How Magnetic Brain Stimulation Helps Relieve Depression

IRA FLATOW: This is Science Friday. I’m Ira Flatow. As the surgeon general has stated several times on this show, we are in a mental health crisis. Depression is the leading cause of disability worldwide. And obviously, a major challenge is that depression can be difficult to treat, especially for people who don’t respond well to talk therapy or antidepressants. But there’s a relatively new technique that seems to have a significant positive impact on people with treatment-resistant depression. It’s called transcranial magnetic stimulation, or TMS. And it uses magnets to stimulate certain areas of the brain.

A team at Stanford developed a version of TMS that received FDA clearance in 2022. And as of this year, it’s covered by Medicare. In studies, patients who use this approach reported depression remission rates as high as 80% to 90%. So how does this approach work? Could this change the way we treat depression and other mental illnesses? Here to tell us more is Dr. Nolan Williams, associate professor of Psychiatry and Behavioral Sciences at Stanford University. He’s also the Director of the Stanford Brain Stimulation Lab, where this technique was developed. And a heads up, we will be discussing suicidal ideation in this conversation. Dr. Williams, welcome to Science Friday.

NOLAN WILLIAMS: Thanks for having me. Really appreciate the opportunity to talk to you about this.

IRA FLATOW: I guess this is really sort of a breakthrough for people who are suffering from severe depression because– what’s it been like, people having thoughts of suicide, trying to get help in emergency settings? It’s not really been very nice for them, has it been?

NOLAN WILLIAMS: It has not. And you’re absolutely correct. So depending upon the state you live in– but like in California, if you were to tell your therapist that you’re suicidal and you wanted to end your life, the next thing that would happen if you’re sitting in their office, in most cases, that they would have the police come. They’d put you in a hold. They’d bring you to the emergency room. You’d be admitted to the hospital. And then you’d realize, outside of the rare situations where people use electroconvulsive therapy, that the patient doesn’t have access to anything beyond the kind of base case oral antidepressants.

IRA FLATOW: Right.

NOLAN WILLIAMS: And that’s where the statistic that people leaving the inpatient hospital are three times more likely to try or actually do end their life by suicide. And so that’s a statistic that is really quite striking. And it’s a reflection of the fact that, as a field, we haven’t had treatments designed specifically for those conditions. So if I’m having chest pain in the clinic, there’s going to be a certain number of tests and treatments. In the ER, there’s more. In the ICU, there’s more, right?

IRA FLATOW: Mm-hmm.

NOLAN WILLIAMS: In psychiatry, there aren’t more treatments as you get into higher acuity settings. And there are no tests. And so the revolution that’s coming for psychiatry is essentially to mimic a lot of the rest of medicine, that we can treat people really quickly and get them out of it in completeness. And I think that’s really the thing that’s coming. And what’s going to be so important for the future of mental health care is the ability to really use state of the art neurobiology to assist in getting people out of these really high-risk states.

One of the reasons why I started down this pathway– on average, people stay in the hospital in the United States about seven and a half days. And so you have to come up with technologies that can get people well in these really short periods of time and not in these extended months-long periods of time, which is true for conventional TMS. It’s true for oral antidepressants. There’s certainly a role for those things. But for people that are at the more severe end of things, being able to treat them really quickly reduces that risk and gives them some hope and gives them access to something that’s going to work in the time frame of an emergency.

IRA FLATOW: So your lab’s version of TMS is called SAINT, and that stands for Stanford Accelerated Intelligent Neuromodulation Therapy. But before we get to that, how does TMS work generally?

NOLAN WILLIAMS: TMS is a device that essentially utilizes something called Faraday’s Law, what we learn in Physics 101, where, if you pulse a magnet, you can generate a current in electrically conducting substances. And in the case of the human brain, the brain itself is electrically conducting, whereas everything around it, the skull, the scalp, the hair, all are not. And so you can actually put a magnet, push it up against the head, have the person receive a stimulation pulse. And it won’t do anything to any of those other structures and will go directly to the brain and turn the brain on. And so that’s the basic idea.

The original forms of this used kind of average placements on the skull itself and used a more inefficient form of stimulation, where we’re stimulating over the course of nearly two months. What my lab figured out is how to personalize this so that each person’s brain is taken into account for planning of where to put the stimulator coil. So we use MRI scans to do that. And then we have developed a rapid form of stimulation that, instead of being applied over nearly two months, we can apply that over a single day and then repeat that over the course of five days. And people, as a generality, get well in about 2.6 days, on average. And so we’re able to, with this kind of rapid stimulation approach and personalized medicine, get people well in a really short period of time at a really high rate of success.

IRA FLATOW: So it’s not a guaranteed cure for depression, right?

NOLAN WILLIAMS: There’s no guaranteed cure for depression. Depression is an illness that comes and goes. And what we are seeing is a functional cure, meaning that, for a lot of people, we can get them well in totality. And if they continue to receive more stimulation whenever they have a new depressive episode, then the idea there is we can maintain folks in a state of wellness continuously with the device. And so if you withdraw the device, they will, in many cases, but not all cases, relapse back to their original state. But if they can continue to receive stimulation, then they can stay well. So that’s the same sort of thing that you see with a cardiac pacemaker.

A pacemaker, for a lot of people, isn’t a cure in the sense that, if they were to take the pacemaker out, then their heart would go back to that abnormal rhythm. But with the pacemaker in, working, and the battery on, and they continue to have it for the rest of their life, it’s a functional cure. And so we see this in a similar way.

IRA FLATOW: So you have to go back for treatment, periodic treatments every what, how many months, weeks?

NOLAN WILLIAMS: It’s different for different people. And it has to do with how severe and resistant your illness is. And resistant meaning not that the person’s resisting, but that the kind of degree of how many meds they’d failed before they came in– and so people that are more severe, in many cases, need it more frequently. So you’re talking about months. Whereas we’ve treated people that are on the milder side from a resistance standpoint– they may be quite severe acutely, but they haven’t been sick for very long. And we’ve seen people like that go for years. So it really just depends on the illness and when you catch it.

And just like a bacterial infection or anything else, depression appears to be more difficult to treat the longer it’s allowed to go and the longer people stay in the state. And so we’ve been just very focused in my lab on this idea that we need to come up with a way– and SAINT is that way for a lot of people– come up with ways to get people well really quickly and to find ways, like these new Medicare programs where people can actually be treated much earlier in the illness. And so they don’t ever get to that really chronic point. If we can do that, then we can potentially have these sorts of treatments work for a much longer period of time. Or in some cases, we have a few people where it just works, and it’s worked for many, many years. And we haven’t seen any signs they’re going to relapse.

So part of that is taking– it sounds like you are, and certainly the surgeon general has said, taking this illness very seriously– it’s very disabling. And really going after it much earlier in the process to get people well quickly–

IRA FLATOW: Your treatment, the SAINT treatment, is a specialized form of TMS, correct, where you’re saying, and your research is showing and your work is showing, that it works a lot faster basically than other forms of TMS? Would that be correct?

NOLAN WILLIAMS: Yeah, that’s right. And so 2.6 days versus– depending upon how you read the literature, I mean, there are faster responders. But for the number of people that we’re seeing get better, the normal form of TMS sometimes takes people 15 weeks. And so being able to get people well in an average of 2.6 days, that’s critically important because, for the working folks that are trying to get better, that are on the edge of losing their job, getting them well in a few days– they can take a vacation to do that and get it done really quickly versus having to do this over a protracted course and having to get permission come off of work to be treated in the middle of the day, that sort of thing, where it’s much harder to do that with the traditional forms. And so we’re really focused on getting people well, to your point, really quickly, and doing it through personalized medicine.

IRA FLATOW: There’s a patient that you treated named Merle a few years back who went through the same treatment. Can you tell us about her story and what changed after that treatment?

NOLAN WILLIAMS: Yeah, so Merle was interviewed on CBS Sunday Morning a number of years ago. So this story is one that I have permission to tell. And so she had been a patient who, as she said in that Sunday Morning special, been through years and years and years of ineffective medication treatments, tens of trials of drugs with little to no effects over time, and got to a place where she was quite desperate to get better and enrolled in our study, was one of the first two participants in our original trials. And within a few days, was completely back to normal, to her old self.

And Merle’s a therapist herself. So she’s seen folks go through these struggles. And they takes a long time or never to get out of these settings, these feelings. And she was able to, within a few days, get back to the Merle that she knew decades before, at a place where she wasn’t depressed. And with repeat treatments and maintenance treatments, she’s been able to stay well for a really long time now, I think four or five years now.

And so there are a lot of Merles out there that are probably folks with similar stories to Merle listening to this. And so I think that the message that I would give is a message of hope. We’re at a place now, with these technologies, where we can actually really get people out of it. And they can resume a normal life. And this has been– the Greeks and Romans used to write about depression, melancholia, and how difficult it was for people. We’ve known this as a problem for thousands of years. And I think we’re right at a place now where we’re going to have tools that we can effectively do something about it.

IRA FLATOW: Mm-hmm. But if it’s only being accepted by Medicare and not your general population of health care providers, how do we get it to those people?

NOLAN WILLIAMS: Yeah, so TMS is paid for by all insurance companies at this point, outside of Medi-Cal. This newer, rapid-acting form is kind of brand new from a commercial sense. And so that just takes time. But having Medicare pay for it essentially right away– they were agreeable to paying for this right after the FDA clearance– is great because it’s a signal that all the folks on disability, all the folks that are 65 or older can get access to this now. And we can start finding those other private insurance companies and working on them to do the same.

IRA FLATOW: Now, your SAINT treatment has been commercialized, correct?

NOLAN WILLIAMS: Yep.

IRA FLATOW: So how soon is it available to everyone outside of California, let’s say?

NOLAN WILLIAMS: Actually, it’s available in Arkansas and South Carolina and Iowa and a bunch of other places soon. And so over the next year, I’d say, where there’s going to be a big expansion there– but yeah, the goal is to have this everywhere where there are Medicare patients that could benefit from it. At and that’s a really great thing. The Center for Medicare and Medicaid Services has done– has built this amazing program called Innovation Funding. SAINT is the first mental health treatment to receive innovation funding. And it received innovation funding for inpatient and for outpatient. And so just really thrilled to see SAINT be a part of that.

IRA FLATOW: Do you have any idea– I know I mentioned this before. When SAINT might be accepted by the general community of caregivers?

NOLAN WILLIAMS: Yeah, I think that the caregivers, it’s been amazing, actually. There’s been, I think, 500 psychiatrists that have reached out to do this. And so on the psychiatrist side, it’s totally there. I think the issue is, for commercial insurance, they really– and it makes sense that they do this. But they really want to have a lot of hoops to jump through to get to a place where they’re willing to pay. And so we’re jumping hoops right now, giving them data, and all of that good stuff. And the hope is that, at some point there’s a calculation within Aetna and Blue Cross, Blue Shield and United and Anthem, all these private insurances, that they can see the real value in getting people well completely and quickly.

And my hope is that, when they do that, then we’re going to be in a position to be able to offer this not just to the folks on disability and 65 and older, but to the working folks that are out there working and have private insurance plan, to your point. And for those of you listening that have those plans, you should still try to look into this, I think. And then some people have been successful at getting single case agreements, where they actually just call the insurance company over and over again. And the insurance company eventually agrees to paying. And we’ve seen success for some people in getting this paid for by just really being clear that your story is one that deserves this sort of payment from insurance.

IRA FLATOW: But you’re saying the other forms of TMS are receiving insurance payments?

NOLAN WILLIAMS: Yeah, the other forms of TMS had to go through the same grind of having to go back over and over again with insurance companies. But now, for conventional TMS, the six-week form of it, it’s paid for by conventional insurance companies, and basically all of them. And so there’s hope for SAINT over the next couple of years for that to be the case. For a lot of people, conventional TMS is helpful today. And so I think that it’s just a matter of really looking out there and seeing what your options are and reaching out and getting your doctor to refer you.

IRA FLATOW: Uh-huh. Dr. Williams, I want to thank you for taking time to be with us, very interesting.

NOLAN WILLIAMS: Yeah, thank you for having me.

IRA FLATOW: Dr. Nolan Williams, Director of the Stanford Brain Stimulation Lab.

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