Brain Stimulation for Depression Treatment with Baron Short, M.D.

Depression is a leading cause of disability worldwide. For some who live with this clinical disorder, traditional drug or talk therapy treatments may not be effective in relieving their symptoms. Today's guest, Dr. Baron Short, Medical Director of MUSC Health's Brain Stimulation Service, looks to provide alternative treatments for patients suffering from depression, including brain stimulation techniques that are providing life-changing relief for some patients.

“[There are] a lot of things happening in the world and people have a lot of different responses, and people could be at risk from those stressors to actually develop the medical condition we call major depressive disorder … It is really important for anybody hearing this, that if they have a condition like that, that is a medical condition related to the brain and it is treatable and people should seek treatment.”
- Baron Short, M.D.

Topics covered in this show

• Short says that major depressive disorder is a medical illness and it is very important that it be treated.
• There is not a specific marker to diagnose depression, so it is mostly treated based on symptoms, including sleep disturbances, loss of energy or interest, concentration issues, or appetite problems. Commonly, people with depression have been suffering for months or years, not just weeks.
• Talk and psychotherapies are common initial treatments, followed by medications. This results in success for 60% of patients. For those who have tried three antidepressant medications without success, the chance that the next one will work is 7%. Other alternative treatments are needed for these people.
• The brain is an electrochemical organ. Dr. Mark George started investigating Transcranial Magnetic Stimulation (TMS) in the early 1990s, and MUSC Health has been at the forefront of developing this treatment and technology. TMS was FDA approved in 2008 and there is insurance coverage for this treatment as of 2013.
• TMS involves using a magnet that produces an electromagnetic pulse and placing it over the top left part of the head. It is a non-invasive treatment that activates the brain tissue in regions of the brain that may have become inactive due to depression.
• The TMS treatments are typically 20 minutes each, and commonly happen over 30 to 36 sessions. Sixty-two percent of people go into remission and there is an 83% response rate to the treatment.
• TMS treatments feel like a tapping sensation on the head. Patients sit back in a reclined chair to receive the treatment. There are few side effects to TMS, and mainly involve discomfort at the site of stimulation.
• People from all walks of life receive this treatment, just as anyone could receive treatment for a stroke or cancer. The doctors work to find everyone’s specific needed brain dose of the treatment.
• Patients with seizure disorders and metal plates in their skulls are not good candidates for TMS. Most insurance companies will authorize TMS coverage after someone has not gotten better from two or more medications. There is no age limit for treatment, but insurance will usually only authorize patients who are 18 or older.
• TMS has been used to treat Obsessive Compulsive Disorder (OCD). They ask the patient to do the thing they don’t like doing (i.e. holding dirt if they don’t like dirt) and then administer the treatment. After 40 treatments, patients tend to see about a 50% reduction in symptoms. TMS has also been used to pain and help with smoking cessation.
• A trial at Stanford University used TMS over a shorter period of time for treatment (just 5 days) and showed promising results. More research is being done on different periods of treatment using TMS.
• People tend to regain a lot of their quality of life after a typical TMS treatment. One year after treatment 30% will see a return of symptoms, but about 70% will not.
• MUSC Health is at the forefront of TMS research and development. If you’re interested, this first step is to set up a consultation with his team. A consult does not require you to get the treatment.
• Short says it is gratifying to see people get better and work on new ways to help treat patients who are really suffering with depression.

Read the show transcript below

Erin Spain: [00:00:04] Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This shows the mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Depression is a leading cause of disability worldwide for many people who live with depression, traditional drug or talk therapy treatments have not been effective in relieving their symptoms. Today's guest, Dr. Baron Short, Medical Director of MUSC Health's Brain Stimulation Service, looks to provide alternative treatments for patients suffering from depression, including cutting edge brain stimulation techniques that are providing life-changing relief for some patients. Welcome to the show, Dr. Short.

Baron Short: [00:00:48] Thanks so much for having me. Happy to be here. 

Erin Spain: [00:00:50] Well, this idea of brain stimulation, I want to talk about that and get into the details. But first, depression: depression is very common. Tell me how prevalent it is and some of the typical symptoms that patients have and how you diagnose it.

Baron Short: [00:01:03] First of all, we all need a reminder that major depressive disorder is a medical illness and not just a social ill. So it's real important to say a lot of stress, a lot of things happening in the world and people have a lot of different responses, and people could be at risk from those stressors to actually develop the medical condition we call major depressive disorder. And that is typically defined by disturbances in sleep. So people could have insomnia or actually hyper-insomnia, loss of interest, loss of energy, impaired concentration problems with their appetite or intake. People can start to feel pretty guilty or hopeless, and as things kind of progress, they can actually feel like life's not worth living and actually even start to develop thoughts or plans of how to end their life. And so it is really important for anybody hearing this that if they're having a condition like that, that that is a medical condition related to the brain and it is treatable and people should seek treatment for that.

Erin Spain: [00:02:00] So how do you diagnose it?

Baron Short: [00:02:02] So currently, major depression is a clinical diagnosis, and this is not uncommon in other fields of medicine, but it is within most of psychiatry that there is not a biomarker or brain test currently to tell us if someone has depression. So it is primarily those symptoms that I mentioned, a certain level of severity of those symptoms for at least two or more weeks of symptoms that remain persistent. And we commonly see people who have this condition for not just a couple of weeks, but commonly months or years.

Erin Spain: [00:02:33] So what's the first line of treatment? What do you do first when someone comes in and you're able to diagnose them?

Baron Short: [00:02:38] So when somebody has been diagnosed with major depressive disorder, it's usually really important to get them into treatment. There are usually a few avenues people take. One is talk therapy or psychotherapy that can be really helpful in helping people reframe how they're thinking and feeling kind of get them back on track and what they're doing to kind of improve those symptoms. When either talk therapy is not helpful or not something that somebody wanted to consider first line, they commonly are looking at medications. There are what they call SSRIs or SNRI medications that make changes in the brain related to serotonin and or epinephrine. The good news is that works in a majority of people, about 60 percent or so of people will have significant improvement. I would say the larger issue is that even within our medical paradigm is that when people are not getting better from those treatments, what do you do? And we know that after somebody tried about three antidepressant medication trials, they have less than a seven percent chance that the next medicine will work. That's actually so important to say again, after somebody has tried three antidepressant medications, they have less than a seven percent chance that the next medicine will work. So at that point, an individual really needs to kind of be redirected to a different mechanism of treatment because they don't need to stay in that suffering state.

Erin Spain: [00:03:58] And here at MUSC health, we do offer brain stimulation treatments, what we're going to be talking about today, as an alternative. So just give me the basics about brain stimulation treatments, including Transcranial Magnetic Stimulation or TMS. How long has this been offered? How long has it been around, and how are you using it at MUSC Health?

Baron Short: [00:04:17] So just a background again for everybody and the medical director of our brain stimulation service and have been so since 2010. We actually take the paradigm of when we're looking at people with severe depression that almost thinking about the brain as a series of dynamic circuits. So a reminder that the brain is an electrochemical organ. So it's not just the chemistry that we can change or modulate - that actually the electrical patterning of the brain is very much a part of the currency of how neurons communicate with themselves. And so one of the pioneers, Dr. Mark George, who's also here at MUSC, he works in our brain simulation service and he is the director of the Brain Stimulation Lab, started doing research with a particular type of treatment called TMS or Transcranial Magnetic Stimulation. He started doing work with that back in the early 90s. At the latest, MUSC has been in the forefront of doing work to show that TMS could be an effective treatment for depression. It got FDA approved in 2008, and we worked really hard to get insurance coverage for this treatment in 2013. Now you could say, Well, now what is TMS? What are we talking about doing?

Erin Spain: [00:05:29] It can sound a little intimidating - brain stimulation.

Baron Short: [00:05:32] That's right.

Erin Spain: [00:05:33] But what is it? What does it look like? What does the device look like? How is it administered?

Baron Short: [00:05:37] Sure. So TMS stands for transcranial magnetic stimulation. That's a real fancy term for: we take a magnet. We run electricity through the magnet. It produces an electromagnetic pulse that we put over the top left part of the head. That pulse will then enter non-invasively through the skin, muscle bone and touch the brain and actually activate this brain tissue. So there's pretty good research that particular types of depression, there's hypoactivity, so the brain is not as active in specific brain regions. So it's a no brainer - pun intended - that if we actually reactivate these brain regions that are underactive, we will see people have a resolution of their depressive symptoms. Usually, people will do a series of treatments, commonly about 30, 36 sessions. Each session takes about 20 minutes. The treatment does take about six weeks. One treatment a day, five days a week for about 20 minutes of treatment. People tend to start feeling better about week four, although many people feel better much sooner, and some people actually feel better later. And real world data suggests that about 62 percent of people go into remission from their depression, or an 83 percent response rate. So what does that mean? So remission means absence of depression. It has resolved, and response means at least half or a 50 percent reduction in symptoms. And again, these are in people that again have less than a seven percent chance that the next medicine will work where, you know, we're 10x-ing their benefit there.

Erin Spain: [00:07:10] You mentioned that the device is put on the left side of the head. Tell me about the placement and why that's important.

Baron Short: [00:07:16] Sure. So we usually put the TMS magnetic coil on the left prefrontal cortex. So, you know, we're just putting it on someone's head or their scalp.

Erin Spain: [00:07:24] On their hair, right?

Baron Short: [00:07:26] Correct. We're literally putting it on the kind of left forehead, very top part of the left head. And the idea is that we're stimulating that underlying cortex that is tends to be hypoactive. And so the idea of reactivating that circuitry over and over and over over the course of a single session, but then over a series of weeks helps that brain activity increase intrinsically all on its own. So the idea is we're actually only giving the brain what it needs. We're not giving it anything extra and we're actually activating that brain region so that on, if you will, patches on its own and then it keeps going, it stays active even without the treatment. So that's a pretty remarkable that this is a very focal type of treatment. I think of it as 21st century neuro psychiatry, where we're saying, here's a focal brain region that's inactive. You can't think your way out of it. You can't take a medication to get out of it, but we can directly activate it non-invasively. You can still work, go to school, et cetera, and we help you recover and get your life back.

Erin Spain: [00:08:26] What does it feel like if you're in the patient's shoes? Explain that to me.

Erin Spain: [00:08:29] Sure. So, you know, it was a good question of what doe TMS actually feel like? And I describe it as like a tapping sensation on the head. Jokingly, we had one patient bring in a woodpecker doll, and we said, "Why did you bring in this woodpecker doll?" She said, "Because this actually feels like a woodpecker on my head," with a smile, right? So the point being that it's slightly uncomfortable, particularly in the first session or two. There's a very interesting neuro adaptation where people actually get used to the stimulation. It's not a psychological thing. It's like the brain actually changes its perception of sensation there. So it really feels like a tapping on the head. It's a little loud. So we had people wear earplugs, but they just sit back reclined in a chair and receive this treatment. It's usually on for several seconds and then off for twice as long. So, for example, one type of device we use, it'll be on for four seconds and then off for 10. When it's off, you don't feel anything when it's on, you feel this tapping on your head or as some would call the woodpecker.

Erin Spain: [00:09:29] And the idea that there's very few to no side effects. Is that right? I mean, in comparison to different drugs and medication.

Baron Short: [00:09:36] That's true. So the side effects are primarily limited to a discomfort at the site of stimulation. And there's a little twitch in the muscle where that magnetic energy enters the skin in the muscle. But in terms of systemic side effects like your GI or gastrointestinal effects or heart or anything, it doesn't do that where we do see that commonly with medication. You know, there are less side effects with teams than there is with medication, that's for sure.

Erin Spain: [00:10:02] You mentioned before, you know, folks in health care who work at MUSC have come for this treatment. Tell me about the wide variety of patients who come to MUSC Health to receive this treatment. The different walks of life, the different occupations - what do you see?

Baron Short: [00:10:17] It's a reminder that just as anyone else could get heart disease or a stroke or cancer, it doesn't matter how big, strong or smart you are, you can develop major depressive disorder. It's a medical condition, and we've treated, I would say, the gamut. So we've treated doctors, we've treated resident doctors, we've treated medical students, we've treated nurses, we've treated physical therapists, we treat teachers, we treat lawyers. So kind of all walks of life doesn't mean you have to be a medical professional to come get TMS. We do have a whole host of folks in business, medical professions, education, knowledge workers and the whole gamut. What we usually do is we have people come in, they get the treatment. What we do is we find each person's specific brain dose. So nowhere else in medicine do we find the specific dose for a specific organ in a specific person. And in this case, we actually do what's called a motor threshold. So we find this bare minimum amount of energy to stimulate the motor cortex over on the left middle, part of the head, top of the head, and we can make the thumb twitch, make the hand twitch. You know you found the dose to activate neurons in that person's brain, and then we move it over into the left front part of the head, say, for treatment of depression. So we see people from all walks of life. We find very specific brain dosing. We're using the currency of the brain to communicate and help this underactive brain region reactivate so people regain their life.

Erin Spain: [00:11:44] Are there some folks who maybe would not be a good candidate for this treatment? They meet the requirements in other ways, but for some reason they wouldn't be a good candidate.

Baron Short: [00:11:53] So I think I think we kind of break that into two components. There's who's scientifically or empirically a good candidate and then who's a good candidate from an insurance perspective. So scientifically, we would not want to stimulate, say, someone with a seizure disorder. There is an exceedingly rare risk of seizure with TMS that one of the ways we mitigate or reduce that risk is we don't tend to treat people with epilepsy. The other would be if somebody had metal in their head. For some reason, the idea that if that metal was magnetized, we could theoretically move. And those are both kind of extreme cases. For most part, people are doing very well, empirically meet criteria if they haven't gotten better from one medication. Most insurance companies now actually will authorize TMS coverage after someone has not gotten better from two or more medications.

Erin Spain: [00:12:44] Is there an age limit? Can children participate in this or the very elderly?

Baron Short: [00:12:49] There's no ultimate upper end. We've treated people in their 80s. I can't say I've treated anyone in their 90s, but if anybody's interested, we'll give it a go. The youngest we've treated is about 14. It's important to say that insurance pretty much will only authorize people 18 and older. But we have treated adolescents and we have treated adolescents that have not gotten better from medication, talk therapy, residential treatment programs. It's quite interesting and gratifying to see these people recover when they couldn't talk their way or hill their way out of it.

Erin Spain: [00:13:20] We've talked a lot about depression as a clinical diagnosis, but TMS is being used in other diagnosis as well. It's being used to treat patients with obsessive compulsive disorder. Tell me how MUSC is studying this and treating these patients and the kind of results you've seen for people suffering from OCD.

Baron Short: [00:13:38] TMS is if we think of it as a tool, we figured out how to treat one disease state depression. We're moving into a second disease state called OCD, and happy to talk about some other conditions, too in other treatment parameters. In terms of OCD, for people who aren't familiar with that, that's called Obsessive Compulsive Disorder. And that's where people commonly will spend hours a day obsessing over - it can be over a variety of things that can actually be embarrassing for people might be around related to sex or some type of religious phenomena or contamination or dirt. And then they have some kind of compulsion or thing they need to do to kind of try to make that anxiety go away. Problem is, it doesn't make the anxiety go away. So then they find themselves over and over checking repetitively in some type of behavior, which can be very life impairing. So the common treatments for that are also certain types of talk therapy and medication. We know that at least half of people don't really get much benefit if they have OCD with conventional therapies. So TMS is another modality that can be used. We stimulate some other brain regions. There's some more middle front brain regions that are stimulated, so it's a different target. So the idea of thinking about the brain has a series of circuits, and we can target different circuits that would treat different diseases. So we're stimulating other brain regions. That's very interesting. We want them to actually increase their anxiety for about five minutes. So we make them do the thing they don't want to do. So if they have a contamination, fear we make them whole dirt or something, right? And then while they're doing that and we've gotten their anxiety up, we've activated that circuit in the brain, then we will give them the TMS and they commonly will get, you know, around twenty nine sessions. That's what was initially FDA approved. But there's also studies to go out to 40 treatments when seeing people get about a 50 percent reduction in those symptoms, which is outstanding. So different disease state with depression, we're going for the cure. With OCD, we're going for a reduction in symptoms. Although people do have, I would say, remissions or cures, but we're try to be conservative and realistic about it and see if we can get a massive reduction. And we'll have people kind of return back to work, return back to their life and really get their quality of life back. It's pretty, pretty awesome.

Erin Spain: [00:15:45] You're talking about treating different disease states. Has this been used proactively, maybe to help prevent certain diseases or to improve memory, things like that?

Baron Short: [00:15:55] Yeah. So, you know, TMS is a tool. It can be used to theoretically to treat any condition where we determine the kind of hyper or hypoactive or hyper-connected or hypo-connected brain regions. So, you know, it was FDA approved for treatment of major depression in 2008, OCD in 2018 and smoking cessation in 2020. So we do actively are available to treat people for smoking cessation, however, it is currently not covered by insurance. So anybody out there wants to put a plug out to their insurer, please do. It's also being studied for things like pain. I did some research in the early 2000s in fibromyalgia. They're actually looking at, you know, say, dementia. There's some studies where they're looking at stimulating multiple brain regions to try to help the brain regenerate because there is literature, say, even with depression, when we stimulate with TMS, we actually make brain regions grow like the anterior cingulate cortex. So it's not brain shrinkage, it's brain growth. So we're at the very beginning of what we can do with this technology. Happy to talk about, you know, some of those innovations. So for example, one innovation that's occurring with TMS is what's called accelerated TMS. And there are a variety of plugs done on CBS and NPR about doing what's called the Saint trial. And so that was done primarily by Nolan Williams, who is a former trainee of mine and used to be here at MUSC. And he took all the good work he learned here, and he took it to Stanford and he did a trial instead of treating somebody one session a day for six weeks, he did 10 sessions a day over five days.

Erin Spain: [00:17:31] That's a commitment.

Baron Short: [00:17:33] That's a commitment. So people are getting roughly one treatment an hour for about 10 hours for five days. What was really appreciably exciting about that is they had about a 79 percent remission rate, meaning people were having an absence of depression within five days. We're not talking weeks, we're talking days. And so that has gotten a lot of attention. We've actually already started to have some people come - people that are familiar with that literature, people who are searching and looking, you know, they're desperate. We've actually started to do that type of treatment. One difference that what we do versus what the Saint trial is. The Saint trial involves neuronavigation, where they're doing an MRI scan of the head and they're using an algorithm to say, what's the best spot for that individual? And so that technology is not quite yet available. Probably be available in another year or so. But what we can do is actually do a lot of TMS. So part of it is if you think about if we were baking a cake, is this all about the ingredients or is it do we get the oven to the right temperature for long enough? And so the thought is, if we can get in a lot of times in a short period of time, you know, eight to 10 treatments in a day, we can see people recover very quickly. So there's still a lot of research to be done with that. But we're already doing that. We're already treating people and we actually have research studies involved with the accelerated TMS here at MUSC Health.

Erin Spain: [00:18:52] I mean, this is incredible for folks. How can this really change their lives?

Baron Short: [00:18:56] You know, it's very interesting. We will see people do this. Maybe they could do TMS when they're barely functioning at work or school. And so we kind of up level their game and their ability to actually kind of perform and engage back in their activities. Usually, they will see a profound improvement in their relationships. As usually when someone's depressed, they're pretty withdrawn and not available for their partner or spouse or friends or their kids. We do see that where people feel quite guilty about not being available. The other thing is just the qualitative change. You know that usually when people are in a depressed state, they're very ruminative. They're thinking a lot about everything and they're kind of like lost in their mind. So people almost like wake up and wake out of that mask of depression so they can kind of reengage the world with a new vigor and life. And it's really rewarding to be a part of that and to help people do that. It is important to say that, you know, people do this treatment while they're awake. There's no risk of any kind of memory side effects. Most common side effect is a discomfort at the scalp, at the treatment site, and that usually lessens within the first week of treatment. People can drive and work, attend school. We have a variety of people, even at MUSC that take time off to come and work. It's important to say medical professionals get ill too. And most people do well. Important thing people will ask is how long does this last? So it's really important to say we have pretty good science to say at 12 months, about a third of people have had a return of depression, but that means about 70 percent have not. And of the people who have a return of depression, if we treat them, nearly all of them get better again, which is really great. And that again, that's better than what we see with medicines. It's important to say about half of people relapse on medications, but if they try the next medicine, they don't have the same chance of recovery.

Erin Spain: [00:20:45] Can you tell me how many people have been treated since this was first FDA approved at MUSC Health? Any idea?

Baron Short: [00:20:50] I know there was like several years ago there was over a million treatments just from one company. I personally have been involved at this point in about 18000 treatments, so I do think that that is something to think about. We used to be the only show in town and there are some other places that have popped up, which I think in the big scheme of things is great. But you know, if you're an educated consumer, you might want to think about, do you want to go to the place that they've had, you know, a machine for a year or two and they got training from the company over two days? Or do you want to go to the place that invented the technology that's trained at this point, hundreds, if not thousands of people and have been involved in tens of thousands of these treatments. I know where I'd go.

Erin Spain: [00:21:32] For someone who's listening, and this is the first time they've heard about this type of treatment. They find it intriguing, but there's still a little apprehensive. Would it work for my loved one? Would it work for me? What would you like to say to them?

Baron Short: [00:21:43] I would like to say, Don't suffer, you know, life is short. What are we waiting for? And if typical conventional talk therapy or medication has not worked, seek consultation with us or with someone. But you know, we are the pros. We are the ones that innovated and developed this technology. We're the ones that continue to do the research to innovate this technology or do a whole host of research trials. It doesn't hurt to come and see us in consultation. We do have people come. It's one call you can call 843-792-5716. Give us a call. Make a consult. There's no pressure. We're not here to force people to try to get treatment. We're here to educate people about treatments and we will talk with them and we'll say, we'll tell people if they're a candidate for treatment or not. And then we leave that to the decision of that person. If that's something they want to pursue, more often than not, we will have people say, I'm tired of suffering, I'm ready to get better. Let's get started with treatment. Have other people say I'd like to think about it and have other people say, thanks for letting me know. And they may come back to us later, but don't wait.

Erin Spain: [00:22:48] Is there anything else you want to add that we didn't get a chance to cover?

Baron Short: [00:22:52] I just want to say I'm really happy to be here at MUSC. I have one of the best jobs ever where I get to see people who have really severe neuropsychiatric illness. They feel guilty and bad, their family feel guilty and bad. Their doctors feel guilty and bad about not being able to get them better. And then we get most of them well. So it's so gratifying to be doing that. It's so gratifying to help so many people. It's gratifying to continue to evolve the technology in our research and innovation, and it's so great to educate. So we educate resident doctors and students in how to do these technologies. So kind of really embody this tripartite mission of, you know, clinical work, research and education. And I think people who come here know that. So we have, for example, we have two locations. We have one in downtown at the Institute of Psychiatry. The other is the East Cooper Medical Arts Center in Mount Pleasant. And we have like the art of Therapy Wall, where we have people who give an expression of their story. And I mean, if you want to like go shed a happy tear, just come down and look at this wall and see how people will write about which say, you know, could you please share your story and they will write, or they may draw a picture about their story, about their journey, about the pain and suffering that they have endured. And then the resolution of that, the recovery of that of the rebuilding and regaining their life, and that this be a beginning. Not like they've nailed it and got it all figured out. It's like they're in this new journey.

Erin Spain: [00:24:23] Fresh start. Yeah. 

Baron Short: [00:24:24] It's a fresh start. So come check it out.

Erin Spain: [00:24:27] Last question: this is the question we ask everyone who comes on the podcast. What do you do to optimize your health and live well?

Baron Short: [00:24:34] Oh, that's pretty easy. So kind of do the foundation. So to optimize my health, I make sure I get myself into bed early enough. I get up early enough to go exercise, so I make sure I get that in. I meditate every day to train my mind and open my heart and keep my mind clear. I make sure I give my wife and kids a big hug and kiss and tell them I love them. Try to realign that today is purposeful and remind myself there is no guarantee I have another day. So this day is it, and bring your best self. Show up. Doesn't mean life is going to be easy. Doesn't mean the day is going to be easy. But I'm going to give it my best. I'm going to own anywhere I make mistakes, but I'm going to try to bring more good into the world. And so that's part of my mission is to bring more good into the world. Make sure I eat healthy. And when I get aligned that way, I'm lit up and I'm ready to bring more good into the world. So that's what I do. 

Erin Spain: [00:25:28] Well, thank you so much, Dr Baron Short, for coming on the show and explaining this technology to us. It's really fascinating and hope that some people hear this and will seek out your treatment. For more information on this podcast, check out advance.muschealth.org.