A Decade of Background Shoved Unceremoniously into 1500 Words

It has been difficult the last few days, although that's a common refrain for me.  I've just been so tired... But, I guess better late than never... my distractions towards maintaining this being ever apparent reminds me of an xkcd comic which basically describes me.

(Photo credit: http://xkcd.com/621/)

On to more practical matters.  Although I am a little bit behind, about a week actually, I intend for this post to describe some of the background on my ailment, the decision making process to go ahead with TMS and what I expect to gain.  The last few days have been difficult in regards to energy levels.  So to get going...

I've always described my experiences with mental illness, and in particular depression, as fighting a specter, a ghost that moves silently, strikes quickly and which does so with crippling intensity.  And like any ghost, as soon as I think I'm through with it, it just appears again.  It is haunting.  According to the National Institutes of Mental Health (NIMH) major depressive disorder alone affects 6.7 percent of the adult, or about 15 million people.   In some way or another, 15 million people in my country are fighting a ghost.

Photo source: Daily HaHa

My particular brand of depression is a little bit different from most people's.  In most people, the most defining characteristics of depression, the sensations of despair, grief, fear, and crushing immobility of the soul last for prolonged periods of time, sometimes for months on end.  My family has far too much experience with this long-term version of affliction as well, but it differs from mine in that it tends to pass, although often for too brief a period.  Although my diagnosis has changed from doctor to doctor, one that has always made sense to me is a combination of major depression at times with something called dysthymia, from the ancient Greek for 'melancholy'.  It is more defined by constant, that is lasting longer than a typical depressive state, feelings characteristic of depression but at a lower intensity.  Instead of occasional bouts of strong depressive symptoms, for a majority of nearly the last decade I have dealt with general feelings of anhedonia and in what is most apparent to me, an overwhelming fatigue.  Both the NIMH and the National Alliance on Mental Illness have a variety of information available about the different types of mental illness.

PET scan of depressed brain vs. nondepressed
(Photo Credit: WebMD) 

Nearly $200 billion in earnings are lost each year from depression related illnesses, and almost 1.4 million people are on federal disability plans due to depression (the linked article provides a good overview on the economic impacts of mental illness.)  As many of you know, I have now been out of work for very nearly a year, and while I did have some concerns with the support I received from my employers and with creative differences, I left my job contracting out writing for the armed forces primarily due to my depression.  Although I have improved in a lot of ways since my departure from employment, I find myself wondering if those improvements are only temporary, and that if the stress of returning to the work force would lead to a serious relapse.  That's why I decided to try the TMS.

Transcranial magnetic stimulation, also known as TMS, is "an external device that delivers transcranial pulsed magnetic fields of sufficient magnitude to induce neural action potentials in the prefrontal cortex to treat the symptoms of major depressive disorder without inducing seizure in patients who have failed at least one antidepressant medication and are currently not on any antidepressant therapy".  At least, according to the FDA.  What it amounts to, and this comes from my layman's understanding of the science involved, is that essentially one is hooked up to a magnetic coil (which is similar to a magnetic resonance imaging (MRI) device) which sends pulses into the prefrontal cortex, which corrects the "polarization" of the neurons in this area of the organ.  I call this, affectionately, "brain shockies".

Now, there have been a few differences in my treatment compared to the letter-of-the-law description of approved TMS. While I have certainly failed one antidepressant therapy (I have actually been on nearly 25-30 different psychiatric medications since 2004, over ten of which have been antidepressants) I am currently on a number of medications: these include lithium (a mood stabilizer primarily used in bipolar patients), risperdone (a antipsychotic also used for mood disorders) bupropion (an atypical antidepressant) and trazodone (a relatively outdated antidepressant used primarily to assist sleep).  I also address low testosterone with Androgel and alertness with Provigil.  According to the treatment plan assigned to me by my physician, I am continuing with my medications while undergoing the treatment.  The goal is that once the treatment is completed, at least some of my medications could possibly be discontinued.

Photo credit: NeuroStar

This is a novel treatment.  While attempts at brain stimulation using magnetic forces have been performed as early as 1910, the first modern study of TMS was not performed until the mid-1980's.  The rTMS device utilized by Neuronetics (manufacturers of the Neurostar repetitive Transcranial Magnetic Stimulation system used in the United States) was not even cleared fully by the FDA until two years ago, and treatments have only truly been undertaken using the system in the U.S. since 2008.  Taking this into account, insurance companies are particularly reticent to even begin to assist in paying for the treatment.  There just hasn't been enough time for this treatment to undergo the research it needs to become a more prevalent procedure.  But, there are numbers available, and this is what I think of as "The $6,000 Coin Flip".

Photo credit: NeuroStar Patient Education Video

This graph is from the Neuronetics video attempting to entice people to select TMS as a treatment, with the statistics coming from the studies performed in the late 2000s (sponsored, of course by Neuronetics).  It shows, as you can see, that about half of patients in the study performed had a significant reduction in depression symptoms (described as approximately 30 percent improvement on questionnaires following treatment).  Now the other column is much more enticing.  A thirty-three percent chance of complete remission? That sounds almost too good to be true.  But, its enough.  All of those statistics and the cost aside, I'm willing to take a coin flip.

As I've mentioned very briefly, the procedure as provided by my practitioner costs, bottom line, six thousand dollars.  That's a lot of money.  A hell of a lot of money.  And also as I've briefly mentioned, insurance companies are very reluctant to pay for the treatment, at least up front. While occasionally people are able to appeal to their company for partial or complete reimbursement, sometimes the process takes up to two years.  As an aside, I don't actually have insurance at the moment, due to having hit 26 and no longer being employed.  We are petitioning the Office of Personnel Management and Blue Cross/Blue Shield in order to be covered as being disabled, but its been an absolute nightmare.  Despite all of this, I actually got kinda lucky on the price.  My doctor, Joshua Sussal out of Greenbelt, has quite a bit of faith in the procedure, and provides it at a discount: half.  That's right, most TMS procedures cost patients twelve-thousand dollars, and that in most cases is out-of-pocket.  While it took me a long time to come to grips with this additional expense when I have placed so much burden on my family being out of work for so long, after a month or so we finally decided that it was time.

Now that I've gotten the logistics out of the way, I intend to start my next article with my experiences at the beginning of the treatment.  Its been a long road, but I think I might just be starting a brand new journey. Please let me know if there is any part of this that is confusing (as I can tell its long-winded) or that leaves anything out.

-Benjamin