DULUTH — Treating depression with medications can be — well, depressing.
“When you’ve been doing outpatient (treatment) for 10 years, you get a lot of patients over time you’re trying to help and trying to help and trying to help, and your medications aren’t going to help,” said Dr. Eric A. Johnson, a Duluth-based psychiatrist.
So Johnson, a telepsychiatrist for Nystrom & Associates, gave himself an extra job on the side. In a room of the Endion neighborhood mansion where he and his wife live, Johnson installed a $230,000 piece of equipment that uses powerful magnetic impulses in hopes of disrupting unhealthy thought patterns.
He set up a reception area just inside an entryway and fashioned another room as a waiting area, and called his business Duluth TMS.
TMS is short for transcranial magnetic stimulation. The Food and Drug Administration in 2008 approved its use for depression when medications haven’t been successful. Treating depression patients with TMS isn’t unique to Johnson in Duluth — St. Luke’s also offers TMS, Johnson said.
But last year, the FDA also approved it for treatment of people with obsessive compulsive disorder, although again not as a first-line treatment. Although it’s much more commonly used for depression, Johnson now is offering TMS for OCD as well.
“We don’t eliminate the OCD,” he said. “But we can make people more comfortable and less symptomatic; make things a little easier for them.”
But here’s the rub: The standard treatment of five daily sessions per week for six weeks costs between $10,000 and $15,000, Johnson said. Medicare and most insurers will cover that for treatment of medication-resistant depression, he said.
But “it can be tricky to get coverage for OCD,” said his business manager, Joe Morales. “This year we had one patient with UCare who was covered for OCD. If we have enough medical documentation, we can get coverage.”
Dr. Alik Widge, a psychiatrist at the University of Minnesota Medical School’s McGuire Translational Research Facility, said last week that he’s equipped to offer TMS for OCD, but so far no insurer has agreed to cover it. This means patients who might benefit aren’t being treated.
“A course of treatment can run north of $10,000, and for many people that’s just outside their reach,” Widge said in a telephone interview.
The fact that insurers are reluctant to cover it bugs him.
“If this was a new treatment for cancer, it’d be covered in a snap, no problem,” said Widge, who researched the treatment for several years at Massachusetts General Hospital before coming to Minnesota a year and a half ago. “It’s a new treatment for OCD, people think, ‘Oh, you should just be able to will yourself out of it.’ There’s still a ton of stigma.”
Part of the challenge is that TMS is too new as a treatment for OCD to really have a sense of how successful it will be, Widge said. As a treatment for depression, published studies show 30-60% of patients getting better, and he said he’s expecting a similar result in treatment for OCD.
What’s clear is that not everyone will benefit.
“It you don’t see anything at four weeks, there’s not a lot of point …” Johnson said, before reconsidering. “Actually, I’ve seen some research that says six weeks.”
Both Widge and Johnson said the first treatment isn’t likely to have much effect, but there can be exceptions.
“One of our clients went running for the first time in two years on the day after her first treatment,” Johnson said.
One individual who experienced noticeable short-term improvement was Courtenay Harris Bond. A freelance journalist in Pennsylvania, Bond wrote a piece for the Philadelphia Inquirer in March 2018 about her own treatment for major depression with TMS. She described the sessions as feeling like an electric woodpecker was hammering on her head but added that, strangely, it wasn’t painful.
At the conclusion of her 30 sessions, she wrote, “I began working and parenting again and ultimately feeling brighter, more hopeful and more resilient than I had in as long as I could remember.”
Her psychiatrist, Dr. John O’Reardon, discussed maintenance treatments for her in the future of one or two per month. He also gave her hope that her depression could be, essentially, cured.
Unfortunately, it didn’t turn out that way. In a phone conversation last week, Bond said she had determined that continuing maintenance therapy would be impractical and too expensive. O’Reardon was out of network for her insurance company, so she had been left paying most of the bill. It also hadn’t been working well enough in her case, she said.
The struggles of nearly a lifetime have resumed.
A depressive episode this fall “really knocked me off my feet in a way that I haven’t experienced since I was probably 18 or 19,” said Bond, 48. “So it was a doozy. But the one that took me to TMS was pretty bad, too.”
She credits TMS for bringing her out of that depression and is grateful to O’Reardon for that, Bond said.
Maintenance therapy with TMS isn’t the norm, Widge said. “Most people don’t need it. But when they do, we do it.”
To the uninitiated, transcranial magnetic stimulation sounds a little creepy.
“We use high-powered magnets,” Johnson said, “flipping them on and off to stimulate the brain thousands of times per treatment and tens of thousands of times per course of treatment.”
Yet there are few side effects and only a few reasons why TMS wouldn’t be appropriate for certain patients. If you have any metal in your head, such as a stent or a clip for an aneurysm, you can’t get TMS, Johnson said. That also applies to certain tattoos that have metallic dyes that could get super heated by the magnets. But you probably don’t have to worry about the fillings in your teeth.
“By the time you get down to the teeth, you’re usually OK,” he said.
The patient may experience a headache, but that usually will go away as soon as the treatment is over, Johnson said. There may be scalp irritation. In the early days of TMS, some patients suffered seizures, and it's still something practitioners watch for, he said.
Unlike some other treatments, there are no long-term cognitive side effects, Widge said. Other than the daily trip to the office, the treatments don’t interfere with the patient's life.
“People are able to come get a treatment and go right back to the office,” he said. “They can go drive their car. They can go to class. They can do whatever they need to do.”
Many of those patients have tried just about everything else.
“A lot of my patients were having years of — decades of — depression, and multiple medications, mood stabilizers, anti-psychotics, ECT (electroconvulsive therapy),” Johnson said. “I would love some easier cases. If somebody has failed two medications, they’re eligible for TMS. They don’t have to go on suffering for decades. Send them to me.”
Business is going well, Johnson said last week, and he’ll be adding a second machine that costs $150,000.