Reflection on Depression

My TMS consultation

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.

TMS consultation

Despite feeling remarkably better in the past few weeks (for no apparent reason!), I'm going to my previously scheduled TMS (transcranial magnetic stimulation) consultation at Stanford Hospital tomorrow.  Given how well I'm doing I may not undergo the procedure, but I still want to learn more.

Specifically,  I'm going to ask the doctor about what types of depression respond best to TMS, who sees the best results, and how long these results appear to last.  I know that he hasn't performed the treatment enough to have figured out statistically reliable answers to those questions, but I'm hoping he may have some anecdotal insights anyway.

I'll let you know what I learn later this week!

Going to be evaluated for TMS!

I've decided to bite the bullet and finally go for it. I have the first of two intake interviews this week with Stanford's Depression Research Clinic where I'll be evaluated for TMS (transcranial magnetic stimulation). I've been interested in the electromagnet-based treatment for years now--it seems like a promising, side-effect free treatment option that might help me reduce my reliance on meds. 

I'm not acutely ill or in any need of an immediate intervention, but I have been in a slight slump recently so I think it's a good time to try this. After all, it takes 4-6 weeks to administer, so it's not something that would be effective in an acute, time-sensitive situation. Trying it when I'm relatively well, but with room for improvement, seems like the way to go.

I'm most excited by the possibility that this treatment could help me regain that last 1/3 of my health. Over the past 13 years meds have helped enormously--even saved my life (or at least my quality of life)--but they've never gotten me more than around 2/3 well. I've been left with residual mood and cognitive symptoms that I would like to tackle once and for all.

1997-2010:  Me (2), Depression (1)

My future goal:  Me (3), Depression (0)!!!!

Playing guinea pig

As I mentioned in my last post, I'm considering TMS (transcranial magnetic stimulation) as an augmentation to my medication. The treatment uses a noninvasive device to send electromagnetic pulses to the left prefrontal cortex for an hour every day for four to six weeks. It costs between $7,000 and $10,000, although I may be able to get the treatment for free if I'm accepted into a clinical trial--otherwise I'll pay out of pocket since it isn't covered by insurance (it's still considered experimental).

$7,000 is a pretty big gamble, and I'm hesitant to cough it up without any idea of whether or not the treatment would work. Overall efficacy estimates vary, but it's not more than 40% (or about 25-30% greater than placebo TMS). But I figure it may be higher in certain subgroups, for certain types of depression, or on brains that are particularly responsive to magnetism. In order to see if I fall into one of those categories, I decided to test the effects of neurostimulation on my brain by getting an MRI. (In a small 2007 Harvard study more than 70% of bipolar patients receiving a MRI experienced positive mood effects, and I figure that response to an MRI is a good indication that one may respond to TMS.) Of course, failure of the MRI to produce results does not necessarily mean that TMS wouldn't work on me, but it could be a good indicator that my brain is particularly responsive to this type of treatment.

Since you can't just walk into a doctor's office and request an MRI for experimental purposes, I had to enroll in a Stanford psychology study that involved undergoing an MRI. So I volunteered for a study on working memory, and spent an hour last week in a scanner looking at objects and listening to sets of tones while trying to remember how many tones I heard each round and which button (left or right) went with which shape.

It was interesting to undergo my first MRI. I was pleased to discover that, while I felt some anxiety, I was far more relaxed in the narrow closed-in tunnel than I would have been a couple of years ago when my claustrophobia was at its worst.

Unfortunately, I didn't notice any significant mood effects after the scan. It's been four days and I'm still in the slump I've been in for awhile. I'm still glad I tried it, even though it was unlikely to give me any useful information. After years of settling for partial remission, I am being more aggressive in seeking out treatments, no matter how unorthodox. I will no longer settle for something less than full health. Of course, I have to balance this determination with acceptance of my situation for what it is so that I can appreciate the health that I do have, but I will continue to make the most of the resources at my disposal until I achieve full remission. 

Vagus Nerve Stimulation for Depression

Vagus nerve stimulation is a fairly new treatment for depression that involves stimulating the vagus nerve in the neck with an implanted electrical device. It's not known exactly how this affects the brain, but the treatment has proven effective for both depression and certain types of epilepsy, and is FDA approved for both indications.

I hear less about VNS than other new treatments like TMS (transcranial magnetic imaging) or DBS (deep brain stimulation). For some reason it doesn't seem to get as much attention--perhaps because VNS produces undesirable side effects in some people--apparently it can affect the voice box, making it difficult for patients to speak clearly. However, the procedure has cured some sufferers. When I looked for an explanation of VNS on youtube I found this clip accompanied by comments from people who have had good experiences with it.

Unfortunately, it costs tens of thousands of dollars, but one commentator was able to get the procedure in India for a fraction of the price in the U.S.  That's risky, but he had a family member who was a doctor India, and so was able to navigate that county's healthcare system safely.

One thing I like about this video is that the doctor readily admits that we don't know what depression is.  That's so true!  It's likely a number of different disorders, which is why different people respond to different treatments. Right now, he also admits, we don't know how exactly VNS works, but it has proven effective and relatively safe so it's worth a shot for many people. 

Homeopathy for depression (or any other condition) is a scam

When I went to pick up my meds last week a new addition to the CVS medicine aisle caught my eye--a homeopathic remedy display. At the time I didn't know what "homeopathic" meant, but I figured it was something like "natural"  or "organic"--or maybe it was the name for what Osteopaths prescribe. On impulse, I purchased sepia, the remedy for mood disorders. Hyperbolic claims of efficacy accompany many alternative treatments, so it pays to be skeptical, but for only $7 the homeopathic remedy seemed worth a shot.

I became even more skeptical than usual when I got home and realized that the sepia tablets were snow white. Since sepia is made from dark brown Cuttlefish ink I expected the pills to have a brownish hue. But after doing some Google research I learned that homeopathic remedies are white or clear because they contain only minute traces (sometimes undetectable, usually less than one part per trillion!) of the active ingredient. Essentially, homeopathic remedies are just water or water-infused sugar pills!!!

Homeopaths claim that the remedies work because the active ingredient "potentiates" the water through a series of steps that includes shaking and hitting the solution as it is progressively diluted. How can this process possibly work?  Well, homeopaths claim the treated water retains some "memory" of the active ingredient. "Water memory," however, is not based on any accepted principle of chemistry or physics.

Almost as odd, the active ingredient in homeopathic remedies is not one that relieves the disorder, but rather one that causes it. A large quantity of sepia, for instance, supposedly induces mood disturbances. The rationale is the "like cures like." While this might work for preventative vaccines, it makes no sense in the context of already existing ailments.

Homeopathic remedies upset me more than vitamins and unproven supplements because at least with supplements there is a plausible theory behind their claims. They could work on the principle that igensted substances can act on our body to treat certain deficiences or counteract certain toxins. Water "memory," however, rest on no scientifically plausible mechanism. You are not actually ingesting anything detectable other than water and sugar!

In my opinion, the whole thing sounds like witchcraft, and I was tempted to ask CVS for my money back. I realize there needs to be room to experiment with unproven therapies, but this just seems to cross some sort of line.

Alternatives to medication and ECT

Although medication and ECT are the primary medical interventions for severe depression, a number of more experimental options are becoming available. In this column about treatment resistant depression a doctor advises a reader to look at transcranial magentic stimulation (TMS), vagus nerve stimulation, and deep brain stimulation (which is where doctors implant electrodes directly into the brain).

Although some of these treatments sound extreme (DBS requires brain surgery), they may actually be safer and more effective options than staying on medication for a lifetime. Moreover, TMS and DBS seem to have very few side-effects. No weight gain, mental fogginess, or drug interactions to worry about!

I asked my doctor about TMS recently but learned that it cost over $200 a session and isn't yet covered by insurance. That makes it over $4,000 for the standard 20-session treatment. One 20-course treatment is still cheaper than a lifetime of meds, but it's my understanding that patients must continue to undergo treatment periodically. At $4,000 a pop, that could add up quickly!

I also looked into DBS but it is still in clinical trials. However, approval should be realtively fast because it has been approved to treat movement disorders like Parkinson's for nearly 20 years (thus its safety record is well-established).

Recovering from depression by reading mystery novels

During my last acute depression I avoided everything that could trigger my sad or scary thoughts. Nearly anything that evoked emotion (whether positive or negative) fell into this category. I stopped watching romantic comedies, tragedies, or virtually any type of entertainment with salient emotional themes. I avoided my normal activities because the flatness I felt in place of my usual enjoyment was too conspicuous. I avoided people as much as I could.

 

All this avoidance left me with an unhealthy amount of time to ruminate on my thoughts--precisely what I was trying to avoid doing. After all, I didn't want to "practice" my irrational thoughts, thereby strengthening them. Avoidence also shrunk my world to just a handful of people, places, and activities. My life played out mostly in my bedroom (almost entirely in my bed), and it probably looked to others like I spent my entire day staring at my peach-colored walls.

Actually, my body may have been immobolized but my mind was racing. It was going over, and over, and over a handful of guilty and scary thoughts that consumed my mind, crowding out my ability to think about (much less do) anything else.

As I recovered, my mind became strong enough to resist the thoughts. Inititally I was only able to keep my mind on something other than the guilty thoughts for a few seconds at a time, but as the months passed I worked up to a couple of minutes of sustained attention. The thoughts would still intrude, but as long as I could keep myself distracted I could minimize my discomfort.

During this recovery, one activity that was both safe (it didn't trigger scary thoughts) and effective (it could keep my mind on something else for awhile) was reading mystery novels. Detective stories provided enough intrigue to hold my fragile attention for a few minutes at a time but they stayed well within the realm of intellectual brain-teasing entertainment--they weren't emotional triggers because their character development and emotional themes were refreshingly superficial. Importantly, they allowed me to escape my narrowed world and sick bed--at least in my imagination.

Below is an article describing just how therpeutic mystery novels can be.

Depression and mystery novels

Of mice and men

Is it good to be a mouse?  Possibly, if you have cancer or an anxiety disorder.  CNN published an article today discussing the scientific breakthroughs made in studies with mice. From cancer vaccines to treatments for depression, mice are usually the first to benefit from our medical advances. (Of course, they're also the first to suffer in the name of science). 

Mice studies are particularly useful for studying mental and emotional disorders in humans. Unlike some medical conditions, mental health disorders are well modeled in mice. Since they share an amygdala and frontal cortex with humans (both implicated in anxiety and depression) scientists can gain insight from mouse behavior into our behavior.

Unfortunately, translating medical treatments from mice to humans is not always straightforward. It can take 10-15 years for a drug to get from rodents to the pharmacy. You can help speed up the process by contributing to NARSAD, the leading brain and behavior research charity in the U.S.

Yesterday I received a NARSAD newsletter detailing research into deep brain stimulation for treatment-resistant depression.  It's now being tested in humans with depression, and may be approved by the FDA in just a few years. (Forgive me for the shameless plug for NARSAD, I'm just especially excited because this is a new treatment for the most intractable cases of depression that could be approved soon!).

Help us follow in the footsteps of mice :). 

"Green" exercise can help depression

I'm headed to Yosemite to enjoy some quality time outdoors for the Memorial Day long weekend. It will be my first trip ever to the park!  (I know, I've lived in the Bay Area for four years and I'm only just now visiting Yosemite . . . bad).

According to a new study it looks like getting some outdoor time may even be healing (although I suspect that outdoor time is good for everyone). Researchers report that exercising outdoors can help depression -- even just 5 minutes of outdoors time can make a difference.

So here's to hiking, relaxing, and hopefully not getting eaten by a bear!