Psychiatry is a field where the treatment of our disorders remains perplexing: We’re still trying to figure out if the best way to treat psychiatric conditions is through psychotherapy, with medications, or for more resistant conditions, by stimulating activity in the brain in several different ways.
The field of brain stimulation includes electroconvulsive therapy, as well as transcranial magnetic stimulation (TMS), direct transcranial current stimulation (tDCS), and deep brain stimulation (DBS), all of which are examples of treatments that are still just coming into their own.
Dr. Dinah Miller
In search of an update on brain stimulation, I met with Dr. Irving Reti, director of the Johns Hopkins Hospital Brain Stimulation Program and editor of “Brain Stimulation: Methodologies and Interventions” (Hoboken, N.J.: Wiley-Blackwell, 2015). We met at a Starbucks in Baltimore, and I’ll tell you that a one-on-one conversation with an expert is a wonderful way to learn about state-of-the-art treatments, the only downside being that Starbucks does not offer CME credit.
Dr. Reti, who went to medical school at the University of Sydney and speaks with a charming Australian accent, trained in psychiatry at Johns Hopkins, and then did a neuroscience fellowship.
“I’d just finished residency training, and I was giving ECT to rats. We were looking at the expression of immediate-early genes. At the same time, I started doing consults in the mood disorders clinic.”
In 2006, Dr. Reti took over as director of ECT at Hopkins, and that same year, Dr. Jimmy Potash got funding to study TMS. Dr. Potash has since moved to the University of Iowa, and Dr. Reti took over TMS administration at Hopkins. Dr. Reti was flattered to be approached by Wiley to edit “Brain Stimulation,” and he talked about how he was pleased with the final edition of the book.
“I ended up getting the top people to write the chapters, people like Sarah Lisanby, Michael Nitsche, John Rothwell, and Mark George. These are the leaders in the field of brain stimulation.”
I asked Dr. Reti to walk me through what was happening in each brain stimulation area.
“In ECT,” he said, “we know a lot more now about how both the settings and the anesthesia regimen affect the outcomes. We didn’t know this when I trained in the ’90s.” Dr. Reti estimated that he’s administered ECT to close to 2,000 patients.
TMS is done less often at Hopkins; he estimated that 10-20 patients receive the treatment, and each patient comes 30-40 times, with each session lasting 40 minutes.
“It’s better than medicine but not as effective as ECT. We’re seeing an efficacy rate around 50%-60%,” and he noted that some patients have trouble tolerating the procedure as the magnetic stimulation can be uncomfortable. “The TMS coil stimulates the scalp nerves and muscles immediately under the coil, which causes discomfort.” He noted that some patients need to premedicate with over-the-counter pain medicines.
“We’re also finding that low-frequency stimulation on the right can be helpful for anxiety,” Dr. Reti said.
He talked about treating patients with psychotherapy along with TMS. The brain changes are thought to increase the brain’s plasticity and perhaps make psychotherapy more effective.
“It’s being studied in drug treatment. You can show someone with an addiction stimuli to trigger cravings, and doing this with TMS may block the response,” he said.
He talked for a while about direct transcranial brain stimulation, which I was not very familiar with. Because it is being used to improve focus-playing video games, the equipment is not being marketed as a psychiatric treatment and doesn’t fall under the domain of the Food and Drug Administration.
“Kids are using it to improve their concentration and performance with video games; all you need is a 9-volt battery and some electrodes that are attached to the scalp. The kits cost about $250, but you can burn your scalp,” he said.
Dr. Reti referred me to an article in the New Yorker on tDCS, “Electrified: Adventures in transcranial direct-current stimulation” by Elif Batuman. He noted that there are studies in progress to look at therapeutic uses for tDCS, including one at Johns Hopkins where neuropsychologist David Schretlen is looking at improving cognition in schizophrenia. Dr. Reti is interested in seeing if tDCS might be helpful in decreasing self-injurious behaviors in autistic children, as ECT has been effective in severe cases. He noted that while ECT and TMS stimulate neurons in the brain to fire, tDCS changes the stimulation threshold without directly causing the neurons to discharge.
Finally, we talked a little about deep brain stimulation. Thin electrodes directly target nodes in brain circuits that can modulate the activity of those circuits. He noted that deep brain stimulation was being used at Johns Hopkins to treat Parkinson’s disease, and other centers have looked at its use for severe obsessive-compulsive disorder and treatment-resistant depression.