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Is Transcranial Magnetic Stimulation the new Prozac?

Brielle Wellington was one week away from succumbing to the disability pension due to chronic pain.

After years of being on the doctors’ circuit stemming from breaking her leg twice while playing roller derby, she was left with debilitating pain and co-morbid depression.

Desperate to be rid of the pain which was aggravated by nine months of undiagnosed osteomyelitis (an infection of the bone) and depression associated with it, the 28-year-old tried everything: Cognitive behavioural therapy, Ketamine injections, “every single drug” prescribed by pain specialists and psychiatrists, and countless diets.

Feeling like she had hit a brick wall, while researching the latest trials conducted at Monash University, her mother Robyn came across TMS: Transcranial Magnetic Stimulation, a non-invasive treatment for depression using pulsed magnetic fields to target and stimulate the cortex of the brain involved in mood regulation, with minimal side effects.

Repeated activation of the left prefrontal cortex is proven to relieve depression and help patients enjoy their lives.

“TMS was a last ditch effort,” Robyn said. “We made an appointment with psychiatrist and TMS practitioner Dr Ted Cassidy. Even though he said it wasn’t necessarily for pain, he had seen it work with people who had pain. He also diagnosed her with severe depression.”

After 10 30-minute treatments Ms Wellington began noticing a change.

“Things like the leaves on trees were in HD and not just a dull, mono colour and foggy. That’s the thing with mental health issues: unless that veil is lifted you have no idea what things should really be like. I feel like I can process things rationally, and that life now has purpose. If I get a suicidal thought, it’s a flicker, and I feel calm.”

Her mother said the transformation was stark.

“She went from being hunched over like a little, old lady, to being upright again. She’s not 100 per cent fabulous, but from where she was where I would have to go to her house every morning, get her out of bed and into the shower, she now has total independence, and she’s working.”

Having worked in psychiatry since 1997, and founding The Hills Clinic mental health hospital and medical centre in north-west Sydney, Dr Cassidy’s passion was being able to treat lots of people, as the need was “huge”.

After years also spent treating patients who would not get better and whom he saw all the time, he thought that there must be a better way to do things.

“That’s when I became interested in the idea of new ways to treat depression, which opened my mind to other treatment approaches like TMS, which I became qualified for in 2014. It had become mainstream and was approved by the TGA (Therapeutic Goods and Services) in 2007 and as of 2015 was in the Royal Australian and New Zealand College of Psychiatrists (Australian) depression treatment guidelines. There is also research backing its validity for stroke rehabilitation, tinnitus, fibromyalgia and migraine.”

With a 60-80 per cent response rate and a 35-40 per cent remission rate, Dr Cassidy said for patients with depression who do not respond to drugs then TMS is their best chance of recovery.

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“There are three ways to stimulate positive mood pathways with the brain if someone is depressed,” explains Dr Cassidy. “One is with drugs, which provide chemical stimulation through the whole body, which unfortunately creates side effects like weight gain and sexual dysfunction. The second is with ECT (Electro Convulsive Therapy), which while stimulating the brain with electrical currents, also [affects] everything else like memory and attention. TMS stimulates the brain without the collateral damage. The magnetic pulse passes through skin, bone like they don’t exist so you can get to a part of the brain without causing damage. It’s highly focal.

“It’s important to add that we don’t have to stop medication straight away. Once we get a response from the patient, it’s then a matter of weaning off the drugs.”

Mainstream Funding the Next Step

Colleen Loo is a professor at the School of Psychiatry at the University of NSW and professorial fellow at the Black Dog Institute who researches brain stimulation. As a practising psychiatrist, Professor Loo runs a TMS treatment clinic at the Black Dog Institute, provides second opinions on novel physical treatments for patients who haven’t done well on standard treatments, and teaches a training course on TMS for psychiatrists and health professionals.

When asked why some psychiatrists still believe it’s “snake oil”, Professor Loo’s response is decisive.

“There is top quality, gold standard evidence of which I chaired in 2013, that TMS is effective in treating depression. The trials we are doing now is to improve the current treatment.

“Our next step is how to get funding for this treatment, as it is not funded by private health or Medicare,” she said. “Patients have to cover the cost and it’s expensive. It’s $160 per treatment with a typical course of 20-30 sessions, which is between $3000-$5000. One of the sad things is when we think it would be helpful to a patient, but they can’t afford. The government is funding alternative therapies, which have fare less efficacy-based research, so they should be looking at TMS.”

War Vets On Board

War veteran Keith Pearse, 53, had worked in the navy on submarines for 25 years before he was medically discharged at the age of 46, with chronic depression, deep seated anxiety, paranoia and chronic post traumatic stress disorder (PTSD).

Hyper-vigilant, and super-stressed, he could not sit in a cafe unless he had his back to the wall observing everything.

Reaching the maximum level of the four medications he was on, 18 months ago he was referred to try TMS, which he could afford, as the Department of Veteran Affairs (DVA) funds the first 30 sessions.

“I did TMS five days a week for six weeks. Even the ‘woodpecker’ type tapping to the head I found relaxing. For a good few months after the first treatment finished I was less grumpy, less agitated and less anxious. I’ve since had to move to the Gold Coast and unfortunately there are no TMS clinics here. I haven’t had it for 15 months, and it has worn off. But I’d do it again in a flash.”

With availability and cost an obstacle, Dr Cassidy said Australia is behind other countries.

“There is virtually no guideline in the world where TMS is not on the guideline for depression. One clinic in Tokyo has 75 machines operating seven days a week. We have less than 1000 people Australia-wide doing TMS per year, yet with the increase in out-patient services over the past three years there has been a 50 per cent increase in people wanting it.

As for Ms Wellington, she is currently medication-free and on a TMS maintenance program of one session a fortnight.

“I’m just lucky that my parents could afford for me to do this. I’m so happy to be a contributing member of society rather than leaching off it.”

Her mother, Robyn, said: “We know people in a similar situation who would benefit greatly but can’t afford it and are now on the disability pension. My goal now is to lobby Medicare to have this as an item number.”

Dr Cassidy likened the treatment’s efficacy to a well-known chemical pill.

“It’s exciting to see people responding who haven’t had results from any treatments in 20 years. Prozac was the new medical breakthrough in 1989 and there hasn’t been anything truly new since then. There are no new classes of drugs coming through, but TMS is part of the exciting new field of brain stimulation. I believe this is the next Prozac if you like.”

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