Depression: Alternative Treatments –
Transcranial Magnetic Stimulation (TMS)
Guest: Dr. Mark George – Psychiatry & Behavioral
Host: Dr. Linda Austin – Psychiatry
Linda Austin: I’m Dr. Linda
Austin. I’m talking, today, with Dr.
Mark George who is Professor of Psychiatry, Neurology, and Radiology here at
the Medical University of South Carolina.
Dr. George, you’ve done some really fascinating research in the area of
new treatments for depression. Can you
tell us what direction that research has taken?
Mark George: Yeah. I’m delighted to be here. I began my career as a photographer, that is,
I did brain imaging. I did lots of
pictures of the brain, and my interest was in emotions, particularly what was
going on in the brain when people are depressed, so what parts of the brain are
shut off or not working. Although we
don’t have a great roadmap, we do understand a lot better, kind of, the
neighborhoods that aren’t working well in depression. We began discovering that eight to ten years
I had an epiphany one day that I was just going to end up being a glorified
photographer. The important thing was
how we could use that information to come up with new treatments. And, luckily, there’s a revolution going on
right now in terms of ways of getting into the brain and stimulating,
discretely, parts of the brain. And so,
I’ve really spent the bulk of my recent career trying to figure out how we use
the roadmap discovered and then couple that with new ways of getting in and
turning on the brain in depression.
Linda Austin: What are those ways, then,
of treating the brain of a depressed person?
We certainly know about psychotherapy, and we know about medication, but
how have you been able to use this technology?
Mark George: Well, there’s a whole host
of technologies, and it quickly becomes kind of an acronym soup, and even I
stumble on them sometimes. But the basic
idea is, if we know that a part of the brain is not working in depression, could
we go in and tickle it, electrically,
and see if we can get people back into health?
And we’ve done before and after pictures of depressed patients who’ve
gotten better with psychotherapy or with medications, and these areas are acting
up when people are better, and return to normal.
there’s kind of a gauntlet there in front us saying, you know, if you can
change activity in these regions, perhaps it’s causal and actually would get
people undepressed. So, I started with a
technology called Transcranial Magnetic
Stimulation (TMS), which is a real trick where you take a powerful handheld
electromagnet, just rest it on your skull, turn it on and off, and the
electricity flowing through the magnet actually creates a transient magnetic
field which gets into the brain and actually causes an electrical current in
the surface of the brain. So, it’s
actually a trick of electrically stimulating the brain, but you don’t have to
break the skin or the skull. And I like
it because it’s noninvasive and pretty safe.
So, we’ve been using that in a series of studies, beginning in
1993. And that technology, TMS, is just
about to come onto the market.
Linda Austin: How effective is that,
let’s say, compared to medications, compared to Prozac, kind of a gold standard
Mark George: There have been a series of
studies. We’ve learned a lot about how
to actually do it, where to put the coil, how to turn it on, how much you need
in a day. So, early on, our effects were
pretty weak, although statistically significant. The most recent trial was published,
actually, this last month in Biological
Psychiatry. It was a large trial, 18
sites around the world and 300 subjects.
In that study, we only took people into the trial who had failed Prozac
or the other drugs, and there was about a 30 percent response rate with the
real treatment in that study, compared to about 10 percent with sham, or fake,
people who failed Prozac, about a third of them will get a response with
TMS. So, how effective is it compared to
Prozac? Nobody has really done a
head-to-head study. It appears to be
more powerful because it’s used in the people who haven’t responded to medications.
Linda Austin: I know that that compares
to the rough figure I always hear for ECT, correct me if I’m wrong about this,
that about 50 percent of patients who fail two different antidepressants may
respond to electroconvulsive therapy.
Mark George: Correct. Right now, as we’re doing TMS, my hunch is
that it’s not quite as good as ECT is, in terms of the response rate, although,
pretty close. The good thing about TMS
is that you don’t have to be put to sleep; there’s no anesthesiologist, and
there are no cognitive effects at all, so people can drive home from the treatment
and continue to work. So, it appears to
be, perhaps, as we’re doing it now, slightly less effective than ECT but
certainly much more tolerable in terms of side effects.
Linda Austin: Much more benign.
Mark George: Yes.
Linda Austin: Much less stigma and, of
course, the memory problems that people complain of, with ECT, wouldn’t be
there. Now, with ECT, of course, one
does, usually, a total of six to ten treatments that are spaced out over
several weeks, how about with TMS, how many treatments do you do?
Mark George: Well, we don’t know. We’re still in the discovery phase with the
technology. The way I started the
studies was modeled on ECT. So, I said,
we’ll do treatments everyday for four to six weeks. The current study, that we’re doing now, for
which we’re accepting patients, is an NIH sponsored study, and we’ve set it up
to really answer that question. So,
people get three weeks of treatment, and if they’re starting to get better,
they’ll continue out to six weeks. And
if they’re not doing well, they get out and get compassionate treatment. Anyway, we hope to be able to answer the
question, do you need three or four, or five, or six weeks in the current study
that we’re doing now.
Linda Austin: Do you anticipate that
this could be used on patients in lieu of antidepressants, as a first line
treatment, or would you imagine that, for whatever reasons, doctors will always
start with a medication?
Mark George: Well, medications are
certainly easier, you go to see the doctor once and then it’s just, you know, a
trip to your medicine cabinet. You don’t
have to get in the car and come down to get a treatment. So, just in terms of ease of delivery, pills
are so much easier. So, most of the
studies that have been done, really, have been in patients who’ve either not
responded to medications or who took medications and found them intolerable
because of side effects.
are some people who talk like you just did, where, what about going with this instead? And some people actually see this as
different than medicines, and even less scary.
I don’t actually understand that approach, but there are some people who
somehow are gravitating towards this more than medications. And, certainly, if you’re not taking something
that goes to your whole body, it’s very focal; there are no side effects, so
you’re freed of any of the side effects of medications, although they’re
becoming fewer with what we have now.
Linda Austin: The single biggest reason
I hear people say they don’t like antidepressants is the sexual dysfunction,
which can be nothing for many people, and quite significant for some. I guess the downside, the one side effect,
though, of TMS is the expense.
Mark George: Well, it hasn’t gone to
market yet, so we don’t really know what the expense will be. That’s all to be determined, if one of the
companies can get FDA approval.
Linda Austin: Where in the country can
people have access to this technology now?
Mark George: Well, they can go to our
website. We are doing an NIH-sponsored
trial which is free if people qualify.
And there are a couple of physicians around the country who are offering
it in their practices. We’ve just
started up what’s called a clinical effectiveness study, here at MUSC, where
we’re giving it to people who wouldn’t qualify for the NIH trial. That study does require that subjects pay for
their treatment, so it’s not free, but it’s certainly easier to take; you don’t
have to come off medications. So, if you
visit the MUSC website and just type in TMS,
you’ll get to our webpage, I think.
Linda Austin: The muschealth.com
Mark George: Right.
Linda Austin: Dr. George, thanks so much
for talking with us today.
Mark George: Thank you.
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