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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.

 

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.

Repetitive Transcranial Magnetic Stimulation and Associative Memory Enhancement

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by Jennifer Bolton and Serena Smith, TMS Clinicians at SeattleNTC

Transcranial magnetic stimulation (TMS), a noninvasive method of brain stimulation, has recently been shown to enhance neural pathways in the brain that are associated with memory function. In memory processing, superficial regions of the brain, such as the lateral-parietal cortex, connect to deeper memory control centers, such as the hippocampus. Because TMS can stimulate only the outer few centimeters of the human cortex, the lateral-parietal cortex has been identified as a target area over which TMS could be used to affect deeper brain structures or regions involved in memory.

In a study by Wang et. al, healthy subjects receiving  rTMS to the lateral-parietal region of the brain were compared to subjects receiving sham treatments. Sham treatment mimics the feeling of rTMS without stimulating the brain. After 5 consecutive days of rTMS, functional magnetic resonance imaging (fMRI) of the group receiving “real” rTMS indicated increased connectivity between the lateral-parietal region and the hippocampus. This increased regional brain connectivity correlated with improvements on associative memory tests. Differences in regional brain connectivity or associative memory test scores were not seen in the sham group. These results support the theory that rTMS given over superficial brain regions can have downstream effects on deeper regions of the brain more directly involved in memory funtions, resulting in significant improvements in memory testing. rTMS shows much promise as a future treatment of memory dysfunction, however, further studies involving patients with disease pathology are needed.

Study:
Wang JX, Rogers LM, Gross EZ, et al. Targeted enhancement of cortical-hippocampal brain networks and associative memory. Science. Published online August 29 2014

Links To news articles about the study:
Magnetic brain stimulation treatment shown to boost memory. The Guardian, August 28 2014

Electrical brain stimulation ‘boosts memory’. BBC News, August 29 2014

Magnetic pulse to head could improve memory of dementia sufferers. The Daily Telegraph, August 28 2014

Likelihood of Remission from Depression with Medications vs. TMS vs. ECT

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Depression is now the leading cause of disability in the world (WHO, 2012), and Transcranial Magnetic Stimulation (TMS) is increasingly recognized as an important treatment option by both clinicians and insurance companies

As such, we are frequently asked about the relative effectiveness of medications vs. TMS vs. ECT for treatment-resistant depression.  While head to head studies of the 3 treatments have not been completed, it is interesting to compare large, multi-site, frequently cited studies of the 3 treatment modalities administered to patients with similar levels of treatment resistance.

These findings are a useful reminder to regularly assess the severity of depression in our patients using depression rating scales, and to be sure that patients with treatment-resistant depression are being progressed through a series of treatment steps including, if appropriate, an evidence-based psychotherapy, additional medication trials, TMS or ECT.

ABOUT SEATTLENTC

Seattle Neuropsychiatric Treatment Center (SeattleNTC) is committed to providing high quality, evidence-based therapies for depression, anxiety, obsessive compulsive disorder and related conditions that have not responded to first-line treatments such as medications and psychotherapy.

OUR TREATMENT APPROACH

At SeattleNTC:

  • Caring for patients is our passion
  • We feel privileged that patients, families and loved ones ask us for help during the most challenging times of their lives
  • Patients who seek our care have often suffered for months or years
  • We strive to be accessible and can typically schedule an initial consultation within 1-2 weeks
  • We use state of the art brain stimulation procedures to help patients get their lives back on track as quickly as possible
  • We strive to provide the most personalized and the highest quality of care possible

PSYCHIATRIC CONSULTATION

 All patients are seen for one or more initial consultation appointments to:

  • Review their psychiatric treatment history
  • Gather information from significant others, psychiatrists, therapists and primary care physicians
  • Discuss the treatment options in detail
  • Collaboratively establish an initial treatment plan

WHY SEATTLE NEUROPSYCHIATRIC TREATMENT CENTER?

Depression and other psychiatric conditions are often resistant to treatment

  • After 3 failed medication trials, depressed patients only have a 17% chance of responding to additional medication trials
  • The same patients have a 58% chance of responding to TMS and a 60-80% chance of responding to ECT
  • Patients often suffer through many ineffective medication trials before TMS or ECT is considered

To Contact Us:

Please Call 1-206-467-6300

Our Office Locations:

Seattle

1600 E Jefferson Street, Suite 401
Seattle, WA 98122

Redmond

18100 Union Hill Road
Redmond, WA 98052