New Treatments and Research Target Anxiety and Depression - Atrium Health

Mental health is more important than ever. It's closely connected to physical health and touches every aspect of life.

"If you don't have good mental health, there is no health," explains Dr. Nicole Aho, interventional psychiatrist with Atrium Health Behavioral Health. "It crosses all fields of medicine and is related to stress, poor sleep and lack of motivation. Mental health can impact every other health condition possible. For example, untreated mental health conditions can make diabetes, heart disease and dementia worse."

Mental health conditions are having a significant impact on young people, especially adolescent girls. Since the start of COVID-19, young girls have experienced an increase in suicidal thinking and suicidal attempts. According to Centers for Disease Control and Prevention, 57% of teenage girls in the U.S. felt persistently sad or hopeless in 2021.

Atrium Health Behavioral Health is dedicated to supporting the mental and emotional well-being of patients. These experts provide innovative treatments that help patients regain control of their lives, whether they're facing mental illness, including depression and anxiety, a substance use disorder or other addictive behaviors.

Atrium Health Behavioral Health Davidson has plans to open a satellite facility that provides transcranial magnetic stimulation (TMS), making it the fourth site to provide interventional therapies within the Greater Charlotte Market. By 2024, this location is scheduled to provide outpatient TMS treatment as well as esketamine therapy to underserved patients.

Atrium Health Behavioral Health's innovative neuropsychiatric treatments and research initiatives are bringing relief and hope to patients throughout the community.

Brain Stimulation Therapies

Brain stimulation, also known as neuromodulation, includes all technologies that help repair electrical signals in the brain. Thanks to advances in neuroimaging (medical imaging that targets the brain), Atrium Health Behavioral Health Interventional and Neurocognitive Psychiatry (INP) doctors can better understand and improve the efficacy of these treatments.

Electroconvulsive Therapy (ECT)

ECT delivers brief, controlled electrical currents to the brain through the scalp. Performed under general anesthesia, ECT creates a controlled seizure that has been shown to improve mood symptoms in patients with severe depression and other mood disorders.

ECT has a 50%-80% response rate in patients with treatment-resistant depression. "It's currently one of our most effective treatments for severe depression," notes Dr. Ruth Benca, academic chair, Atrium Health Behavioral Health Service Line. "By creating a seizure, it may increase brain plasticity (adaptability), which can improve our emotions."

Although ECT has been around for 80 years, there's still a lot of stigma around the treatment. "We use newer ECT devices and protocols to help reduce side effects," Aho explains. "We still use this treatment after so many decades because it's still very effective. We've just modernized it and made improvements."

With ECT, the most common side effect is short-term forgetfulness, mostly around the time of treatment. Other common side effects of ECT and anesthesia can include nausea, headache, stomachache and muscle aches. There's no clinical evidence that shows that ECT causes brain damage, personality changes or dementia. Any short-term forgetfulness that occurs after ECT is usually temporary.

According to a study published in Biological Psychiatry, the results from cognitive testing performed before and after ECT revealed that all cognitive variables analyzed returned to normal 15 days after treatment.

Since anesthesia is used, patients must have transportation support for their ECT appointments. In addition, patients may need pain medication during treatment to minimize discomfort.

TMS

TMS is a neuromodulation treatment that delivers brief, magnetic pulses to regions of the brain that can affect mood. Just a few weeks of treatment with a tiny electromagnetic coil placed over a specific region of the scalp can provide relief.

The FDA has approved TMS to treat severe major depressive disorder, major depressive disorder with anxiety and obsessive-compulsive disorder. Specific TMS devices have also been approved to help patients with smoking cessation. While TMS can be helpful in treating bipolar depression, it has not yet been approved by the FDA for this condition.

TMS has helped many patients battling treatment-resistant depression. Most patients start to notice benefits within four weeks of treatment. TMS has a 40%-50% response rate in patients with severe depression after six weeks of treatment. The sooner you introduce TMS, the higher the response rates tend to be.

But what about long-term results? A study published by The Journal of Clinical Psychiatry revealed that about two-thirds of patients were still well 12 months after treatment when they continued adjunctive care, like medication and therapy. In a study published by the same journal, 62.5% of patients continued to respond well one year after treatment.

For most patients, TMS causes no side effects. In some cases, patients may get headaches. Other side effects may include scalp discomfort at the treatment site and tingling or spasms in the face muscles.

Researchers are studying a new TMS protocol called Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT). The protocol uses the first device to combine personalized neuroimaging and neuronavigation (computer-assisted guidance within the brain or skull) with TMS to enhance the efficacy of treatment. Treatment is given over a five-day period. There are 10 sessions a day, with each session lasting about three minutes.

SAINT has been approved by the FDA and has proved very effective in small trials. It's especially appealing to emergency departments, where some patients have to wait several days for inpatient psychiatric care. Rapid TMS could help patients find relief sooner and help reduce the burden on emergency departments.

Atrium Health Behavioral Health experts can use a rapid protocol similar to SAINT to treat serious mental health conditions quickly if needed. The TMS treatment is delivered without the use of neuroimaging, since the SAINT neuroimaging device is not yet available.

Closed-Loop Stimulation

Disturbed sleep is often a precursor to mental health conditions, and continued sleep issues can make them worse over time. According to Benca, there are brain wave patterns that only occur during sleep, which are vital to learning and cognitive function as well as brain plasticity. Research is underway to determine if abnormalities in brain activity in certain mental health conditions, such as mood disorders or mild cognitive impairment (MCI), can be corrected through closed-loop stimulation during sleep.

"In clinical research, we've shown we can stimulate slow wave activity – one of the brain wave patterns related to the functional aspects of sleep," Benca explains. "We measure brain wave patterns during sleep. When the patient gets to a certain stage, we can enhance those waves using one of two types of stimulation. We can stimulate the brain by playing tones in the ear that aren't loud enough to wake the patient or by applying very mild electrical stimulation to the patient's scalp." 

Researchers with the Department of Psychiatry and Behavioral Medicine at Atrium Health Wake Forest Baptist are studying how closed-loop stimulation could improve cognitive symptoms in patients with MCI by enhancing sleep quality, which could help slow the progression of Alzheimer's disease.

Personalized Psychiatry

Atrium Health Behavioral Health will soon have access to a new brain mapping device that delivers more targeted brain stimulation therapies.

"In addition to treatment, we use brain stimulation as a research tool to study the brain," explains Aho. "Our goal is to work toward personalized psychiatry. We're using brain mapping to identify more effective treatment locations for TMS. This can help us treat mental health conditions but also better understand and characterize depression."

One day, Atrium Health Behavioral Health experts hope to use individualized brain maps to determine which patients are more likely to benefit from specific treatment protocols and treatment locations.

Esketamine

Esketamine is a medication that's used to treat severe depression and depression with suicidal thinking. It treats these conditions very rapidly and can be more effective than traditional depression treatment. Esketamine is only approved by the FDA for use in conjunction with another antidepressant. It's administered through a nasal spray. 

"The good news is you only need to be treated twice a week for four weeks," notes Aho. "By that time, you'll pretty much know if esketamine works for you. That's much faster than traditional antidepressants, which take four to six weeks to start working. If esketamine does work, you can continue treatment as a maintenance program."

Esketamine may cause an increase in blood pressure. Some patients have reported out-of-body experiences and hallucinations. In rare cases, brain bleeds have occurred. Because of these risks, patients are required to stay at the clinic for two hours after treatment for monitoring. Patients will need help with transportation following treatment, and they must wait 24 hours (following a restorative night of sleep) before resuming driving and working.

Why Choose Atrium Health

Atrium Health Behavioral Health offers patients a one-stop shop for neuropsychiatric treatment. During a single consult, doctors can discuss all available interventional therapies – ECT, TMS and esketamine.

 "If you try a treatment that doesn't work, you can try another one without having to attend additional consults, saving time and money," says Aho.

Atrium Health Behavioral Health experts also have connections with other medical services throughout Atrium Health. 

"We can collaborate with your neurologist much easier than other institutions," Aho explains. "This helps alleviate some patients' fears about how our treatments will react with their underlying health conditions. Plus, we collaborate with our anesthesia team to ensure patient safety throughout their neuropsychiatric procedure."

The majority of doctors with Atrium Health Behavioral Health are members of the Clinical TMS Society and the International Society for ECT and Neurostimulation. "This allows us to stay engaged with the most advanced treatments in the world of neuromodulation," says Aho. 

The Atrium Health Behavioral Health team works with medical students and residents who help them stay up to date with the latest techniques. The team also works with the Department of Psychiatry and Behavioral Medicine at Wake Forest Baptist, which also provides TMS and ECT services. These collaborations support ongoing innovations in research, technologies and therapeutic treatments.

"It's incredibly rewarding to help people return to their lives, jobs and families and to see them make progress over the years," Aho comments. "I enjoy being able to offer unique treatments to patients and help them understand their safety and benefits. Even just talking about the causes of depression and targeting brain networks can help patients understand their illness better and avoid guilt or shame."

To learn more, visit Atrium Health Behavioral Health INP or call 704-512-7578. If you need immediate assistance with a mental health condition, call our 24/7 helpline at 704-444-2400.

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