Stimulating the Brain When Pills Don’t Work

TMS offers a noninvasive, targeted treatment for the depressed.


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Photo courtesy of TMS Health Solutions

Hannah Stillman, 33, had been taking medication to treat depression for the past decade without relief. “I had periods of stability, but I never felt like the depression lifted,” said Stillman. She had tried over 10 antidepressants, but her symptoms, excessive sleepiness, constant exhaustion, and zero motivation, persisted and made it difficult to work or get out of bed. Intractable depression like Stillman’s is described as treatment-resistant. Last summer Dr. Ryan Blum, her psychiatrist at Kaiser Permanente Oakland, recommended she try transcranial magnetic stimulation, known as TMS. “I’d tried years of pills, so I figured why not,” said Stillman.

TMS isn’t that new, but it has emerged as a treatment option for depressed patients when antidepressants don’t work. The FDA gave the OK for TMS, a type of noninvasive brain stimulation with few side effects, to treat depression back in 2008. Major depression affects 10 percent to 15 percent of the population, and treatment-resistant depression is common. One-third to one-half of individuals who take antidepressants fail to respond fully. Many insurers now cover the cost of TMS for depressed patients who have failed to respond to medications.

TMS uses magnetic waves to create electrical currents to stimulate the brain and help the nerves function better. While the patient sits in what looks like a dentist-office chair, a magnetic coil is directed toward the top of the forehead at the hairline on the left side, targeting the prefrontal cortex, the part of the brain that under-functions in depressed individuals. The TMS machine generates a magnetic pulse every three seconds, gently and repetitively stimulating a 2-centimeter region of the brain. “It felt like a tapping sensation, a bit strange. I had a mild headache during the first session, but that was about it,” said Stillman. Each session lasts about 30 minutes and the patient undergoes 36 treatments over a two-month period.

“Some people start to feel better in the first two weeks, which can be a good indicator of whether the treatment will work, but not everyone does,” said Kennedy Cosgrove, M.D., medical director of Kaiser Permanente Oakland’s Interventional Psychiatry Program. “The big turnaround for patients usually happens between treatments 20 and 30, at the four- to six-week range.” Cosgrove acknowledged that if a patient is ready to make the time commitment for TMS treatment, they are ready to feel better. .

This was Stillman’s second trial with TMS. She had tried TMS a couple years earlier and her symptoms dramatically improved. “I felt incredible,” she said. However, Stillman fell into another major depressive episode. About three weeks in, the TMS treatment clicked. “My brain felt different. I could feel it,” said Stillman. “I can handle the punches life throws at me now. I’m going to be OK, and I haven’t felt that way before, not without this intervention.”

Kaiser Oakland’s TMS clinic opened in March 2018; prior to that, patients were referred to outside providers. Kaiser Oakland has fully treated 35 patients with refractory depression, and the patient response is in line with what’s been reported in TMS clinical studies, said Cosgrove.

Randy Whitman learned about TMS through a post on Facebook. The 54 year-old dad had spent the past 20 years battling depression and dealing with breakdowns, crippling insomnia, constant exhaustion, and weight gain. Antidepressants had little to no effect, and he was unable to work. “I was frustrated by the fact that I wasn’t getting any better. I was barely coping, and I wanted try something different,” said Whitman. He found his way to TMS Health Solutions, the largest TMS provider in Northern California with seven locations in the Bay Area

Whitman started TMS sessions in November and finished in February. “My right eyebrow would twitch with each tap. It hurt a little, but it never bothered me enough to want to stop,” Whitman said. He started to feel better right away and wondered if it might be a placebo effect. “But they monitored my response closely using a depression scale, and I continued to feel better,” he said.

TMS is growing in access and scope. Last year, TMS Health Solutions treated over 800 depressed patients with TMS across their clinics. Over 100 patients received TMS therapy in Oakland alone. The health care company has also expanded the types of patients being treated with TMS.

Joshua Kuluva, M.D., director of neurology services for TMS Health Solutions, leads the company’s pilot programs for TMS to treat mild dementia, neuropathic pain, and traumatic brain injury. Kuluva has been impressed with the results. In patients with mild dementia, TMS works as a cognitive booster, slowing the progress of the disease, he explained. Their pain patients have experienced up to a 50 percent reduction in symptoms. In the brain injury patients, the goal is to help reduce associated symptoms like headache, dizziness, and nausea, and address the depression, which often accompanies the disorder.

Kuluva believes the use of TMS will continue to expand. TMS is targeted directly to the involved part of the brain and has fewer side effects than medications that affect the whole body. And for the depressed patient who responds well, he described TMS as durable — of the individuals who achieve remission from their depression, nine months later, 80 percent have not relapsed.

A couple weeks after completing his TMS sessions, Whitman didn’t feel quite as good as during the treatment, but he did feel more capable, energetic, and balanced. “TMS improved my life,” said Whitman. “I’m better able to address the issues that caused the depression and anxiety. I feel like I have a future. I’m working part time and hope to move on to full-time work. The future looks brighter.”

The patients’ names in this article have been changed.

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