This past week the American Journal of Psychiatry published an exciting new study “Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression (SAINT),” which is highlighted in this recent piece in Inverse. We interviewed our Chief Services Officer and co-founder Owen Muir, MD, who was excited to explain how this treatment works, why it’s so important, and how it’s helping to treat depression.
Q: What is treatment resistant depression and why is it so problematic, especially during a pandemic?
Treatment-resistant depression is a huge problem because we have a lot of medications that don’t work well and unfortunately the most effective treatment at this time (in New York City at least) is no longer readily accessible in the pandemic. That treatment is Electroconvulsive Therapy or ECT, which used to be called shock therapy. It sounds scary, but it is and has always been the gold standard treatment. It is the type of treatment that other treatments are measured against and it has been used to treat depression that doesn’t respond well to other treatments for the better part of the last 50 years. For doctors who take care of patients with hard-to-treat depression, we knew ahead of time what covid-19 would do to the hospital system and we were deeply concerned for our patients who have severe and suicidal depression. Taking ECT away from psychiatrists is like taking the hose away from firemen. This procedure is an inpatient treatment that must be done with access to anaesthesiologists, so during this pandemic it is not an option for many.
Q: If ECT is not accessible, what does that mean for patients?
This brings us to why this article is so exciting, because it lays out the effectiveness of a different treatment protocol that does not require hospitalization. Transcranial Magnetic Stimulation has been used to combat treatment-resistant depression since 2008 but the SAINT protocol used by Dr. Nolan Willam’s team at Stanford is the first to show data that rivals ECT. To give you an idea of how exciting this is, consider this stat from the published article: 90% of patients had remission of their depression at the end of the treatment (which is only five days long). Importantly, these patients all had severe depression that had not responded to many other treatments, in some cases including ECT. Regular antidepressants, for comparison, have a rate of remission of 30% and they take 8-12 weeks to achieve that result. In short, were this research not so carefully done I would be the first to find it unbelievable.
Q: What does this mean for Brooklyn Minds?
For Brooklyn Minds, this is extremely validating. We have been comparing data with Dr. Williams and his lab for over a year now and the SAINT protocol, which we perform using a different TMS machine that does not require MRI guidance, has been part of our arsenal of treatments almost since the start of our TMS program. Our approach was standardized to match Dr. Willaim’s lab after a meeting of the minds (over brunch in Vancouver) in 2019. Just when NYC has our most important treatment for suicidal depression taken offline due to the pandemic, we now have the publication of evidence supporting an approach we have been pursuing for a while. In short, SAINT saves the day! We now have proof that this treatment for suicidal depression has remarkable remission rates even for people who have failed to improve using multiple other treatments.
Q: So how does this work?
TMS uses magnetic pulses to create electrical current in the wires in your brain; they are called axons and they allow nerves to carry information from one part of the brain to another. Most antidepressants only deal with the end of that journey like the synapse at the end of an axon. Instead of monkeying about with chemicals, we are directly making neurons in the brain fire and teaching them how to fire faster than they were before. SAINT is different from standard TMS because you’re getting the same change in neuronal firing in five days that traditional methods would achieve over seven months. Practically, no one gives patients seven months of TMS. SAINT is 90,000 pulses to the brain in one week, spaced precisely to ensure that your brain learns the lesson most robustly. Neurologists say “neurons that fire together wire together” and the SAINT protocol is an exciting application of this principle. The data clearly shows that more pulses in a shorter time frame have a more dramatic effect. With this knowledge we can treat depression more effectively.
