Questions and Answers: What to do if depression medications don't help

Approximately 30-40% of patients do not respond to medications for depression and obsessive-compulsive disorder (OCD), but half of them can benefit from a non-invasive office procedure. p>

In honor of National Mental Health Awareness Month in May, we speak with psychiatrist Katherine Scangos, MD, PhD, co-director of the Transcranial Magnetic Stimulation (TMS) Program and neuromodulation at UC San Francisco.

TMS is a logical next step for many patients who have insufficient response to standard treatment, according to Scangos, who is affiliated with the UCSF Weill Institute for Neuroscience and is an assistant professor of clinical psychiatry.

Scangos is especially happy for patients who have found success with TMS after long periods of depression. She admires those who have been able to reconnect with family and friends, make plans, and engage in activities they had been putting off.

How does TMS work?

The treatment involves delivering brief magnetic pulses to the brain through an electromagnetic coil placed on the patient's head. This causes electrical currents that stimulate nerve cells in certain areas of the brain. In patients with depression, the target area is the dorsolateral prefrontal cortex, a part of the brain involved in the cognitive processing of emotions. In OCD, impulses are sent to other parts of the prefrontal cortex associated with repetitive behaviors.

Most of our patients undergo a newer version of TMS known as intermittent theta rhythmic stimulation, which takes only three minutes. Because no sedatives are required and side effects, if any, are minimal (the most common being scalp irritation), patients can return home or work immediately after the procedure. The course of treatment usually consists of 20-30 sessions over four to six weeks.

How quickly does it start working?

Some patients begin to feel improvement after one to two weeks. Others may need four weeks or longer. Depression and OCD can be lifelong disorders, and repeated treatments may be required after several months or years.

For depressed patients undergoing TMS, half may experience at least a 50% reduction in symptoms. For those with OCD, half may experience at least a 35% reduction in symptoms.

What are the criteria for TMS?

Most patients have major depressive disorder and have completed several courses of medication and counseling with more than one therapist before beginning TMS. Insurance companies typically require that patients with depression or OCD, which is often accompanied by depression, have not experienced significant improvement after trying at least two medications. We work with patients ranging in age from approximately 21 to 70 years old, but we treat each individual individually.

Who is not suitable for TMS?

Patients with anxiety disorder without depression may not respond to TMS. People who are pregnant, have a high risk of seizures, have epilepsy, or have metal implants in the head should not undergo this treatment.

TMS is not suitable as a first step for patients in crisis requiring immediate relief. The drug esketamine (Spravato) may improve your mood within hours or days. Electroconvulsive therapy (ECT) can relieve symptoms faster than TMS and is more effective. But it involves the use of anesthesia and electrical stimulation to induce seizures, making it more invasive than TMS.

Research is exploring the use of therapy for chronic pain, anorexia, post-traumatic stress disorder, schizophrenia, anxiety and addiction. The results are encouraging for some but not all of these conditions.

Do patients continue to take antidepressants and therapy?

We ask patients to continue taking their regular medications and psychotherapy during TMS and for at least a year after treatment. Often medications provide some benefit, but are not enough to relieve symptoms. We also notice that patients become more receptive to psychotherapy as TMS progresses and mood improves.

How to understand that the patient is getting better?

We track patients' scores with a test that evaluates symptoms such as decreased appetite and sleep, difficulty concentrating, sadness, internal tension, and slowness in daily activities. And we look for signs that patients' emotions have improved and they are becoming more sociable and expressive.

We find out that they are doing household chores, perhaps washing clothes and preparing dinner. They tell us they call friends, watch movies and TV shows that make them laugh—activities they haven't done in months or years. It is very rewarding when patients reach this stage of recovery.