A week and a half ago I had a 90 minute consultation with the head of the Depression Clinic at Stanford Hospital to discuss undergoing transcranial magnetic stimulation (TMS), a treatment I've been following for the past several years as it has been winding its way through regulatory approvals and efficacy trials. The doctor I met with at Stanford actually ran some of these early trials so he had a wealth of knowledge about the treatment.
Prior to my appointment, my regular doctor sent the clinic a write-up of my medical history, and I completed an extensive intake questionnaire with a nurse practitioner on the phone. When I arrived I also had a chance to describe the course of my depression for thirty minutes or so. I recounted my unexpected descent into depression in high school, the residual symptoms that plagued me even after SSRIs took me out of the blackest depths, my breakdown and continual struggle in college, and my most recent major episode at age 25. We went over all the medications I had tried, my robust but incomplete response to them, and the symptoms I continue to struggle with even when not experiencing an acute episode. I also expressed that I was doing very well today, and was leaning toward not having the treatment at this time.
He noted that several features of my depression stood out to him. First, he said that the early age of onset, when followed by recurrent episodes, generally indicates a course that will need treatment for a lifetime (the nurse practitioner also noted my early age of onset and said that it's often an indication of bipolar disorder). My type of depression, the doctor said, often responds well to mood stabilizing medications in addition to antidepressants. (I told him that, in fact, it's only since I began taking a mood stabilizer, Lamictal, that my mind has regained much of the clarity it had before I became depressed.)
He also noted that the extreme feelings of guilt and intrusive thoughts about past misdeeds that plagued me for months during my last episode are worrysome because the presence of this new symptom indicates that the episodes are becoming more severe. While not quite delusional, these "overvalued ideas" indicate that my thoughts are becoming more detached from reality during my episodes.
Regarding my residual cognitive complaints--lack of concentration, disorganization, etc. that worsen during each episode, he said it's likely that an acute episode of depression is neurotoxic, and that anyone who has experienced one will also experience some degree of subtle but lasting neurocognitive impairment. He stressed the importance of avoiding future episodes in order to keep these impairments from getting worse.
(This worried me because I was hoping that the cognitive changes I've experienced were a symptom that I could treat and get rid of--not a permanent change in my brain. Since the appointment, I've tried to remind myself that the brain is plastic and I may be able to figure out ways to compensate for any deficits.)
Regarding TMS, he said the efficacy rate is around 50%, and that researchers are still tweaking the TMS protocol. Currently the 5cm rule--the rule of thumb that the magnetic pulses are aimed 5cm in front of the region of motor cortex that makes the opposite side thumb twitch--is one that doctors use based on convention, and he thinks there may be a more accurate way to identify the appropriate region of cortex to stimulate. In a few years, improvement to the protocol may increase efficacy.
He also mentioned vagus nerve stimulation as an alternative treatment. It's where a pacemaker like device implanted in the chest delivers electrical stimulation to a part of the vagus nerve located in the neck which, in turn, stimulates the brain. The benefit of VNS is that it doesn't wear off like TMS or ECT because the device remains on permanently (or until it is turned off or removed).
Overall the consultation confirmed some of my suspicions (the need for long-term medication; the complicated nature of recurrent depression and its possible relation to bipolar disorder; the usefulness of mood stabilizers in treating this type of depression; the subtle cognitive impairments that are so hard to overcome entirely). And even though I've decided not to undergo the treatment it was good to learn more about it so that I can act more quickly in the future if I am in a situation where I need to use it.