Antidepressant alternatives
Consider options other than medication.
Even before the pandemic, when it came to antidepressant use, Canada had one of the highest consumption rates in the world.
And then, along came COVID-19, which, according to Express Scripts Canada, is likely a factor in 2020’s 11-percent, year-over year increase in prescription antidepressants. There were two noticeable spikes: during the first wave and around Thanksgiving.
This is probably unsurprising to many, given that we are social animals in isolation and there have been multiple warnings of a looming mentalhealth crisis since pretty much Day One. Dealing with it will be a challenge, particularly because medication doesn’t work for everyone.
“The National Institute of Mental Health spent about $35 million to determine the effectiveness of medications and psychotherapy. The rule of thumb is that, with each new prescription, the chances of people getting better goes down and the incidence of side effects goes up,” Dr. Leo Steiner, a psychologist and founder of TMS Clinics of Canada, said about a 2006 study that surveyed over 4,000 patients.
“The first medication has about a 30-per-cent remission rate and then, after that, if the first medication fails and a patient is switched to a new treatment, chances of remission go down to 25 per cent and then 12, and then seven and five per cent.”
So what’s the alternative? Steiner is an advocate of a combination of psychotherapy and repetitive transcranial magnetic stimulation (TMS), a treatment that was approved by Health Canada for “treatment-resistant depression” in 2002. It’s an intensive regimen — three to five days per week for six weeks — but it boasts a 50-per-cent remission rate and has been shown to be effective, even with patients for whom three, four or five medications
have failed.
We asked professor Lara Boyd, a TMS researcher at the University of British Columbia’s Centre for Brain Health, how the technology works.
“What transcranial magnetic stimulation does is use electromagnetic induction, so it kind of plays with magnetism so that it can actually pass a current through your scalp, through your skin and into the top layer of your brain,” explained Boyd. “It does that painlessly because it’s not actually an electrical current, it’s this magnetic current.”
Boyd continued: “And what’s really neat about it is that it can then activate the neurons in the top layer of your brain.”
That, she said, is a little like turning on cells that haven’t been active, although she qualified this explanation by saying it’s a little more complicated than that. And we should also mention that Steiner uses “deep” TMS, which passes the current a little deeper than other TMS machines.
Still, all TMS operates on the
same theory, namely that with depression there’s an asymmetry in the activity levels of neurons in different parts of the brain and TMS is designed to even out the activity levels. Steiner likened it to a ballroom dancing team, with a lead and a follow.
“The lead knows what to do and when to do it, but it doesn’t have the energy or the passion of the follow,” he said. “The follow has the energy and passion, but doesn’t know what to do. When they’re dancing together nicely and holding hands it’s a beautiful dance, but if there’s sudden loud feedback from the speaker they lose their grip and can’t find each other.”
The “follow” here is, in essence, the mood. And when the mood becomes painful, we might try to control it with problematic behaviours, including compulsive actions and/or turning to addictive substances.
To get the duo dancing in harmony again, the theory is that TMS reactivates the “lead’s” neurons, which haven’t been doing their job. But TMS is only part of the solution; cognitive behavioural therapy (CBT) and behavioural activation therapy (BAT) sessions play a role, too.
“The psychotherapy works on
the same circuitry, so it helps the rational part of the brain wrestle back that control over the emotions so the psychotherapy and the TMS feed off of one another,” Steiner explained.
BAT, which falls under the CBT umbrella, is largely about adopting healthy habits, including exercise, shopping and cooking for yourself, getting enough sleep, making social connections and having reasons to get out of bed in the morning.
Having a pet to look after is a surprisingly effective piece of the puzzle.
Steiner recommends people redouble their efforts with these things and, in addition, give themselves room to be depressed sometimes, as well as giving themselves permission to be happy, especially now, with so many of us feeling the effects of not going out and being subjected to the onslaught of continuously bad news.
So why aren’t we hearing more about it? Could it be unpleasant side effects? There are concerns about seizures with TMS, but everyone we interviewed says they’re exceedingly rare.
“I think one of the advantages of TMS is that it has very low side effects compared to medication and I think that’s why there’s so much demand,” said Sara Tremblay, a neuropsychologist at the Royal’s Institute of Mental Health Research in Ottawa.
“So far, with my clients that we’ve treated, that’s something they’ve told us they really appreciate. The only side effect that people can experience is a small headache, especially at the beginning but only during treatment. Typically, it lasts five to 10 minutes and after a few treatments typically disappears.”
Likely the biggest factor in why we don’t hear much about TMS is the fact that it’s not covered by Ontario’s Health Insurance Plan. There are TMS machines in some hospitals and several private clinics, but it can’t be called widely available.
By contrast, the treatment is covered in Quebec (where Tremblay started her research before moving to Ottawa) and she said that’s meant that TMS is available in that province, even in remote areas.
The second biggest factor? Probably fear.
“When I describe to you what we’re going to do, that we’re going to put currents of electromagnetic pulses into your brain, that can sound really scary,” Boyd said.
“For a long time, people have been hesitant or frightened of the approach just because it’s so different from other things that we do, but it does turn out to be an incredibly safe approach.”
And, even though it doesn’t work for everyone, it’s encouraging to have a possible treatment option for those who have found that medication doesn’t work.
“It’s a tremendous instrument to have in the tool box because so many people are not helped with present treatment options,” said Steiner. “Psychotherapy helps for a lot of people, but when depression is profound it can be too late for that.
“When depression is profound, you can’t talk to a mood.”