Digging out: TMS offers option for treatment-resistant depression
Northeast Mississippi Daily Journal - 11/10/2017
Nov. 10--For more than 30 years, Karr Ayres felt buried alive by depression.
"It's like you've dug a deep hole and pulled dirt in over you," said the 64-year-old Hickory Flat woman.
She stayed home, away from others. She went through course after course of different medications without relief.
Ayres found help with transcranial magnetic stimulation -- TMS for short. It uses a magnet field generator to deliver pulses of electric current to the brain to stimulate activity. It's allowed her to return to church, enjoy her grandchildren and travel with her husband.
"I was able to start functioning as a human," Ayres said.
TMS, which was FDA approved in 2008, can be very helpful for those with treatment-resistant depression, said Tupelo psychiatrist Dr. Harrison Evans.
Under American Psychiatric Association guidelines, TMS is considered a treatment option for depression after patients have failed one medication. Insurers can have different requirements, but coverage for the procedure has steadily increased.
In addition to patients who failed to get better on medication, the guidelines also allow for those who couldn't tolerate the side effects of medication and those who can't take SSRIs, like pregnant women, to be treated with TMS. However, people with metal medical devices or metallic tattoos in their heads or necks can't receive TMS.
Two 2013 studies -- one conducted by the manufacturer and the other by the National Institutes of Health -- found that a third of people with treatment-resistant depression achieved remission, and 50 to 60 percent reported their depressive symptoms improved.
"There are good one-year (remission) rates with no depression in the first year," said Evans, who is based at North Mississippi Medical Center Behavioral Health Center in Tupelo and is the only doctor currently offering the treatment in Northeast Mississippi.
More than sad
Clinical depression is a disease of the brain, Evans said.
"Depression isn't about being sad," Evans said. "We're not promised to always be happy. Being sad or anxious is part of the human condition."
What separates depression from the blues is impairment of function, Evans said. People with depression have disturbed sleep and trouble concentrating. They aren't able to engage their brain. It is incredibly difficult for individuals and families.
"Depression is the second leading cause of disability," Evans said.
Researchers are discovering depression has a biological basis, Evans said. When doctors look at PET scans, which register metabolic activity, in a person with depression, there is much less activity in the brain than someone without depression, Evans said.
TMS appears to help patients with treatment-resistant depression by stimulating brain activity. The field generator is positioned on the left side of the forehead, Evans said. The magnet pulses reach one part of the brain, but they stimulate activity across the brain.
The typical course of TMS treatment is delivered five days a week for six weeks. Patients are awake and alert during the treatment and don't have any restrictions after treatment. Most people complete another seven treatments over two months to taper down.
"You do need to have your eyes open," Evans said, as the goal of the treatment is to stimulate the brain. He encourages patients to watch mindfulness videos during treatment, but he's had some complete homework assignments and grade papers.
There's nothing physically striking the skull, but many people describe a Woody Woodpecker sensation as the magnet pulses fire during the first few sessions. Only 3 to 4 percent experience side effects so disruptive they can't continue with the treatment, compared with 50 percent on some medications.
TMS tends to work slowly, Evans said. Family members typically see a change in persons with TMS in about three weeks. The people getting treated typically notice a difference in themselves in about four weeks.
All of the studies were done without medications to avoid confounding the studies. As a matter of practice, Evans uses a combination of psychotherapy, mindfulness training. TMS and medication.
"I want as many treatment variables as I can get," to help patients with serious depression get better, Evans said.
The other major treatment available for treatment-resistant depression is electroconvulsive therapy, commonly called ECT. It uses electricity to cause a seizure. It tends to work very quickly, which is why it might be recommended if a patient is facing a crisis and were suicidal.
However, it does require sedation and side effects can include memory loss.
TMS isn't recommended for someone at high risk for suicide.
"I would wait until they are stable," Evans said.
In the two years he has been offering the treatment, Evans said he's treated nearly 30 people and only one didn't respond to treatment.
"This is a serious illness," Evans said. "Therapeutic treatment is available."
In hindsight, Ayres' depression started after the birth of her first daughter, but she didn't recognize there was a problem until after the birth of her second daughter three and a half years later.
The crippling depression made it impossible to work, take care of her children and be a wife to her husband. Her mother-in-law stepped in to help raise her children. It was as if she had a dark cloud in front of her eyes that kept her from functioning. Loud noses and small rooms filled with people left her agitated.
"I stayed in bed; I didn't go out," Ayres said. "I had to be by myself."
She went through multiple doctors and rounds of different medications for depression.
"I could own a pharmacy with all the medicines I have tried," Ayres said. Pharmacogenetic testing would later suggest she has poor metabolism for responding to medications commonly prescribed for depression.
Even though her Christian faith is deeply felt, she felt separated from God at her lowest moments.
Her husband kept pushing to find a treatment that would work for Ayres; his persistence ultimately led them to Evans and TMS treatment.
"God made him my earthly rock," Ayres said. "If he had not been out there fighting for me, I would probably be in a hospital somewhere."
With TMS, the improvement was gradual. The early treatments left her exhausted with a mild headache, but those side effects quick resolved. Slowly the fog lifted for Ayres.
"It just made me realize life was out there," Ayres said.
She was able to get out in her garden and return to church. She is an active part of the lives of her daughters and her grandchildren, who are now 8, 3 and 6 months old.
"Before, I couldn't be around them," Ayres said. "Now I look foward to seeing them."
She now has the resilience to be strong for others. In the past year, she has coped with a near- fatal stroke and terminal cancer in her extended family.
"There's no way I could have been there for my family," before TMS treatment, Ayres said. "At the time I needed to be strong, I was strong."
Because she had such a long depression, Ayres continues with monthly maintenance treatments most of Evans' other patients don't require.
She's found great comfort in a passage from II Corinthians -- "Praise be to the God and Father of our Lord Jesus Christ ... who comforts us in all our troubles so that we can comfort those in any trouble with the comfort we ourselves have received from God."
"There is a way out," Ayres said. "It might not be this treatment for your, but there is help out there if you seek it."
(c)2017 the Northeast Mississippi Daily Journal (Tupelo, Miss.)
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