Andy Landgrebe had lived with a debilitating mood disorder for years and was beginning to doubt he would find adequate treatment. He moved among major cities doing stand-up comedy, working for The Second City, and writing, while also adjusting to new therapists and medications for his bipolar disorder (BD).“When you’re looking to get treated, sometimes you don’t even know what’s going on with your body or your brain,” he says. “To admit there’s something wrong inside your head is a journey itself, but then to get treatment for it is even more difficult.”

Landgrebe had tried over a dozen different medications with no consistent benefit. When he moved back to his hometown of Iowa City, Iowa, he had reservations about trying a completely new approach, transcranial magnetic stimulation (TMS).

TMS for depression was approved by the U.S. Food and Drug Administration (FDA) in 2008 and has been available to patients with treatment-resistant depression at University of Iowa Hospitals & Clinics since 2016. Recent FDA approval of a new way to deliver TMS, which decreases the time required per treatment session, combined with additional technology at UI Hospitals & Clinics provides more patients the opportunity to explore TMS.

Treatment targets prefrontal cortex

Landgrebe, 36, was diagnosed in his early 20s with BD, a fairly common mental illness marked by episodes of manic highs and depressive lows. His last manic episode was over a decade ago, but his BD manifests mainly through depression—and late last year he hit a low.

“I was in a bad place in September, as bad as I’ve ever been,” he says, adding that he had thoughts of suicide, was having difficulty getting out of bed, and lacked motivation to go to work. After graduating from the Iowa Writers’ Workshop Summer Program, he began to lose interest in finishing short stories and projects, which at one time consumed much of his time and energy.

His wife and parents urged him to try TMS. With this procedure, a handheld device containing an electromagnetic coil is placed against the patient’s scalp over the prefrontal cortex, a brain region that tends to be underactive in people who are severely depressed. Electrical stimulation is delivered through the coil. Daily stimulation can cause long-lasting changes in the excitability of the cortex, leading to an antidepressant effect.

Each TMS treatment lasts roughly 40 minutes, and a patient receives the treatment five days a week for four to six weeks. TMS is noninvasive and patients say the process feels like a rapid tapping on their scalp. The most commonly reported side effect is a temporary headache following treatment.

Aaron Boes, MD, PhD, UI assistant professor of pediatrics, psychiatry, and neurology, says over half of patients respond favorably to TMS, meaning the severity of their symptoms decreases by 50% or more. A third of these patients reach remission, or are no longer depressed at the end of the treatment course, he says.

A new protocol, called intermittent theta burst stimulation (iTBS), can deliver the stimulation in less than four minutes. The newer, faster approach uses a complex rhythm of stimulation that mimics how brain cells communicate with one another, making it more effective in driving changes in brain excitability, Boes says. A large, multi-site study with roughly 400 participants showed the faster protocol was just as effective as conventional TMS treatment, and iTBS received FDA approval in August 2018.

Along with offering treatments that take less time, the Iowa Brain Stimulation Program has also added a second TMS device, enabling providers to offer the treatment to more patients sooner.

“Previously we’d have to tell patients that it would be six to eight weeks before we could get them in for treatment,” says Nick Trapp, MD, in the Department of Psychiatry. “And now we can start treatment the next day or so.”

‘Feel like the person you’re supposed to be’

When Landgrebe started TMS in early December he had reservations and wasn’t fond of the unusual sensation that comes with the treatment, but he eventually grew accustomed to the daily routine. He particularly enjoyed catching up with technician Chris Sanborn and watching episodes of “The Office.”

“After a while it felt like you were coming to say ‘Hi’ to a friend for 45 minutes,” Landgrebe says. “TMS treatments are probably the same in a lot of different places, but it feels far more seamless with the staff here.”

Landgrebe started to notice an improvement in his mood later in December while experiencing the joy of Christmas morning with his 4-year-old son. And then in mid-January he was awed by several eagles hunting along the Iowa River.

“I remember thinking, ‘Wow, that is absolutely beautiful,’” he says. “But then I remember thinking, ‘When was the last time, in January, that you looked up and said anything was beautiful?’”

Along with these noteworthy, self-aware moments, he was itching to return to work and to finish writing projects he had neglected. Landgrebe tapered off TMS shortly after.

“Today’s a good day,” he says. “I attribute it directly to TMS. You don’t feel like a different person, you feel like the person you’re supposed to be.”

It’s important to note that Landgrebe continues to see his regular psychiatrist and therapist. If he starts to feel low again, he says he may go through another round of TMS treatment.

“I’ve got another tool in the toolbox to work on this thing that sometimes gets broken,” he says.

Trapp and Boes agree that watching patients recover, as Landgrebe has, is the most rewarding part of their job, especially since their patients often come to TMS discouraged that previous treatments for their depression didn’t work sufficiently.

“When someone is finishing their treatment course and they say that their life is totally different now—that it’s easier for them to interact socially, or their spouse notices a difference—that reaction is my favorite part of my job,” Boes says. “It’s not too often in medicine where you have that kind of dramatic change over the course of a few weeks, especially for long-standing, chronic depression that’s been going on for decades.”