DULUTH — A 2006 medical trial studying antidepressant medications found evidence that the more medications a patient tries, the less likely they are to experience remission from depression symptoms. Shortly after, the Food and Drug Administration approved transcranial magnetic stimulation as an alternative treatment option for medication-resistant depression.
TMS uses targeted magnetic energy to stimulate the front left area of the brain, which is used for mood and emotion regulation and cognitive function. The noninvasive procedure is done in a daily, outpatient setting that takes about 30 minutes for about seven weeks. TMS is offered locally by several medical providers, and is now more likely to be covered by insurance than in years past.
Psychiatrist Eric Johnson, who owns Duluth TMS in the Northland Medical Center, said he was getting discouraged by having so many patients who weren’t helped by SSRIs (selective serotonin reuptake inhibitors). He became familiar with the 2006 STAR*D trials (“Sequenced Treatment Alternatives to Relieve Depression”) funded by the National Institute of Mental Health, and began looking into other avenues for depression treatment. He purchased his first TMS machine in 2017.
“After a while you start collecting folks who you can’t help,” Johnson said. “As you try more and more medications, you have a less and less chance of getting remission, and remission is really the thing. Response is cool, but it’s associated with a higher rate of medication relapse. … A lot of psychiatrists aren’t aware that only 5% expected remission rate on a fourth medication, according to the STAR*D trials.”
During TMS treatment, the patient remains awake and aware for the approximately 20-minute process. A magnet is placed in the same spot, over the neocortex, during each treatment. About 2,000 magnetic stimulations are delivered in that time.
For 49-year-old veteran Jack Lee, who received TMS treatment for his severe depression at St. Luke’s earlier this year, the experience wasn’t exactly comfortable, but he didn’t feel any major discomfort during his treatment.
“It’s a magnetic pulse that’s so strong and so singular right to a certain spot that it feels like someone’s tapping your head with their finger,” Lee said. “So it’s like, tap, tap, tap, tap, tap, like 20 times, and then it stops and you have like a five-second break, then it taps 20 times or 30, and it does the same thing for about 20 minutes, every day, five days a week.”
Patients will return for the therapy five days a week for a six- or seven-week period, in which time the stimulation helps create habits for the brain to continue using the neocortex.
“When the neocortex is on, that’s where we live,” Johnson said. “That’s where we’re creative, we’re in the moment and we’re figuring things out and we’re plotting our course and deciding what we want to do. We’re goal-oriented, optimistic, problem-solving — that’s all functions of the higher brain. And that’s just quiet during depression.”
Tim Weber, director and owner of WebMed Mental Health Services, describes the brain during depression as a walk in the woods. Early in life, you can easily find your way along the path in the woods to the park, which is an analogy for the pleasure center of the brain.
“As we grow up and have different experiences and traumas and interventions in our life, with each one of those you deviate from that path that you know to get to that park,” Weber said. “TMS puts tiki torches up on that previous path. Walking that path for one day is not going to trample it down. But you walk that way every day for six weeks, and that pathway will be trampled down and you’ll now know that pathway and just walk that.”
TMS is a noninvasive treatment, but it does have some mild side effects — the most common one being headaches. Other side effects include lightheadedness, scalp discomfort at the stimulation site and facial twitching, tingling or spasming. There is also a rare seizure risk.
TMS is similar to electroconvulsive — or electroshock — therapy, but the treatments have some significant differences. St. Luke’s psychiatrist Nathan Chan said the goals of both neuromodulation methods are the same: to stimulate parts of the brain that are understimulated in depression.
However, ECT requires general anesthesia to complete, and induces a seizure with controlled electrical currents. TMS is not always as effective at ECT, but TMS is less invasive and has less-severe side effects. Patients can drive to and from TMS treatment and do not require any sedation or recovery time.
Popularity in Duluth area
TMS is available at St. Luke’s Mental Health Clinic in Duluth, at Duluth TMS and at WebMed in Cloquet. St. Luke’s began offering the treatment two years ago and has treated 22 patients in the past year. Currently, St. Luke’s has four TMS patients. WebMed began offering TMS about a year ago, and has seen a dozen patients since then. Currently, Weber said he has three TMS patients.
Johnson at Duluth TMS said he sees an average of 12-20 patients at a time between his Duluth and St. Cloud clinics. He said more people in St. Cloud seem to know about the treatment option, but he sees patients in Duluth from across the Iron Range and northern Wisconsin.
Johnson, Weber and Chan all said they feel the resource is underutilized in Duluth. Weber said part of that reason may be due to lack of awareness that the option exists. Chan said he and other St. Luke’s Mental Health Clinic staff are trying to spread the word to practitioners that TMS is an accessible option for patients.
Lee, who is a social worker and teacher, had no idea TMS existed until his psychiatrist suggested he try it.
“My initial thought was, ‘This looks like something out of the future.’ I graduated with my clinical degree in social work at St. Scholastica and I had never heard of anything like that in my training,” Lee said. “I thought I’d heard of all the different types of theoretical orientations that social workers and psychologists use to help people.”
Lee said he preferred the idea of TMS over other alternative treatment options, including ECT and ketamine therapy.
“Just sitting in a chair and having a woodpecker on your head for 20 minutes really isn’t a big deal,” Lee said.
Chan said another part of the reason TMS is underutilized is the barrier of needing to come to the clinic regularly, although many people are able to make their appointments around their work or family schedules.
The treatment can also be expensive if not covered by insurance — costing thousands of dollars, even sometimes over $10,000. However, most insurance companies will now cover TMS therapy. The catch is that in order to be covered, most companies require three to four medication failures first, and sometimes psychotherapy sessions.
“Realistically, if we use this earlier in the process for treatment of mental illness, we may see even better results,” Chan said. “One thing we find is that no matter what kind of treatment a patient is getting, if they’ve tried and failed a bunch of different things, whatever the next thing is is a little bit less likely to work.”
According to data from Johnson combined from his Duluth TMS and St. Cloud TMS clinics, 74% of 205 patients surveyed experienced either remission or at least a 50% decrease in depressive symptoms. He said this data is slightly above average success rates from research, which generally finds about 45% of patients experience remission, or no depression symptoms, while an additional 25% of patients have some positive response to the treatment.
“It is a next step when somebody is suffering, on medication and trying their best, for years,” Johnson said. “Six weeks later, they can go into remission 45% of the time, even after decades of depression and medication failures.”
It is common for TMS patients to require additional sessions later on. Chan said after a year, about a quarter of TMS patients had a relapse of depression, but most people who responded the first time will respond again.
“I think it helps us understand that with something like depression — or even anxiety or any other mental illnesses, really — the source of it is a physical change in our brain,” Chan said. “I think that helps some people understand that it’s a real experience, a real disease, and it has identifiable symptoms. When people start feeling better it’s like, ‘Wow, that was because I literally had a physical illness.’”
Chan and Johnson said it’s common for their patients to gradually take less medication for depression after TMS, but both treatment options are safe to do simultaneously.
How quickly TMS begins working varies for each patient, but usually suicidal thoughts improve early on in treatment. On average, TMS is ineffective for about 30% of patients who try it.
“It’s probably artificially low because by the time we get to TMS, they’ve often tried so many things that it’s less likely that any one treatment is going to work,” Chan said.
For Lee, who suffers from complex mental health struggles that stem from his childhood and military service in the Coast Guard, TMS has helped him make small changes to his everyday life that let him get out of bed and out of the house with his 120-pound Newfoundland therapy and service dog, Nova. Although he still has depression symptoms, he’s noticed a gradual, positive change in himself.
“I think they’re small, but they’re really, really vital,” Lee said of the changes.
The PHQ-9, or Patient Health Questionnaire-9, is a quiz patients take to determine the severity of their depression symptoms. The scores range from zero to 27, with anything 20 or higher classified as severe depression. TMS therapy has helped Lee reduce his PHQ-9 scores from around a 24 down to a 16 after years of SSRIs and other treatment attempts have not.
“I certainly didn’t have a huge, noticeable benefit in the beginning,” Lee said. “What I have noticed is my PHQ-9 scores are lower than they traditionally had been, and really that’s all I was hoping for. I was setting my bar as low as I could because I have this little black cloud that’s been following me most of my life.”
He now feels more able to sustain the relationships in his life, and even has discovered himself feeling more outgoing in public settings. In addition, he’s been able to reduce his therapy hours.
“I’m not a full-blown happy guy, but I’m at peace knowing that this might be how I am the rest of my life,” Lee said. “I’m at peace with the fact that I did this treatment instead of some of the others out there.”
He still feels frustrated that TMS isn’t more widely referred to by psychiatrists, and he acknowledged that improving his mental health has taken a lot of vulnerability and hard work. He encourages other people who struggle with depression and other mental health disorders to advocate for themselves in order to get the treatment they need and deserve.
“It’s super-safe, it’s very effective and it’s a means of treatment for depression for when people are tired of medications not working, exhausted from going through trials and waiting four to six weeks for them to start working just to find out they haven’t,” Weber said of TMS. “It’s a non-medication means of trying to tackle depression. The results that we’ve witnessed from people that have had successful trials of TMS have been pretty amazing.”
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