Insurers are starting to cover TMS for depression (after determining that SSRIs or other medications aren’t working for the patient). A full course, 24-36 treatments, of TMS can cost well over $10k. Though this is purely conjecture on my part, one way tDCS might make it into the mainstream is as a method to ‘top up’ post-TMS treatment as effects begin to fade.
Published on Jun 19, 2017 | YouTubeUCLA
As the number of people suffering from depression rises, doctors are looking for new, more targeted ways to treat it. One approach used by doctors at UCLA and a handful of other centers nationwide is to beam magnetic pulses deep into patients’ brains, a therapy known as transcranial magnetic stimulation (TMS). The therapy is time-consuming, and only a few hospitals or clinics offer it, but its ability to work in a fundamentally different way from medications is also what makes it so promising for people not helped by drugs.
Now that TMS has been approved for the treatment of depression we’re seeing a lot more stories in the news. Naturally this is in part due to the marketing efforts of the four device makers currently FDA approved: Brainsway, Magstim, Magvita, and Neurostar. No doubt patients and doctors are eager to try an alternative where antidepressants didn’t work!
I will update this post as I find new and interesting news stories related to TMS and depression.
Fascinating stories of people with Aspergers who discover feelings and empathy as participants in TMS (Transcranial Magnetic Stimulation) studies. Begs the question, what if, as the effects of TMS fade, tDCS could be used to ‘top up’ their emotional awareness?
Frame of Reference From NPR’s amazing ‘Invisibilia’.
We all carry an invisible frame of reference in our heads that filters our experience. Alix and Hanna talk to a woman who gets a glimpse of what she’s been missing – and then loses it.
Market forces, the for-profit bias that imbues every aspect of health care in America, skew R&D towards solutions and products that are highly profitable. That’s one of the reasons I was so curious about tDCS. You can do it at home. It doesn’t cost a fortune. My initial curiosity was inspired by research papers that seemed to indicate the potential for cognitive enhancement, primarily memory and learning. Many papers later, I’m not so sure, but where it comes to tDCS and depression I’m much more confident. There does seem to be an overwhelming amount of both research and anecdotal evidence to support the use of tDCS in depression. If that were better known, perhaps someone like the woman featured in this NBC news clip would have had somewhere to turn when she was denied coverage for continuing TMS treatment for depression.
No mention of tDCS in his journey to find relief from severe depression, but some new to me and interesting information about treating his depression with Transcranial Magnetic Stimulation. Especially interesting is that a genome test recommended by his psychiatrist led to the awareness that many of the drugs typically used to treat depression would most likely be overwhelming to his system. Also that his insurer, Anthem Blue Cross (through the ACA, Obamacare) covered his TMS treatment. Links below to full article.
Transcranial Magnetic Stimulation, or TMS, is a depression treatment that was approved by the FDA in 2008. It involves placing a magnetic coil on the patient’s head, and stimulating neurons in a specific part of the brain known to be underactive in depression (the dorsolateral prefrontal cortex). Best of all, it has very few side effects: only some uncomfortable tapping on the head where treatment is applied. There are none of the standard side effects we’ve come to associate with medications.
Dr. Shapiro’s company (he is the co-founder and non-executive director), Pure Tech Health created Tal Medical, to develop an LFMS treatment/device.
This is most likely the nexus for looking into LFMS in the first place:
The panel discusses TMS, which has recently been approved by the FDA for treatment of depression. But Dr. Shapiro goes on to discuss LFMS, which (to my readers anyway) is especially interesting because it uses so little power to achieve its effects. (As opposed to TMS which is too complicated and powerful to ever become part of the DIY community. Never say never!)
In 2013, Tal received initial proof-of-concept data from a randomized, double-blind, sham-controlled trial in patients with major depressive and bipolar disorders conducted by McLean Hospital, a leading psychiatric research hospital affiliated with Harvard Medical School. In the study, a single 20-minute treatment demonstrated rapid onset of action, substantial effect size, and a strong safety profile. Given this unique, rapid effect of LFMS treatment, the National Institute of Mental Health has selected LFMS for a multi-site clinical trial. The trial is examining the efficacy and durability of the treatment over an extended period of time in patients with major depressive disorder.
Researching possible patents led to Michael Rohan, Ph.D. and the Harvard Low Field Magnetic Stimulation Lab. I assume there is a partnership between the Harvard Lab, McLean Hospital and Tal Medical, though I could not find any formal announcement. Click through the lab link to do a deeper dive into ongoing research they are presently involved with, including clinical trials.
Effect of tDCS Current on Single-Pulse MEP (motor evoked potentials) Amplitudes This figure taken from Batsikadze et al. (2013)) shows that the “classic” inhibitory profile of 1 mA of cathodal DC stimulation is reversed when intensity is increased to 2 mA.
The Effects of tDCS Polarity. One of the features of the literature in tDCS cognitive studies is the implicit assumption that anodal stimulation is always excitatory and cathodal stimulation is always inhibitory (see Horvath et al., 2015a). Bestmann et al. (2015)) have given a detailed account of why this cannot be the case. It is broadly true that polarity-dependent tDCS changes are directional; however, the effects are not uniform under the electrodes (Batsikadze et al., 2013) and interactions with different cell morphologies and cortical surface shapes create inhomogeneities that in turn change the net effects of stimulation (Bestmann et al., 2015). This is one reason to approach the link between assumed physiology and behavioral effects with caution. It is an important message of this Primer that the field needs to stop making naive one-to-one links between polarity and behavior.
Not tDCS. It looks like TMS (Transcranial Magnetic Stimulation) but I’ve not heard of TMS being applied for more than short bursts before. Also of note in the article is the description of their target:
Their training programme targets the brain’s ‘dorsal attention network’, which links regions of the prefrontal cortex – the bit of the brain above the eyes that helps us make decisions – and the parietal cortex, the ‘switchboard’ for our senses, which is above and slightly behind the ears.
(Caroline Williams)The pulses were aimed at my left prefrontal lobe, to dampen the activity there (Caroline Williams)When I get to the stimulation the next day, it’s not as bad as I feared. At least not at first. For the first minute or so it feels a bit like popping candy is going off under my skull. Five minutes in, though, and it’s seriously annoying – like the worst school bully ever repeatedly flicking me on the head.In all, I have two eight-minute-long sessions of magnetic stimulation, each followed by a 12-minute-long session of computer-based training. I also do three 12-minute blocks of training twice a day, over the internet, wherever my laptop and I happen to be.
TMS, not tDCS but fascinating that they’re having success treating PTSD and autism.
“Right now it’s like we’re selling snake oil,” acknowledges Kevin Murphy, a pediatric radiologist and oncologist running the PTSD and autism trials. “It’s hard to believe, and if I hadn’t had my own son treated, I wouldn’t have believed it.”
Murphy says that after three to four months of magnetic therapy, his 10-year-old, who has Asperger’s syndrome, showed major improvement, to the point of no longer needing a constant one-on-one school aide, reading at a high school level and acing spelling tests when before he could barely write.
“I have colleagues saying, ‘What’s the mechanism?’ ” Murphy says after his talk at the Oakley conference. “I say I don’t know. I’m not at the point where I can say I understand these things.”
It’s like magic, then?
Yes, he says, then mentions a medieval cure. “It’s like gold dust on the belly.”
Though TMS not tDCS, it would be interesting to see the original paper (Targeted enhancement of cortical-hippocampal brain networks and associative memory – paywall). My understanding is that the hippocampus is a difficult target for tDCS. But perhaps insights from this study could lead to ideas for a ‘memory enhancing’ tDCS montage.
To test this, Voss and his team of researchers had 16 healthy adults between the ages of 21 and 40 undergo MRIs so the researchers could learn the participants’ brain structures. Then, the participants took a memory test which consisted of random associations between words and images that they were asked to remember. Then, the participants underwent brain stimulation with TMS for 20 minutes a day for five days in a row. TMS uses magnetic pulses to stimulate areas of the brain. It doesn’t typically hurt, and has been described by some as a light knocking sensation. The researchers stimulated the regions of the brain involved in the memory network.
Throughout the five days, the participants were tested on recall after the stimulation and underwent more MRIs. The participants also underwent a faked placebo procedure. The results showed that after about three days, the stimulation resulted in improved memory, and they got about 30% more associations right with stimulation than without. Not only that, but the MRIs showed that the brain regions became more synchronized by the TMS.
[Apologies for audio quality. It won’t happen again.]
Dr. Jim Fugedy runs the Brain Stimulation Clinic, in Atlanta, GA, and has been treating patients using tDCS since 2007. Download the interviewhere (zipped mp3).
Dr. Jim Fugedy
The Brain Stimulation Clinic in Atlanta is the destination for memory and learning enhancement and treatment-resistant patients who suffer from chronic pain, fibromyalgia, migraine headaches, CRPS, depression and tinnitus. Transcranial direct current stimulation (tDCS) therapy is provided in a pleasant, relaxing environment. Instruction, training and supervision for home use is also available for select patients.
Jim is an anesthesiologist.
The study Jim refers to regarding Felipe Fregni & fibromyalgia: A randomized, sham-controlled, proof of principle study of transcranial direct current stimulation for the treatment of pain in fibromyalgia (full pdf)
tDCS for treatment of fibromyalgia is not certified – it’s ‘off label’
Device is certified, but not for tDCS = no insurance code, can’t be billed to insurance
20 minute treatment for 5 days.
For fibromyalgia – reduces pain, improves issues – fatigue, compromised mental function
(ActivaDose ii Update 3/16 now available as complete tDCS kit through Caputron Medical, use voucher code ‘diytdcs’ for generous discount.)
Most benefit… chronic depression, treatment protocol based on Colleen Loo, Black Dog Institute 6 weeks, follow up maintenance. Up to 8 weeks of treatment + 1-2 treatments follow up maintenance. Daily 20 minute sessions
Can be treated at the clinic for 1-2 weeks. Or home treatment package.
“To treat depression, I place the anode over the left dlpfc (left dorsolateral prefrontal cortex) and the cathode over the contralateral supraorbital area. I have tried positioning the cathode over the contralateral dlpfc and extracephalically (opposite shoulder or upper arm), but the contralateral supraorbital locations provides the most robust effect.” (Correspondence)
Pain montage 2mA, anode M1 & cathode contralateral supra-orbital area
For chronic pain, the M1 is the most used area and that’s almost always my first choice. But you can use the cathode over the somatosensory (S1) cortex, to down-regulate the patient’s perception of pain.
And you can also stimulate the Dorsalateral prefrontal cortex which is involved in the emotional component of pain.
Looking at stimulating right dorsalateral prefrontal cortex to attenuate anxiety.
… it may be a location
for the non-pharmaceutical treatment for ADD.
Office visit $150.
Home use treatment package $2400 includes in-office evaluation and training, ActivaDose ii device, electrodes, and unlimited follow-up via visit, phone, skype…
Only side effect Jim has seen is skin burn (but easily avoided with sponge electrodes).
(Patient with skin burns who’d been treated by a doctor using electroencephalogram (EEG) electrodes.)
Tinnitus responds well, though temporarily, to tDCS
Anode, right dorsalateral prefrontal cortex, cortex opposite supra-orbital Harvard one day course on how to treat with tDCS. Taught 3-4 times a year.
Contrast with approved Electromagnetic treatment for depression (I think he’s referring to TMS transcranial magnetic stimulation here) A 6 week 30 treatment protocol costs between $10-15,000. Affects last about 6 months. And even though it’s certified, it’s not covered by insurance.
…”in the 12 years that it’s been used there have been no side effects reported other than skin (irritations).
“You know we hear stories about Canadians having to wait for surgery. But in the United States, if you don’t have the money and you don’t have insurance, you don’t have to worry about waiting, you won’t get the surgery.”
You can reach Jim at: doctorfugedy [theAtSignHere] transcranialbrainstimulation.com
Every military application of tDCS I’ve seen so far specifically mentions drones and drone pilot training. This logo has a drone in it! For the record, I think the use of drones is illegal and immoral, and that the deaths of innocents is un-American and unacceptable. That said, the tDCS research coming out of this sector is fascinating and will no doubt have an impact beyond military training.
Most of us are attracted to the idea of DIY tDCS because of the low entry barrier – a nine volt battery and a simple circuit (at least in theroy). But also because so much of the science literature coming out around tDCS hints at exciting possibilities for enhancing our cognitive abilities. The thought of DIY TMS, with it’s high voltages never occurred to me. I was shocked! to find these videos of DIYer Ben Krasnow on Youtube. HatTip to Marom Bikson, this came to me by way of his Twitter @MaromBikson
At around minute 13, Tali Sharot describes how she and collaborator Dr Ryota Kanai were able to influence the outcome of experiments designed to test optimism bias by applying TMS (transcranial magnetic stimulation). Amazing!
One way to think about this (very generally) is that, in this case, TMS had both a positive and negative impact. This should also serve as cautionary to anyone self-experimenting with tDCS.
I recently reached out to Dr. Mark Beeman of Northwestern around the subject of testing the efficacy of tDCS especially in the context of DIY. I became aware of Dr. Beeman’s work through the new Jonah Lehrer book, ‘Imagine’. (I haven’t read it actually, but have listened to Lehrer discuss the book at length in numerous podcasts.) Dr. Beeman took the time to respond to my email stating that he was in fact at work on some experiments that use tDCS. About self-experiments, he had this to say…
I’d be hesitant to do too much self-experimentation. Not that I worry about causing direct damage, but brain activity is often a delicate balance, and enhancing some process may have adverse effects on another.
I also heard back from the Laboratory of Cognition and Neural Stimulation at the University of Pennsylvania. They are who posted the questionnaire. Basically it was just a follow-up email asking more questions. I have yet to correspond with anyone personally and they have so far signed their emails as Research Specialist.