Speaking of Psychology - The promise of brain stimulation treatments for depression, with Sarah Lisanby, MD, and Diana Daniele

Episode Date: April 26, 2023

Transcranial magnetic stimulation (TMS) has been a treatment option for people with major depression since it was approved by the FDA in 2008. Today, it is also used to treat obsessive compulsive disorder and anxiety and for smoking cessation. Sarah “Holly” Lisanby, MD, director of the Noninvasive Neuromodulation Unit at the National Institute of Mental Health, talks about how TMS works and recent advances in TMS treatment, as well as other brain stimulation treatments such as electroconvulsive therapy. Writer Diana Daniele also offers her perspective on how TMS helped her overcome treatment-resistant depression. For transcripts, links and more information, please visit the Speaking of Psychology Homepage. Learn more about your ad choices. Visit megaphone.fm/adchoices

About 21 million adults in the U.S. suffer from depression. For some of them, the first-line treatments of therapy and antidepressant drugs don't help. So what can they do? In recent years, another treatment option has emerged, transcranial magnetic stimulation, or TMS, which uses high-powered magnets to stimulate electrical activity in targeted areas of the brain and can alleviate or put into remission people's treatment-resistant depression. Brain stimulation treatments, including TMS, are not new, but in recent years they've become more effective and more available, and TMS has earned the approval of the U.S. Food and Drug

Administration. So how does it work? What is happening in the brain during TMS treatments? What mental health disorders can it treat? Only depression, or does it work for, say, anxiety? Who is it most useful for? Are there people who should not try it? And are there side effects? Who can administer it and what other types of brain stimulation treatments are researchers investigating? Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association

that examines the links between psychological science and everyday life. I'm Kim Mills. We have two guests today. Our first is Dr. Sarah Lysenby, a Psychological, psychiatrist and the director of the non-invasive neuromodulation unit and director of the Division of Translational Research at the National Institutes of Mental Health. Dr. Lisenby's research focuses on brain stimulation interventions for treating depression. She has led pioneering work in areas including transcranial magnetic stimulation, electroconvulsive therapy, and magnetic seizure therapy. Before joining NIMH, she was chair of the Duke University Department of Psychiatry and Behaviorary. Sciences, and founded and directed both the Duke University and Columbia University divisions of brain stimulation. She has published more than 280 scientific papers and received numerous

awards for her research. Our second guest is Diana Danielle, a writer and publicist living in Los Angeles. She recently wrote a column for Newsweek on how TMS therapy helped her heal from treatment-resistant depression and anxiety, and she's writing a memoir that recounts her experiences with chronic migraines, depression, and anxiety. Thank you both for joining me today. Thank you. Thank you for having us. Dr. Listenby, I understand you go by Holly. Is it okay if I call you that? Yes, please do. Great. So could you start us off by giving a brief explanation of how transcranial magnetic stimulation works? What happens during treatment? What's happening in the patient's brain? Certainly. So transcranial magnetic stimulation, or TMS, is a medical

procedure where we deliver magnetic fields to the head using an electromagnetic coil. The coil is held on the head, and it induces a very strong but brief magnetic field, and that magnetic field is turned on and off very rapidly. This rapid change in the magnetic field induces tiny electrical pulses in the brain, and we can focus very precisely where in the brain the electrical stimulation is being applied. And what this allows us to do is stimulate specific regions of the brain in order to treat the circuitry underlying serious conditions like depression. So do we know why it works? Well, we know a lot about what it does. And prevailing theories are that TMS works by targeting distributed networks within the brain that are implicated in depression.

So we learned about networks involved in depression by using neuroimaging tools like magnetic resonance imaging or functional magnetic resonance imaging or MRI, also other imaging tools like positron emission tomography or pet. And what we've learned from the literature about the brain circuits underlying depression using those tools implicated specific regions of the brain, such as the left frontal cortex, So basically on the left front part of the brain, as well as connected regions within the brain, an area of the brain called the limbic circuit, which involves other regions of the brain, that help people modulate their moods and their resilience to stress and things like that.

So by targeting these regions, TMS seems to be able to change the functioning of these circuits. The evidence for that comes from imaging studies where the effibanky, MRI was done before and after treatment for depression using TMS. And these studies do suggest that not only does TMS improve mood and also can alleviate anxiety and treat other conditions like obsessive-compulsive disorder or OCD by modifying the functioning of these circuits. So, Diana, can you tell us your story? How did you come to try TMS therapy?

And what was it like for you? Well, I had been, it had been almost four years that I had been trying to heal myself. And every year that passed with the psych meds and the therapy and without any alleviation, the kind of deeper I got into the hole. And then the deeper you are in the hole, the less able you are to advocate for yourself or to find something else. But I was fortunate because a dear girlfriend, who's also a neighbor, had had PPD post-partum depression, and she'd gone to a psychiatrist in Los Angeles, Dr. Meryl Sparago, and she didn't know what it was called.

She didn't know how it worked, but she said it's non-drug. And I think he can help you. So she persistently called his office because it was closed to patients. And so I was the only, like, non-pregnant woman because his, you know, market is people who are depressed before, after they give birth, and they can't take drugs because of, you know, he's, you know, being pregnant or nursing. And so he uses his TMS machine. So I went in with my husband and he said, I think you're a candidate and I thought, oh, no, it's like another, you know, new antidepressant. And he walked us down the hall, opened the door, explained how it worked. It looked like a dental

chair with like a arm coming out of it. And my insurance covered it. And I did it for six weeks. And it was like a slow, steady getting better. And now I'm like 100. everybody I knows is I'm like 110%. And for me, I go back once a month as like an insurance policy. Like I go once a month to try to keep it going. I don't have any like, you know, there aren't any studies, Holly, about whether that works or not. I'm not sure. But it's worked for me. I got better in 2018. And so now it's been five years. Well, that raises the question. Then, Holly, let me ask you how long do TMS effects last? I mean, do. Does one have to go back for sort of a tune-up like Diana just explained? Well, it is important to be on some form of therapy to prevent the depression from coming back.

And different people do it differently. Studies suggest that like Diana's experience, that continuing to get TMS sessions on a spaced out, you know, a matter, in your case, once a month, for some people, it might be every two weeks or something like that, that can help prevent the depression from coming back. For other people, though, medications may be effective on their own to prevent the depression from coming back. And that is what we studied, a combination of medications as well as kind of a tapering off and maintenance form of the TMS. And this does help to sustain remission over the long term.

Studies have looked at six months, a year, two years, some even longer, finding good maintenance of benefit with these strategies. I think the important point here is if you stop the TMS and go on nothing, no medication, no form of therapy, no continued TMS, then the risk of the depression coming back is pretty high. So it's really important to have a strategy to prevent relapse. Now, what other conditions is TMS approved to treat? I heard you mention obsessive-compulsive disorder a moment ago, Holly. Right.

So obsessive-compulsive disorder are OCD. That is one of the approved indications. for specific type and location of TMS. And it's not just the TMS, but it's combined with a form of exposure therapy. So the two are given in tandem. The exposure therapy activates circuits in the brain that are related to OCD, and then the treatment is applied right away. So it's sort of a synergistic effect.

It's also been found to be helpful in anxiety symptoms in people with depression. We know that anxiety and depression can really go hand in hand. It's also been approved to help people stop smoking. So people who are trying to stop smoking, this has been helpful as well. Now, in terms of other future indications, there are a lot of studies underway looking at TMS for a variety of applications, such as treating pain and other indications, which I could talk more about. but what I've mentioned so far are the main ones that are currently approved today.

And I should point out it's only approved for adults. And that's a big gap because we know that children and adolescents can suffer from depression and anxiety and OCD and really need effective treatment. So that remains an area of active research to see if this can be safe and effective for young people who are experiencing these conditions. Diana, let me ask you, have you experienced any side effect? I understand that some people get headaches afterwards. Have you had anything like that? You can get a light headache.

I never have, but I'm pretty tough on headaches. Before I, you know, kind of slipped down the slope of depression and anxiety, I had suffered for five long years with chronic migraine. And a comorbidity of that is depression. So I was cured from the chronic migraine. I haven't had a migraine since 2014. I haven't had anything. So, Holly, how difficult is TMS to access?

Is it available in most areas? I mean, I understand that the machines are quite expensive. Do many psychiatrists have them? I would say that the access has been increasing over the years. Remember, this was approved by the FDA in 2008. So it's been around for quite a while. It's not like it's, you know, that new. And so access has been expanding.

And, you know, there's some regions of the country where access might be more than others, but I think it's really growing. There are organizations that represent TMS providers, and you can go to their website to find whether there's a provider near you in whatever state that you're living. And that map has really been growing over time. So I would say that it is increasing. But we have a far way to go, though, I have to say, to really meet the mental health needs of our nation, not only with respect to access to TMS, but also equitable access across different demographic groups, across people with different types of insurance or those who are on Medicare or Medicaid or maybe uninsured. So we do have challenges, but it has been improving over time. Does insurance typically cover it? I mean, if it's prescribed to you by a psychiatrist,

will your insurance company fight it? Well, I can answer that, and maybe Dana would want to give her personal experience, but I could say that one of the things that the payers look for is, is this an improved indication? And they look for whether it's medically justified. And that evaluation can be on a case-by-case basis, but generally speaking, they would want to see that you have tried other treatments, other medication treatments, and that they weren't effective before then moving on to TMS.

But I defer to Diana because she has personal experience with this. Yes. And we didn't have any problem getting our insurance to cover it because I had almost four years of taking like everything under the sun, anti-psychotics, anti-anxiety, different, like the now antidepressant, the SSRI. So, yeah, so I wish that I would have found out that I would have found out that I were. was treatment resistant like I still could have had it after two years of depression. But I didn't even know that term until after I was suicidal and I ended up in the psych ward at UCLA Neuropsychiatric

hospital. And my physicians there pronounced me treatment resistant. And they, my husband came in. We had our talk and they urgently recommended electroconvulsive therapy. And I did my first two treatments while still an inpatient. But sadly, it didn't help me. So I then went to my psychiatrist because the TMS did help me. And I had a great psychiatrist. I'm very loyal. She had really supported me. But my friend said, you have to see Dr. Sprague. So I felt guilty, but I went to see him. And then I asked her, she helped me with so many other things, occupational therapy, the UCLA outpatient. Why did you tell me about it? it. So Holly, she so smart, but didn't realize, she said ECT is more effective. So then the statistics

were TMS. So I didn't tell you about TMS. I do know about it because if ECT didn't work, TMS never would. So I went back to Dr. Sprague and he said they're like apples and oranges. They're working in different functions, different parts of the brain seizing it versus like tapping on it. And so I feel like it would be great if more doctors knew that. because what if there are other psychiatrists who think that if I did ECT, TMS wouldn't work? Is that true, Holly? So I'm happy to respond to that. I think that your experience, Dana, is very important to help us understand how we need to match the right treatment for each individual person and not just think about, you know, groups of people.

Now, the literature does show that for a group of people, the ECT, tends to have a higher response rate than TMS. But that doesn't mean that's going to be true for every single person. And in your case, it wasn't true. The TMS was effective, whereas the ECT wasn't. So I think that this is a challenge in our field. It would be so helpful if we had a test, some sort of tool that we could use to figure out which treatment is going to work for you, Diana, and to be able to give that to you before you have had to suffer for years. with depression that was not remitting. And to have such severe impacts on your life, it can be life-threatening, as you mentioned,

it's a challenge in the research field to develop those tools so that we can bring the right treatment to the right person at the right time. That is a limitation. But we are supporting research to try to address that. Amen. Now, electroconvulsive therapy has a, a bit of, shall I say, a poor public image. A lot of us are old enough to have seen one flew over the cuckoo's nest, and that's our image of what happens to people who get ECT. I want to ask you, Holly, is that accurate, fair? What is ECT like these days? And is it more effective than we have been led to believe? I mean, a lot of people have talked about losing their memory, for example, after going through ECT. So I'm happy to respond to that.

And also, Dana, you have lived experience with having ECT. So we want to hear your voice on that, too. I can tell you that from my perspective as a psychiatrist, having given ECT and had patients before, during, and after, and based on the literature, ECT is highly effective, especially in situations where medications aren't working. often when TMS doesn't work, and when a person is in need of very rapid response, such as they may be having thoughts of wanting to in their life and be at risk for suicide. Also in individuals who have psychotic subtype of depression where they may be hearing voices or having delusions is a very dangerous form of depression.

Now, in terms of the public image, which has been shaped by fictional portrayals like cuckoo's nest, which is, which was fiction. modern ECT bears no resemblance to that. First of all, it's done under anesthesia. You're asleep for the procedure. There's no pain during the procedure. You're unconscious. You are being monitored by doctors under general anesthesia. The treatment lasts less than a couple of minutes.

And it is true that there are side effects from ECT, memory loss being a very important one. But with modern ECT, we've modified the treatment in terms of where the electronic are placed on the head and how much electricity is given. And these modifications have dramatically reduced, although not yet eliminated, the risk of memory loss with ECT. I am also a family member of a person whose life was saved by ECT. So I'm a believer in this, both as a family member and as a physician. But I'm really interested to hear your story, Deanna, because you personally experienced this? Yes. And at the time, it's since I've done this, I looked up ECT. There's a great book by,

she's now past Carrie Fisher, wrote a book about how ECT, it was like, TMS is to me as ECT was to her, like a lifesaver. And also on, I was just watching with my husband during the pandemic in the show Homeland with Claire Daines. She has bipolar in the show and it's part of the storyline. She under, show her undergoing ECT and then they put that thing in your mouth so you don't bite your tongue off. And I was like getting like PTSD because when I was laying there about to be put under, I can't see myself. I saw myself as the doctor saw me. And it still was a little scary for me. And so I had heard of a woman who forgot her wedding day. So I went in and I knew there was a chance of losing memory. What happened for me is,

I did it for about two months once a week. And by the seventh and eighth time that I did it, I was waking up and I didn't know. I knew I was in the hospital. I didn't know my name. I had this feeling of this crawling thing about where I am. I was very, very, very confused. It was creepy.

And in addition, it wasn't really helping me. And so I told my husband, I'm quitting. This is not the thing for me. So, Holly, are there individuals who would be poor candidates, let's say, for TMS? So we think about who is TMS likely to benefit and who is TMS likely to have more side effects with. So let me start with who is likely to benefit. So the labeled indications such as depression, anxiety, OCD, after a person has tried at least several medications. those would be good candidates. I think the concern of side effects, people who would be

vulnerable to significant side effects, would be people who have epilepsy. So the most serious known side effect of TMS is seizure. So if a person has a seizure disorder like epilepsy, or if a person has a risk for seizure because they have a brain tumor or other brain lesion that might be, for example, from multiple sclerosis or MS, or maybe someone who's had a stroke, these things cause brain lesions that could put that person at more risk of seizure with TMS. And so when we evaluate people, we look at what's the lot of likelihood of benefit? And then we screen them for risk factors that might increase their chance of having an adverse side effect from TMS. Now, is everybody's brain the same?

Because when you're putting the magnets on people's heads, how do you know that? that you're in exactly the right spot for the right person. And you mentioned, Holly, I think going on the left side of the brain, is it different for left-handed people versus right-handed people? That's such a great question. And everyone's brain is different. And in fact, everyone's brain is different. Even your own brain over time changes, right?

And so in the early days of TMS, we did not have great tools to personalize where the TMS was being placed. Our tool was literally a tape measure. We would find the area of the brain that would cause a twitch in the hand, so that's the hand area. And then we would use a tape measure and measure five or six centimeters in front of that. We called that the prefrontal cortex or sweet spot. Now we have better tools.

And in fact, there's a new protocol called the Saint Protocol, which is for Stanford Accelerated TMS. And what that does is you get a brain scan. So each person gets their brain scanned, use. functional magnetic resonance imaging. And that brain scan is used to determine the right spot for that person in the prefrontal cortex that taps into the network of distributed brain areas that we think are important for depression.

And that approach may be more effective to tailor the treatment for each individual person. Were there any issues for you, Diana, when you first started? Like, did they land on the right spot? He had my sweet spot. Yeah, I mean, it wasn't the one, the saint. I have been in touch with Dr. Nolan Williams, who was the head at the brain stimulation lab at Stanford, who did that. And he was very really wanted to tell me that they didn't even take like easy people for that study. They took treatment resistant people, you know, because sometimes when there are studies, you want to get like a good, healthy people that could be helped.

but they were doing people that were really hard. So I think that's very exciting. And also, Holly, because people, like I was privileged, my husband worked. I wasn't working. And I had child care. So I was able to do six weeks. Now, six weeks for people who work is almost impossible unless they took disability. And people who work and need child care and couldn't afford the, you know what I mean?

So there's like barriers for certain people. now that they can do it in five days, one of the men that was in the press article, he was an engineer who'd been depressed for years. And then he was able to get a week off work. He did the five days with them. And he said, you know, before I got here, I'd rather stick my needle in my eye than go to work. And now I can't wait to go and tell everyone how I feel. So that was really great.

And I think that this making it more accessible to people, like you were talking about accessibility on all these different levels, but this is another problem with the protocol. If we can shrink it like that, you know, and then the people that got the patent, they're trying to get it into psych wards and emergency rooms for acute suicidality. Let me ask you a question, Holly, about more invasive brain stimulation treatments, because I understand that there are some that involve implanting electrodes in the brain. What's the state of that research? Yes, you're referring to deep brain stimulation or DBS.

And I actually have been part of some of those trials that examined DBS for depression. And also we're now funding new studies on this. So the procedure involves implanting small electrodes into deep regions of the brain. So this is a surgery. It's a brain surgery. So that's why it's called invasive. It does have the risks of brain surgery, which include the risk of bleeding or infection. But we actually have a lot of experience doing deep brain stimulation in other conditions in a safe and effective matter,

such as for Parkinson's disease and certain movement disorders, where DBS is FDA approved and really has transformed the care for people with Parkinson's disease, which is a very important and can be disabling disorder. DBS really has been able to restore function and quality of life for people with Parkinson's disease. So there's a great hope that as we learn more about the circuitry underlying depression, that DBS could be adapted to other conditions like depression and obsessive-compulsive disorder. In fact, OCD, there is a type of FDA approval already for the DBS. treatment of OCD, and it's called a humanitarian device exemption or HDE. It means OCD is a rare

condition, and this humanitarian device exemption allows the FDA to approve a treatment for these rare conditions. Now, the state of research on DBS for depression, unfortunately, there have been two major industry-sponsored trials on DBS for depression that did not succeed in findings. it effective and I was part of one of those trials. But that's not the end of the story. We've learned a lot about how to make the treatment more individualized, how to find the right spot for each person, just like we were talking about finding the right spot for TMS. The same really goes also for DBS. And also exciting research recently has been using implanted electrodes to discover the temporal pattern of brain activity changes over time that can be used.

to trigger the stimulation so that the stimulation is being given when and where it's needed for each person. Now, these studies I'm referring to are being supported by the National Institute of Health Brain Initiative, which was a White House sponsored initiative to really transform the way we study and treat brain disorders like depression and OCD. And we're really looking forward to the results of the studies that are currently underway with these more advanced approaches to tuning brain circuits. And we will see the results of those studies in the coming years. You know how I asked you, Holly, about TMS versus ECT. What are the ways, like if you're going to treat depression, like if TMS didn't work for me, would then I be ruled out of the deep brain stimulation,

the DBS, or it's all different and you can try everything? Yeah, well, that's a great question. So each study has different inclusion, exclusion criteria, but I can say the study I was part of, and typically you would want to see that the person has tried less invasive approaches first. And those less invasive approaches certainly could include TMS, medications, even ECT, before you go to a study where you're getting a surgery and implanted electrodes. So most of the people that we enrolled in those studies had already had. ECT, many of them had already had TMS and did not rule them out. But again, the criteria for each specific study are, you know, individual. Oh, I'm so glad you're doing that because that means

they've had it even longer, if they've already gone through all those gates, because nobody offers you, you know, ECT or TMS. You have to be on the drugs for a long time. And sometimes you could have already been held, but you didn't even know it was there, like the awareness of it is not as high as would be beneficial for people. Let me switch gears a little bit to some reports about people buying in-home brain stimulation devices, especially something that's called a transcranial direct current stimulation or TDCS. Holly, do these work?

I mean, do they treat depression? Some people think that they may improve focus and concentration, but is there any research to back that up? So we are now talking about a different type of technology that applies electrical currents to the scalp, not to induce a seizure, but very weak electrical currents to change brain activity. So whereas TMS applies magnetic fields to induce tiny electrical currents in the brain, technologies like transcranial direct current stimulation or TDCS apply electricity directly to the scalp to induce these weak currents or to change.

change polarization of the brain. So I've been part of studies and published on this TDCS for the treatment of depression. There have been some promising studies suggesting that it could have benefit in depression. It certainly has a very excellent safety profile. For one thing compared to TMS, TDCS does not have a risk of inducing seizure or memory loss like ECT. But I can tell you that at least the study I was part of, unfortunately we did not find, We did not replicate the evidence that TDCS was effective in treating depression. So I would say the literature is mixed on this point, but just like the other technologies we've

been talking about, our knowledge of where to place the TDCS electrodes, how to configure them, in whom would they likely to be beneficial, is evolving. And it remains an active area of research. So I would say one of the advantages of TDCS type of technologies, because they're so safe, is that they could be used at home. Whereas you wouldn't be doing that with TMS, because you need to be in a context with medical supervision. But TDCS is a technology that's more portable.

It's very cheap. So when you think about the global mental health needs of not just our nation, but low-and-middle-income countries, technologies like TDCS could really have an impact. if we can figure out how to use them effectively. And that is, it's not yet FDA approved and it continues to be an active area of research. I do know that there are companies that sell similar technologies as lifestyle products, but not with medical claims.

It's popular in the gaming community as a way of increasing focus or attention, like you mentioned. But if a person has depression, that's a significant medical illness. they really should see a doctor, see a therapist, see a clinician to evaluate them and then to have a treatment plan that is clinically appropriate. Well, that makes sense. So what's next on the research horizon? Holly, what else are you working on and what else might TMS be able to treat at some point? So one of the things that we've learned about TMS is that the effect of TMS on the brain

depends on what the brain is doing at the time you're being stimulated. So, for example, if you think about moving your hand, when we stimulate the hand air of your brain, we get a larger response in your hand. So we're generalizing that concept to try to combine psychotherapy with TMS. The way this works is we administer a form of cognitive behavioral therapy while the person is getting TMS.

We target this based on functional MRI to try to target networks of brain areas that are involved in the particular types of cognitive functions that the therapy is tapping into. And so this, we're looking for a synergistic effect and really a merger between psychotherapeutic approaches and brain stimulation approaches. You could think of it as using the TMS to boost learning, to boost plasticity of the brain, that then the therapy can take advantage of. So that's one direction, and we're actively enrolling in a study with this combination.

We're also trying to re-engineer ECT to make it safer. And we have a number of ways of doing that. You mentioned one using magnetic stimulation to induce more focal and targeted seizures without as much electricity as we get in the brain with ECT. We have some other electrical approaches to doing that as well. Individualized low-amplitude seizure therapy is one where we give weak electrical currents to stimulate more localized seizures. And we have a study that is just giving electrical fields without inducing a seizure.

What we want to understand with the suite of studies is, is it the electricity or is it the seizure or both that drives the powerful clinical effects of ECT? Because by better understanding how that treatment works, we'll be better prepared to re-engineer an intervention that focuses on the benefits and avoids the side effects. So, Diana, you get the last word with us today. You definitely are sort of a walking example of how TMS can benefit people's lives. What are the prospects for you, since you're continuing to get it at least once a month? Do you feel like this is how you're going to live out your life? Yes, Kim, that is how I'm going to live out my life. That's one. Second, I must say, my daughter is 15. And when she was 13, when we were in lockdown, a friend in her friend, it wasn't her best friend, but it was her friend in the friend group. Her boyfriend broke up with her. She had a difficult home life. And she was threatening suicide. My daughter came downstairs, wild-eyed and teary, pulling at my arm. I need you. They won't talk to me on the suicide hotline because I'm under 18. So one of the biggest things I want to do with my book, besides what everybody know about TMS

and how it worked for me, is to try to get TMS covered for the under 18s. For kids, because of the teen mental health crisis, you know, we keep hearing about, which is so true and which I've experienced, because, you know, most of them, except Prozac, have a black box warning. And so they don't even, you know, there's not a lot of options for kids. And I have run across TMS places in the United States. They will do it for someone under 18, but it is not covered by insurance because it's not FDA approved. And so what I would like most in life is to have the FDA approve it for under 18.

I had to put that in. Just, I know I said that was the last question, but Holly, how close are we to FDA approval for kids under 18? So there was an industry-sponsored trial to try to support FDA approval of TMS and the treatment of adolescent depression. Unfortunately, that trial was not successful in demonstrating the level of efficacy that the FDA needs to see. It did show that it was safe. That's really important. But I think what this teaches us is that just back to everyone's brain is different, the brain changes over the course of development. And using an adult dose of TMS on an adolescent may not be the right strategy.

And so I think there's a need for research on adolescent depression to really understand what is driving depression in the youth so that we can tailor the treatment to their needs rather than giving them the adult dose, which we've already seen is not effective. And that is an active area of research. So I really do encourage the researchers out there to pay attention to this area, to submit grants on this topic, and to really invest in understanding the causes of depression and suicide in youth. It's so critically important. And, Dana, you said it very well. I agree with you. Well, I want to thank you both for joining me today. This has been really interesting, and I appreciate both of your contributions to the this fascinating discussion today. Thank you. Thank you. Thank you so much. Great meeting you.

You can find previous episodes of Speaking of Psychology on our website at speakingof psychology.org or on Apple, Stitcher, YouTube, or wherever you get your podcasts. If you have comments or ideas for future podcasts, you can email us at speaking of psychology at APA.org. Speaking of psychology is produced by Lee Weinerman. Our sound editor is Chris Condyenne. Thank you for listening for the American Psychological Association. I'm Kim Mills.