Myths and Mental Illness: Week 4

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The following guest article from Swedish Health Services/Providence Health & Services is the fourth in a series debunking myths about mental illness that will be featured here on the SeattleNTC blog.

Myth #4: Children are too young to develop mental illness


From inconsolable preschoolers to moody teenagers, how do you know if it’s just a phase or a symptom of mental illness?

“The difficult thing for parents is identifying what is a normal part of growing up, and what needs intervention,” said Dr. Joyce Gilbert, medical director of the Sexual Assault Clinic and Child Maltreatment Center at Providence St. Peter Hospital in Olympia, Wash.

A phase is something that is developmental or temporary, and comes and goes. On the other hand, mental illness is something that does not dissipate. If a child is not overcoming a “phase” then parents, teachers, physicians and others should ask why and engage with resources early to ensure the child gets the help needed.

Mental illness can happen to anyone at any age, and in fact, one in five children suffers with mental health conditions such as anxiety, difficulty focusing and social challenges. Half of all lifetime mental illnesses begin by age 14; brushing off issues as a phase kids and teens will eventually grow out of can lead to other problems later in life.

Early intervention is key
“Most of the time, the first signs of mental health issues occur in preschool or kindergarten, when children are surrounded by other children,” said Felisha White, RN, Psychiatric Center for Children and Adolescents at Providence Sacred Heart Medical Center in Spokane, Wash. “At that point, it becomes clear to their teachers and their parents that they aren’t behaving like their peers.”

For older children, White suggests watching for sudden behavioral changes, such as angry outbursts, declining grades, isolation from friends, or disruptions in normal sleeping, eating and hygiene habits.

 

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Sources: National Alliance for Mental Illness; National Institute for Mental Health

Myths and Mental Illness: Week 3

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The following guest article from Swedish Health Services/Providence Health & Services is the third in a series debunking myths about mental illness that will be featured here on the SeattleNTC blog.

Myth #3: Mental illness often leads to violent and dangerous behavior


When news of a shocking incident such as a mass shooting first reaches us on TV, it’s likely that we’ll hear the words “mental illness” as the media speculates why it happened. But less than five percent of violence in the United States is caused by people with mental illnesses. The truth is, a mentally ill person is more likely to be a victim of violence — at four times the rate of the general public.

“The majority of individuals living with mental illness have productive relationships and are described by others as loving and caring people,” said Tamara Sheehan, director of psychiatry, Providence Sacred Heart Medical Center & Children’s Hospital, in Spokane, Wash.

About one in five adults in America experiences a mental illness. When people in this group are involved with violence, severe conditions such as untreated psychosis or co-occurring drug or alcohol abuse are typically contributing factors.

 

Sources: Mental Health Myths and Facts; National Alliance on Mental Illness.

Myths and Mental Illness: Week 2

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The following guest article from Swedish Health Services/Providence Health & Services is the second in a series debunking myths about mental illness that will be featured here on the SeattleNTC blog.

Myth #2: You can just “snap out of it”


We wouldn’t expect a person with a broken leg or diabetes to just” snap out of it,” and in the same way we shouldn’t expect a person to think their way out of a mental illness.

“This misunderstanding is harmful because it creates unreasonable expectations and unnecessary suffering for people who have mental illness,” said Robin Henderson, PsyD, chief executive of behavioral health for Providence Medical Group in Oregon.

Many complex factors can contribute to mental illness, including genetics, hormonal changes during pregnancy, chronic physical illness and even traumatic experiences.

“We need to realize that as humans, our mind and body are connected by more than our neck,” Dr. Henderson said.

When to get help

Everyone experiences difficult times in life, and sadness can be a normal reaction, but it usually lessens with a little time or is manageable.

“When the feelings persist to the point that your quality of life and daily functioning are affected, you should reach out for help from a professional,” Dr. Henderson said. “Depression is a real illness, and we know that many people who get treatment, get better.”

About 16 million Americans have depression. If you have been experiencing any of the following symptoms for more than two weeks, you may be suffering from depression and should contact your primary care provider:

·       Changes in sleep or appetite
·       Difficulty concentrating
·       Loss of interest in hobbies and activities
·       Decreased energy
·       Low self-esteem
·       Feelings of hopelessness
·       Physical aches and pains

Sources: National Institute for Mental Health; National Alliance for Mental Illness.

Myths and Mental Illness: Week 1

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The following guest article from Swedish Health Services/Providence Health & Services is the first in a series debunking myths about mental illness that will be featured here on the SeattleNTC blog. 

Myth #1: Mental illness only affects certain types of people

Each year, almost 1 in 5 Americans experience mental illness, according to the National Alliance on Mental Illness. More than half won’t be treated due to stigma, lack of access to services or lack of knowledge about help that is available.

As part of our commitment to improving the lives of people with mental illness, we’re launching a series of articles to debunk the myths surrounding these life-threatening conditions. We hope you find them helpful to someone you care about. —Amy Compton-Phillips, M.D., executive vice president and chief clinical officer


Mental illness is a reality for millions of Americans of all ages, races and cultural backgrounds. Like physical illness, mental illness is a medical condition.

“It doesn’t matter what you look like or where you are from, mental illness can affect anyone,” said Arpan Waghray, M.D., medical director of behavioral health at Swedish Health Services. In fact, 50 percent of Americans will have a mental illness at some point in their lives—ranging from a short-term bout of the blues, to depression or anxiety.

As common as mental illness is, it can be easily swept under the rug due to many persistent myths that make it hard to reach out for help.

“Research shows us that negative perceptions can hold people back from seeking treatment and sometimes even prevent them from revealing issues to their doctors,” Dr. Waghray said. “These findings stress the importance of educating the public on how to support people who have a mental illness, and also the need to remove barriers to treatment.”

Sources: National Alliance for Mental Illness; Centers for Disease Control; American Psychological Association

When Symptoms Return

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By Joshua Bess, M.D.

Patients who have been treated for depression with Transcranial Magnetic Stimulation (TMS) or Electroconvulsive Therapy (ECT) can sometimes go the rest of their lives without needing to undergo additional TMS or ECT treatment. But these patients are the exception, not the rule.

Most patients who have undergone acute treatment with TMS or ECT will experience a return of symptoms at some point. It may be a year after treatment, or it may be longer. Each person is different. But relapse at some point is more likely than not.

Therefore, it’s important for all patients who undergo TMS or ECT to realize going into it that although the treatment is likely to help them significantly, it is probably not a lifelong cure, and they and their care team need to be prepared for the possibility of relapse.

At SeattleNTC, we want to have frank conversations with our patients about the potential for symptoms to return. If we can talk openly about this possibility, we will be better prepared to address symptoms if and when they return. We may even be able to prevent relapse.

Following acute treatment, we have two options. One is to take a “watch and wait” approach, which is not the same as doing nothing. Rather, we continue to communicate with patients about how they are doing and to consult with their general psychiatrist or therapist. If symptoms come back or get worse again, we encourage patients to come and talk to us so that we can decide, together, whether to reinitiate treatment.

A second option is to continue treatment, even before symptoms start to return, as a means of preventing relapse. This is similar to staying on medication even after symptoms subside. In the case of “maintenance” TMS and ECT, treatments are less frequent than during the acute course, but the protocol for each treatment is the same one that helped the patient get better.

We stress with our patients that even if they are feeling better it’s essential to continue seeing members of their care team so that if there are any signs that symptoms may return we can intervene immediately – and, hopefully, well before symptoms become so bad the patient is in crisis.

Remember that depression is somewhat like cancer in that people who have recovered from cancer can be “in remission” for years, but you can never say with 100 percent that the cancer is gone. It’s the same with treating depression. There are people who are in remission for years but usually that is because they continue to undergo active monitoring or treatment.

So to our patients, we say: please don’t ignore any signs of distress that indicate you may be relapsing. The earlier we can intervene with treatment, the sooner you’ll be feeling better again.

 

TMS for Depression during Pregnancy and Postpartum

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By Suzanne Kerns, M.D.

Women who suffer from depression during pregnancy or in the postpartum period might not seek treatment if they assume medication is the only treatment option available to them. Although concerns about taking medication while pregnant or breastfeeding are understandable, untreated depression can also be very dangerous.

Women who want to avoid or limit the use of antidepressants may consider Transcranial Magnetic Stimulation (TMS) as a safe and effective treatment option. Approved by the FDA in 2008 for treating depression, TMS works by delivering electromagnetic pulses to specific areas of the brain that regulate mood.

A standard treatment course is five sessions a week for four-to-six weeks. Each session lasts about one hour. Patients remain awake and alert during the treatment, and there are minimal side effects.

Several research findings have shown that TMS is a safe and viable treatment for women who are pregnant or postpartum.

  • A University of Pennsylvania study of TMS and pregnancy found that among 10 pregnant women treated with TMS, 70 percent responded well within just 20 sessions, with no adverse effects on pregnancy or fetal outcomes. The only side effect was a mild headache in four of the patients.[1]
  • Another study that focused on TMS during postpartum found that eight of the nine women who were treated with TMS experienced complete remission of their depression.[2]

In addition to being safe and effective for patients, TMS has not been shown to have adverse effects on a fetus or nursing child. A recently published study looking at 26 children ages one to five years old, whose mothers had received TMS treatment during pregnancy, found there were no differences between the children born to women who had TMS during pregnancy and children born to women who did not undergo TMS.[3]

TMS’s safety and effectiveness make it an ideal option for women with a history of non-response to standard antidepressant medications that are deemed safe in pregnancy or for women who don’t want to take medication during pregnancy or while breastfeeding. Unlike antidepressant medication, TMS does not enter the bloodstream, and therefore does not have any known or foreseeable effects on a fetus or nursing child.

[1] Kim, DR, Epperson, N, Paré, E, Gonzalez, JM, Parry, S, Thase, ME, Cristancho, P, Sammel, MD, O’Reardon, JP. (2011) An open label pilot study of transcranial magnetic stimulation for pregnant women with major depressive disorder. Journal of Women’s Health 20(2): 255-261.

[2] Garcia, KS, Flynn, P, Pierce, KJ, Candle, M. (2010) Repetitive transcranial magnetic stimulation treats postpartum depression. Journal of Brain Stimulation 3(1): 36-41.

[3] Eryılmaz, G, Sayar, GH, Özten, E, Gül, IG, Yorbik, O, Işiten, N, Bağci, E. (2015) Follow-Up Study of Children Whose Mothers Were Treated With Transcranial Magnetic Stimulation During Pregnancy: Preliminary Results. Journal of Neuromodulation 18(4): 255-60.

 

TMS versus ECT

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By Joshua Bess, M.D.

The first line of treatment for patients suffering from anxiety and depression is typically antidepressant medication and psychotherapy. If these treatments have not been as effective as hoped, it may be time to consider brain stimulation therapy.

There are two kinds of brain stimulation technologies that are FDA-approved for depression. One is Transcranial Magnetic Stimulation (TMS) and the other is Electroconvulsive Therapy (ECT). TMS and ECT are safe and effective treatment options for adults who have tried medication and psychotherapy for anxiety or depression without seeing good results.

Both TMS and ECT work by stimulating specific areas of the brain that regulate mood. In most cases, it makes sense to try TMS first because TMS can improve brain function without cognitive side effects and does not require anesthesia.

TMS involves placing an insulated coil over the scalp to deliver electromagnetic pulses to specific areas of the brain that impact depression. Patients remain awake throughout the treatment, which is non-invasive. The most common side effects are slight discomfort at the site where the coil sits on the scalp during treatment and a mild headache afterward. Patients can resume their usual daily activities, including driving, immediately after a treatment.

Studies have shown that TMS is highly effective for treating medication-resistant depression, with response rates between 40 and 60 percent and remission rates between 35 and 40 percent. While some patients see results in just two weeks, an average treatment course is four to six weeks.

TMS is almost always the first choice for brain stimulation treatment. If a patient is suffering from severe depression and is perhaps even suicidal, ECT may be an appropriate treatment option. ECT is also considered when a patient does not respond to TMS. ECT involves passing electrical pulses through a person’s brain to produce intense brain activity during a brief period of time.

Between 80 and 90 percent of our patients who undergo ECT treatment see improvement. We typically see positive clinical response and substantial reduction in suicidal thoughts among our patients within one to three weeks.

Most of our patients tolerate ECT remarkably well. Immediate side effects can include nausea, headache, jaw pain, muscle ache and muscle soreness, as well as confusion. Patients may also experience memory loss, although memory problems from ECT usually resolve within a couple of months after completing treatment.

Both TMS and ECT can be used in combination with medication and psychotherapy. Many patients have better results when brain stimulation is used to augment existing therapies.

SeattleNTC is the only medical group in the Seattle area that offers both TMS and ECT. We work closely with patients and their referring providers to determine the most appropriate course of treatment.

Repetitive Transcranial Magnetic Stimulation: Potential in the Treatment of Alzheimer’s disease and Dementia

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by Jennifer Bolton and Serena Smith, TMS Clinicians at SeattleNTC

Alzheimer’s disease is the most common cause of dementia, a general term for the deterioration of brain function. At age 60, the risk of developing Alzheimer’s disease is 1 in every 100 people; this risk increases to 30-50 in every 100 people by the age 85.[1] Alzheimer’s disease is characterized by the loss of memory, language, and judgment that noticeably interferes with occupational and social functioning. There is no known cure for Alzheimer’s disease, however therapies do exist to combat symptoms. Though the exact mechanism is unknown, one such potential therapeutic aid for Alzheimer’s disease and dementia is repetitive transcranial magnetic stimulation (rTMS), a noninvasive form of brain stimulation, administered over the dorsolateral prefrontal cortex (DLPFC). Circuits connecting the DLPFC to deeper areas of the brain, including the basal ganglia, have been shown through imaging studies to be important in many cognitive functions. Stimulating the DLPFC may reinforce these circuits, thereby improving their function.

In a study by Ahmed et al 45 patients diagnosed with Alzheimer’s disease were randomly assigned to receive three different rTMS treatments: bilateral high frequency rTMS (20 Hz), bilateral low frequency rTMS (1 Hz), and bilateral sham rTMS (simulation of rTMS without stimulating the brain). [2] rTMS was administered bilaterally over the DLPFC, and all patients received daily rTMS sessions for five days. The subjects were evaluated in terms of stages of dementia, activity levels, and depressive symptoms. Patients receiving bilateral high frequency rTMS tended to improve more than those in the other treatment groups across all rating scales. A statistically significant difference was found between the outcomes of the patients receiving high frequency rTMS and those patients in the sham and low frequency groups.

Additional analyses were performed after splitting subjects into two sub-groups based on the severity of dementia: mild/moderate dementia and severe dementia. Out of all of the patients receiving high frequency treatment the mild/moderate group significantly improved, whereas those in the severe group did not. Out of all patients receiving low frequency rTMS (1 Hz), there was significant improvement in daily activity scores in the mild/moderate group only. In this same group, there was no significant change in either dementia or depressive symptoms. The group of patients receiving sham treatment for Alzheimer’s disease did not significantly improve in any of the three categories.

This study supports that multiple bilateral high frequency (20 Hz) rTMS treatments administered over bilateral DLPFC of patients with mild/moderate dementia can lessen the severity of dementia and depression as well as improve activity levels. Although additional studies should be conducted to provide more evidence for this treatment, the data presented above indicates that rTMS may hold potential for the treatment of the early stages of Alzheimer’s disease.


 

[1] Burns A, Jacoby R, Levy R (1991) Neurological signs in Alzheimer’s disease. Aging 20:45–51.

[2] Ahmed MA, Darwish ES, Khedr EM, El serogy YM, Ali AM. (2012) Effects of Low versus high frequency of repetitive transcranial magnetic stimulation on cognitive function and cortical excitability in Alzheimer’s dementia. J Neurol 259:83-92.

Repetitive Transcranial Magnetic Stimulation: A Tool for Long-Term Smoking Cessation

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by Jennifer Bolton and Serena Smith, TMS Clinicians at SeattleNTC

Tobacco use is the leading cause of preventable death in developed countries[1]. Despite smokers frequently identifying tobacco use as harmful and expressing a desire to reduce or stop smoking, most smokers have difficulty abstaining. Eighty-five percent of those who attempt to quit smoking without assistance relapse, with the majority resuming use within one week of quitting. Numerous aids have been helpful in increasing immediate abstinence rates, but the long-term outcomes are still disappointing.  After 6 months, common aids, such as nicotine gum and bupropion (a prescription medication) result in abstinence rates of only 19% and 24% respectively. [2]

The addictive properties of tobacco are caused primarily by the action of nicotine on the central nervous system. Initially, nicotine increases the release of dopamine a neurotransmitter or chemical messenger, in the reward centers of the brain. However, prolonged exposure to even low concentrations of nicotine can cause the desensitization of dopamine neurons, making them harder to activate[3]. Decreased activity in the reward-related brain circuits is correlated with higher levels of craving and relapse.

One tool being studied to treat smoking addiction is repetitive transcranial magnetic stimulation (rTMS), a safe and noninvasive method of brain stimulation that uses magnetic pulses to produce changes in brain activity. rTMS can trigger dopamine release and generate lasting changes in neural excitability.  It has been hypothesized that by increasing the activity of the neural circuits involved in nicotine addition, rTMS may help people stop smoking cigarettes

There are two basic forms of rTMS, conventional and deep.  Conventional rTMS, which stimulates relatively superficial layers of the brain, has been shown to reduce cigarette consumption and cravings, at least temporarily, by a decade of research. Amiaz et al. discovered that rTMS administered daily for 10 days to the left dorsolateral prefrontal cortex (DLPFC), a region of the brain with strong connections to reward circuitry reduced the consumption of cigarettes, dependence on nicotine, and the craving provoked by smoking cues.[4] However, these effects tended to fade quickly.

In contrast, a recent study by Dinur-Klein et al. suggests that targeting deeper targets, such as the insular cortices, may offer improved, long-term outcomes. In an attempt to find a more durable treatment, Dinur-Klein et al. used a deep rTMS H-coil to target both the right and left dorsolateral prefrontal cortices as well as the insulae—deep brain structures that have been implicated in craving by neuroimaging studies.[5]

In Dinur-Klein et al.’s study of deep TMS for smoking cessation, adults were recruited who smoked at least 20 cigarettes a day and had previously failed cessation with other treatments. Participants were randomly placed into 6 experimental groups with variations in rTMS frequency (high frequency, low frequency, sham, or simulated stimulation), and differences in smoking cues (with cues and without cues before each treatment).  Each group received a total of 13 daily TMS treatment sessions and had cigarette consumption monitored by self-reports and analysis of urine samples for levels of cotinine, a metabolite that appears in urine after nicotine has been consumed.

In the low frequency rTMS and the sham groups only 9% of participants abstained from smoking at the end of the 13 treatments and none remained abstinent 6 months later.  However, the groups receiving high frequency rTMS showed a significant reduction in cigarette consumption and nicotine dependence. Specifically, the group receiving high frequency rTMS after being shown a smoking cue exhibited the greatest response with a 44% abstinence rate at the end of the 13 treatments and a 33% abstinence rate at a 6 month follow up. Thus, being shown a smoking cue followed by high frequency rTMS more than quadrupled the likelihood of abstinence after the 13 treatments and helped subjects maintain long-term abstinence.

In conclusion, deep TMS has promise as a safe, effective, and durable treatment for cigarette addiction.  However, these findings are very preliminary, and additional research is necessary prior to the routine clinical application of rTMS for this indication.  


 

[1] World Health Organization (2013): WHO report on the global tobacco epidemic. Geneva: World Health Organization

[2] Agency for Healthcare Research and Quality (2008): National Guideline C Treating tobacco use and dependence: 2008 update. Rockville MD: AHRQ. Page 109.

[3] Pidoplichko V, DeBiasi M, Williams J, Dani J (1997): Nicotine activates and desensitizes midbrain dopamine neurons. Nature V 390: 401-404.

[4] Amiaz R, Levy D, Vainiger D, Grunhaus L, Zangen A (2009): Repeated high-frequency transcranial magnetic stimulation over the dorsolateral prefrontal cortex reduces cigarette craving and consumption. Addiction 104:653-660.

[5] Dinur-Klein L, Dannon P, Hadar A, Rosenberg O, Roth Y, Kotler M, Zangen A (2014): Smoking cessation induced by deep repetitive transcranial magnetic stimulation of the prefrontal and insular cortices: A prospective, randomized controlled trial. Biol Psychiatry 76:742-49.