Outpatient Therapy For Depression Becoming Increasingly Affordable
An outpatient treatment for severely depressed patients who get no relief from drugs or talk therapy is becoming increasingly available and affordable.
Psychiatrists say the treatment, repetitive Transcranial Magnetic Stimulation (TMS), could help many of the patients who remain trapped by major depression even after trying a whole menu of antidepressants. That amounts to millions of people, said Dr. Glenn Currier, chairman of psychiatry at the University of South Florida.
“Medications only work a little more than half the time” among severely depressed patients in the real world outside clinical trials, Currier said. “That’s the dirty little secret of the field.”
Such patients often have difficulty maintaining a job and close relationships. They may seek relief from alcohol or illegal drugs, and they are at risk of suicide. Effective care wasn’t available outside a hospital.
TMS, by contrast, can be done in a doctor’s office, with the patient sitting in what looks like a dentist’s chair. A magnet is placed on the patient’s scalp, just above the left side of the forehead, with careful calibration determining the exact site. Once activated, the magnet will create current that passes through the skull and stimulates nerve cells in the brain region that controls mood.
The pulse is delivered with a rapid, ear-splitting rat-tat-tat that lasts four seconds, followed by a half-minute rest. That rhythm continues for half an hour to 45 minutes, and is repeated five days a week for four to six weeks. The strength of the pulse can be gradually increased over the course of treatment.
About 70 percent of TMS patients will get relief from the depression, Currier said, and the remission lasts at least a year for most.
“Some people need a booster” later on, he said, “but for the majority of people, once and that’s it.”
One of Currier’s patients at USF Health is Linda, 66, from Key West. She talked about the procedure on the condition that her last name be withheld, for medical privacy.
“It’s not really painful, it’s more irritating,” she said, between bursts of loud taps. “It’s no more painful than getting your hair done.”
It’s loud, though, requiring everyone in the room to wear earplugs.
“Some people describe it as a woodpecker,” said Terri Taylor, the USF Health technician who delivers and monitors the treatment.
Linda had almost completed her six-week series. Currier asks how she’s doing, although he can tell from her smile.
“I’m doing good today, really, really, good today,” she said. No headache or other side-effects.
The only stress, she said, is navigating the Tampa traffic. She’s not used to it, since she lives in Key Largo.
Linda and her husband moved temporarily to a Tampa suburb after she tried for a year to get into a TMS program in Miami, without success.
Meanwhile, the private-practice psychiatrists she says she has consulted – eight of them in the last three years — kept prescribing the same anti-depressants that had not worked for her in the past.
Even though Linda is an ideal candidate for TMS – she said she has tried and failed 26 different drugs over the years – not one of those psychiatrists mentioned it as an option, she said.
“And I’m quite angry about that,” Linda said. “I think the psychiatrists out there should tell us depressed people that are suffering that this is an option.”
She said she heard about TMS on a daytime TV talk show. Intrigued, she looked it up on the Internet, sticking to the medical journals and sites with good reputations.
“I thought it would help me as soon as I started reading the scientific information,” she said.
Until TMS, the alternative for severely depressed patients who didn’t respond to drugs or talk therapy was electroconvulsive therapy, or ECT. Sometimes called shock treatment, ECT delivers a current so strong that it induces a seizure and requires hospitalization and anesthesia.
Currier, a specialist in suicide prevention, says ECT is indicated for patients in crisis who might otherwise kill themselves. While TMS takes six weeks, ECT can be done right away.
“It’s quick, but it causes a whole (brain) seizure and has side effects associated with it, including often memory loss,” Currier said. “So it’s a big thing to do and people don’t do it unless they really need to.”
A series of ECT treatments can offer a success rate of 80 to 90 percent, about 10 to 15 percentage points higher than TMS, Currier said. But TMS is much easier.
“You’re awake through it, it doesn’t hurt,” Currier said. “People are watching Disney Movies as they get these treatments.”
The Food and Drug Administration approved the first TMS equipment, the NeuroStar System by Neuronetics Inc., in 2008 based on its record of safety. But it was slow to reach patients.
Insurers wouldn’t cover it, pending more clinical trials to determine success rates for various kinds of patients, at various doses and lengths of treatment. The technology was too pricey for most community psychiatrists – not just the machinery and software, but the trained technicians to run the labor-intensive treatment.
Some patients could afford to pay for the treatment themselves, but not many. So access to care depended on insurance coverage. That began to come about after publication of a September 2011 study by the federal Agency for Healthcare Research and Quality showed a significant improvement in major depression after TMS treatment.
Medicare and the VA cover the procedure, as do some commercial carriers including United Healthcare and most state Blue Cross/Blue Shield programs, including Florida Blue.