New Treatments for Managing Depression
Major Depressive Disorder is the second leading cause of disability in the United States and the cause of 40,000 suicides annually. Cutting-edge doctors at Psychiatry Associates of Kansas City are working to change those statistics.
Imagine suffering from depression for almost half your life. For 31-year-old Sarah, major depressive disorder had taken over her daily existence since she was a teenager. By the time she hit 30, she had already tried to commit suicide and had been hospitalized twice. She says her medications weren’t working as well as the doctors had hoped. Then, her life changed when she was introduced to TMS therapy at the Psychiatry Associates of Kansas City.
Front Row (left to right): Dr. Steve Segraves, Dr. Erick Brown, Dr. Sherman Cole, Dr. Kevin Mays, Dr. Lolitta Aznaurova
Back Row (left to right): Dr. Irfan Handoo, Dr. Wade Hachinsky, Dr. Jaclyn Legg, Dr. Dennis Owens, Dr. Sasha Hamdani, Dr. Andrew Segraves, Dr. Chris Van Horn, Dr. Ely Tamano, Dr. Michael Everson
psychiatry associates of kansas city, congratulations to dr. Van Horn (left) and dr. Mays (right) for being selected by their peers as 2018 kansas city top doctors
TMS (short for Transcranial Magnetic Stimulation) is FDA-approved for the treatment of major depressive disorder in patients who have not responded well to antidepressants. It uses non-invasive magnetic waves to stimulate or inhibit nerve response, and induces electrical currents to targeted sections of the brain.
Dr. Ely Tamano, M.D., with PAKC, says TMS has been successful in helping patients get their lives back. “TMS is not a cure for treatment-resistant depression, but it a promising treatment for the symptoms,” he says.
For Sarah, TMS has been a game changer. “I know experiences aren’t the same for everyone, but I could feel something like a rush of endorphins during my very first treatment. The symptoms of my depression immediately started to lessen. After my first course of therapy, I felt like a different person. I have since completed another full course of therapy and continue to receive maintenance treatments. TMS therapy has changed my quality of life tremendously.”
TMS is just one of the new treatments that PAKC uses in treating its patients. The practice has a history of being at the forefront of the latest developments in psychiatrics, and recently created a new division called Advanced Psychiatric Solutions of Kansas City (APSKC).
The new clinic, in the same Leawood building as PAKC’s long-standing practice, is concentrating its efforts on innovative new treatments for clinical depression. APSKC has an active clinical trial unit, offering patients the opportunity to participate in the development of new treatments for psychiatric disorders. Current studies include drugs in development for potential use in the treatment of Tourette’s Syndrome and Postpartum Depression.
“Treating depression and related disorders is complicated,” Tamano says. “No two patients have the exact same origins or symptoms for depression, or the same reaction to treatments. That’s why we’re concentrating our efforts on innovative new treatments for clinical depression.”
APSKC has acquired MagStim equipment to perform TMS treatments, and most insurance companies will cover the 30-treatment protocol. Sarah says TMS treatments were easy to fit into her schedule and easy to do.
Patients, like Sarah, who qualify for TMS undergo 30 treatments – five days a week for six weeks. Each treatment takes about 40 minutes, and patients can immediately go back to work or school. Tamano says patients usually begin to notice the antidepressant effect after about 10 treatments into the protocol, and then there is a gradual lifting of their mood.
After every five treatments, patients fill out a PHQ9 questionnaire rating their depression symptoms. Tamano says the worst score on the scale is 27, and the practice sees many patients with initial scores above 25. A score of 4 or lower is considered remission, and many patients score below 4 after completing the full TMS treatment.
“The success rate with TMS is not perfect,” Tamano said. “About 40 percent go into remission, while another 40 percent have a reduction in their symptoms; and 20 percent of patients show no response.”
Sarah thanks TMS and the doctors at APSKC for giving her a renewed life. “For the longest time I was only operating at about 50 percent of my capacity mentally, emotionally and physically. After TMS, I feel as though I’m capable of being 100 percent myself again. I have returned to working full-time and have also become a full-time graduate student.”
41-year-old Cora says her “tortuous path with depression” began more than 25 years ago. She credits TMS with saving her life.
"They give you this nine-question quiz every time you see the doctor. On a scale of 0 being the best, to 27 being the worst, I had scored consistently between 20 and 24 for decades. I felt and looked dead inside. I had no sparkle in my eyes, and I was just going through the motions to be able to pay the bills. I cried almost 24/7 for no reason and it was disconcerting to everyone. I just didn’t care anymore."
"When my six weeks were up and I had finished my six maintenance sessions over the following two months, I was a new person, or better yet, the old person I had once been. My quiz score on my last day was 4. I thought I’d never see a number that low ever again. I still have to take my medications so I don’t relapse because my depression was so severe, but I would do the “Brain Magnets” a hundred times over even if my insurance hadn’t covered it. Now I tell everyone I know who has been struggling with severe depression to talk to their doctor about TMS because if it could help me, I am sure it could help anyone. I thank Dr. Handoo and the TMS techs at PAKC for giving my life back to me and my family."
— Cora, 41, Independence
Another cutting-edge medication being used by APSKC for patients with treatment-resistant depression is ketamine. Dr. Dennis Owens, M.D., says ketamine has impressed psychiatrists with how rapidly it brings symptom relief -- sometimes within hours or days.
At the Leawood office, ketamine treatments are a joint venture between APSKC and Mobile Anesthesia Care, a division of Anesthesia Associates of Kansas City. The ketamine clinic runs every Monday, and with an on-staff psychiatrist, each procedure is supervised by a board-certified anesthesiologist who administers the medication and monitors the patient for any respiratory complications. The clinic opened for treatments in January 2017, and has the capacity to treat up to 18 patients a day.
There is one designated staff member who acts as a “concierge,” working with patients and insurance companies to set up coverage for TMS. For patients who are self-paying for either treatment, the clinic can provide information about a company that provides interest-free financing.
Ketamine infusions – given once a week for a total of six treatments – are given through an IV, and each treatment takes under an hour. APSKC is the only provider of this treatment in the Kansas City region.
“Ketamine has been used for depression in a few other areas of the country for a while,” Owens says. “It can dramatically lift some people out of severe depression, but it does not work for everyone. About 50 to 70 percent of patients respond well to ketamine.”
Unlike many other antidepressants, ketamine targets the glutamate receptors in the brain, Owens explains, adding that the effects seem to fade over seven to 14 days. However, for patients who are debilitated by major depression, often with suicidal thoughts, ketamine can be lifesaving and allows patients to continue their treatment with traditional antidepressants.
“With ketamine, we are very careful to make sure the patient has no diagnosis of alcohol or drug dependency,” Owens says. “We also want them to have a family member or friend for support, someone who will drive them home from appointments and stay overnight to monitor them for nausea or other side effects.”
For ketamine or TMS treatments at APSKC, adult patients can be referred by their own family doctor, a therapist, a psychiatrist, or even inquire on their own. There is a thorough screening process, starting with a patient questionnaire and an initial psychiatric evaluation. Only patients who meet the criteria are considered candidates. At present, neither treatment is being offered to adolescents.
Dr. Christopher Van Horn, D.O., is anticipating that TMS will be used for adolescents with treatment-resistant depression at some point. “Preliminary data indicates that they appear to be safe and well-tolerated interventions,” Van Horn says. “I have referred a couple of adult patients to the clinic who have completed trial after trial of antidepressants. I have seen some pretty remarkable responses with both treatments.”
PSYCHIATRY ASSOCIATES OF KANSAS CITY - CHAMPIONS FOR MENTAL HEALTH
“One of the things that excites me so much in this practice is the variety of innovative things our doctors are doing,” says Dr. Sherman Cole, M.D.
The practice was started by two physicians soon after World War II in an era when psychiatrists were in very short supply. Through the years, the practice added more psychiatrists, expanded its scope and changed its name. Yet it remains dedicated to its original goal of serving at the forefront of psychiatric services in the region.
Unlike many private medical practices that get absorbed by corporate health-care entities, PAKC remains wholly owned and operated by the psychiatrists themselves. Doctors there are committed to maintaining that independence, with no pressure to meet patient quotas—a choice they believe translates into better patient care.
Although clinical depression is a common diagnosis, PAKC doctors also see patients with a variety of issues, including anxiety, substance or alcohol abuse, bipolar disorder, personality disorders, and dementia. All age ranges – from children to elderly – are treated at the clinic, with some psychiatrists in the group specializing in specific populations. Several psychiatrists work specifically with child and adolescents patients, two others treat children, teens and adults and others in the practice focus exclusively on adults and senior patients.
Locally, and especially nationally, there is a shortage of psychiatrists trained to treat patients 18 and younger, says Van Horn. Being dual board-certified to work in adolescent psychiatry and general psychiatry requires an additional two years of training. PAKC now has several psychiatrists on staff who have that specialized training.
“It is really a wonderful practice, and unique to the area,” says Van Horn. “We are doing things here that no one else is doing.”