Dr. Jonathan Downar
Dr. Downar demonstrates the rTMS machine on a staff member. The procedure is used on hard-to-treat depression and some other mental illnesses too. (Photo: Aisha Dar, rTMS Clinic)

Dr. Jonathan Downar, neuroscientist and psychiatrist at Toronto Western Hospital, spent four years completing a PhD in brain imaging.

But when it came time for him to practice psychiatry he was surprised to realize he could be a good psychiatrist without applying all of the anatomical knowledge he had obtained.

"'Where' is pretty irrelevant for most of psychiatry, because I can't make medications just go to the left frontal lobe, or therapy just to the right frontal lobe," he says.

While trying to figure out how to make his knowledge of brain anatomy useful in the clinic, it clicked to him.

"I realized that really what I had to do is focus on treatments that were anatomically specific in their effects because then, 'where' matters," Dr. Downar says.

But when exploring options for depression treatment, people tend to focus on two things: therapy and medication. What often goes unacknowledged is the third option, repetitive ​transcranial magnetic stimulation (rTMS).

rTMS uses magnetic pulses to stimulate the brain in an attempt to strengthen weak connections or weaken connections that are too strong. Dr. Downar says one of the biggest barriers in understanding rTMS as an option for depression treatment is most people haven't even heard of it, despite the fact that it has been approved by Health Canada since 2002.

The second barrier is accessibility, including both cost-efficiency and transportation to clinics.

"One of the biggest issues with rTMS is you still have to come into the clinics to get the treatment."

While the quit rate for patients receiving rTMS treatment is only around five per cent, versus 25 per cent for those on medication, the reason for their quitting is often because of the commute to the clinic.

A major goal of the rTMS clinic, a part of the Centre for Mental Health at Toronto Western Hospital, is to find ways to make the treatment more accessible to patients seeking an alternative to medication and therapy.

Dr. Downar says the research dedicated to this treatment is crucial because about two per cent of Canada's population (around 700,000 people) have treatment-resistant depression, meaning they won't be successfully treated by medication or therapy. For them, rTMS is a new glimmer of hope their hard-to-treat conditions can improve.

Since science and brain imaging allows doctors to see which brain circuits are either too strong or too weak, they are able to target the problem areas – the ones causing depression. After roughly 20-30 sessions of stimulation – depending on your condition – the depression will gradually improve.

In terms of effectiveness, Dr. Downar says about one third of people get a full remission, but there's another one third of people who he thinks can come close to remission by treating multiple brain areas. For the last one third the treatment seems to be ineffective.

The success rate and number of people this treatment has proven to help keeps Dr. Downar motivated and inspired to find a way for it to be accessible to anyone who needs it. 

rTMS has been around for over 20 years, but has been quite slow to take off because it has always been expensive, with little to no public funding in Canada, making it difficult for those needing the treatment to get it.

Digital images of the brain
Digital images of the brain are shown on the screen during rTMS treatment. Dr. Downar’s hope is for the rTMS procedure to be done safely and effectively at home, cutting down patients’ commute times. (Photo: Aisha Dar, rTMS Clinic)

In a collaborative study with UHN, University of British Columbia and the Centre for Addiction and Mental Health from April 2018, Dr. Downar and his colleagues were able to come up with an rTMS treatment that would take only about three minutes per session, yet was just as effective as the standard treatment sessions that typically take 37.5 minutes. The treatment was recently approved by the FDA in August, 2018.

Using a shorter treatment not only brought waitlists down to a maintainable level, but also decreased the cost from about $250 to $50 per treatment session, Dr. Downar says. This is a significant decrease, but still poses a problem for many patients where funding is not available.

Dr. Downar's overall hope for UHN's Centre for Mental Health is to pioneer an approach to mental healthcare that is more readily available, integrated and universal, bridging the gaps in accessibility often seen in this area of healthcare. 

While Dr. Downar focuses his efforts on trying to do this effectively for rTMS, there is still a road ahead to achieving this model.

"When you got to the cancer clinic, no one tells you that you have to get in three different five month- long lineups for your radiation, your chemo and your surgery," he says.

"Ideally, there's one front desk and they just take you in and they try to put together a comprehensive treatment plan. We need that same approach here in mental health. And we're going to try to get there."

For Dr. Downar, the next step in attaining this standard of care is continuing his research in making rTMS treatment even less expensive and more accessible. The goal is to develop a type of rTMS that is so simple and safe patients can perform the treatment themselves in the comfort of their own home.

"The next big thing I think is going to be to try and demonstrate that there is a way rTMS can be done as safely and effectively at home as it can be done in the clinic," he says.

"This includes showing how rTMS has a better success, fewer-side effects and fewer safety issues than medications, and that everything we do in this room could also be done just as easily by the patient in their bedroom at home, with the right safety measures in place, so long as we can make the treatments simple and user-friendly.

Dr. Downar points to the fact that patients have already been taught how to perform some medical procedures at home, such as injecting their own insulin or doing their own wound care. 

"If we can show at-home rTMS is less risky than either of those procedures, and less risky than sending a depressed person home with a bottle of medications on which they could overdose, then we actually have a good argument for home-based rTMS treatment. And with that being demonstrated, we're one step closer to access for everyone."​

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