Addressing TRD on Tampa Bay Medical News

Addressing TRD

By: LYNNE JETER

University of South Florida psychiatrist Dr. Patrick Marsh treats Lindsey Underwood with the Neurostar TMS device. TMS is one of the non-drug options for treatment-resistant depression offered by the USF Health Neurotherapies Clinic.

Non-Medication, Non-Invasive TMS Outpatient Procedure Highlights USF Neurotherapies Program

When University of South Florida (USF) psychiatrist Patrick Marsh, MD, was learning how to perform brain stimulation therapies at the Medical University of South Carolina, he volunteered to experience transcranial magnetic stimulation (TMS), an outpatient procedure that’s a non-sedative alternative to electroconvulsive therapy (ECT). Via magnetic pulses, his instructor, Ziad H. Nahas, MD, an associate professor in psychiatry and behavioral sciences at MUSC, briefly stimulated the part of Marsh’s brain that controls speech. (See related story below.)

“It was very strange to be talking and suddenly get the feeling that your tongue isn’t working,” recalled Marsh, chief of the Neurotherapies Program at USF Health. “I briefly lost the ability to speak until the magnet was turned off, but it certainly wasn’t harmful or painful.”

Mapping the brain is one way TMS is making a name for itself in the scientific community, yet its main purpose is to alleviate treatment-resistant depression, or TRD, Marsh said, pointing out that TMS belongs to a group of neurotherapies– including ECT, deep brain stimulation (DBS) and vagal nerve stimulation (VNS)–that can help improve symptoms of TRD by stimulating brain cells electrically rather than with medications.

When Marsh joined USF, he collaborated with Francisco Fernandez, MD, chair of USF’s Psychiatry Department, who had a long-time relationship with Nahas and a strong interest in bringing TMS and other neurotherapies to USF. Together, Marsh and Fernandez started the USF Health Neurotherapies Program last year.

In scientific terms, TMS is a noninvasive method that causes depolarization in the neurons of the brain, using electromagnetic waves to induce weak electric currents via a rapidly changing magnetic field. A variation of TMS—repetitive TMS, or rTMS—has been tested as a treatment tool for various neurological and psychiatric disorders including auditory hallucinations, dystonia, migraines, Parkinson’s disease, strokes and tinnitus.

“While the technology is new to clinical practice, TMS has been used by the scientific community since 1985,” said Marsh. “The vast majority of its use prior to looking at TRD was for looking at architecture of the brain.”

In October 2008, the FDA approved the NeuroStar TMS Therapy System as an outpatient intervention for patients diagnosed with TRD—but not for those suffering from bipolar disorder, depression with psychosis, or a high risk of suicide.

USF Health is the fourth Florida site to acquire the NeuroStar system. Even though its manufacturer, Neuronetics, has sold several hundred systems around the world, with the vast majority in the United States located in the Northeast and on the West Coast, USF is among an elite few university-based programs around the globe to have the NeuroStar system.

Here’s how TMS works: In a 37-minute, prescription-only procedure given daily by a psychiatrist, typically over a four to six week period (20 to 30 treatments), the patient remains awake and alert while the TMS device sends magnetic pulses, similar to what a patient would experience in getting a magnetic resonance image (MRI) of the brain, to the left prefrontal cortex to generate weak electrical currents. Those currents activate neurotransmitters in the part of the brain that has been linked to depression.

“TMS is a very good option for patients with TRD,” said Marsh. “The FDA approved TMS for TRD patients who failed to achieve satisfactory improvement after a single anti-depressant. More rigidly defined, it means the failure of at least one trial of a SRRI medication. Because TMS is new and typically not paid for by insurance, most folks have failed 10 to 25 medications for two to three years before they make their way to a specialty clinic like ours. It’s approved much sooner in the treatment process, and we’d like to treat people much sooner, but they usually don’t come to us until later, when their symptoms are unbearable. About half of our patients are referrals from providers in the community, such as psychiatrists who are familiar with TMS and understand the ease of administration and the beneficial effects. The other half is patients who either seek us on their own or have family members who encouraged them to consider TMS.”

The full treatment cost ranges from $8,000 to $14,000, depending on the length of time treatment takes, which in some cases extends to eight weeks. Still, many patients pay for TMS out of pocket rather than follow the treatment options that insurance will cover, such as ECT because of the stigma involved, or in some cases DBS or VNS, said Marsh. USF offers all four neurotherapies.

“But, once all of the regulatory and insurance issues are resolved,” he added, “most everyone will likely prefer TMS, because it’s a non-invasive alternative and has fewer side effects than any other neurotherapy modality.”

Concerning the risks of TMS, there are few, Marsh noted.

“Contraindications to TMS include magnetic materials inside the head, such as aneurism clips,” he explained. “The rule of thumb is that if the patient is safe to have an MRI, he’s safe to have TMS. The only other significant adverse reaction we worry about is the miniscule risk of the treatment causing a seizure in patients. The magnetic stimulation itself, compared to medications or other treatments for TRD, is much safer. Once the magnet is off, the effects of the magnet on the functioning part of the brain go away. The stimulation to the brain stops while the downstream effects that cause a change in mood persist.”

Related Story

Neurotherapy Modalities May Improve Patient Response

The Neurotherapies Program at USF Health provides many neurotherapy modalities that may improve responses in patients for whom medication therapies for chronic neuropsychiatric illnesses have not provided satisfactory results, or for patients who have experienced negative side effects from medications.

Since 1997, the deep brain stimulation (DBS) method has been used in more than 55,000 patients worldwide for tremor, Parkinson’s disease, primary dystonia and obsessive-compulsive disorder (OCD). Now FDA approved, it safely and effectively manages some of the most debilitating motor symptoms of Parkinson’s disease and essential tremor. In special cases, DBS is used for dystonia and OCD.

“Electrical leads are surgically implanted in the brain in a structure called the anterior limb of the internal capsule (AIC),” explained Patrick Marsh, MD, chief of the Neurotherapies Program at USF Health. “These leads are connected to one or more neurostimulators implanted near the collarbone. The neurostimulator contains a small battery and computer chip programmed to send electrical pulses to control symptoms. The stimulation may be programmed and adjusted non-invasively by the clinician to help maximize symptom control and minimize side effects.”

The Neurotherapies Clinic at USF Health consults with OCD patients for DBS, Marsh added.

For more information, visit http://health.usf.edu/medicine/psychiatry/neurotherapy/.