Depression: Alternative Treatments – Transcranial Magnetic Stimulation (TMS)

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Depression: Alternative Treatments – Transcranial Magnetic Stimulation (TMS)




Guest:  Dr. Mark George – Psychiatry & Behavioral Sciences

Host:  Dr. Linda Austin – Psychiatry


Dr. 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?


Dr. 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 ago. 


I think 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.


Dr. 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?


Dr. 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.


So, 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.

Dr. Linda Austin:  How effective is that, let’s say, compared to medications, compared to Prozac, kind of a gold standard medication?


Dr. 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, treatment. 


So, in 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.


Dr. 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.


Dr. 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.


Dr. Linda Austin:  Much more benign.


Dr. Mark George:  Yes.


Dr. 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?


Dr. 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.


Dr. 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?


Dr. 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.


There 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.


Dr. 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.


Dr. 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.


Dr. Linda Austin:  Where in the country can people have access to this technology now?


Dr. 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.


Dr. Linda Austin:  The website.


Dr. Mark George:  Right.


Dr. Linda Austin:  Dr. George, thanks so much for talking with us today.


Dr. Mark George:  Thank you.


If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection:  (843) 792-1414.


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