Neuromodulation techniques: how they work, when and why they are therapies to focus on in the future

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«I couldn’t stand the psychotropic drugs any longer. I felt better, but due to the side effects I gained weight and suffered from sleep disorders. I had already completed my psychotherapy journey, yet, according to the psychiatrists at the mental health center I had turned to, I couldn’t abandon the pills: I had a serotonin deficiency and I had to manage it with drugs.”

The story of Alberto, 52 years old, begins nine years ago. A diagnosis of depression, anxiety and panic attacks faced with a long course of psychotherapy and psychotropic drugs, which become an essential element of his daily life, leading to addiction. «The turning point came when I decided to leave my job after 20 years of seniority to undertake a very demanding consultancy job, which required a lot of concentration and night’s rest. Through a post on social media I discovered the existence of Transcranial Magnetic Stimulation, a neuromodulation technique that can act on drug addiction, depression and various sleep problems, which I suffered from. I immediately informed myself and evaluated
the possibility of trying it together with the psychologist who was following me and who knew this type of therapy well.”

The medical center that Alberto goes to provides him with a support team that takes care of his medical history. «They investigated and evaluated my case, explaining to me that through TMS it would be possible to rebalance the mechanism that synthesizes serotonin permanently and without side effects». The therapy is not invasive and Alberto copes 20 sessions lasting 30 minutes each, once a day. «You only feel a small blow on the skull, quite painless, then nothing else. Apart from the first few times when I felt a little lost, I immediately started to see some benefits. I was always under the supervision of the doctors and the psychiatrist at the center had started to gradually take me off the drugs. Yet, at the end of the therapy I felt so good that I wrote to him saying I wouldn’t take them anymore. In fact, it has been like this since that day.”

Today Alberto lives a normal life, he is calm, he no longer has mood swings and after more than a year he has no longer needed to resort to psychotropic drugs. His case is one of many that are helping to increase interest in non-invasive neuromodulation that acts on brain activity to obtain a change on a behavioral or motor-sensory level. It includes techniques such as Transcranial Direct Current Stimulation (tDCS) or Alternating Current (tACS) − characterized by small painless electric shocks − or the Transcranial Magnetic Stimulation, also known by the acronym TMSThat uses electromagnetic waves. What differentiates these methodologies is mainly the instrumentation used and the depth of action.

In recent days, even the famous rapper and entrepreneur Fedez has said that he has decided to undergo transcranial stimulation to treat an acute form of depression.
«TMS in particular has obtained approval from the FDA and the EMA, i.e. the regulatory agencies in the United States and Europe, precisely for the treatment of resistant major depression, for anxiety disorders and for obsessive compulsive disorder» , explains neurologist Graziella Madeo, a doctorate in neuroscience in the United States and now responsible forNeuromodulation and clinical research unit Of Brain&Care, a specialized center, with offices in Milan, Rimini and Turin. «The studies carried out up to now indicate that, depending on the stimulation protocols used, a rate of disappearance of symptoms between 50 and almost 80% can be achieved for severe depression», specifies the specialist.

Recently, Transcranial Magnetic Stimulation has also obtained approval for the treatment of addictions to psychoactive substances and smoking. «An important step for pathologies that have a significant socio-economic impact and for which specific drugs are not always available», underlines Madeo. «An example is cocaine addiction on which studies, although there is a certain heterogeneity, have shown that TMS is associated with a benefit in reducing the desire and impulse to take the substance and with a significant reduction in use. A study conducted by our group on 284 people with cocaine addiction followed for two years and 8 months showed a significant reduction in use and the absence of relapses in 18% of the subjects examined one year after starting treatment. These data certainly require further confirmation, but they open important therapeutic windows for a pathology that still remains orphaned from the point of view of the pharmacological approach. Similar research is also giving positive results in the symptomatology of some behavioral addictions, such as pathological gambling, which have an impact on the general population between 0.8% and 12%”.

But what exactly happens in the brain with Transcranial Magnetic Stimulation? «When these repetitive magnetic impulses are transmitted through a coil positioned on the patient’s head, there is the ability to enhance the activity of that brain area weakened in its function due to the pathological condition, or to reduce it if instead in that area brain activity is excessive. An important aspect is that TMS stimulates plasticity, that is, our ability to memorize through the strengthening of synaptic connections or the creation of new connections. In this process, those substances that allow the brain to function correctly are also stimulated, namely serotonin, dopamine and endorphins, and this in the face of generally minimal and transitory side effects, such as a slight discomfort in the region of stimulation or a headache. passenger’s head”.

In recent years, especially Transcranial Magnetic Stimulation has had a very important technological evolution, as highlighted by the neurologist Brain&Care. «Today there are various coils available with which these magnetic fields are generated, including focal ones which allow the identification of specific brain regions to be stimulated in real time, thanks also to the neuronavigation software with which they are associated. Added to these are coils that generate a larger magnetic field, as in the case of Deep TMS, a treatment that can reach greater brain depth. Even more advanced instruments then allow the patient’s MRI to be loaded and, through the neuronavigation software, to identify exactly the brain area to be stimulated. All this offers extremely greater treatment accuracy than, for example, the tDCS».

Scientific-technological evolution continues and development prospects are progressively extending to other fields as well. «There are currently research protocols in which neuromodulation is also used for forms of the autism spectrum and in problems related to attention deficit disorder», adds Madeo, who is next November 18 will be Scientific Director of 2nd Congress on the well-being of the brain and mind of Milan, during which the leading experts in the field of neuromodulation will discuss the increasingly integrated use of these therapies. «It is important to consider that for some pathologies, where to date we do not have specific drugs and there are no effective therapies, these techniques that allow us to modulate brain activity can offer hope, first of all disorders related to neurodevelopment».

TMS and TDCS therapies, where and how in Italy

A medical prescription is required for non-invasive neuromodulation. It is therefore necessary to have a diagnosis and a therapeutic program established by a specialized doctor, be it a psychiatrist, a neurologist or a physiatrist.

In Italy, neuromodulation is performed in private clinical centers (for a stimulation session the costs vary from 100 to 200 euros) and also in public facilities, in any case it is not included in the outpatient services provided by the National Health System. However, some public structures already use these non-invasive therapies free of charge within some programs with multidisciplinary approaches. «Currently, in our facilities, we practice TMS or direct current stimulation on hospitalized patients or those who access day hospital when neuromodulation is foreseen within their treatment program, covered by the NHS», explains the professor Luigi Tesioprimary of Physiatry And Director of the Department of Neuro-rehabilitation Sciences and of the Neuromotor Rehabilitation Research Laboratory of theAuxologico IRCCS. «Generally therapy it is required within psychiatric programs to treat addictions or depression, or to intervene on pain resulting from damage to the central nervous system, or motor control difficulties or for neuropsychological problems, such as aphasia and language disorders linked to brain damage. Therapy alone is indicated in few circumstances, although it can work for brain injury pain, as well as for certain speech disorders. In all other situations it is inserted within an integrated program”, explains Professor Tesio, also specifying that “neuromodulation is a very interesting technique, it is not invasive, it has few side effects and above all the direct current one has practically no contraindications, if not epilepsy. The fields of application are already very vast and the prospect is that it could become, over time, a routine approach. But it is good to keep in mind that it is a therapy, not a “magic” solution: to deal with a certain pathology, the thing to look for is not brain stimulation itself but the specialist who treats that problem. He will be the one to evaluate whether and under what terms it will be appropriate to provide for its application.”

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