Brain Stimulation Therapies

Fall 2016: Volume 72, Number 2

Brain Stimulation Therapies for
Treatment-Resistant Depression

by Ken Melman, MD

As mental health practitioners, we are all very familiar with the suffering associated with treatment-resistant depression and the frustrations we experience when depression does not respond, or respond fully, to our interventions. Treatment resistance is one of the primary reasons why depression is the leading cause of disability worldwide.

We also know both the power and the limitations of antidepressant medications. As demonstrated by the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, one of the largest studies in the history of the NIMH, only one third of patients responded to initial pharmacologic treatment. And even after four systematic, intensive, evidence-based trials of single or multiple or augmented pharmacologic regimens (plus an option of cognitive therapy), only two thirds of patients achieved remission of their major depressive episode. For patients who did not respond to the first or second antidepressant treatment, the cumulative likelihood of responding to the third or fourth antidepressant treatment was 6% and 5%, respectively.

For patients with depression whose condition does not respond to psychotherapy or medications, the consensus among depression treatment guidelines is to strongly consider two FDA-approved treatments for depression: transcranial magnetic stimulation (TMS or rTMS) and electroconvulsive therapy (ECT).


TMS is an excellent treatment to consider for patients with treatment-resistant depression. Since it produces no cognitive side effects, does not require anesthesia and is extremely well tolerated, patients undergoing TMS can continue to work and remain active in other important life activities. Since TMS is an adjunctive treatment, patients are also encouraged to continue psychotherapy and their usual medications while undergoing TMS.

TMS is now covered by all major health insurance companies as well as Medicare. Most coverage requires failure (or intolerance due to weight gain, sexual side effectssee_survey_below, etc.) of four antidepressant medications in at least two different classes. Some payors also require a trial of psychotherapy with documentation of non-remission using standard depression rating scales such as the BDI or PHQ-9. In most cases, depression must be severe or have been severe at the start of psychotherapy or medication management. Discounted fees can help keep TMS accessible for patients who do not qualify for insurance coverage.

In large scale, multi-site studies of “real world” TMS as well as in our practice, the response and remission rates for treatment-resistant depression are 58 percent and 37 percent, respectively. While we always hope for even better results for our patients, these outcomes are far more promising than the comparative results for antidepressant medications.

ECT is universally recommended for patients who do not respond to TMS or whose depression is so severe (including suicide risk) that immediate, definitive treatment is required. With remission rates in the 60 percent to 90 percent range, it remains our most powerful antidepressant treatment. By using unilateral electrode placement and ultra-brief pulse width stimulus parameters, the cognitive side effects are almost always tolerable and are sometimes absent altogether.

Psychotherapy- and pharmacotherapy-resistant depression is common, often disabling, and can lead to profound suffering by patients and their loved ones. TMS and ECT are evidence-based, FDA-approved treatments that may be helpful or even life-saving, and should be considered as treatment options for your patients with treatment-resistant depression.

 Seattle Neuropsychiatric Treatment Center (SeattleNTC) is an independent, subspecialty psychiatric practice offering TMS, ECT and other psychiatric brain stimulation services. With five psychiatrists and three offices (Seattle, Issaquah and Redmond), we aim to maintain short wait times for consultations and treatment initiation. We value collaboration with patients, families, psychotherapists and other members of the treatment team. For more information or to make a referral, visit or call 206-467-6300.

Ken Melman, M.D. is the founding partner and a practicing psychiatrist at SeattleNTC. He is on the clinical faculty of the University of Washington Department of Psychiatry and has served as Medical Director of Behavioral Health Services at Swedish and Providence Medical Centers. SeattleNTC is a teaching site for the University of Washington Psychiatry Residency Program and has an affiliation with the Swedish Neuroscience Institute.


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