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We speak with Heather Luing, a psychiatrist specializing in treatment-resistant depression. As depression rates in the U.S. have tripled over the last year, we explore why traditional treatments may not work for everyone and discuss innovative therapies like transcranial magnetic stimulation (TMS). Heather sheds light on how TMS offers hope for patients struggling with ongoing symptoms, the science behind it, and why it’s still underutilized despite its effectiveness.
Heather Luing is a psychiatrist.
She discusses the KevinMD article, “Can a magnet treat depression?”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Heather Luing. She’s a psychiatrist, and today’s KevinMD article is “Can a Magnet Treat Depression?” Heather, welcome to the show.
Heather Luing: Thank you. I’m excited to be here.
Kevin Pho: So, let’s start by briefly sharing your story and journey.
Heather Luing: Yes. Well, I’m a psychiatrist. I trained at the University of Florida. I’ve pretty much spent my career doing all different types of psychiatry within the state of Florida. And I’ve spent a lot of my time treating very acute patients. So, patients who are hospitalized, acutely suicidal, dealing with really severe depression. And so over the years, I’ve really developed a lot of interest in mood disorders and how we can effectively treat those. And that’s where I’ve focused my clinical energy for the last few years.
Kevin Pho: Alright, and your KevinMD article was written a few years ago, “Can a Magnet Treat Depression?” I’m sure that topic is still very relevant today. Before talking about the article itself, what led you to write that article on KevinMD in the first place?
Heather Luing: Yeah, you know, I think it’s interesting in psychiatry because we have historically had really limited ways to treat depression. However, when new opportunities to use different modalities to treat depression do emerge—like TMS did back in 2008—they take a long time to be widely adopted. And so I really wrote the article just to spread the word about other ways to treat depression and, and hopefully increase awareness.
Kevin Pho: Alright, so when you say TMS, that’s, of course, transcranial magnetic stimulation. So tell us about your article and then TMS in general.
Heather Luing: Yes. So my article was written really kind of as a basic primer on TMS, again, to help spread awareness not only to psychiatrists, but really, depression ends up impacting all specialists. So, whether that’s primary care or a different type of specialty, probably every doctor and provider is going to encounter depression. So just understanding that there are other ways to treat depression if medications and therapy alone are not effective.
Kevin Pho: Alright, so what exactly is TMS? And tell us a little bit about the science behind why it works.
Heather Luing: Yeah, so TMS is transcranial magnetic stimulation. What it does is it uses a small but high-powered magnet to treat a specific area of the brain called the left dorsolateral prefrontal cortex. And what we know from a lot of imaging studies using PET and functional MRI is that in patients with depression, that part of the brain is really hypoactive. And so by using this gentle, non-invasive magnetic stimulation, we can activate that part of the brain to work much more normally and really restore the normal working of the brain to treat the depression at the source.
Kevin Pho: And you mentioned it’s non-invasive. So from a patient experience standpoint, walk us through a typical session. What exactly would that be like for the patient?
Heather Luing: Yeah, that’s a great, great question, because I think patients have a lot of anxiety when they hear brain stimulation at this point. It sounds scary. The reality is it’s really not. So what it is is they’ll come in, they’ll sit in a reclining type chair. They’ll have the magnet applied to this part of the head right here, the left frontal part. And then it’s a series of gentle tapping. And so that will go on for 19 minutes. They’ll sit there kind of quietly in the chair. A lot of times they can talk to the, they can watch television or listen to music. It’s really quite relaxing. And at the end, they don’t have any change in their normal activities. They can drive, they can go back to work, and really do their normal things.
Kevin Pho: And do they actually feel anything during this, these 19 minutes?
Heather Luing: You do. Probably the way we describe it most commonly is it’s like a woodpecker tapping on your head. It’s a strange, kind of alien feeling. It’s not something that you can probably equate to something else you’ve felt, but it shouldn’t be painful in any way. And the reality is what you’re really experiencing is the scalp, the nerves in the scalp, and those actually toughen up fairly quickly. So, the first couple of sessions are usually the most intense, and then patients really quickly adapt to it.
Kevin Pho: So after the initial session, what can a patient expect in terms of how they feel, in terms of onset, what can they expect after that?
Heather Luing: They normally feel pretty normal, so there’s not a whole lot of side effects, which is one of the great things associated with TMS. The most common side effect is a little bit of scalp tenderness. The second most common is headache, but most of the time you feel pretty normal after you leave your session. Occasionally a little bit tired, occasionally a little bit activated where it’s harder to sleep, but for most people, they feel pretty normal. As far as how long it actually takes to work, it’s not a super fast-acting therapy. So, in the clinical trial, it was around the 20th treatment where patients started seeing the positive effects. The treatments themselves are administered in a dose of 36 treatments. So, that’s 30 treatments Monday through Friday with a six-treatment taper. So you can see you’re about four weeks in when the average patient starts seeing that clinical improvement.
Kevin Pho: And then would this be used in conjunction with whichever antidepressant medication a patient would come in with?
Heather Luing: Yeah, it usually is. The reality is when they did the clinical trial, they took patients off their antidepressants. So it used a standalone treatment there, but clinically it has been used much more widely as more of an augmenting agent. So, most people, if they’ve had some improvement on their antidepressant, but not enough to be in remission, they’ll continue taking that antidepressant and use the TMS to hopefully drive them into complete remission of symptoms.
Kevin Pho: So if a patient starts a group of sessions with TMS, we’re talking about four to five weeks, perhaps. Tell us about some of the data about the efficacy behind TMS.
Heather Luing: Yeah, so the data is really robust. In the clinical trials, they had about a 70 percent response rate. So, response being at least a 50 percent improvement or more in clinical symptoms. And that’s really very similar to what we see in clinical practice as well. I think we probably see slightly more than that because of the way we use it as an augmenting agent instead of standalone, but really very similar results.
Kevin Pho: And in terms of the endurance of these results, do you notice any relapse? How long does this efficacy last for?
Heather Luing: Yeah, that’s one of the great things about TMS. So, a lot of times what we find is when a treatment takes a little bit longer to work, sometimes that is countered with it lasting longer. And that’s indeed what we see with TMS. So, even though we don’t have any cures for depression, we only have treatments, TMS tends to be very long-lasting. So, in the clinical trial, if you were a responder to TMS, they followed you out for a year, and what they found is 80 percent of those patients were still improved at the end of the year. Now, we at our center have been providing TMS since 2017. I certainly do see some repeat patients, but I also see a lot of patients who have had very long-lasting results into multiple years.
Kevin Pho: And how widely available is TMS? You certainly work in a relatively heavily populated area. Is this readily available throughout the United States?
Heather Luing: It is. It’s definitely grown in the period of time that we’ve been involved with TMS, which I think is wonderful because it really needs to be in every community. And in fact, that was actually our motivation originally for starting a TMS center was that we couldn’t get our inpatients into TMS treatment that was close by and quick enough that they could actually get in without a long waiting list. But more and more centers have opened, more and more manufacturers are making TMS machines. So, I do think it’s something that if someone is interested in, they will be able to find, if not one, multiple centers in their area.
Kevin Pho: So give us a couple of case studies of a typical patient that you would see as a good candidate for TMS, just to bring everything that you said into a better illustration. What typical patients would you see that would be appropriate candidates for this?
Heather Luing: Yeah, so the American Psychiatric Association actually recommends TMS as a second-line treatment. So, after one inadequate response to an oral antidepressant, in reality, because of insurance constraints, patients do often have to be a bit more treatment-resistant to access this. In general, though, two antidepressant failures, sometimes plus or minus an augmenting agent, is enough for somebody to meet criteria and be a good candidate. And in fact, if we treat patients with these modalities earlier in the course of their illness, we have a much better chance of getting them into full remission. So, I would really argue anyone who’s had an inadequate response on two antidepressants and is interested in TMS is actually a really good candidate.
Kevin Pho: And any difference in terms of the age of the patients, in terms of their response and tolerance of the treatment?
Heather Luing: It is FDA-approved for 18 and up. There was a recent study that one of the TMS machines has done with adolescents, so I think that is going to allow 15 and up to eventually have insurance coverage for this treatment. And there’s really no upper limit. Because of the fact that it’s such a safe treatment, with so few side effects, it’s actually a great treatment for people with other medical conditions, for people who are elderly and more complex, and also for people with special situations like maybe they’re having renal impairment or hepatic impairment that make medications difficult. It’s also a great option for lactating mothers. So, I think there’s really a lot of patients that it’s an ideal fit for.
Kevin Pho: So I treat a lot of patients with medications for depression in my own primary care clinic. What would you define as a treatment failure? What would that look like in a primary care setting?
Heather Luing: Yeah, so really we define treatment response as 50 percent or more improvement. So, if you have less than 25 percent improvement, then you’re a non-responder. If you fall between that 25 and 50 percent, that’s an inadequate response. So, it’s really anyone who just, the med hasn’t worked for them or it hasn’t worked well enough to get that 50 percent improvement, or they don’t tolerate it due to side effects.
Kevin Pho: And as you know, there’s a little bit of stigma associated with TMS due to mainstream media and a lot of misperceptions. So, say in a primary care setting, if a patient, what you thought was an appropriate candidate for TMS, how would you bring up that potential option with that patient, knowing that there’s a little bit of stigma associated with it?
Heather Luing: Yeah, you know, it’s really sad that in mental health in general there’s still stigma. So, I hear from some of the primary care doctors in my community that I work with, even when they recommend psychiatry, sometimes there’s pushback from patients. But I think, you know, obviously when you’re in primary care, you’re going to have a very good relationship with your patient, with good rapport. I think if you can recommend seeing a specialist like a psychiatrist or a specialized service like TMS, and really, you know, show them that you believe in this, that it’s scientifically rigorous, you know, we have FDA approval. I think those things really go a long way in cutting down stigma. I think essentially, you know, education is so important. And as a doctor, I see myself as one of my primary roles in educating patients. And I think when we’re treating patients with depression, in order to really be getting informed consent from them, they should know what all the FDA-approved options are, which includes TMS. But it also includes some of our newer medications that a lot of people don’t always think about. So, I think just talking about it helps a lot.
Kevin Pho: So, now that you have this platform, are there any misperceptions specifically about TMS that you typically see on social media or mainstream media that you’d like to clear up?
Heather Luing: Yeah, I think for one thing, that it’s invasive. You know, it is considered a non-invasive treatment, and it’s really one of the most sort of benign as far as side effect profile things that we do in psychiatry. So, that would probably be the first one. OK, maybe the second one would be that it would be painful, and I have really just not found that to be true. If you have somebody who’s a skilled TMS provider, they will start TMS in a nice, slow, gentle way and make it very tolerable for our patients.
Kevin Pho: Alright, so having listened to everything you said, give us a case study. Tell us a success story where TMS really made an appreciable difference in a patient’s life. And certainly, it could be hypothetical or could be an amalgamation of cases, but give us a sample case study—kind of a before and after.
Heather Luing: Yeah, you know, I feel so lucky that this is what I get to do all day, so I see these patients literally on a daily basis, but I think probably some of the more dramatic cases I have seen have been individuals that I’ve met on an inpatient unit. So, I remember one gentleman in particular, really a high-functioning individual, very well-educated, in a job where he was really well-respected in the community, and he was just still struggling with severe depression, with suicidal ideations, and was kind of at the point where he felt ready to give up. He’d tried medications, they hadn’t worked, and he really felt like he was at the end of the road and hadn’t heard of TMS. His psychiatrist hadn’t ever told him about it. So, when I brought it up to him, talked with him and his wife, you know, they were very receptive but still a little bit doubtful that this would give them the relief that they were looking for. And we brought him into the center as soon as he was discharged from the hospital, started his treatments, and he went into full remission. And just the gratitude and thankfulness from him and his family is something that I think I’ll carry with me for the rest of my life.
Kevin Pho: And is depression the only behavioral health condition that TMS is indicated for?
Heather Luing: So, it’s the most widely used. Depending on where you are in the world, there are different indications for TMS. In the U.S., traditionally, it has been treatment-resistant depression that has been accessed with TMS. But there are, depending on the machine, now also indications for OCD, for depression with anxious distress, now the new adolescent depression indication, and also a really exciting but not funded by insurance indication for tobacco cessation. So, I think that when you look at device companies versus pharmaceutical companies, it takes a lot longer for us to get indications for devices, and it can take a lot longer for insurance to start covering those. But I anticipate, you know, in the next 10 years, we’re going to have a lot more access to TMS for different psychiatric disorders.
Kevin Pho: And to be clear, Medicare and most commercial insurers cover it for treatment-resistant depression?
Heather Luing: They do. In fact, Medicare is one of the best. In our particular Medicare setting, it’s actually only one antidepressant failure required for Medicare patients. And if they have a secondary insurance, it’s zero out-of-pocket cost for them. So, really exciting. And most commercial plans, the VA, and some states’ Medicaid plans will also cover it.
Kevin Pho: So, in terms of the future of TMS, where do you envision it going? Any new innovations on the horizon in terms of the direction of TMS in the next couple of years?
Heather Luing: I think we’ll see more movement in treating anxiety disorders and treating substance use disorders. So, depending on where you stimulate the brain, what sort of frequency you’re using for stimulation, there are different protocols that are currently used either on an experimental basis or, in some places, on an approved basis to treat these disorders. So, when we think about the brain, we want to challenge ourselves to not think about it simply in terms of chemicals, but also to think of it in terms of circuits. And circuits are really what we’re targeting with TMS. So, I think we’ve only scratched the surface of its clinical utility.
Kevin Pho: Now, for the patients who may be listening to you and may be interested in TMS, what kind of questions should they ask to determine whether that’s the right treatment for them, whether that doctor is the right doctor? Obviously, you work for a TMS center. So, what kind of questions should patients ask if they want to move forward with potential TMS?
Heather Luing: Well, I think an important question to ask is, do they meet the criteria, or is their insurance going to cover it, and what would the cost be for them out-of-pocket? Those are always important questions. And when looking for someone to treat with TMS, I would encourage them to look for a board-certified psychiatrist. By the time patients are getting TMS treatment, it is a specialized treatment, and a board-certified psychiatrist is going to have the correct training to manage that, as far as TMS, but also any medications or contraindications that they may have.
Kevin Pho: And certainly, is TMS included in terms of the board certification for psychiatrist training?
Heather Luing: Yes and no. So, depending on when you’ve gone through training, most psychiatrists will have an option to have some exposure to TMS. But I think it’s still underutilized. Even in some academic programs, there’s not a subspecialty at this point, specifically for interventional psychiatry. But interventional psychiatry is a growing subspecialty. And so what you’ll find is people will seek out additional training opportunities. Certain academic facilities offer them. The TMS Society offers a training called “Pulses” several times a year. So that’s usually where further training is obtained by psychiatrists.
Kevin Pho: We’re talking to Heather Luing. She’s a psychiatrist. Today’s KevinMD article is “Can a Magnet Treat Depression?” Heather, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.
Heather Luing: My biggest take-home for the audience is that depression is a treatable condition. And the reality is, in the U.S., many people are untreated or ineffectively treated for depression. This is a really exciting time in psychiatry for depression treatment because we have so many more options now available than we did, and so many more that are in the pipeline for development. So, it’s really a time of hope, of opportunity to find an effective treatment. So, my message really is, find somebody who can help you get your depression into remission. And if you’re treating patients with depression, have remission be the goal.
Kevin Pho: Heather, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.
Heather Luing: Thank you. It was my pleasure.
