New treatments focus on the brain

While perusing mental health-related news for potential blog postings, I noticed multiple announcements regarding transcranial magnetic stimulation (TMS) for treating obsessive-compulsive disorder (OCD). Upon reading the press release from Achieve TMS which states “There are no systemic side effects, and patients are able to safely drive to school or work immediately afterward,” a fearful question from my inner skeptic popped into my head: Does anyone remember lobotomies?

Discovered during research on Parkinson’s disease, the FDA approved deep brain stimulation (DBS) for use in the treatment of treatment-resistant depression and now other forms of it are approved for OCD. It may not be long until variations of these treatments become available for other disorders such as dermatillomania and other BFRBs because they are included in the OCD spectrum of disorders despite significant differences.

Messing with the Brain

Neuropsychiatry took the place of the field known as psychosurgery. As the modern age of medicine developed in the early twentieth century, the field of psychiatry sought to establish a connection between mental illness and the brain. The goal was to show that the brain caused mental illness, which meant that if the brain could be fixed, so could people. Pardon the oversimplification, but this was also the time when some of the first psychotherapeutic medications were introduced. The results of research at that time produced procedures such as lobotomy and electroconvulsive therapy (ECT) as well as lithium and Thorazine.

Fast-forward to the present and there are more medications for mental illness than ever before with millions of people taking psychotropics as well as limited use of ECT for treatment-resistant depression.

Types of “Brain Surgery”

The following is a list of neurological procedures. including short descriptions of what they are, approved for use for various mental health disorders. For longer, more complete descriptions, see the National Institute of Mental Health’s website.  

Electroconvulsive Therapy (ECT)

• Uses electric current by placing electrodes on the head between which the current passes through the brain causing a seizure.
• Used for treatment-resistant depression, bipolar, and schizophrenia.

Vagus Nerve Stimulation

• A pulse generating device is implanted in the upper chest with a wire attached to the left vagus nerve. Every five minutes, a 30-second pulse is sent to the wire which stimulates the vagus nerve to deliver signals to the brain.
• Originally used for those with epilepsy, it can be used for treatment-resistant depression in some cases.

Deep Brain Stimulation

• Pair of electrodes surgically implanted in the brain with a battery pack in the chest.
• Stimulation of the brain is constant.
• Approved for use with movement, seizure and tic disorders as well as experimentally for depression and OCD.

Transcranial Magnetic Stimulation (TMS)

• Uses magnetic energy to stimulate the brain at a targeted site with intermittent pulses over 30-60 minutes.
• The magnetic energy does not reach as far into the brain, so targeting is easier.
• Approved for use with treatment-resistant depression and OCD.

Each of these procedures warns of side effects including discomfort, headaches, dizziness, mood changes, nausea, muscle aches, and memory loss. Proponents of the new TMS device state it does not have side effects like medication does, which may be true, but anytime something foreign is introduced to the body, the body reacts. Everyone reacts to medications and other therapeutic interventions differently, so it is challenging to predict outcomes or side effects.

Research

Outcome research does not provide concrete evidence that these treatments work. When the company who makes the machine provides outcome research in full support of the treatment, those results should be met with skepticism. The best-practice standard for treatment-related research is the double-blind randomized controlled trial. Not many of those provide conclusive results either.

“Although open-label trials of deep brain stimulation for treatment-resistant depression at multiple targets have been encouraging, controlled trials for approval from the U.S. Food and Drug Administration have been negative” (Dougherty, 2018).

Even though the FDA approves a medication or treatment for use for a particular condition or population does not mean it works for everyone nor does it mean it will be used properly. Additionally, the guidelines for use are vague. It is meant for those with “treatment-resistant” depression, yet at which point does someone qualify for that definition. Without definitive diagnostic procedures and widespread use of brain imaging for diagnosis, it is likely that this treatment will be recommended for people who are not good candidates.

The Quick Fix

Americans are obsessed with quick fixes. People reach for medication and skip therapy even though evidence shows better outcomes when people use both. Medication works faster and takes less effort. The press releases and news stories about TMS make it sound like a miracle treatment. For some people, it may be true, but so were lobotomies.

Recommendations

If you or someone you love is considering DBS or TMS, consider these tips.

• Diagnostics. Get several opinions from several experts. Make sure the diagnosis is accurate and supported.
• Try multiple treatments and give it time. Try different interventions and work with a therapist who specializes in your diagnosis. When working with a good therapist, expect to experience some results after 6-8 sessions even though full recovery may take longer.
• Research the procedure. Talk to your provider about current research on outcomes. Look for side effects and how people feel months or years after the procedure.
• Ask multiple providers about the procedure. Since TMS is not paid for by most insurance yet, it will be a self-pay treatment which means providers will be looking to make money from it. Go through assessments with multiple providers and compare notes regarding their observations. If you work with a therapist, get wise counsel from them.
• Evaluate risks and worst-case scenarios.  

When considering treatments that introduce external stimuli to your brain, be careful, be cautious and make informed choices.