New Hope for Treatment-Resistant Depression at VA's Neuromodulation Clinic

For Veterans struggling with major depressive disorder that hasn't improved with traditional treatments, there is a new innovative clinic offering novel therapies at the Philadelphia VA Medical Center. The Treatment-Resistant Depression (TRD) Neuromodulation Clinic provides cutting-edge treatment approaches like repetitive transcranial magnetic stimulation (rTMS) and esketamine for veterans whose symptoms have not resolved after multiple attempts with antidepressant medications.

"Treatment-resistant depression is defined as depressive episodes that don't get better after trying at least two different antidepressants at adequate doses and duration," explained Kim Harper, Behavioral Health Outpatient Nurse Manager who oversees the Neuromodulation Clinic. "Around 1 in 7 Veterans have major depressive disorder, and for those who don't respond to initial treatments, we now have advanced options available right here."

Both rTMS and esketamine therapies are delivered through the Neuromodulation Clinic after Veterans receive an in-depth evaluation and referral from their primary mental health provider. During rTMS, magnetic pulses are administered to stimulate low activity in specific areas of the brain. Esketamine is a nasal spray version of ketamine that is administered under clinical supervision.

"The clinical trials for these therapies have shown really promising results, with 40-70% of patients experiencing an improvement in their depressive symptoms that hadn't responded to other treatments," said Harper. "It's an incredible opportunity for our veterans."  

The rTMS treatment consists of daily sessions 5 days a week for 6-9 weeks. The esketamine therapy starts with twice-weekly treatments for a month followed by once-weekly sessions, with the option for ongoing maintenance treatments as recommended by the clinic's psychiatric providers. Both treatment paths often include an added psychotherapy component.

"Once the Veteran has been evaluated by the Neuromodulation clinician and accepted into the program, here is what they can expect," Harper explained. "For rTMS the veteran will have daily treatments Monday-Friday for 6-9 weeks. For esketamine, the veteran will begin with treatments twice a week for 4 weeks, once a week for 4 weeks, and ongoing treatments will be determined by the clinician."

Air Force veteran Michael R., who recently completed 9 weeks of rTMS treatment after years of struggling with treatment-resistant depression, shared, "I was at the end of my rope, having tried so many antidepressants without any relief. This clinic gave me a second chance."

While the therapies can potentially cause temporary side effects, Harper noted, "The potential side effects for rTMS are mild to moderate headache, discomfort at the treatment site, lightheadedness, tingling of the face. For esketamine the potential side effects are increased blood pressure, nausea/vomiting, headache, dizziness, sedation, anxiety, fatigue, feeling detached from reality."

Despite the risk of temporary side effects, Michael said the benefits have been life-changing. "I feel present again and can finally see a path forward. I'm so grateful this innovative treatment was available to me as a veteran."

The Neuromodulation Clinic currently treats around 4 veterans per day with rTMS and 3 at a time with esketamine, with plans to expand capacity. "We would like to offer these services to all veterans that are candidates for the treatment so this will require us to expand our operations," said Harper. "We are in the process of getting a second rTMS set-up and will move towards offering both treatments during different hours of the day as our treatment interest and patient load increases."

Veterans interested in being evaluated must be referred by their primary VA psychiatrist, as Harper explained, "Veterans can only be referred to the clinic by their primary psychiatrist. The psychiatrist will have a conversation with the veteran to determine if they meet the criteria for either treatment."

"Our mission is to leave no Veteran behind on their journey to mental health recovery," Harper said. "This cutting-edge clinic offers hope for those whose depression has felt treatment-resistant and intractable in the past."

The Philadelphia VA's new Neuromodulation Clinic is raising the standard for how veterans access innovative, specialized depression treatments in a patient-centered environment. The clinic is open Monday-Friday (except federal holidays) from 8am-4:30pm. For any questions about the clinic or the therapies offered, please call 215-823-4036.

Thanks to the bravery of veterans like Michael who put their trust in these novel therapies, the path forward is looking brighter for so many struggling with persistent depressive symptoms.