Lifesaving, noninvasive options for treatment-resistant depression

Five percent of the global adult population experiences depression, involving a persistent depressed mood, sadness, or loss of pleasure or interest in activities for long periods of time. Depression is different from regular mood changes and feelings about everyday life. It can affect relationships with family, friends and community. It can also result from or lead to problems at school and work.

Treatment, though, is not one size fits all. Depression is usually treated with medication, psychotherapy or a combination of the two, yet up to a third of patients with depression don’t respond to traditional forms of treatment. Those with depression who have previously tried at least two antidepressant medications and felt little or no improvement meet the criteria for treatment-resistant depression.

“This is a huge area of suffering for the community and a (growing) area of research in psychiatry,” says Nadia Haddad, MD, Chair and Service Line Medical Director of the Department of Behavioral Health.

Research shows that those with treatment-resistant depression, who have tried two antidepressants and are not experiencing effects, have significant responses to interventional psychiatry treatments. These treatments include Electroconvulsive Therapy (ECT), Transcranial Magnetic Stimulation (TMS) and IV ketamine infusions.

Boulder Community Health (BCH) offers all three treatments at the Center for Interventional Psychiatry (CIP) at Della Cava Family Medical Pavilion.

“These are techniques that sometimes require a more hospital-based setting, certain expertise or specialized equipment,” says Dr. Haddad. “People in the community go to a psychiatrist or a nurse practitioner and they are trying and trying and trying medications and this can go on for years.

“The literature is really showing that trying more and more medications is not as effective after the second antidepressant.”

In honor of Mental Health Awareness Month, here is an overview of BCH’s noninvasive, neuromodulation interventions for psychiatry. Additional information about each of these treatments is available here.

“We have for so long, in the treatment of mental illness, been struggling with all of these societal challenges around functioning with depression, and we continue to do the same things over and over again,” Haddad said. “… I think more and more research is supporting that … having these options is the most effective thing we can be doing.”

Electroconvulsive Therapy (ECT)

ECT is the oldest, most established of the three psychiatric treatments at BCH. Research has revealed it also shows the strongest response.

“ECT has gotten a bad rap from One Flew Over the Cuckoo’s Nest many decades ago. It’s a very safe, very effective treatment,” says Dr. Haddad. “When people are having significant psychiatric issues, they need immediate treatment, or they are actively/imminently suicidal, ECT can really saves lives.”

Collectively, our psychiatrists have nearly five decades of experience and have performed more than 60,000 ECT treatments, making them the most experienced ECT practitioners in the Mountain States region. Our psychiatrists also work closely with patients’ referring clinicians, striving for seamless integration of care.

ECT delivers an electrical impulse to the brain and induces a medically controlled seizure in patients while they’re under brief anesthesia (just a couple minutes). During the outpatient procedure (usually held in the morning), the patient is under the care of a psychiatrist, anesthesiologist and registered nurses.

“It’s like a hard reset for the brain, like turning your computer on and off,” says Dr. Haddad.

At the beginning, a patient may undergo ECT treatment three times per week. After a couple of weeks, if a patient is responding to the treatment, treatment frequency decreases to twice a week or once a week. A psychiatrist may also taper treatment to once every couple weeks or stop treatments.

• Anesthesia: Required. Following the five-minute procedure, patients rest under nursing supervision. Patients are advised not to drive and to take it easy for the rest of the day. They may resume their daily activities the next day.

• Side effects: General anesthesia always presents its own risks and complications. The most common side effects of ECT on the day of treatment include nausea, headache, fatigue, confusion and slight memory loss, which may last minutes to hours.
   
• Treats: Depression, bipolar disorder (manic episodes), psychosis and catatonia.
   
• Insurance: Generally covered by most health insurance plans, including Medicare and Medicaid.

Transcranial Magnetic Stimulation (TMS)

TMS – a newer, noninvasive intervention in psychiatry – uses magnets and magnetic forces, instead of electricity (like with ECT). The patient sits comfortably in a chair for the duration of the 30-minute treatment while able to scroll their phone, read, listen to music or watch TV.

During TMS therapy, an insulated magnetic coil – near a patient’s head – delivers short electromagnetic pulses to target the exact areas of the brain affected by depression. The pulses stimulate and activate neural pathways of the brain that control mood so that the inactive signals begin firing and working again. The pulses of TMS to the brain areas can be delivered at high or low frequency. Patients do not feel pain or the electric current.

• Anesthesia: Not required. Patients can drive to and from each treatment. Since this therapy does not affect cognitive function, patients can continue with daily activities immediately after treatment.

• Side effects: Typically, well-tolerated with very few side effects. Potential side effects may include headache, light-headedness, mild discomfort, and twitching or tingling in the scalp.
   
• Treats: TMS is FDA cleared for treatment of Major Depressive Disorder (MDD) for those who have failed to receive satisfactory improvement from prior antidepressant medication. BCH utilizes the MagVenture TMS Therapy system, which is also FDA-approved.
   
• Insurance: Conventional TMS treatment is covered by Medicare and ComPsych. The treatment is not covered by Medicaid or Medicare Advantage Plans. For questions about specific commercial insurance coverage, please consult with your insurance provider.
  
  BCH has partnered with MDsave to help you afford your out-of-pocket costs for certain procedures. With MDsave, you can save an average of 50% on your health care costs when you pay upfront compared to the national average. For TMS, there are separate vouchers for one treatment session, five treatments or Accelerated - 10 treatments.

IV Ketamine Infusions

In recent years, ketamine therapy has surged in popularity. There are three ways to deliver ketamine for the treatment of depression: Intravenous (IV), intramuscular (IM) ketamine and nasal spray. IV ketamine, which BCH offers, is considered most effective – the gold standard – because of faster onset and more consistent dosing.

Ketamine infusion has been found to provide rapid relief for patients with hard-to-treat depression and may also be effective in reducing suicidal ideation. While antidepressants could take many weeks to work, IV ketamine often works within hours to days.

Patients receive a sub-anesthetic dose of ketamine through an intravenous needle over the course about 40 minutes, while siting in a comfortable chair under the supervision of a psychiatrist and registered nurse.

An acute course of IV ketamine consists of approximately four to eight treatments, two to three times per week. Once the acute treatment phase is completed, maintenance doses are recommended as needed, depending on the patient’s response.

• Anesthesia: Not required. For some time, ketamine was used solely an anesthetic.
   
• Side effects: Ketamine does carry a risk of abuse, so it’s safest to distribute in a controlled dose within a supervised clinical setting. While receiving the ketamine, patients may experience a wide range of effects, such as altered consciousness, perceptual distortions or even out-of-body-type experiences. Some people report feeling reduced physical tension. Others have sometimes reported anxious feelings.
   
• Treats: Major Depressive Disorder (MDD) and treatment-resistant depression (TRD)
   
• Insurance: Self-pay; not yet covered by insurance. Ketamine infusions at BCH are only available through the self-pay option. MDsave vouchers can be purchased here. No insurance authorizations are required.

Since these treatments require consultations with a psychiatric provider, those services can be billable to insurance. For questions about specific commercial insurance coverage, please consult with your insurance provider.

BCH has offered ECT since 2011; TMS since fall 2023; and IV ketamine since spring 2024. These treatments are administered at the Della Cava Family Medical Pavilion, 4801 Riverbend Road.

Referral Form for TMS, Ketamine and/or ECT

Call 303-415-4299 for more information or questions.

“Having a center like this, like CIP, in our community, with three different interventions that we can choose from is really big news for all the people suffering with depression or who have loved ones who have depression,” says Dr. Haddad.