Joan Camprodon, neuropsychiatrist: There is a lot of taboo around electroconvulsive therapy, but it reduces the intensity of depression

When depression sets in, it is usually combated with medication and psychotherapy, but these treatments leave many without relief. Transcranial magnetic stimulation (TMS) is an alternative for those who do not respond to conventional methods. The technique consists of applying magnetic fields to stimulate nerve cells and modulate their activity in order to reduce or eliminate symptoms of depression. Unlike other techniques, such as deep brain stimulation, it does not require surgery and allows the brain to be stimulated quite precisely. TMS has also been shown to be useful against obsessive-compulsive disorder, tobacco addiction, and migraines.

Joan Camprodon (46), director of neuropsychiatry at Massachusetts General Hospital in Boston, is one of the world leaders in this type of treatment. A few days ago, he participated in a conference on neuromodulation organized by the Spanish Society of Clinical Psychiatry (SEPC) at the Infanta Sofa University Hospital in San Sebastian de los Reyes (Madrid). At the event, he spoke about the potential of the technology to help patients who do not respond to other therapies and which will be applied to more areas in the coming years.

Question. In the long term, can these tools replace drugs for diseases such as depression?

The answer. Stimulants are becoming more precise and safer, but they will not necessarily replace drugs. As a clinician, I believe that we need to have as many tools as possible, with maximum safety and maximum effectiveness, to be able to combine them in a way that is individualized. We don’t want to cure depression or schizophrenia, we want to cure the person suffering from depression or schizophrenia, and we need to personalize treatments. This is important because depression is not a disease, it is a clinical syndrome. It’s like a headache, which can occur because someone has a migraine or an intracerebral hemorrhage because they hit their head. If I give migraine medicine to three people with headaches, only those with migraines will respond; a person with a headache will still have pain. Depression is the same, there are many different illnesses that lead to what we call depression, and the same treatment does not work for all of them.

P. Can these techniques help improve knowledge of this clinical syndrome and its treatment?

A. Stimulation tools, which change the brain, are combined with tools that measure it, such as MRI or PET (positron emission tomography), which allow us to understand, in a non-invasive way, what is happening in the brain when we apply a treatment. This way we know what happens when treatment doesn’t work and what happens when it does, and from there we can design strategies to optimize how to bring about the necessary changes in the emotional, cognitive or behavioral circuits of a depressed person.

P. Are these therapies expensive compared to other alternatives?

A. If compared to other stimulating tools or pharmacology, from a strictly economic point of view, beyond personal and social influence, it is very effective, because it works very well in patients who are very resistant to treatment and very expensive to treat in one day. -During the day. This economic vision is important when it comes to convincing politicians to allow these tools to be covered by the public health system: it still surprises me that they are not included, because the evidence is so strong. Deep brain stimulation is done for Parkinson’s, but very little, and electroconvulsive therapy is done, but only a little, and it comes late, because it is applied when a person has had the disease for 15 or 20 years, and there are many [hospital] confessions or suicide attempts. There is a lot of taboo around electroconvulsive therapy, but there is evidence that it reduces the intensity of depression, the risk of suicide, improves functionality and integration into the family. Electroconvulsive therapy is done differently than years ago. It doesn’t require surgery, but it does require general anesthesia, with muscle paralysis, like when you operate on someone. This avoids the risk of joint, muscle or bone injury.

P. Do you think we can strive to significantly reduce the impact of mental illness, or is it an inseparable part of being human?

A. It’s a bit like cancer, the price we pay for the biological complexity of our bodies, for the cognitive complexity and behavioral and affective sophistication of our brains. This won’t go away. The prevalence of schizophrenia, for example, is 1% in Spain, India, Nepal, the United States and Uruguay, and is very persistent.

P. With this type of technique that is non-invasive, not very expensive and relatively easy to apply, is it possible to use brain stimulation not only for the sick, but to improve the abilities of healthy people?

A. It is biologically feasible. A healthy brain can be modulated to maximize its functions. This is already done in elite athletic centers, with specific nutrition or sleep patterns, along with cognitive training. A person who studies medicine for six years optimizes his cognitive abilities. And it is technically possible to use our tools, not only to increase the level of function of a person who has a deficit due to a psychiatric or neurological disease, but to optimize it in a healthy person and prevent it from falling into a pathological state. state in the future. It is an important bioethical debate that we must keep in mind in science and at the societal level. Who will have access to these technologies? Maybe people who already have certain advantages and who would widen the gap? Is putting a helmet on your head very different from studying 10 hours a day for a year and improving your ability to concentrate? These are important questions.

P. Does this manipulation carry risks?

A. When you change one thing, you change the others, because everything is very connected. What is the risk of using these stimulation tools in a healthy brain to, for example, increase attention? What other functions have been degraded? What mindfulness training can do is not that different from what stimulation can do, but there are different connotations. I see the greatest value in prevention. What can I do to minimize the likelihood of changes that lead to disease? What can I do to prevent a person who has had a stroke from having another, or to prevent someone who has suffered a traumatic event from developing post-traumatic stress disorder? We could optimize the brain to make it resistant to disease.

P. Are there any side effects? Are they similar to other treatments?

A. They are very different, for one main reason. The drug passes into the blood and reaches all organs. To get to the brain, where you want it to go, it has to go to the liver, heart and muscles. And when it gets to the brain, it doesn’t just go to the parts you want it to reach, it hits everything. They are systemic treatments and much of the side effects of the drugs have to do with that. With brain stimulation, except for electroconvulsive therapy, only some parts of the brain are reached, which means that the range of side effects is more limited, although, like any treatment, there are some.

P. Does the fact that these types of treatments work mean that the brain is a machine that can be fixed, like when we take a car to a mechanic?

A. Reductionisms will always explain the problem poorly and there are biological reductionisms that try to reduce everything to nuts and bolts, which in this case would be electrical patterns or, as it used to be said, chemical patterns. But thinking that everything is psychological or that these psychological processes are completely separate from biology is also reductionist. They are one and the same, two sides of the same coin. If I as a scientist bring the tools to measure the brain, I will see the brain, and if I bring the tools to measure the mind, I will see the mind. The subject of study is complex. But an emotion doesn’t stop being real because I can explain it to you in biological terms or because I can modulate it with brain stimulation.

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