Hampton VA part of a pilot program treating medicine-resistant depression
By Courtney Mabeus
Charlene Campbell slipped a blue cap over her ponytail, velcroed a chinstrap into place and popped in her mouthguard.
As she settled into her seat at the Hampton Veterans Affairs Medical Center’s Behavioral Health Center, Dr. Kenneth Miller guided a plastic helmet-like device, lined on the inside with coils, over her head.
“On the count of three, I’m going to go ahead and get you started,” Miller, a psychiatrist, said. “Ready?”
With her left hand, Campbell, an Army military police veteran from Yorktown, popped a thumbs up. In her right hand, she gripped a small, white rubber stress ball emblazoned with the VA’s crisis line logo.
Miller counted down: “One. Two. Three.”
In the span of two seconds, 36 magnetic pulses fired into Campbell’s dorsolateral prefrontal cortex, the part of the brain that manages executive function. A rapid knocking – a sound like a jackhammer muted by walls and distance – filled the room. Campbell’s hand tensed around the ball, not because of pain but to steady slight twitching caused by the motor stimulation. Twenty seconds later, 36 more pulses, another squeeze.
After a few rounds of pulses, Campbell pulled out her iPhone. Holding it in her left hand, she used the fingers on her right, which still held the ball, to scroll through news and Facebook to catch up with posts from family during the 20-minute procedure.
Campbell was in her third week of deep and repetitive transcranial magnetic stimulation, also known as TMS, at the Hampton VA – one of about 30 veterans centers nationwide that offer the treatment as part of a pilot program.
Early every Monday through Friday for four weeks, before she headed to work, a machine shot 1,980 pulses into her brain with the goal of alleviating the depression she has dealt with for 20 years, along with anxiety and post traumatic stress. She said she was able to hide her feelings and could function daily, though she often isolated herself from her husband and five children.
“I was very depressed for a very long time,” Campbell said.
An estimated 16.2 million U.S. adults – 6.7 percent of the adult population – experienced a major depressive episode in 2016, according the the National Institute of Mental Health. As many as 20 percent of patients experiencing depression may fail to respond to traditional treatments like medicine and psychotherapy, according to a four-year clinical trial of veterans who received TMS published in June in the Journal of American Medicine Association Psychiatry.
The procedure uses an electromagnetic coil placed against the head to deliver pulses to the brain that stimulate and activate nerve cells in the cerebral cortex. The treatments are non-invasive and do not require surgery or sedation. Short-term side effects include scalp discomfort and headache, but because the treatment is relatively new, long-term effects remain unknown.
“Those brain cells are part of circuits and those circuits, amongst other things, regulate mood and motivation,” Dr. Irving Reti, director of the Brain Stimulation Program at Johns Hopkins University, said.
TMS has grown in popularity since it was cleared for use by the Food and Drug Administration in 2008 for patients with major depressive disorder for which at least one anti-depressant has failed to work. Eastern Virginia Medical School has been using TMS since 2010; Virginia Commonwealth University, the University of Virginia, and some private providers in Hampton Roads also offer it.
The Hampton VA has seen 13 active patients since opening its behavioral health center in April, with more scheduled soon, Miller, who directs the TMS clinic, said. Data is being shared to see how effective it is and how it aligns with research that’s been completed. Hampton VA patients receive a minimum of 20 outpatient treatments during the “acute” phase before tapering off. Patients must have a referral and a diagnosis of major depressive disorder, and previous treatment options must have failed, Miller said.
Researchers say TMS may also prove useful in treating post traumatic stress, strokes, traumatic brain injury, Alzheimers, addiction and other conditions. In 2016, Dr. Serina Neumann, a psychologist and researcher at EVMS, did a study on combat veterans with post-traumatic stress that combined TMS with a form of talk therapy. She wants to follow up on a finding that showed cognitive function improved with the treatment and would like to test if it also might help those with mild traumatic brain injury.
While the cost of TMS to treat depression at VA was not clear, a study released in April in the Journal of Neuropsychiatry and Clinical Neurosciences estimated a 30-minute session in 2009 at $300.
Data on the effectiveness of TMS, and how it is carried out, varies. An NIMH five-year clinical trial published in 2010 in JAMA Psychiatry found that 14 percent of TMS participants went into remission as opposed to 5 percent of those receiving sham treatment. Remission rates reached 30 percent during a second phase in which all participants received TMS.
Those participants weren’t taking anti-depressants, said Dr. Mark George, who directs the Brian Stimulation Laboratory at the Medical University of South Carolina. George also co-directed a VA clinical trial of 164 veterans who received TMS or a sham treatment, the results of which were published in June. Participants had to have failed at least two anti-depressants but were allowed to continue with medications they were currently taking. They were also not excluded if they also had post-traumatic stress or histories of substance abuse, which are common among veterans.
The VA study found little difference between those who received TMS and sham: 40 percent who got TMS reported remission; 37 percent of those receiving sham did so. That lack of difference disappointed George, who speculated reasons the sham rate was so high: Many of the participants were socially isolated before treatment and may have simply benefited from the study’s interaction with hospital staff. Others may have inflated their response because of their attachment to the warrior ethos of military service.
“You’ll do anything that you can to help your fellow soldier, and a lot of the veterans who participate in this trial and other research still have that credo,” said George, who is also a physician at the Ralph H. Johnson VA Medical Center in Charleston, S.C.
But a 40 percent remission rate is a lot higher than the 14 percent in the earlier NIMH study.
“The great news is that about 40 percent of these patients got substantially better,” George said. “I mean, they got their lives back.”
It’s possible that the stimulation itself may make a difference in alleviating medicine-resistant depression. Where the recent VA study used a type of coil to that’s more commonly used in TMS, called a “figure-8,” the Hampton VA’s device, manufactured by BrainsWay, uses a coil called “H1.” That coil produces deeper brain stimulation, though it is less targeted and more broad, researchers say. Data provided by BrainsWay showed that 42 percent of patients achieved remission within 20 sessions. Among those who continued to 30 sessions, 51 percent reached remission.
Campbell traces some of her struggle to an incident during a seven-month deployment to Saudi Arabia during Operation Desert Storm/Desert Shield from 1990 to 1991. She was a first responder in Dhahran, where a Scud missile bombing on a transient U.S. barracks killed 27 soldiers and injured nearly 100 personnel. The attack was among the deadliest of the war and she said she blamed herself for failing to do enough to save her fellow soldiers. Seeing and dealing with so much, she shut her emotions off.
“Of course you think there’s something you should have done differently,” Campbell said. “You should have gotten there faster, you should have been better trained, you should have had more equipment.”
Campbell was treated by a civilian doctor, but felt a disconnect because of her military service. She sought treatment at the Hampton VA around 2010. Prescription pills only worked sometimes, and she has continued to take a low dose of the anti-depressant Trazadone, from which she is slowly tapering. Others, like Xanax, didn’t work at all.
“All I can say is your typical anti-anxiety drug and anti-depressant didn’t work,” she said.
Therapy helped some, but Campbell said she hit a wall. Intellectually, she said, she knew what was happening inside her head but her heart wasn’t feeling it. She could have given up, but her doctors, who referred her for TMS treatment, and her family kept her going.
“It’s never too late to be the best mom in life I can be,” Campbell said. “It just isn’t, you know? I know that my struggle has been their struggle also and you know that is something that I will always feel bad about but, I know it’s never too late for me to be better for them.”
It didn’t take long for Campbell to notice improvements in her mood after starting treatment. During her first week, she slept better. In her second week, she was bouncing back from her anxiety and depression quicker. Things that previously provoked her anxiety, like a hefty work load, weren’t weighing on her as much.
Campbell completed the acute phase of treatment in late June, in time for a family vacation. By early July, she said, she wasn’t sure remission was something she might ever achieve, but her depression was more manageable and her anxiety was “real low, whereas before it was really unmanageable.” She said she would go back to the VA for more treatments in the future.
“I’m doing really good and feeling good,” she said.