frontal lobes.  Since it activates the brain directly, it can work even in cases where medications and therapy fail.  Over 50 percent of patients show a good response to treatment.

Led by Dr. Jonathan Downar, a prominent neuroscientist and psychiatrist, the team at TWH is pioneering the use of rTMS as a whole new way to treat depression and anxiety. Since opening its doors in 2011, Dr. Downar’s clinic has seen a 400 % increase in patients, including veterans.

Altum Health, a department within UHN located at the Toronto Western Hospital has recently opened a second rTMS clinic to provide veterans with increased access to rTMS.

To give you a first-hand account how rTMS is used in the treatment of depression, we interviewed Dr. Downar himself. 

“Before we ask you about how rTMS, can you talk to us about how the brain works?”

“The brain is an enormous, busy network of billions of neurons, all connected up to one another.  It’s hugely complicated, but you can think of it a bit like the network of streets in a huge city.  On a network of city streets, you can have lots of different patterns of activity, depending on what the city is trying to do.  We call one pattern “morning rush hour”. for getting people to work.  We have another once called “evening rush hour”, for getting people back home.  We have one called “cottage traffic”, for getting people out of town on the weekend, and so on. 

If you look at a “traffic map” on Google you can actually see the city going through all these different patterns through the week, depending on what the city is doing.  And if we scan the brain, we see something similar: the brain is constantly changing from one pattern of traffic to another, depending on what we’re thinking about.”

“What happens in depression then?”

“Imagine what would happen if the city streets got filled up with traffic, so that rush hour lasted 24 hours a day.  You’ve got gridlock - suddenly the city can’t function any more.  It can’t do all the different things it needs to do. 

In the case of depression, it’s quite similar: the brain gets ‘stuck’ in one pattern of traffic, like mental gridlock.  Until you get the brain unstuck, it can’t function – just the same negative thoughts, over and over, shutting out all normal activities. 

Now, sometimes, you can get the brain unstuck with therapy.  And sometimes, you can take medication to change the brain chemistry a bit, and that will clear the gridlock.  But for at least one out of three people with depression, neither of these options work.  That’s where brain stimulation comes in.”

“What exactly is rTMS?”

“rTMS uses powerful magnetic field pulses to directly activate target brain regions. The rTMS device has a stimulation unit that generates brief pulses of strong electrical current and is connected to a hand-held electromagnet called a coil, which contains loops of wire.

When the hand-held coil is placed against the surface of the head, the magnetic fields are powerful enough to pass through the scalp and skull to stimulate the area of the brain that lies directly underneath.

The coil converts the electrical current into magnetic field pulses that are as strong as those in an MRI scanner, but focused into an area just a few centimetres across.”

“How exactly does rTMS work to treat depression?”

There are many different stimulation patterns that can be used for rTMS, each with slightly different effects on the brain. For the treatment of depression, we aim the stimulator at the brain circuits for self-control: self-control of your actions, self-control of your thoughts, and self-control of your feelings.  Those circuits get shut off by the gridlock of depression, and that’s why people can’t just “snap out” of feeling depressed even when they try.

Using high-frequency stimulation, we try to exercise those circuits and make them stronger.  When it works, you can feel yourself getting back in control of your thoughts and feelings again.  Once those brain circuits are re-activated, people say that they can “snap out” of depression more easily.  Those negative thoughts and feelings stop taking over your brain.  The gridlock is over - you start to get interested in life again.

“How long does rTMS treatment take?”

“The standard course of treatment requires 20-30 separate sessions of treatment, each session lasting approximately 20-30 minutes. With once-daily treatment, the course will last 4-6 weeks.

If treatments are given several times per day, the course is shortened to as little as 2-3 weeks.”

“Are there any side effects with rTMS?”

“The most common side effect with rTMS is discomfort during the stimulation session itself. In addition to stimulating the brain, the magnetic pulses of rTMS can also stimulate the nerves in the areas of scalp, forehead, or face near the stimulation coil. This creates a sensation similar to static electricity and can feel like an elastic band being snapped against your forehead.

Over the counter pain remedies such as ibuprofen (Advil) or acetaminophen (Tylenol) can be helpful for the first few sessions.  After the first week or so, your nerves get used to the stimulation and it becomes much less uncomfortable.”

“What are some of the advantages of rTMS over other forms or treatment?”

“rTMS has the advantage of working even in cases where medications and therapy have failed.  For most people, that’s the big draw – a treatment that gives them a better than 50% chance of improving, even when nothing else has worked.  It doesn’t seem to matter whether you’ve tried 1 medication or 10 medications – your chances of success are the same.

Another advantage is the lack of side effects.  Once you get past the scalp pain and the headaches of the first few sessions, it’s really quite easy to tolerate.  With medications, more than 25% of people stop taking the treatment because of side effects: problems with sleep, appetite, nausea, diarrhea, trouble focusing or concentrating, weight gain, jitteriness, or sexual side effects.

With rTMS, our numbers show that 95 percent of people who start a course of treatment make it all the way to the end, without having these kinds of side effects.  rTMS has no known side effects on memory, attention, concentration, or intellectual function. rTMS also does not require anaesthesia or sedation, so people undergoing treatment can usually continue with their daily activities immediately after treatment.  We have people who come in for treatment on their lunch hour, then go back to work again.”

 What type of results can I expect from rTMS?

 “Currently, up to 60 percent of patients with treatment-resistant depression experience at least a 50 percent reduction in symptoms and 35 to 45 percent get all the way to remission.

The effects of rTMS typically last for at least 6 months in 90% of cases, and generally last for 6-12 months. But there are some patients who lapse back into depression after an average of about 10 months following initial therapy. For these patients, “booster” treatments with rTMS can be provided to restore mental wellbeing.”

Through the work of Dr. Downar we have seen some very promising results with rTMS and a new hope for the treatment of treatment-resistant depression. It is important to note thought that as depression lifts, focusing on life stressors that tend to push you over the edge is just as important as the rTMS treatment itself. If a job or interpersonal conflict is repeatedly sending a person into depression, rTMS provides a window of opportunity to fix it. “What we are trying to do is get you to the point where you can climb the stairs yourself – this is not an escalator ride up.”  

For further information about our new rTMS clinic please call 416-603-5800 x.4779 or visit our website @: http://www.altumhealth.com/.