Resetting the Brain

From left to right: Anca Zinnes, M.D.; Nicola Sater, M.D.; and Erica Richards, M.D., Ph.D.; with behavioral health nurses Agnes and Michael
From left to right: Anca Zinnes, M.D.; Nicola Sater, M.D.; and Erica Richards, M.D., Ph.D.; with behavioral health nurses Agnes and Michael

Addressing treatment-resistant depression through the Johns Hopkins Psychiatry and Behavioral Health Program

Depression can descend like a dark cloud, preoccupying the mind and blotting out memories of better days. Despite the strong feelings of loneliness and isolation it often brings, depression is anything but unusual. In 2016, the latest year data
is available, some 16.2 million Americans aged 18 and older experienced a major depressive episode, or 6.7 percent of U.S. adults, according to the National Institute of Mental Health. And depression is becoming more prevalent; a study published in the journal Psychological Medicine in October 2017 found that the rate of depression increased significantly in the U.S. between 2005 and 2015.

Although the number of new medications to treat depression has multiplied over the past few decades, a large subset of patients still struggle to find relief. The large STAR*D trial, conducted by the National Institute of Mental Health and reported in 2006, found that more than half of patients did not experience full relief from the first medication they tried. Up to a third did not find relief even after trying four different medications.

Patients who do not respond to multiple antidepressant medications or cannot tolerate medication side effects may have treatment-resistant depression. This can be demoralizing; however, there are still treatment options for these patients, notes Erica Richards, MD, PhD, chair and medical director of the Department of Psychiatry and Behavioral Health at Sibley.

The new Psychiatry and Behavioral Health Program offers two noninvasive, well-documented therapies that are available on an outpatient basis: “Transcranial magnetic stimulation, or TMS, and electroconvulsive therapy, or ECT, are treatments that are able to help many people who have not benefited from medication,” says Dr. Richards.

DEEP STIMULATION

Both TMS and ECT work by resetting the brain circuits involved in depression, although in different ways. TMS uses a treatment coil, placed on the head over the left temporal region of the brain—the left prefrontal cortex—which is linked to mood control. The coil generates highly concentrated magnetic fields (the same type and strength used in an MRI) that turn on and off rapidly to produce lasting changes in brain activity. Throughout the short procedure, patients are awake and alert.

“With TMS, we’re looking at stimulating specific parts of the brain that play a role in depression and reward circuits,” says Dr. Richards. For the past four years, Sibley has been using a new type of TMS technology, known as deep TMS, or dTMS, which reaches deeper and stimulates more of the brain, compared to traditional TMS technologies. Treatments last 20 minutes, compared with 35–40 minutes for earlier forms of TMS.

“We’re talking about 30 minutes of your time, and it’s noninvasive,” Dr. Richards says. “Often people come before or after work, or even during their lunch breaks. There are no significant side effects.”

Sessions are scheduled five days a week for the first six weeks, followed by up to 12 weeks of a taper consisting of treatments two to three times weekly. “We typically see improvement between treatments 16–20,” Dr. Richards notes. The sessions are covered by many insurance providers. Data show the patients are getting better—even 16 weeks after the completion of treatment—there’s still a significant improvement in their depression, she says.

RAPID RESPONSE THROUGH ECT

ECT is another valuable tool in the treatment of depression. While the patient is asleep with general anesthesia, and the muscles relaxed, a low-voltage electrical stimulus generates a controlled seizure in the brain that typically lasts less than a minute. Twenty minutes later, the patient is usually fully awake, and most people are able to leave the hospital within hours. “This is not what you may have read about in books or seen in movies,” Dr. Richards says. “It is well-tolerated, and we have ample data showing its effectiveness. We can see results as quickly as the first three treatments, which can provide significant relief for patients who have been suffering from severe depression.”

“One of the deciding factors in choosing to use ECT “is the degree of suffering and severity of depression,” Dr. Richards explains. “It is not the answer for everyone but can be lifesaving for some patients with unipolar and bipolar depression, and it has stood the test of time.”

A GROWING TEAM

Sibley is one of the few regional hospital-based services in the area. “We’re growing,” Dr. Richards says. “We are expanding inpatient and outpatient services with the support of The Johns Hopkins Hospital, highlighting its commitment to the Washington, D.C., community. We have a diverse group of providers dedicated to serving patients of all ages, from young adults to the elderly.”

The inpatient team includes Anca Zinnes, M.D., who plays a key role in the ECT and TMS programs; Nicola Sater, M.D., who treats conditions that often occur in conjunction with depression, including eating disorders and insomnia; and Dr. Richards, who specializes in women’s mental health, including pregnancy and peripartum issues.

Sibley also has a very experienced team of psychiatric nurses to help care for patients admitted to the hospital and in the outpatient clinic, Dr. Richards says. “In addition, several private psychiatrists within the Sibley community, including Drs. Celia Oliveira, Frank Moscarillo, Terry Teplitz and Stephen Polakoff provide ECT and/or TMS services,” Dr. Richards says. “The team also provides consultation services to the rest of the hospital, collaborating with other doctors in the treatment of medical  and surgical patients. Dr. Teplitz specializes in geriatric psychiatry consults.”

The behavioral health team also consists of psychiatric social workers who help conduct mental health evaluations in the Emergency Department and will soon be offering outpatient treatment options. The team works closely with other providers at Sibley, including the physicians in the pain and bariatric surgery programs, Dr. Richards notes. “We appreciate that there are mental health concerns often associated with a multitude of illnesses,” she says. “Working together, we help our patients get better faster.”

For more information about the Johns Hopkins Psychiatry and Behavioral Health Program, call 202-243-5178.


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