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Kalispell Veterans Affairs clinic uses new tech to treat depression
The Daily Inter Lake - 9/2/2023
Sep. 2--A large, reclined chair surrounded by medical machinery never fails to grab the attention of Dr. Gilbert Esser's patients when they enter his office at the Veterans Affairs Clinic in Kalispell.
After letting them land a few jokes, often comparing him to literature's Victor Frankenstein, Esser explains the purpose of the contraption: transcranial magnetic stimulation, or TMS, a relatively new treatment for depression.
"Initially, there was a lot of resistance and I had a hard time, so to speak, convincing people to do this," said Esser, who sees around a dozen patients a day. "And now we are at a point where it's probably going to be a problem because so many people want to do it."
TMS is a noninvasive form of brain stimulation that uses changing magnetic fields to induce electric current to a specific area of the brain. Developed in the 80s and approved by the Food and Drug Administration in 2008, TMS treatments have shown therapeutic potential for neurological disorders and mental illness.
Esser likes to keep up to date on the latest developments in treatments for his patients. His focuses as a physician include depression, post-traumatic stress disorder and substance abuse -- three conditions that affect veterans in the United States. Esser administered electroconvulsive therapy, otherwise known as ECT, at a larger hospital for many years and often thought about how his patients in Kalispell might benefit from it. But the Veterans Affairs clinic cannot offer the treatment, as it requires anesthesia and is typically done in a hospital setting. Much of the stigma attached to ECT comes from its early use, and though there are still some side effects, the treatment is considered much safer today, according to the Mayo Clinic.
He heard about the growing availability of TMS treatments about three years ago. Esser joined forces with Dr. Elizabeth Walter, a physician with the Billings Veterans Affairs, who located a research program associated with the federal agency in Palo Alto, California that could get them the TMS machines.
"She's amazing and has a lot of energy," Esser said. "But as a single provider, she was not able to pull that off because you need coverage if you are absent. And how do you do that in a big state like this? I said, 'OK, I'll cover you in Billings and we're going to cover for each other.' Once we had that set, she was able to push forward to get us a chair."
In his 15 years with Veterans Affairs, he's employed the latest developments in treatment for substance abuse, like Suboxone, but hasn't seen as many developments come along for people struggling with depression.
Patients will get three-and-a-half minute treatments daily for six weeks in a standard TMS protocol. But in Northwest Montana, many of Esser's patients live too far away from Kalispell to go to the clinic everyday, so they've adopted an accelerated treatment plan.
"It's also three minutes but five times a day," Esser said. "They come in at 8 a.m. and get the first treatment, then they wait 50 minutes and they get the second, wait another 50 minutes and so, they're here a little over half a day."
The accelerated treatment, known as intermittent theta burst stimulation, was approved by the Food and Drug Administration in 2018. Esser cites a 2023 study produced by Florida researchers that looked at outcomes for 19 veterans who underwent the accelerated treatment. They took five treatments a day for five days and results showed a 47% remission rate. For people suffering from Major Depressive Disorder, remission means returning back to a normal level of social functioning.
According to a 2010 report from the Effective Health Care Program, which is part of the U.S. Department for Health and Human Services, other depression medications like selective serotonin reuptake inhibitors had remission rates of between 30% to 45%. But those are medications that people take on a daily basis.
When a patient sits down in Esser's TMS chair, he must first locate the area of the brain to send the electromagnetic impulses. He starts by measuring their head and fitting them with something like a swimmer's cap, where he marks the treatment area and sends small pulses to set the intensity of the machine.
"I go around and try to find the spot where the patient moves their thumb when I send an impulse and then I measure out how strong I need to set this machine so that I get a regular thumb movement," Esser said.
An electromagnetic coil is placed against the scalp, which sends magnetic pulses that stimulate nerve cells in the region of your brain involved in mood control and depression. Esser said they only use the swimmer's cap for the first measurement, from then on, the machine has mapped the patient's head. This is helpful for situations where another doctor might have to fill in or pick up on someone's treatment.
"It's a little bit like my kid's Xbox with Kinect, you have the camera out and the kid stands in front of it. Like motion capture, so same idea, right? Similar, just a little bit more refined, really making sure that you're in the same space," Esser said.
According to the Mayo Clinic, side effects may include scalp pain and discomfort, headaches, lightheadedness and facial twitching. Although, Esser said he prefers those over the side effects of other depression treatments.
"The side effects I have seen from TMS treatments are local. Some people have headaches," Esser said. "But, you start low and increase the strength of the magnetic field as needed or as tolerated, and they get used to it. I have not had anybody dropping out yet of my treatment due to pain or discomfort."
He said though their data on how well the treatment works has not reached the remission rates of the larger studies cited, he is pleased with his patients' outcomes.
He said clinicians are more likely to have their sickest patients try the new treatment first, since they have tried many other avenues with no luck.
"They're kind of trying this on the more sicker patient population, but still, the response rate is very good. I'm very happy and more importantly the patients are actually happy," Esser said.
The VA in Montana is working to roll out a mobile TMS treatment clinic and Esser said another chair might be available soon at the clinic in Helena.
As someone who grew up in Germany, Esser had a connection with World War II through most of the older people he knew. Though a civilian, he relates to veterans and feels strongly for their cause. Plus, he thinks they enjoy his German "directness" -- getting along with patients who are short with him because it's simply what he's used to back home.
"They're phenomenal to work with, and then when they get better it's even more incredible. Because often they come pretty beaten up and hopeless or disillusioned about the system. So, if we have the chance to change that, which I often have, it's a really happy day." Esser said.
Reporter Taylor Inman can be reached at 406-758-4433 or by emailing email@example.com.
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