Stimulating the Brain

We’ve known about magnetism itself for a long time. We’ve used it and relied upon it for centuries. We even understand how it works. Still it continues to fascinate and mystify us. There was even a time when some people believed that magnetism could control the mind.

But transcranial magnetic stimulation is not science fiction nor is it a new age fad. It’s a safe, non-invasive procedure that uses electromagnetic energy to stimulate the brain. TMS has been used in research since 1985. Since the late 1990s, it’s also been used clinically, not only as a treatment for depression, but for several other conditions as well.

We already have a treatment that uses electricity to stimulate the brain. Electroconvulsive therapy (ECT) has been around for over 70 years and is still considered to be the “gold standard” for treatment of severe depression. Although it is generally regarded as being effective, it is interesting to note that ECT was approved for use before the FDA existed. There have been no randomized controlled studies regarding the effectiveness of ECT since the 1980s. In fact, the FDA is currently considering reclassifying ECT devices and possibly requiring new studies to be done in order to demonstrate safety and efficacy.

In recent years, implanted electrodes have also been introduced, such as the vagus nerve stimulator (VNS). This is a very invasive treatment that involves surgically implanting the device in the neck and attaching it to the vagus nerve. Although it has been approved by the FDA, it is rarely used, not only because of concerns about safety, but also because it has not been very effective. Another still experimental device for treating depression is deep brain stimulation, which is also a neurosurgical procedure that is very risky and highly invasive.

Not only is TMS safe and effective, but it doesn’t even involve the use of electrodes. That’s because electricity and magnetism are two different aspects of the same phenomenon. Every electrical current generates a magnetic field and a magnetic field can cause an electrical current to flow in a nearby conductor. This was discovered almost 200 years ago by the English physicist Michael Faraday.

TMS takes advantage of this relationship between electricity and magnetism by using an electrical current to generate a magnetic field which then induces an electrical current in the brain. So transcranial magnetic stimulation is actually transcranial electrical stimulation, but without the use of electrodes. The therapeutic effect from TMS doesn’t come from the magnetic field itself but rather, from the electrical current which it induces. 

Introduction to TMS-The Problem of Depression

In 25 years of clinical practice I have not seen a treatment for medication resistant depression which is as safe and as effective as transcranial magnetic stimulation (TMS). It has now been one year since I decided to make a major career change and devote my practice primarily to TMS. I continue to see the same excellent results that prompted me to make that career change and in this next series of posts, I will focus on TMS.

The Problem of Depression

Depression is a major public health problem. In the United States, almost 20 million people have some form of depression. Only about half will ever be treated and of those, only about half will make a full recovery. Even with treatment, depression can still mean a lifetime of suffering.

But the full impact of depression is even greater than most people realize. According to the World Health Organization, in 2004 depression was already the world’s third leading cause of disability and by the year 2030, it’s expected to be the leading cause. In this country, depression is already the leading cause of disability for people between the ages of 15 and 55. Most of them are not dealing with the acute symptoms of an acute episode but instead are struggling with the chronic and persistent symptoms of treatment resistant depression. In October 2008, the FDA approved the use of transcranial magnetic stimulation specifically for treatment resistant depression.

TMS at the 2010 APA Meeting in New Orleans

I just returned from New Orleans where I attended the 163rd annual meeting of the American Psychiatric Association. As expected, New Orleans was hot and humid but every bit as fun as I remembered from my last visit before Katrina. It was great to see old friends and colleagues and to meet new ones for the first time.

This year I participated in several important events.  On Sunday, I had the honor of giving a brief presentation about my TMS experience to everyone who attended the 60 Million Pulse dinner hosted by Neuronetics. That was a fun event, but on Monday I was part of a more serious panel discussion about the use of TMS in clinical practice with my esteemed colleagues Dr. Timothy Derstine of State College, PA; Dr. Carl Wahlstrom of Chicago, IL; and Dr. Todd Hutton of Pasadena, CA. 

All of us have been using TMS since shortly after it was cleared by the FDA and we had the opportunity to share some of our clinical experiences thus far. Although all of us have had the satisfaction of seeing our patients respond to TMS, it was interesting to see how our experiences differed in certain ways. For instance, I was the only one on the panel to have had the experience of treating adolescent and geriatric patients. Many in the audience were psychiatrists who have been thinking about adding TMS to their practice but some had more experience with TMS than any of us on the panel. I was especially pleased to meet Dr. Alexander Lyford-Pike from Montevideo, Uruguay. 

On Monday evening I demonstrated the use of the Neurostar TMS Therapy device at a press briefing and throughout the meeting I had the opportunity to introduce colleagues to TMS through brief presentations at the Neuronetics information booth. 

Among the scientific papers presented at the meeting, Drs. Mark George, Sarah Lysanby, and Ziad Nahas reviewed the findings from a major study published in this month’s Archives of General Psychiatry, which demonstrated that patients with treatment resistant depression are more than 4 times as likely to respond to TMS as they are to another medication trial. This study was noteworthy for several reasons. First of all, it was one of the largest, multisite, randomized controlled studies of TMS to ever be performed. It was sponsored by the National Institutes of Health. It used a much more sophisticated sham TMS control than any previous TMS studies. And it was published in one of the most important peer reviewed psychiatry journals in the world.  

All in all, this year’s APA meeting was an interesting and rewarding time. When I started doing TMS back in January 2009, I was only one of about a dozen doctors in the country using the newly approved Neurostar device. Now there are 190 Neurostars around the country. I am glad that this important and highly effective treatment is now available to so many people. Although routine insurance coverage is still probably about a year away, more and more insurance companies are paying for TMS as it becomes increasingly clear that TMS is, in fact, a major advance in modern psychiatric medicine.

Beginning with my next post, I will describe in detail how TMS was developed and how it evolved to become a truly revolutionary treatment for depression and how it may one day revolutionize the treatment of a range of other neuropsychiatric conditions.  

What Is Psychiatry And What Does A Psychiatrist Do?

When a woman is pregnant she goes to see an obstetrician. If someone has a heart problem, he goes to see a cardiologist. When someone suffers from depression or anxiety, they are often unsure of where to turn for help. And if they see a psychiatrist, they are sometimes not even sure about what type of doctor they are seeing. After 25 years of practice, I continue to be struck by how many otherwise knowledgeable and well educated people do not know the difference between a psychiatrist and a psychologist.

Psychiatry is a medical specialty, just like obstetrics or cardiology. It is also one of the most rapidly advancing medical specialties. Its scientific foundation is neuroscience, which is growing at a more rapid pace than any other branch of science. Psychiatrists are more closely akin to neurologists than psychologists.  After all, both specialties are regulated by the same American Board of Psychiatry and Neurology.  Yet the general public and even other medical specialists still tend to envision psychiatrists as sitting behind a couch scribbling Freudian jargon, while interpreting their patients’ dreams.

So before venturing further into any discussion about The Mindful Brain, I would like to share some of my thoughts about what psychiatry is and what a psychiatrist does. 

• A psychiatrist is a fully trained medical doctor (MD). The process of becoming a psychiatrist involves the standard four years of medical school followed by a year long hospital internship, rotating through all of the major medical specialties, including intensive care medicine and surgery. This is followed by three or more years of additional specialized training.
• Psychiatry focuses on brain disorders that affect behavior, thought, mood, and cognition. These can be either primary disorders themselves or the result of general medical conditions or substance use.
• Psychiatric disorders are the result of complex interactions of genes and the environment. Some psychiatric disorders begin to develop during fetal life, while others appear much later, even in advanced old age.
• Psychiatric disorders are very common, affecting anywhere from 25% to 50% of the general population in various studies. They can range from very mild to extremely severe and disabling.
• The complete assessment of psychiatric disorders almost always requires information provided by someone who knows the patient well.
• As a fully trained physician, a psychiatrist can integrate biological, psychological, and social factors in order to render an accurate diagnosis, and administer pharmacologic/physical treatments as well as psychotherapeutic treatments to repair both the brain and the mind.
• As with all medical disciplines, the best outcome in psychiatry is full remission and recovery. The worst outcomes are death from suicide, homicide, self-neglect, coexisting medical illness, or rarely, from treatment itself.
• Social and occupational disability can occur with some psychiatric disorders but most are not disabling and with proper treatment, most patients can lead full, productive, and happy lives.
• Psychiatric diagnoses have far more reliability than ever before, especially as the underlying brain pathophysiology of specific psychiatric disorders becomes better understood.
• Severe psychiatric disorders can sometimes impair the insight of the person who has the illness, which can interfere with treatment. 
• Many current medication treatments came about because of accidental discoveries but groundbreaking advances in genetics and neuroscience are leading to breakthroughs that are reshaping the treatment of psychiatric disorders.
• Drug treatments and neurostimulation are regulated by the FDA and are approved for specific uses based on large, placebo-controlled trials but the various forms of psychotherapy and other “alternative” treatments are not, some of which have little, if any, proven value.
• The medical model is as appropriate for the treatment of psychiatric disorders as it is for the treatment of cancer or heart disease. However, social stigma, political influences and the preponderance of non-physicians in the mental health care system (psychologists, social workers, pastoral counselors, etc.) have shifted psychiatric treatment towards a predominantly social model. 
• These allied health care professionals are usually highly trained and quite competent with their own unique skills and expertise. They share the same goal, which is to help the patient make a full recovery and enjoy their full, human potential. Unfortunately, in some cases the lack of any medical evaluation can result in wrong diagnosis and incorrect treatment or even lack of treatment.
• Medical doctors are certainly not perfect either and sometimes fail to correctly diagnose or properly treat a patient. Criticism of individual physicians may be entirely justified in some circumstances. For example, some obstetricians may indeed perform more caesarian sections than are necessary and some cardiologists may perform more cardiac catheterizations than are necessary. And it is certainly true that the health care delivery system in this country is in need of improvement in a number of respects. But rarely does one hear wholesale criticism of a specific medical specialty. Psychiatry however, has more detractors and self-appointed critics than any other medical specialty, which is the product of a malignant mix of ignorance and self-interest, especially by cults, such as Scientology, which offer their own unscientific “solutions” to mental illness, usually at a substantial price. 
• The future of psychiatry is bright because it is intimately linked to neuroscience discoveries, which will ultimately delineate specific brain pathways underlying psychiatric illness and treatment.
• But even within the specialty of psychiatry itself there are differences of opinion and differences in clinical practice. For most of the 20th century, American psychiatry was heavily influenced by the psychoanalytic ideas of Sigmund Freud and his followers. While many of these ideas can still provide useful insights into human nature, our growing understanding of the basic brain problems responsible for most psychiatric symptoms will vastly change the practice of clinical psychiatry.  

I have chosen to devote my efforts to one of the most important and exciting developments in modern psychiatry--transcranial magnetic stimulation (TMS). My next post will provide an introduction to TMS.  

www.tmsnewengland.com

Sleep Deprivation: A Cure for Depression?

The New York Times Opinionator blog ran an article on Wednesday about the fact that short term sleep deprivation can alleviate the symptoms of depression. (http://opinionator.blogs.nytimes.com/2010/04/07/in-sleepless-nights-a-hope-for-treating-depression/?) Based on the comments posted, it seems like this article caused a bit of confusion for some folks. As a neuropsychiatrist as well as a sleep medicine specialist, I'd like to try to clarify a few points.

First, the fact that depression improves after a night of partial sleep deprivation has been known for years. Over the course of 20 years of practicing inpatient psychiatry, I would often prescribe a maximum of 4 hours of sleep per night for some of my more severely depressed patients. They were not cured by this, but they almost always improved enough so that, the following morning, we could have a rational discussion about their illness and how best to proceed with treatment. Many of these patients were so severely depressed that they had given up all hope of ever feeling better. Antidepressant medications take time to work. What I found was that a night or two of partial sleep deprivation could bring about enough improvement so that a patient could actually begin to feel hopeful and recognize that, with proper treatment, more sustained improvement could be achieved.

What can be confusing is the fact that insomnia is also a symptom of depression. This not only contributes to feeling irritable and physically exhausted, but is also responsible for at least some of the concentration and memory problems that go along with depression. Sometimes just getting a good night's sleep can go a long way to improving a person's cognition. In addition, there is plenty of evidence to suggest that chronic insomnia can predispose a person to developing depression, sometimes not until years later.

It's important to bear in mind however, that depression and insomnia are two different conditions. Most insomniacs are not depressed and depressed persons are just as likely to sleep too much as they are to sleep too little. What is interesting about the Opinionator article is that it calls attention to the fact that there is still a complex and incompletely understood relationship between depression and sleep. This is currently an area of intense research.

While short term sleep deprivation can bring about short term relief from some of the symptoms of depression, longstanding or permanent relief takes time and a carefully thought out treatment plan. This is what I strive to achieve with my patients, whether treating them with TMS, standard antidepressants, meditation, exercise, or a combination of therapies, which may sometimes include partial sleep deprivation.

What is "mindfulness"?

As you’ve probably already noticed, the word “mindful” is used a lot these days. Every other self-help book seems to have something about mindfulness in the title and this blog is called The Mindful Brain, but what exactly is that supposed to mean?

The word “mindful” has been part of the English language since the 16th century, as in “be mindful of the stairs so you don’t trip”, and basically, it means to pay attention. But the way it’s used here means something more than that. Here, being mindful refers to a special way of paying attention, not only to what’s happening around you, but to what’s happening inside of you at the same time--bodily sensations, the flow of thoughts and feelings in your mind, as well as the content of those thoughts. 

At the same time, it also means not getting caught up in trying to figure out what it all means. Rather, being mindful means noticing these things almost as if you were an outside observer, carefully watching everything that happens, but without trying to analyze it or draw any conclusions about it. Even something as mundane as washing the dishes can be done mindfully if you focus on what’s happening in the moment, without dwelling on what happened at work that day or thinking about that phone call you’ve been meaning to make or wondering when you’re going to go through that stack of mail that’s been piling up on the counter. 

Being mindful is different than being introspective. When we use introspection, we deliberately set out to analyze and understand, through the use of logic, how all those thoughts and feelings are connected and what it all means. This is the traditional approach used in psychotherapy and it can lead to important insights. The focus of introspection is the self. The focus of mindfulness quite different.

It seems paradoxical at first, but by focusing on what’s happening in the moment, we become attuned, not only to ourselves, but to the world around us and everyone and everything in it. Rather than getting caught up in ourselves however, we become more more connected to the world around us. This, in turn, leads to better understanding and more compassion for those around us.

This concept of mindfulness is drawn from Buddhism, but it has nothing to do with religion. It’s a way of thinking and also a way of thinking about thinking. It’s really a psychological concept that can be used by people of all faiths. Western psychology has begun to use mindfulness as a psychotherapeutic tool, one which can be used by anyone in everyday life. Developing the ability to be mindful can help anyone lead a healthier and happier life.

In Western science, there has been a growing interest in Buddhism in recent years. Physicists in particular have commented upon the similarities between certain Buddhist concepts and the often strange, counter-intuitive ideas of quantum physics. Now neuroscientists are beginning to pay attention to these concepts and that is partly what this blog is about.

On April 7, PBS television will air a 2 hour documentary on the life of the Buddha.(http://www.pbs.org/thebuddha/?gclid=CN7prISK86ACFcN05Qod9xEiFw) If you are already familiar with some of the ideas of Buddhism, you probably already know about it. If not, you may want to check it out.

In Nature's mirror, we can see the ongoing process of growth, renewal, and transformation in ourselves.

Today is Easter, which means spring has arrived. The grays and browns of winter are quickly fading as green grass, yellow forsythia, pink dogwood, and purple tulips bring color back to the landscape. Songbirds return from their winter sojourn, bringing music to the morning stillness. Chipmunks and squirrels emerge from their winter sleep and once again scurry about in search of food and perhaps a mate. For thousands of years people have celebrated the arrival of spring as a time of renewal, regeneration, and rebirth.

For those who have seasonal affective disorder, spring's arrival means welcome relief, but for many who have chronic and persistent depression, spring may bring a mix of feelings. It's hard not feel a little happiness, and perhaps even a fleeting moment of joy, as life on Earth once again emerges triumphant. But even this may not be enough to offset the feelings of isolation and loneliness that are so often a part of depression.

Set aside some time today for a walking meditation. Step outside and experience what is happening around you. Look carefully, but mindfully. Don't try to think about it too much. Don't try to analyze it. Just see it, hear it, and smell it. Just experience it. The chipmunk isn't thinking about what happened last week and the robin isn't worried about what might happen tomorrow. They are just living in the moment, the only moment that exists.

As the Earth breathes new life into itself with each emerging blade of grass, you breathe new life into yourself with each breath you take. Each emerging thought, perception and feeling is like a blade of grass that brings with it the possibility of growth and renewal. Think about that.

And think about this. Every atom of your being was forged in distant galaxies billions upon billions of years ago. On a small, inconspicuous planet in a far corner of one particular galaxy, these atoms have coalesced, as never before, to create a living creature who has never before existed and who will never exist again. You are here now, in this one fleeting moment, the only moment that exists. Make the most of it.