A depression treatment often used as a last resort for people who do not respond well to drug therapy is gaining traction after proving successful on a number of patients.
Repetitive transcranial magnetic stimulation, or rTMS, is currently used as a treatment of last resort.
For 19-year-old Perth student “Max”, who did not want his real name used, little else had worked to treat his depression.
“I was very low and sad and demotivated,” he said.
“Before the treatment I was having trouble even getting out of bed, eating, taking care of my hygiene.”
His mother “Carly” said when depression affected her son, it would hit him hard.
“He really can’t do normal everyday things that other people take for granted – he often can’t get out of bed, he can’t get out of the house, he can’t get to a university lecture or a day’s work,” she said.
“It sounds bizarre but he just can’t – he can’t get that motivation.
“It’s not just about feeling sad – although there’s a certain element of that – it’s about just not having the energy and the will to complete very simple daily tasks.
“It’s very difficult for him because he feels like his life is passing him by and he can’t achieve things that he knows he wants to achieve … so it’s fairly devastating, from what he has told me, to actually experience it.”
Max was a little apprehensive about rTMS before the first session at Graylands Hospital.
“You sit down in a chair. It’s a bit like a dentist’s chair, and they put a wand up to your head, it makes a clicking noise,” he said.
It freaked him out “a little bit”.
“They put electrodes on your head before they do it. It was a little bit scary but I got used to it fairly quickly,” Max said.
There were daily sessions for a month and it took a little while before he noticed any difference.
“It took about two weeks to take effect,” Max said.
“After the treatment I can do all of those things [sleeping, eating, working, going to university] and I’m pretty much back to my normal self.”
‘Neurons are firing’ so brain works better
Senior scientist in electro-physiology at the hospital’s department of neurophysiology, Dr Greg Price said rTMS clinical treatments started in Western Australia in 2011.
“It basically induces wave forms in the cortex of the brain and makes neurons fire,” he said.
“When it’s applied to a particular area, it is used as a treatment for depression.
“It’s not the first treatment that’s tried but if a patient tries at least two anti-depressant medications then we’ll administer a trial of rTMS.
“It’s usually fairly severe patients, probably a slightly larger proportion of females to males, all ages.”
It has the effect of stimulating certain parts of the brain.
“When those neurons are firing … the synapses work better, and somehow by those synapses working better, it makes that part of the brain work better,” said Dr Price.
“That part of the brain is then more active where previously it had been shown to be hypo-active in depression.”
Carly said Max completed high school before he was diagnosed with depression.
“During year 12, he had what I now know were bouts of depression but we weren’t able to recognise what they were at the time,” she said.
“Looking back it’s pretty easy to identify. He went through stages where he literally couldn’t get out of bed.
“He was formally diagnosed with depression when he left school and tried to start university, and his life just fell apart, which is apparently reasonably common in teenage boys.
“They’ve left the security of school and they’re suddenly in this big grown-up world and if they’re prone to that, then that’s often when it will manifest in a particularly bad episode.”
Treatment of ‘last resort’ offered after drugs did not help
Carly said Max dropped out of university and they cared for him for a time.
“He started drug therapy with fairly limited improvement,” she said.
“In the course of this diagnosis and attempt at treatment, he was diagnosed with autism spectrum disorder, more specifically Asperger’s, and again, looking back, we can see that this has been a big feature of his life.
“Often undiagnosed autism or Asperger’s – the figures where the sufferers end up with depression are quite high, and that makes a lot of sense. You realise that you’re a bit different from everybody else, you don’t know why, you don’t have a name for it, and it’s no surprise really that you’re going to end up depressed.”
Carly said treating the depression with drugs had little impact.
“It wasn’t very successful – that’s probably still a learning journey where his drug treatment is tweaked. It’s a lot better than it was in the early days,” she said.
“He also had several stays in hospital which wasn’t the answer for him either.”
It was also difficult to know whether they were making the right decisions.
“It’s frightening; you don’t know what has happened to your child and you don’t know if the way they’re being treated is the best way,” Carly said.
“It’s very obviously a long-term illness – you can go for a long time without seeing an improvement, and as a parent, that’s pretty devastating that you feel you can’t fix this problem.
“It’s a problem that not a lot of people understand. They don’t understand when I say he can’t get out of bed.
“They will say things like, ‘well, make him, I’d make my child’ and reflect on the way that you might have brought this child up.”
Dr Price said rTMS treatments do not work for everyone.
“We have found that approximately 20 per cent of people don’t get a benefit from the treatment. Approximately 40 per cent get remission – that is, they reach a level that is not considered to be depressed – and about 40 per cent get a benefit but it’s not to remission,” he said.
“Essentially that means things like energy levels are better, it means sleep usually is better, it means thoughts of suicide are less, it means anxiety typically is lessened. It could be anyone or a combination of those.”
rTMS treatment still being tweaked
Dr Price said only about 60 to 70 patients in WA are treated with rTMS a year, and researchers are still feeling their way on what works best.
“It’s definitely a new treatment – people are still working out the best parameters, the timing, how many stimuli to apply, how many to apply, what intensity to apply, that’s still being worked out,” he said.
For some people, there is an immediate and lasting benefit.
“In our experience, we have some people who respond well, and they stay well indefinitely,” said Dr Price.
“Other people, they respond well and after a year or so, they’ve suffered a relapse, and will come back in for another session.
“There will be patients who will relapse in a shorter term – three months is at the low end but there are people who relapse over that time.”
Dr Price would like to see the treatment made more widely available.
“I believe the benefits that people report from the rTMS make it worthwhile and it’s got a strong rationale in that rTMS will make neurons fire and we know that when neurons fire, they work better,” he said.
For Carly, rTMS has made an “enormous” difference for Max, and the family.
“It’s very, very draining caring for a depressed person,” she said.
“It’s difficult on his siblings because he takes a lot of care and they lose a lot of time from their parents.
“When he’s well, with the Asperger’s he’s a bit eccentric, but that’s fine; as he says ‘normal is boring’ and we like eccentric.”
With rTMS treatment, Max is back to his normal self.
“At the moment, he’s at work today, he’s back at uni, he’s able to … function,” Carly said.
“My hope is that he will end up on some sort of maintenance program with this and be weaned off the drug therapy.”
The health department said there were no plans to extend rTMS treatment at this stage.