Share ThisEditor's Update: This article was first published February 7, 2024. It was most recently reviewed and updated December 20, 2024.
“Mental illnesses are amongst the most functionally disabling diagnoses in all of medicine,” says Steven Forman, MD, PhD, medical director for the Allegheny Health Network (AHN) Center for Psychiatric Neuromodulation. “But it doesn’t have to be that way. Substantial benefits can be achieved with neuromodulation, a therapy to target stimulation and alteration of nerve activity in the brain.”
Transcranial Magnetic Stimulation (TMS), a type of neuromodulation therapy which uses an electromagnetic coil to target stimulation to specific parts of the brain, is giving hope for people with treatment-resistant depression and obsessive-compulsive disorder (OCD). This noninvasive option for patients who haven’t found relief through standard treatments, such as medications or talk therapy, is rapidly gaining popularity as depression rates continue to rise across the United States.
Highly skilled and passionate about neuromodulation therapy, Dr. Forman took some time to discuss treatment options for medication resistant depression and OCD through TMS.
Emily Beatty: Let’s start from the beginning. What made you want to become a psychiatrist?
Dr. Steven Forman: It’s ironic — becoming a psychiatrist was not a long-term goal for me. I attended Massachusetts Institute of Technology (MIT) and was mainly interested in math and science. I was accepted to the MD-PhD program at Mount Sinai in New York City with plans to pursue a career as an academic medical scientist. I completed my first two years of medical school, then went on to complete my research in biochemistry and blood clotting enzymes, followed by my clinical rotations. At that point, I really knew nothing about psychiatry.
On the first day of my rotation in psychiatry, I met a patient with florid bipolar mania and another with severe tardive dyskinesia. My eyes were immediately opened to the help these patients needed. Over the course of my rotation, that patient with bipolar mania responded positively — even with the treatments available in the mid-80s. It was very gratifying to see a patient get substantially better in just a few short weeks. This really piqued my interest in the field of psychiatry.
I later had the opportunity for an elective rotation with Dr. Stephen Rayport, then a young psychiatric investigator at Columbia Presbyterian. I was so inspired by this rotation, I applied for a psychiatry residency, matched in Pittsburgh, and have been here since.
Emily Beatty: You joined AHN in 2023 to lead the Center for Neuromodulation. Can you tell me more about how neuromodulation works?
Dr. Steven Forman: Neuromodulation is the specific application of energy to the brain. That energy can be magnetic, electric, acoustic, or even light. Neuromodulation precisely applies that energy in patterns and locations in the head to help change the way the brain is responding to produce adaptive or helpful outcomes for a patient's illness. Depending on the protocol, neuromodulation can make brain circuits fire faster or slower.
Emily Beatty: What made you interested in this specialized therapy?
Dr. Steven Forman: I have always been drawn to making and building, and neuromodulation is basically a ‘hands-on’ way of doing psychiatry. Neuromodulation is an ongoing and interactive treatment between the patient and the clinician. The clinician places the TMS coil on the patient's head, adjusts the TMS machine, and monitors the stimulation protocol each day with the patient over the course of their treatment. The daily engagement of the treatments is what attracted me to this specialty.
Emily Beatty: The mental health crisis has gained a lot of attention in recent years, but you don’t often hear about treatment options that don’t work. Tell me more about treatment-resistant depression. What exactly does this mean for a patient who is suffering from depression?
Dr. Steven Forman: Research shows that one-third of adults receiving their first antidepressant medication reach remission of depressive symptoms. Though the likelihood of remission decreases with each subsequent antidepressant trial. About one-third of cases will fail to achieve remission even after a patient tries four antidepressants. So, although antidepressant medications are effective and should be the first-line treatment, they don’t work for all patients.
If a patient has residual symptoms or doesn’t respond at all after a couple of antidepressant trials, or doesn’t tolerate antidepressant medications, another good option is TMS.
Emily Beatty: Are there situations that make treatment-resistant depression more likely?
Dr. Steven Forman: There are a few things to consider. If a patient is taking a medication and experiencing a side effect they don’t like, it is less likely the patient will take that medication in the proper way which decreases its efficacy. Comorbidities can also affect the way a medication works, increasing the likelihood of treatment-resistant depression. PTSD, sleep apnea, or thyroid disease, if undetected, can decrease the likelihood of an effective response to antidepressants.
As part of the screening process for treatment-resistant depression, we review all potentially modifiable factors that may have limited previous responses to antidepressant treatment. We can’t pinpoint why some patients don’t respond to antidepressant medications. Fortunately, TMS can still be quite effective regardless of the source of prior treatment resistance.
The initial course of TMS treatment typically consists of 5 treatments per week over a 6-week period. Each treatment session lasts approximately 20-40 minutes.
Emily Beatty: How common is OCD in patients and what are treatment options for it?
Dr. Steven Forman: OCD is present in about 2-3% of adults in the United States. Major depression is nearly 10 times more common than OCD. Treatment options for OCD and depression are similar. SSRI antidepressants are the first-line medication option, combined with a behavioral psychotherapy called exposure and response prevention or ERP. During ERP therapy, patients are exposed to stimuli that trigger obsessive thoughts but are prevented from making their typical compulsive responses. With repeated exposure, eventually, the undesired OCD thoughts and behaviors tend to fade out. However, many patients with severe OCD find the triggering process so anxiety-provoking that they cannot successfully engage in ERP therapy.
One of the advantages of TMS as a treatment for OCD is that it decreases the severity of the OCD symptoms, and at the end of the TMS treatment, the patient can potentially revisit ERP implementation to effectively decrease symptoms further.
Emily Beatty: Who is the ideal patient for TMS?
Dr. Steven Forman: There's truly not an “ideal patient” for TMS, but there are practical issues that must be considered. More and more insurance companies are covering TMS treatment for Major Depression and OCD. For insurance authorization, a patient’s depressive symptoms should be at least moderately severe in the current episode, and they must have failed at least one or more adequate courses of antidepressants. For TMS treatment for OCD, patients must have failed both a medication trial and a course of ERP.
Moreover, there are some contraindications to TMS treatment. For example, the patient can’t have a seizure disorder or have metal in their brain, like a cochlear implant or a vascular clip.
Finally, there are logistical considerations. Outpatient TMS requires 30-36 daily treatments, five days a week, Monday-Friday. Patients must have appropriate transportation to get to the clinic every day. We do our best to accommodate patient’s schedules, but if a patient can’t come consistently for their treatments, they won’t really get the full benefits of TMS treatment.
Emily Beatty: Are there any risks of TMS treatment, and how long do the benefits last?
Dr. Steven Forman: TMS as FDA-cleared is generally regarded as a very safe and easily tolerated treatment. While the risk of seizure from TMS is quite rare, less than one percent, we carefully screen and monitor patients to ensure they are appropriate to receive TMS and are at low risk for seizure. There is no evidence that TMS produces any adverse long-term problems like epilepsy, or deficits in cognitive, immune or endocrine systems. More commonly patients may experience mild headaches during the initial phase of treatment, but these readily respond to over-the-counter pain relievers.
The duration of TMS benefits is a topic of active investigation. We tend to see TMS as an additive treatment with medications and psychotherapy. Data shows that patients do significantly better if they’re seeing both a primary care physician and a psychiatrist in tandem following TMS treatment. Current estimates suggest that combined psychotherapy and TMS treatment can achieve remission rates of up to 66%.
Emily Beatty: How does your team work in tandem with PCPs? Do you share insights on patient progress after TMS treatment?
Dr. Steven Forman: Upon getting the referral from a PCP, we evaluate the patient and make our evaluation notes accessible to that clinician. Once we get started on the TMS course, we provide a summary evaluation that measures symptom levels once a week that’s also shared with the PCPs. We continue to maintain an open line of communication with the patient’s PCP, knowing that after treatment, the patient will continue with their PCP or primary behavioral health provider for ongoing monitoring.
Emily Beatty: If a patient is interested in TMS, what should their course of action be?
Dr. Steven Forman: The first step is for the patient to speak with their PCP or pre-established behavioral health provider and discuss TMS as a treatment option. Patients can call the main intake number for the Psychiatry and Behavioral Health Institute, (412) 330-4429, to also schedule an appointment.
Emily Beatty: It’s an exciting time to be in the healthcare field as medical advances and technological breakthroughs help improve the patient experience each day. What excites you about neuromodulation research and uses, and what do you hope the future will hold for this treatment option?
Dr. Steven Forman: Accelerated versions of TMS — in which up to 10 treatments are provided per day — have been shown to induce depressive remission in as few as five days. This compares very favorably to the standard protocol we’ve discussed which takes six weeks.
There are also exciting investigations to improve treatment outcomes using TMS stimulation sequences in which the TMS stimulations are synchronized to the patient’s actual ongoing brainwave activity.
New technologies are constantly advancing to allow more precise modification of brain activity to treat illnesses. Some focused ultrasound applications, which are still experimental, can selectively break the blood-brain barrier in a particular location which can allow medication to target that specific spot in the brain.
Finally, a recent report in the New England Journal of Medicine discussed targeting ultrasound to patients with Alzheimer's to get a release of the amyloid-reducing medication in specific spots in the brain.
There is a lot of promise happening in the field of neuromodulation, and I’m excited to see how we can leverage these advancements to change the lives of our patients and their families.
Steven D. Forman, MD, PhD is a psychiatrist and the medical director for the AHN Center for Psychiatric Neuromodulation. He diagnoses and treats patients with treatment-resistant depression and OCD. Dr. Forman is skilled in TMS, esketamine, and interventional psychiatry.
He attended medical school at the Icahn School of Medicine at Mount Sinai in New York City and completed graduate studies at the City University of New York. Dr. Forman did his residency and clinical research fellowship at UPMC Western Psychiatric Hospital and CMU in Pittsburgh, Pennsylvania.
He is certified by the American Board of Psychiatry and Neurology. Dr. Forman believes in staying positive and going with what works for each patient, especially the appropriate application of new psychiatric interventional technologies.
For more on neuromodulation, check out Dr. Forman’s interview on KDKA Radio’s Medical Frontiers show:
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