Science Friday - How Magnetic Brain Stimulation Helps Relieve Depression

Episode Date: October 8, 2024

As the surgeon general has stated, we are in a mental health crisis. Depression is the leading cause of disability worldwide. And a major challenge is that depression can be difficult to treat, especially for people who don’t respond well to talk therapy or antidepressants.But there’s a relatively new technique that seems to have a significant positive impact on people with treatment-resistant depression, even sending many of them into remission. It’s called transcranial magnetic stimulation (TMS) and it uses magnets to stimulate certain areas of the brain that play a role in depression.A team at Stanford developed a protocol for TMS that received FDA clearance in 2022 and, as of this year, it’s covered by Medicare. In a study from 2021, it was shown to improve remission rates for depression by up to 80%, with one patient calling it “a game changer.”So how does TMS work, and could it change the way we treat depression and other mental illnesses?Ira Flatow is joined by Dr. Nolan Williams, associate professor of psychiatry and behavioral sciences at Stanford University, where he’s also the director of the Stanford Brain Stimulation Lab. They talk about the advances that Williams’ team made with their SAINT protocol (Stanford Accelerated Intelligent Neuromodulation Therapy), patient experiences with the technology, and potential future applications of this technique.Transcripts for each segment will be available after the show airs on sciencefriday.com. Subscribe to this podcast. Plus, to stay updated on all things science, sign up for Science Friday's newsletters.

A new non-drug treatment is sending many people with depression into remission. You know, we're at a place now with these technologies where we can actually really get people out of it and they can resume a normal life. It's Tuesday, October 8th, and you're listening to Science Friday. I'm Cyfry producer, D. Peter Schmidt. Depression is the leading cause of disability worldwide. And obviously, it is very difficult to treat. But there's a relatively new technique that seems to have a significant positive impact on people with treatment-resistant depression. even sending many into remission.

It's called transcranial magnetic stimulation, or TMS, and it uses magnets to stimulate areas of the brain that play a role in depression. A team at Stanford developed a version of TMS that received FDA clearance in 2022, and as of this year, it's covered by Medicare. So how does this approach work? And could this change the way we treat depression and other mental illnesses? Here's our inflato with more. Here to tell us more is Dr. Nolan Williams,

Associate Professor of Psychiatry and Behavioral Sciences at Stanford University. He's also the director of the Stanford Brain Stimulation Lab where this technique was developed. And a heads up, we will be discussing suicidal ideation in this conversation. Dr. Williams, welcome to Science Friday. Thanks for having me. I really appreciate the opportunity to talk to you about this. I guess this is really sort of a breakthrough for people who are suffering from severe depression because what's it been like, people having thoughts of suicide trying to get help in emergency

settings? It's not really been very nice for them, has it been? It has not, and you're absolutely correct. So if you're suicidal and into the hospital, you'd realize outside of, you know, the kind of rare situations where people use electroconvulsive therapy, that the patient doesn't have access to anything beyond the kind of base case oral antidepressants. You know, and that's where the statistics, that people leaving the inpatient hospital are three times more likely to try or actually do in their life by suicide, right? And so that's a statistic that is really quite striking. And it's a reflection of the fact that as a field we haven't had treatments designed specifically for those

conditions. So if I'm having chest pain in the clinic, you know, there's going to be a certain number of tests and treatments. In the ER, there's more. In the ICU, there's more, right? In psychiatry, there aren't more treatments as you get into higher acuity settings, and there are no tests. And so the revolution that's coming for psychiatry is essentially to mimic a lot of the rest of medicine, right, that we can treat people really quickly and get them out of it in completeness. And I think that's really the thing that's coming and what's going to be so important for the future of mental health care is the ability to really use state-of-the-art neurobiology to assist in getting people out of these really high-risk states. You know, one of the reasons why I started down this pathway,

you know, on average people stay in the hospital in the United States about seven and a half days. And so you have to come up with technologies that can get people well in these really short periods of time and not in these kind of extended months-long periods of time, which is true for conventional TMS, it's true for oral antidepressants. There's certainly a role for those things, but for people that are, you know, at the more severe end of things, being able to treat them really quickly reduces that risk and gives them some hope and gives them access to something that's going to work in the timeframe of an emergency.

So your lab's version of TMS is called Saint, and that stands for Stanford, accelerated, intelligent neuromodulation therapy. But before we get to that, how does TMS work generally? TMS is a device that essentially utilizes something called Faraday's Law, what we learn in kind of physics 101, where if you pulse a magnet, you can generate a current and electrically conducting substances. And in the case of the human brain, the brain itself is electrically conducting, whereas everything around it, the skull, the scalp, the hair, all or not. And so you can actually put a magnet, push it up against the head, have the person receive a stimulation pulse, and it won't do anything to any of those other structures, and we'll go directly to the brain

and turn the brain on. And so that's the basic idea. The original forms of this used kind of average placements on the skull itself and used a more inefficient form of stimulation where we're stimulating over the course of nearly two months. What my lab figured out is how to personalize this so that each person's brain has taken to account for planning of where to put the stimulator coil. So we use MRI scans to do that. And then we have developed a rapid form of stimulation

that instead of being applied over nearly two months, we can apply that over a single day and then repeat that over the course of five days. And people, as a generality, get well in about 2.6 days on average. And so we're able to, with this kind of rapid stimulation approach and personalized medicine, get people well in a really short period of time at a really high rate of success. So it's not a guaranteed cure for depression, right? There's no guaranteed cure for depression.

depression is an illness that comes and goes. And what we are seeing is kind of a functional cure, meaning that for a lot of people, we can get them well in totality. And if they continue to receive more stimulation whenever they have a new depressive episode, then the idea there is we can maintain folks in a state of wellness continuously.

with the device. And so, you know, if you withdraw the device, they will in many cases, but not all cases relapse back to their original state, but if they can continue to receive stimulation, then they can stay well. So that's the same sort of thing that you see with a cardiac pacemaker. Pacemaker for a lot of people isn't a cure in the sense that if they were to take the pacemaker out, then their heart would go back to that abnormal rhythm. But with the pacemaker in, and working in the battery on and they continue to have it for the rest of their life, it's a functional cure. And so we see this in a similar way. So you have to go back for treatment, periodic treatments every what, how many months, weeks? It's different for different

people and it has to do with how severe and resistant your illness is. And resistant, meaning not that the person's resisting, but that the kind of degree of how many meds they'd failed before they came in and so people that are more severe in many cases need it more frequently so you're talking about months whereas you know we've treated people that are on the milder side from a resistance standpoint they may be quite severe acutely but they haven't been sick for very long and we've seen people like that go for for years so it really just depends on the illness and when you catch it and just like you know a bacterial infection or anything else you know depression appears to be more difficult to treat, the longer it's allowed to go, and the longer people stay in the state.

And so we've been just very focused in my lab on this idea that we need to come up with a way and say it is that way for a lot of people come up with ways to get people well really quickly and to find ways like these new Medicare programs where people can actually be treated much earlier in the illness. and so they don't ever get to that really kind of chronic point. If we can do that, then we can potentially have these sorts of treatments work for a much longer period of time, or in some cases we have a few people where it just works. You know, it's worked for many, many years and we haven't seen any signs they're going to relapse. So, you know, part of that is taking, it sounds like you are, and certainly the surgeon general has said, taking this illness very seriously. It's very disabling and really going after it much earlier in the process to get people well quickly.

Your treatment, the saint treatment, is a specialized form of TMS, correct? Where you're saying and your research is showing and your work is showing that it works a lot faster basically than other forms of TMS. Would that be correct? Yeah, that's right. Yep. And so 2.6 days versus depending upon how you read the literature, you know, I mean, there are faster responders, but for the number of people that we're seeing get better, you know, the normal form of TMS sometimes takes people 15 weeks. And so, you know, being able to get people well, you know, on an average of 2.6 days, that's critically important because for the working folks that are trying to get better, you know, that are, kind of on the edge of losing their job, getting them well in a few days, they can take a vacation to do that and get it done really quickly versus having to do this over a protracted course and having to get permission to come off of work to be treated in the middle of the day,

you know, that sort of thing where it's much harder to do that with the kind of traditional forms. And so we're really focused on, you know, getting people well, to your point really quickly and doing it through personalized medicine. There's a patient that you treated named Merle a few years back who went through the same treatment. Can you tell us about her story and what changed after that treatment? Yeah. So Merle was interviewed on CBS Sunday morning a number of years ago.

So this story is one that I have permission to tell. And so, you know, she had been a patient who, as she said in that Sunday morning special, been through years and years and years of ineffective medication treatments, you know, tens of trials of drugs with little to know effects over time and got to a place where she was quite, you know, desperate to get better and enrolled in our study was one of the first two participants in our original trials. And within a few days, it was completely back to normal, to her old self. And, you know, Merle's a, therapist herself.

You know, so she's seen folks go through these struggles and it take a long time or never to get out of these settings, these feelings. And she was able to, within a few days, get back to the Merle that she knew decades before in a place where she wasn't depressed. And with repeat treatments and maintenance treatments, she's been able to stay well for a really long time now, you know, I think four or five years now. And so, you know, there are a lot of Merle's out there. There are probably folks with similar stories to Merle listening to this.

And so I think that, you know, the message that I would give is a message of hope. You know, we're at a place now with these technologies where we can actually really get people out of it and they can resume a normal life. And that's, you know, this has been the Greeks and Romans used to write about depression, melancholia and how difficult it was for people. We've known this is a problem with thousands of years, and I think we're right at a place now. We're going to have tools so we can effectively do something about it. But if it's only being accepted by Medicare and not your general population of health care providers, how do we get it to those people? Yeah, so TMS is paid for by all insurance companies at this point outside of MediCal. This newer rapid acting form is kind of brand new from a commercial sense.

And so that just takes time. But having Medicare pay for it essentially right away, they were agreeable to paying for this right after the FDA clearance is great, right? Because it's a signal that all the folks on disability, all the folks that are 65 or older can get access to this now. and we can start finding those other private insurance companies and working on them to do the same. Now, your St. Cheapen has been commercialized, correct? Yeah. So how soon is it available to everyone outside of California, let's say? It's actually, you know, it's available in Arkansas and South Carolina and Iowa and a bunch of other places soon.

And so over the next year, I'd say, where there's... There's going to be a big expansion there. But yeah, the goal is to have this everywhere where there are Medicare patients that could benefit from it. And that's a really great thing. The Center for Medicare and Medicaid Services has built this amazing program called Innovation Funding.

Saint is the first mental health treatment to receive innovation funding and it received innovation funding for inpatient and for outpatient. And so just really thrilled to see Saint be a part of that. Do you have any idea? I know I mentioned this before when Saint might be accepted by, you know, the general community of caregivers. Yeah, I think that the caregivers, you know, it's been amazing actually. There's been, I think, 500 psychiatrists that have reached out to do this. And so on the psychiatrist side, it's totally there. I think the issue is for commercial insurance, they really, you know, and it makes sense that they do this, but they really want to. to have a lot of hoops to jump through to, you know, get to a place where they're willing to pay,

you know, and so we're jumping hoops right now, giving them data and all that good stuff. And the hope is that at some point there's a calculation within, you know, Etnam, Blue Cross, Blue Shield and United and Anthem and all these, you know, private insurances, they can see the real value in getting people well completely and quickly. And my hope is that when they do that, then we're going to be in a position to be able to offer this, not just to the folks on disability and 65 and older, but to the working folks that are out there working and have a private insurance plan, to your point. And, you know, for those of you listening that have those plans, you should still, you know,

try to look into this, I think. And then, you know, some people have been successful at getting single case agreements where they actually just call the insurance company over and over again, and the insurance company eventually agrees to paying. And we've seen success for some people in getting this paid for by just really being clear that your story is one that deserves, you know, this sort of payment from insurance. But you're saying the other forms of TMS are receiving insurance payments. Yeah, you know, the other forms of TMS had to go through the same, you know, grind of having to go back over and over again insurance companies. But now for conventional TMS, the six-week form of it, it's paid for by conventional insurance companies and

basically all of them, you know, and so there's hope for St. You know, over the next couple of years for that to be the case for a lot of people. Conventional TMS is helpful today. And so I think that it's just a matter of really looking out there and seeing what your options are and reaching out and getting your doctor to refer you. Dr. Williams, I want to thank you for taking time to be with us. Very interesting. Yeah, thank you for having me. Dr. Nolan Williams, director of the Stanford Brain Stimulation Lab. That's all the time we have for today. Lots of folks help make the show possible, including John Dancosky, Kathleen Davis, Robin Kasmur, Emma Gomez. On tomorrow's episode, how your ability to deal with stress could depend on what's in your gut microbiome.

I'm Cyfry producer D. Peter Schmidt. See you then.