Dr. Roach: TMS is a treatment option for some kinds of depression

Keith Roach
To Your Health

Dear Dr. Roach: After reading your recent column regarding psilocybin for depression, I looked online and found information on transcranial magnetic stimulation. I had three rounds of electroconvulsive therapy, and had to stop the last two because the amnesia and reactions to anesthesia were so bad. Can you give me your input on TMS as a treatment for depression? I am bipolar but have suffered debilitating depression for many months. Changes in medication either haven’t helped or have caused uncomfortable side effects. Over the years, I have tried just about everything, and I’m at a standstill. Thank you.

— P.S.

Dear P.S.: Depression, whether by itself (unipolar) or as part of bipolar disease, can be challenging to treat when the usual treatments fail, which is far too common. In addition to novel medication treatments such as psilocybin (derived from hallucinogenic mushrooms) and ketamine, there are therapies designed to directly stimulate the brain.

Electroconvulsive therapy is one of these, and it is often tried in people who have a poor response to both medication and psychotherapy. Since its side effects were so bad for you, I think it very reasonable to consider another treatment that has increasingly become accepted, transcranial magnetic stimulation.

TMS has been used mostly for people with “ordinary” depression, but it has been studied for people with depression as part of bipolar disease — bipolar disease must include at least one episode of too much energy, referred to technically as mania — and is about as effective as it is in unipolar depression. Some experts recommend TMS in people with bipolar disease, while others await more data.

It is known that strong magnetic fields can depolarize neurons in certain areas of the brain, but the exact mechanism as to how this can treat depression is not understood. In two well-done studies, subjects were randomized to getting “real” TMS or “sham” TMS. Roughly 25% of people getting the sham treatment (with no actual magnetic stimulation) had a response, while 45-50% of those getting active TMS had a response. In bipolar disease, the treatments are often given weekly. Most studies looked at TMS in addition to, not instead of, medication. No factors to help predict who might respond were identified. The major side effect was seizure at the time of stimulation, with less than 1% of people having this.

I think that TMS is an option to consider for a person who has had poor response to other treatments, certainly in people with unipolar depression, and possibly in those with bipolar depression.

Dear Dr. Roach: Are you aware of any nonpharmaceutical treatments that are effective at reducing symptoms of BPH (benign prostatic hyperplasia)? I’m 69 years old with mild yet annoying symptoms — a slow start and weak stream, but no blood in the urine or pain. I’m assuming it’s BPH. I like to keep drugs to a minimum. I have no other health issues.

If non-pharma steps simply don’t work, what’s your opinion on the best drug to try?

— K.B.

Dear K.B.: In general, there are two types of treatments for a benign enlarged prostate: medications and procedures. Among medications, the prescription treatments are effective, but they have potential side effects. No over-the-counter treatments — such as saw palmetto, beta-sitosterol, Pygeum africanum and Cernilton — have been proven to be safe and effective for long-term use, although many men use and get relief from them.

There are a variety of procedures to help the prostate, including traditional surgery, electrocautery, laser vaporization (such as GreenLight), microwave, water vapor, urethral lift and embolization. The choice of which procedure falls to a urologist, to whom I refer if medication treatments are ineffective.

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