How brain stimulation can treat depression, according to this ASU expert

Note: This interview was originally published in Doing Well, a health news outlet from ASU Media Enterprise and ASU Learning Enterprise. Subscribe to Doing Well to get interviews with health experts delivered to your inbox weekly.

By Mia Armstrong-López and Kitana Ford

Each year, around 21 million adults in the U.S. — about 8% of the population — experience a major depressive episode: a period of at least two weeks when they lose interest in daily activities and have problems with things like sleep, eating, energy, concentration and self-worth.

While the experience of depression is widespread, the nature of the illness can make it feel isolating and all-consuming.

But it doesn’t have to be.

There are effective treatments for depression, including psychotherapy, medication and — maybe less heard of — brain stimulation. Thankfully, there are many different professionals and experts who can accompany people through the process of diagnosis and treatment, including psychiatrists, psychologists, social workers, therapists, counselors and primary care providers.

One such expert is Dr. Sarah “Holly” Lisanby, a psychiatrist, the founding dean of ASU’s School of Medicine and Advanced Medical Engineering, the former director of the National Institute of Mental Health’s Division of Translational Research and one of the nation’s leading researchers in brain stimulation treatments for mental health conditions.

We discussed with her the factors that cause depression, how depression shows up in the brain and promising new treatments. Dr. Lisanby also shared thoughts on how to make the most out of your time with a mental health provider.

Note: This Q&A has been edited for length and brevity.

Question: What do we know about the factors that can cause depression?

Answer: There are multiple factors that cause depression: biological contributors, psychological contributors, societal contributors.

It's really important for people to understand that depression is treatable, that it is a medical condition. One of the things about depression is that it can make you feel hopeless. It can make you feel like there's nothing that can help. That's the illness — that's not reality. The reality is depression is treatable, and people shouldn't suffer in silence.

Experiencing loss, experiencing trauma, losing a loved one — it's natural to go through a period of grieving. But when that grieving doesn't stop, and when it is interfering with your ability to function — or if you're beginning to have thoughts of wanting to end your life — that's gone from grieving to depression. Exposure to stress can contribute to the development of depression. That doesn't mean that the stress on its own causes depression, but it's a contributor.

Another contributor has to do with hormones. Women are more likely to get depression, and there are certain periods in a woman's life where she is more at risk.

There are disparities in health outcomes by virtue of things like your zip code, which is related to your economic advantage, your opportunity to access healthy foods, green spaces, education or employment. If you are being exposed to instability in your housing, employment or nutrition — these are things that have a direct impact on your general and mental health.

When we treat depression, we have to consider all those contributors.

Question: What would you say to someone who has been recently diagnosed with depression to help them understand their treatment options and navigate next steps?

Answer: Getting that diagnosis is the first step toward getting effective treatment and recovering. It’s so important because many people go undiagnosed. Once you have the diagnosis, now we can start your treatment plan. We have a broad range of things we can do, and we're going to be with you every step of the way. Your care team should include your physician, who might be prescribing a medication. You might have a therapist. You're going to have follow-up visits to check your progress and answer questions.

It's also important for a person to know they are not alone. Depression is common. If you don't know someone who has depression, it’s possible that they just haven't told you — because you probably know a lot of people who have depression, given how prevalent it is. A person should not feel ashamed — depression is not your fault. It's an illness. It's not a weakness.

There are groups and organizations that provide support — the National Alliance on Mental Illness, the Mood Disorders Support Group, Mental Health America, the American Psychiatric Association; these are trusted sources that can really help you. Knowledge is power.

Question: One of the hard things about our health care system is that you may only have 15 minutes with a provider. How can we get the most out of the time we have?

Answer: Providing access to mental health care is a challenge. There are areas where it's less available. Primary care practitioners deliver a lot of mental health care in our country. So if you have a family practitioner or a nurse practitioner, start with that person. They will be able to help identify whether you're going to need mental health care. Often your primary care provider will be able to diagnose and prescribe a first-line treatment for depression, and they may also help refer you to a psychiatrist or a psychologist.

To maximize your time with any provider, it's really helpful to bring notes, write down what you're experiencing in as much detail as you can. When did it start? What are you experiencing difficulty with? Bring a handwritten or typed note and hand it to your doctor, or if they have a secure email where you can email it to them in advance, that's really helpful. Also bring any medications you're taking. Some medications can have side effects that can masquerade as depression. So bring all your pill bottles, or ask your pharmacy to give you a list of your medications and bring that to your doctor's appointment.

It's also really important to understand that the doctor-patient relationship is a confidential one, and you can share with your doctor what's really going on, because they need all of that information. If you're using alcohol or other drugs, it's important for your doctor to know that, because using substances might be part of why your depression is not responding to treatment, or it might be complicating your treatment. Come prepared to talk and always ask questions. There are no stupid questions in the doctor's office.

It can also be helpful to bring a family member or an advocate who might help you remember what's been going on or provide additional information that can be useful.

Question: How are new research and technology changing the ways we diagnose and treat mental health conditions?

Answer: One example is magnetic resonance imaging (MRI). There are different types of MRI. A structural MRI takes a picture of the structure of your brain, and that helps us determine whether there might be a structural change causing your symptoms — for example, if you had a tumor or a stroke.

But for many people with depression or other psychiatric conditions, the problem is not with the structure of the brain; the problem is with the function of the brain. A functional MRI captures the dynamics of how your brain works, how different parts of your brain are connected to other parts, how they communicate, and how they respond to certain stimuli. For depression, we have identified changes in the functioning of networks in the brain. One of the key regions of the brain involved in those networks is the prefrontal cortex, which is behind your forehead, and that information has been very useful in developing next-generation treatments for depression and other conditions.

One of those next-generation treatments is called transcranial magnetic stimulation, or TMS. Our brains run on electricity. We've known this for decades, and you may have heard about brain waves. Your brain is generating electrical activity. With TMS, we can change those electrical patterns to treat specific circuits in the brain that are related to depression.

Question: How does medication to treat depression work?

Answer: Medications for treating depression have been around for decades. There are multiple generations of these medications, and they differ in how they work at a chemical level.

Neurotransmitters are the chemicals in the brain that communicate from one neuron to the next. Each generation of medications may target a different set of neurotransmitter receptors. The way they work is: You take a pill, and it circulates into your bloodstream and is distributed into your brain and the rest of your body. The action at the level of your brain is to alter the functioning of neurotransmitters, such as serotonin.

When you take a medication, it's important to understand that, to exert the changes in your brain, it has to build up over time — so it can take four to six weeks for the depression to start to lift. If you're feeling like it's not working fast enough, talk to your doctor to have a clear understanding of how long it should take to kick in.

Question: How does psychotherapy to treat depression work?

Answer: There are many different types of psychotherapy. One of the things that's important to know about psychotherapy is it actually changes your brain, and we know that because of imaging. There are studies that do brain imaging before and after certain forms of psychotherapy, and it shows changes in these circuits that are involved in depression, obsessive compulsive disorder or other conditions. So whether you're using medication or therapy, the target is changing brain function.

Question: How does brain stimulation work, and what specific treatments are available?

Answer: In the early days, brain stimulation in psychiatry meant one thing, which was electroconvulsive therapy, or ECT. Now it means many things, because we have more tools to modulate function in the brain in a more precise and safer way.

ECT has changed a lot since the early days, and it's important to understand that it is a modern procedure done in a controlled setting monitored by physicians, and it's done under anesthesia. The fictionalized portrayals like "One Flew Over the Cuckoo's Nest" — that's not modern ECT. To get accurate information about modern ECT, it's important to go to a trusted source like the National Institute of Mental Health or the American Psychiatric Association.

Transcranial magnetic stimulation uses magnetic fields that are rapidly turned on and off to induce weak electrical currents in targeted regions of the brain. TMS is now FDA cleared for the treatment of depression, anxiety associated with depression, obsessive compulsive disorder, smoking cessation and migraines. In contrast to ECT, TMS is less effective in the more severe cases of depression. But over the years, we've developed ways to make TMS more effective and faster-acting.

An investigational treatment developed in my lab merges elements of ECT and TMS — it’s called magnetic seizure therapy, or MST, which uses magnetic fields to induce targeted seizures in small, confined regions of the brain that are important for treating depression.

MST is not FDA approved at present. But we hope the research could lead toward the evidence the FDA would need.

There are other devices as well. One is called vagus nerve stimulation. There's also a new frontier of next-generation treatments in development, including novel approaches such as deep brain stimulation.

Question: How should I think about whether I might be a good candidate for these types of brain stimulation treatments?

Answer: A good candidate for TMS would be someone who has already tried medication, and it was not fully effective for them. You don't have to wait until after you've tried two, four, six medications before asking your doctor, "Is there something else I could do?"

It's really important to know about these options, because not every doctor does TMS — your doctor might have to refer you to a different provider. That's a common part of psychiatric practice; you discuss: Here's the range of treatment options, and here's the ones that I think are right for you at this point. But then also talk about the alternatives.

The bottom line is, we have a broad range of options to find the treatment program that's right for you.