Ernest Rasyidi, MD, a Psychiatrist at St. Joseph Hospital talks about how NeuroStar works to treat depression.
Interview conducted by Ivanhoe Broadcast News in May 2018.
Tell us a little bit about NeuroStar system, how does it work?
Dr. Rasyidi: NeuroStar is one form of Neurostimulation using a modality called transcranial magnetic stimulation abbreviated as TMS. This is a really exciting new procedure that’s been developed over the past ten years or so but is really expanding in terms of its usage clinically. What it does is it generates a very powerful magnetic field which we can then target in to certain parts of the brain to stimulate activity. This has been proven in evidence based as an appropriate treatment for depression which is how it is currently being used. But there is a lot of exciting potential in terms of the future potential uses that we’re just starting to learn about and explore.
Let’s talk about the depression, how does it work?
Dr. Rasyidi: Sure. We know that within depression certain parts of the brain, certain regions, to get a little technical: one area that we call dorsal lateral prefrontal cortex, I know it’s a mouth full but you’ll see it when we set up. It is one region of the brain that we know tends to be underactive. There are various ways to try to stimulate and raise that activity of the brain. Traditionally talk psychotherapy has been one way to do it. Medications have been another way. But for some people who are maybe not responding to either of those treatments or experiencing various side effects, TMS now offers another option in terms of how to stimulate that activity and how to get those neurons in the brain firing and releasing their neurotransmitters.
How well does it work?
Dr. Rasyidi: It’s pretty much on par with medications meaning that many people will respond though we acknowledge not all. Currently the way it’s been approved and designed by the FDA is that it is appropriate for people who have failed at least one medication trial. Meaning if they are suffering from depression, they’ve been diagnosed by their doctor, they’ve been prescribed medications, they’ve had a good trial enough time to see if it responds and it doesn’t work. Or if they just couldn’t tolerate the medications due to side effects they are technically a candidate for TMS.
What’s the protocol for it, once a week?
Dr. Rasyidi: TMS as it’s designed currently, the way it’s been tested and approved by the FDA is a thirty session course stretched over the course of six weeks. So what happens is after the patient has been evaluated and deemed appropriate for TMS they come in for their initial session. During that initial session certain calibration and measurements are taken to determine what is the best location for that patient is and what power setting to use. They then receive their first treatment on that first day. They then will return for twenty nine additional treatments traditionally five days a week for six weeks. And that completes the course.
And it’s durable, the response is?
Dr. Rasyidi: The effects can be lasting. Now you do need to remember that depression is often what we consider a chronic relapsing illness. So in that way it is similar to other conditions such as hypertension or diabetes. We may manage it for a period of time and there may be periods of time where it sort of goes in to remission and then there may be future episodes down the road. Actually with major depression we know that that’s a fairly high likelihood. The treatment again is pretty comparable to medications, it’s effective. Now down the road a person may experience another depressive episode and may need an additional treatment but that’s really no different than our existing treatments with medication and therapy.
And safe enough to do it repeatedly?
Dr. Rasyidi: Correct, so one of the major advantages we’ve had various forms of Neurostimulation for a while, the most famous probably being electro convulsive therapy or ECT. That has been proven to be effective but that does have certain drawbacks. Because of how ECT works, ECT the goal is to actually stimulate enough electrical activity that the patient has a seizure which I know sounds scary but that is fundamentally how it works. Now the way we keep the person safe is we use anesthetics to paralyze them so that their muscles are not contracting during the seizure. If people think of the olden days and the scary horror stories. We used to use ECT without anesthetic and people would flail around. Now people essentially look like they’re sleeping. But because they’re having a seizure there are certain side effects such as memory loss. Especially with repeated exposure. In TMS we are stimulating but not to the point of seizure, the goal is actually avoid having seizure. Because of that we don’t require anesthetic, there’s no memory loss associated with it and people for the most part drive themselves to the appointment, receive their treatment and drive themselves home which is not an option with ECT. With ECT you have to have transportation set up.
For Carolyn how effective has this treatment been?
Dr. Rasyidi: Carolyn has been an interesting case. She unfortunately has struggled with depression for many years. She’s been through many different treatments with varying degrees of success. When we have this device here and had an opportunity to treat her with something she had not been exposed to prior, I think she was real excited. Carolyn had a little bit of sensitivity during the adjustment phase which does happen with some people. She’ll be able to tell you after that first session she was having some side effects in terms of muscle twitch on the forehead which occasionally happens. One of the more dramatic examples actually she wasn’t too sure if she would be able to tolerate it, we reassured her. By the second or third session essentially it was very easy. And so now she’s tolerating it very well and she’s beginning to see the improvements that come with that.
What haven’t I asked you about it that you think we should include in this story?
Dr. Rasyidi: My feeling is that with Neurostimulation we are sort of entering a new era of mental health treatment. If you look at it historically at first we had Freudian psychoanalysis, various forms of talk therapy, that was about a hundred years ago. About fifty years ago we started developing medications and that opened up a whole new window. As we know medications are not a hundred percent. They provide some options but they have some limitations. I think we are now entering the third era of Neurostimulation where again we’re just adding to our toolbox and growing. Right now like I said its FDA approved for depression but there is a lot of research and experimentation going on for other conditions that it may treat. Bipolar disorder, PTSD, obsessive compulsive disorder. A lot of the other conditions that people with mental health disorder suffer from. It is also potentially opening another window and this brings up certain ethical questions in terms of, there’s various terms for it, cosmetic psychiatry, elective psychiatry, cognitive enhancement. What that basically means is we are running experiments where it looks like we can actually make people smarter to certain degrees. Hence cosmetic is the term meaning you don’t necessarily need this but some people are going to opt for this the way some people may opt for cosmetic surgery. That may be a direction we’re going in but that will bring up a lot of questions that we’ll have to decide as a society what we want to do with that. We’re just really, really early on right now.
So for the OCD, bipolar is it in trials right now?
Dr. Rasyidi: Some places will do it off label, and I do need to clarify that, that is considered off label. In that it has not been sanctioned by the FDA. Like other treatments prescribers, clinicians have the discretion to use their treatments off label which we often do with medications anyway. The major stumbling block is that insurers, the agents responsible for reimbursement will not authorize payment for an off label usage. In those cases people are either going to have to be enrolled in a clinical trial or they’re going to be paying out of pocket.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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