Archive for Press & Awards
Though treatments exist, fewer than half of those suffering from depression receive help, according to the World Health Organization. Original Article: Depression Treatments: Looking Back, Looking Forward (October 3, 2013)
In the last decade, treatment for depression has come a long way. Short of electroconvulsive therapy, which could lead to memory loss, the only viable options were antidepressants, which come with complicated, systemic side effects. But today, non-drug technologies for treating depression have been improving patient outcomes. A technology that has been making rapid progress is Transcranial Magnetic Stimulation (TMS).
TMS has been in use since the 1980s but not adopted medically for the treatment of depression until 2003 when TMS machines were made available to Canadian doctors. In the United States, TMS didn’t win approval from the FDA until 2008.
That year, Drs. Alan Manevitz and James Halper were maintaining their practice on Sutton Place South, just off the East River. The two doctors had been in practice together for over a decade, combining psychopharmacology with psychotherapy.
They came across TMS through published research and decided to take a deeper look.
“It sounded very exciting,” Dr. Halper said. “It’s not just chemicals in the body that go all over the place. Here was a way to target the parts of the brain we wanted to change while avoiding systemic side effects. Antidepressants had turned out to be less effective than we hoped.”
Depression manifests biochemically as a deficiency in the production of the neurotransmitters dopamine, norepinephrine, and serotonin. Traditional antidepressants work by making the patient’s existing neurotransmitters stay in action longer.
No matter how far the pills can stretch a limited number of neurotransmitters, they don’t address the fundamental shortage in neurotransmitter production, Dr. Manevitz said.
So, in 2008, he and Dr. Halper bought their first TMS machine, which turned out to be the first in New York City and the third in the world.
People experiencing depression exhibit too much activity in the brain’s right hemisphere and too little in the left hemisphere, according to researched published by the National Institutes of Health.
TMS delivers powerful magnetic pulses to the brain’s left hemisphere, increasing the amount of neurotransmitters the brain produces.
TMS is a magnet and not radiation, and the most common side effect is fleeting pain or discomfort at the treatment site. Fewer than 1 percent of patients experience a seizure.
Patients are expected to commit to a six-week course of 40-minute sessions over five consecutive days a week. The patient sits in the TMS chair with the magnet placed over the left side of the head.
Patients can read or watch television, but cannot fall asleep.
The treatment feels like a woodpecker tapping, said practice coordinator Joanna Robben, but patients typically become desensitized to the sensation after four sessions.
On the first day the doctors offered TMS, patients flocked in from all over the world, particularly from Japan.
Now, almost 500 providers across the country offer TMS for depression, according to Neuronetics, the leading manufacturers of TMS machines.
TMS used to be a last intervention, recommended only after a patient fails to see improvement after trying three or four classes of antidepressants.
“Now people are thinking, why not try it first?” Dr. Manevitz said.
TMS as a Tool
This fall marks Manevitz and Halper’s fifth year treating patients with a NeuroStar TMS machine.
Neuronetics, its manufacturer, says that 1 in 2 patients improved significantly, and 1 in 3 patients were completely free of depression symptoms after six weeks of treatment using NeuroStar.
“All the research shows that therapy and medicine together work better than therapy or medicine alone,” Manevitz said. “So now here was TMS, and we said what if we gave medicine, therapy, and TMS?”
The doctors’ hunch turned out to be correct. In a retrospective study of their first 100 TMS patients, 70 percent entered remission and 90 responded.
A New York-based psychologist (name omitted for privacy) who struggled with depression for over 40 years began TMS with Manevitz this spring.
“As I get older, medications become more toxic to elderly patients,” she said. “The amount changes, side effects become greater. As you get over 65, you might develop tremors and cognitive impairments.”
TMS made her realize for the first time that she hadn’t been feeling well because she didn’t know what feeling well was like, she said.
“I responded to it immediately. I felt well…I slept better, my thinking patterns changed, I felt a sense of joy—I was really happy. It wasn’t a high. It was a very good feeling of well being.”
Another patient, a lawyer based in New York, didn’t feel the results immediately.
“I ended up doing two courses of 40 sessions,” he said.
“It took close to 10 sessions before I started to see subtle benefits. But I kept with it.” This was close to four years ago. Several months ago he experienced a new bout of depression and got a “refresher session” for the first time. “I instantly felt better,” he said.
Of the treatment, he said, “I felt like I was getting flow to a part of my brain that wasn’t getting enough flow.”
TMS is not a silver bullet, this patient said, but one of several tools to be used in treating depression.
The doctors coached him on how to maintain healthy relationships and to change negative thinking patterns as part of a bio-psycho-social approach.
“One thing we noticed was that therapy seemed to flow better after the [TMS] treatment,” Manevitz said. “Somehow the patient was more open.”
Always ready to add cutting-edge technologies into their patients’ treatment options, Manevitz and Halper bought a Brainway TMS just over a month ago. Brainway was approved by the FDA earlier this year. It works on a slightly different mechanism and targets a deeper part of the brain.
“We see psychiatry as a work in progress,” Halper said. “It’s a very exciting field. It’s always evolving. I’m hoping to combine TMS with more neuroimaging to target it more, and see if we can predict patient response with neuroimaging.”
A New York City research and information company called Castle Connolly Medical Ltd. publishes an annual guidebook, Top Doctors: New York Metro Area, which lists what it has determined to be the top 10 percent of the region’s physicians. For the past eight years, Castle Connolly has been providing New York Magazine with a shorter version of this list for the magazine’s “Best Doctors” issue. These doctors represent the top 2 percent of New York area physicians, as determined by Castle Connolly.
Dr. Alan Manevitz is ranked again as among the best doctors by New York Magazine in their 2013 survey.
Martha Rhodes experienced her first bout of depression at 13. By her late 50s, she had taken just about every antidepressant there is, including Zoloft, Lexapro and Paxil — which did the trick for many years, but had side effects — then Effexor, Lamictal, Seroquel and Abilify.
After a suicide attempt in 2009, she tried something radically different: transcranial magnetic stimulation, or TMS, a treatment in which magnetic pulses are used to stimulate parts of the brain believed to be involved in mood regulation. Unlike electroconvulsive or shock therapy, which is also used to treat stubborn depression, TMS does not generally produce seizures.
Every day, she spent just over half an hour in a chair with a powerful magnet affixed to the front left side of her head. After four weeks, “I woke up and something was different,” said Mrs. Rhodes, who wrote a book, “3,000 Pulses Later” describing the treatment. “I felt lighter. I didn’t wake up in the morning and wish I were dead.”
For Mrs. Rhodes, 63, a former advertising executive in Danbury, Conn., TMS treatment was transformative, and she no longer needs antidepressants. But there are still many questions about just how many severely depressed patients respond to TMS, which requires daily office visits for several weeks, costs thousands of dollars and is often not covered by insurance.
For the therapy, patients sit in a doctor’s office with a large magnet pressed to the left side of their heads. The idea is that a pulsed magnetic field, similar to that used in M.R.I.’s, creates an electrical current in the surface of the brain that “resets” the patient’s mood regulatory system.
TMS is approved specifically for patients whose depression does not respond to antidepressants or who cannot tolerate the drugs’ side effects, which include weight gain and loss of sex drive. Many of these patients are desperate for alternative treatments, but it’s not certain that TMS can provide the help they need.
“While it’s fairly clear that TMS is effective in some percentage of patients with major depressive disorder, it’s still not very easy to know in advance who those patients are,” said Dr. Steven J. Zalcman, the head of the clinical neuroscience research branch of the National Institute of Mental Health.
The American Psychiatric Association’s practice guidelines say that TMS confers “relatively small to moderate benefits,” and the results of clinical trials have been decidedly mixed. “The glass is half full or half empty, depending on where you’re coming from,” said Dr. Mark S. George, a professor at the Medical University of South Carolina in Charleston.
Dr. George was an investigator in the first independent, randomized trial of repetitive TMS to treat resistant depression. While that study found that nearly three times as many patients went into remission after TMS treatment, compared with those receiving a placebo, the absolute numbers were still small: Only 14 percent of treated patients recovered, compared with 5 percent in the placebo group.
A newer variation of the treatment, deep TMS, developed by an Israeli company called Brainsway and approved by the Food and Drug Administration this year, brought a higher response rate in a randomized trial: 30 percent of 233 patients in the trial achieved remission, compared with 14.5 percent of the control group.
The device targets deeper regions of the brain, like the nucleus accumbens, which plays a pivotal role in the reward circuit of the brain, company officials say.
In industry-financed studies that allowed subjects to continue their antidepressant medications while undergoing TMS treatment, which experts say is a more likely situation in the real world, response rates were significantly higher than in the randomized trial conducted by Dr. George. A recent study, as yet unpublished and also financed by equipment makers, that followed patients for a year reported the treatment had a lasting effect, with nearly half the patients maintaining improvement for 12 months.
An advantage of TMS treatment is that it is not invasive and, unlike medication, appears to have few side effects, just occasional discomfort or mild pain in the scalp at the site of the treatment, or headaches. Few patients drop out of treatment because of the pain, however.
Long-term effects are not known, but TMS does not take a toll on memory and cognition, as electroconvulsive therapy can. In rare cases it may cause seizures.
In a demonstration of TMS at the Manhattan offices of Dr. Alan Manevitz, the patient, a 55-year-old woman who asked not to be identified to preserve her privacy, sat in a chair while a small, heavy magnet held by a mechanical arm was positioned over the prefrontal cortex of the brain.
There was no anesthesia or sedation. The patient was allowed to read or watch TV, just not fall asleep. Nodding off seems unlikely, however, since the treatment makes a strident woodpecker-like rat-a-tat sound that lasts for four seconds, followed by 26 seconds of silence before resuming. A daily session lasts about 37 minutes.
The patient, who has had a full course of TMS and is now receiving occasional treatments, said the therapy had pulled her out of severe long-term depression.
“I didn’t even realize I’d slipped,” she said. “I wish I’d done this a long time ago.”