and be able to pee first so try and get
this magnet on my head I'm Dave Bogart
I'm the vice president of research
programs and Industry Relations at the
Ontario Brain Institute so on behalf of
the board members of the OB I some of
whom are here today and a lot of our
colleagues who are here today and on
behalf of our president who actually
can't be here today Don stus is in
London at a meeting of the Ontario ecd
planning for an event that's going to
happen in September we're excited about
that but disappointed that he can't be
with us anyway I want to welcome you to
this first OB I event highlighting the
discoveries of Ontario's top
neuroscientists and it's held in
partnership with the globe and mail and
we're thrilled that they are partnering
with us in this way OPI is a
not-for-profit Institute that was opened
a short while ago in 2011 and it's
funded by Queens Park we are one answer
to a huge need and an even bigger
opportunity mental health and addiction
disorders cost Ontario's economy thirty
nine billion dollars every year thirty
nine billion dollars is a huge number
isn't it and it's a little hard to
visualize I was scratching my head
thinking what can you get for thirty
nine billion dollars and I discovered
you could buy about 135 of those
Dreamliners that air canada is waiting
for in fact they've only ordered 37 so
you could buy three times as many as
they want any way to that cost we have
to add the very human toll faced by the
families of people who were afflicted
with autism Alzheimer's epilepsy
addiction depression and many other
devastating brain disorders so the 39
billion is for just part of the puzzle
the picture that we're trying to solve
along with this huge need comes an
extraordinary opportunity Ontario has
more than 800 neuro scientists a huge
bank of talent that is tackling issues
of concern to us all so it's no surprise
that some of the most promising
discoveries around diagnosing treating
and even curing brain disorders are made
in Ontario including the one we're going
to hear about in a few minutes the
opportunity comes in getting faster and
better breakthroughs to patients to
markets and to the world the OPI has no
labs we don't do research ourselves we
bring together the key players from
researchers and clinicians to patients
and companies large and small to speed
things up to do science differently one
of our mandates is to showcase that to
the public the latest advances in brain
science and that's why we're here this
morning that's why I urge you to join
the OPI community bookmark our website
brain institute CA and follow us on the
social meter on social media you can see
our twitter account on the screen beside
me now i want to welcome a member of the
board of directors of the ovi who is
going to introduce our speaker dr.
Jonathan Downer and our moderator the
globe and mail's Andre Picard Valerie
Pringle is known to you all very well as
a journalist and broadcaster but she's
also one of the most effective mental
health advocates in the country her
volunteer work on the board of the
Centre for Addiction and Mental Health
Foundation comes out of her own family's
experience with depression and anxiety
she knows what it takes to shine a light
on these shadows so please join me in
welcoming Valerie Pringle anybody has
ever said to me I miss you in the
morning well here it is it doesn't
happen very often but it's an enormous
pleasure for me to be here as a board
member of the Ontario Brain Institute
these people are the smartest people in
the whole world and Meredith and I sit
at these board meetings and go holy moly
they are the most brilliant human beings
and they are doing such exciting and
wonderful things as David mentioned
I am an advocate I mean we started off
my husband dies donors to camh inspired
by the spectacular Michael Wilson who's
sitting beside me is my breakfast date
and you know as I became part of a
public awareness campaign for them and
put a public face on it talking about my
daughter's experiences with mental
illness although as I said in my family
like any other family runs the gamut
from you know drug addiction alcoholism
bipolar you know just every normal
Canadian family so you know I've
realized the hunger for openness and
also the hunger for hope and good news
and I think that's one of the reasons
we're here today we want to share news
as David said about the incredible
neuroscience that's going on much of it
right here in Ontario and the two
individuals who are going to be speaking
to you today are doing a great deal to
move this file forward and overcome the
burden of brain disorders the moderator
today is the great Andre Picard who's
been with a globe and mail for 20 years
or so he's a great author a speaker I
think considered universally the top
health journalist in the country he
takes enormously complex issues as you
read him in the globe and shines a light
on them and makes them understandable
and has moved health policy and public
policy forward on many many issues
mental health being you know one of them
at first and foremost but but on every
health issue he was named canada's first
public health hero by the canadian
public health association and also he
was named a champion of mental health by
the canadian alliance on mental illness
and mental health and he's a stellar
journalist and our speaker Wow another
genius person everybody's going it's not
brain surgery well this order is and off
I'm a little afraid living in this world
but I'm just doing my bath so I'll be so
excited to hear what he has to say dr.
Jonathan downer
received his PhD in brain imaging from
Toronto Western medical degree
University of Calgary completed
residency at U of T has established his
specialized clinic at Toronto Western
which now receives more than 400 annual
referrals using new technologies to
treat patients with medication resistant
major depression bipolar eating
disorders OCD post-traumatic stress
disorder you know he's translating what
is going on in cutting-edge research for
a new generation of more effective and
rapidly acting treatments for patients
with brain disorders and and we'll just
say this is an aside but it's critically
important he also participates in the OB
I funded research program can bind
looking into depression and this study
focuses on depression aiming to shorten
the path from diagnosis to treatment and
matching individuals to the right
treatment faster we know that's where we
have to go and that's where we're going
and there is information on those little
green tables behind the carrot muffins
David at the back of the room if you
would like to know more about this and I
should just also mention that dr. downer
is a co-author of a forthcoming textbook
on cognitive neuroscience from Oxford
University Press it's our great pleasure
to have Andre Picard and Jonathan downer
here today but first of all let me
welcome to the podium dr. Jonathan
downer
well thank you very much for all of the
kind introductions and thank you all for
coming at such an early hour to come in
here I'm very honored that you've all
arrived thanks also to everybody who
introduced me for not pointing out that
all of my depression patients have to
come and see dr. downer when they come
for treatment make things more confusing
my assistants name is sunny so that
makes anything as Canadians of one of
our greatest and proudest achievements i
think is is universal health care the
only problem is that if your illness is
a mental illness and I think anybody in
this room who's ever tried to find a
psychiatrist for themselves or for a
loved one or so on would agree with me
that universal health care at least for
mental health is a dream that we are
still struggling to achieve am I right
about this I used to think my job as a
clinician scientist was to use all of
our tremendous advances over the last 20
years to develop more effective
treatments the problem is that's not
what my patients were telling me all of
my patients were asking a different
question not why aren't my treatments
working five percent better than they
were last year but they're asking me is
why can't I find a psychiatrist I'm
going to argue that the issue is
primarily with the cat the technologies
and the kinds of treatment that we're
able to deliver in the year 2013 no
matter what the size of your economy
whether you're in norway saudi arabia
luxembourg o Canada we simply can't
would never have the financial resources
available to do the kind of psychiatry
we're doing and offer that type of care
to everybody who needs it so nowadays I
think my job as a clinician scientists
is to develop more cost-effective ways
of doing the treatment and that just
comes from pure mathematics so let me
take you through that a bit why is it so
hard to find a psychiatrist here are
some numbers on the screen the top
number is the number of us Canadians
there are a little over 35 million of us
one out of five of us during the course
of our lifetimes is going to suffer a
major mental
severe enough it is going to interfere
with our ability to function at work or
elsewhere so that's a little over seven
million 4100 is the number of
psychiatric MDS we have psychiatric
specialist we have so if every one of
those seven million people wants to have
a psychiatrist we have about 40 100
people to work with that number could
potentially go up a little bit it's not
going to go up by a factor of two or
three or five or ten that there isn't
the funding for that there isn't going
to be the funding for that but the
implications of that is that as a
psychiatrist and every psychiatrists in
this room and elsewhere our fair share
is 1800 patients every one of us has to
somehow provide effective psychiatric
care at 1,800 patients that's that's
just what the numbers tell us now GPS
will typically carry their practice
around 2,000 3,000 patients in Ontario
the average last time I check was around
150 so we're off by a factor of 10 and
again I'm going to argue that this is
just simply a function of the kind of
psychiatry were able to practice the
things that have to change if we go back
to 1890 the situation was even worse
let's i'm going to divide a Gotham call
us psychiatry 1 point 0 psychiatry 2
point 0 in the psychiatry three-point oh
so 1890 Sigmund Freud era people laying
on couches undergoing psychoanalysis
let's say your psychiatrists and you're
giving people psychoanalysis so an hour
a day on the couch five days a week
though and you're doing that for maybe a
whole year before you're able to move on
to the next person so during the course
of a single day if you do an eight-hour
day you've got eight patients and those
are the only eight patients you're going
to see for the rest of that year so your
ratio is 128 I'm not going to argue
about the merits or demerits of
psychoanalysis all i'm going to say here
is that you can't build a healthcare
system out of it that's universal you
will never have enough psychiatrist to
do that in nineteen sixty so a 70-year
step forward some interesting things
happen a whole bunch of new types of
therapies like cognitive behavioral
therapy and new treatments like sort of
medications came out that we're able to
treat things like schizophrenia and
major depression and bipolar disorder so
all of a sudden I'm going to argue that
what those really accomplished were to
create a kind of a leap forward a
psychiatry two point oh
that in terms of health care system what
it allowed is freak psychiatrists
deliver reasonably effective care even
though they weren't seeing the person
every single day for an hour maybe even
seeing them you know for 30 minutes
twice a month or for an hour once a
month what that allows you to do is see
more like 120 patients in your practice
and that's closer to what we're running
now now we're at about a hundred and
fifty so the healthcare system that we
are running in 2014 is actually mostly a
combination of psychiatry two point oh
and in many cases still psychiatry one
point oh there's still a lot of people
out there practicing psychiatry one
point oh and that's the reason that it's
so hard to find a psychiatrist that's
all we have it's not a situation that
I'm particularly happy with now imagine
if I sometimes draw an analogy to the
fracture clinic which is downstairs or
hospital she's hundreds of people and an
individual fracture specialist can see
lots of people down there we don't have
a fracture crisis where if a person
breaks their leg on a ski slope we have
a fracture crisis in carrier we're only
one in five people with broken legs is
able to actually get in and get treated
and imagine if that were the secure
ation where the streets were filled with
people hobbling around on crutches and
sitting in wheelchair saying do you know
where I can find a good fracture asst
time looking for a fracture is Steph oh
you did well you might and is it well
until you find one there's an
eight-month waiting list but in the
meantime my grandmother says if you're
bounding up this way or you know or
maybe you just need to be strong or just
walk on that broken leg and just do it
yourself you know this is really your
own we don't say these things for
fractious we would never accept that and
yet if you look at the numbers I mean
major mental illness like depression or
schizophrenia or bipolar disorder
community and can be more disabling than
a broken leg so I think my job as a
clinician scientist and probably the job
of all of us at work in mental health
care is to focus on the central problem
the central problem is accessed what we
want to get to is 70 years on is
psychiatrie three-point Oh some kind of
system where at least for MDS a single
psychiatrist can provide effective cared
up to 1,600 patients everything I'm
going to talk to you about today is
directed toward that goal so it's not
really a talk about the brain it's not
really a talk about brain stimuli
all of it is really how do we get to
psychiatrie three point 0 because the
goal should be and must be universal
health care for everybody who needs it
in the field of mental health that's
what this is all about so the psychiatry
three-point oh I want us to get to is
going to be more accessible it's going
to be more effective it's going to be
more rabbit an on-set we're not going to
be looking at 23 months to get better we
want one to two weeks to get better and
above all more cost-efficient is we're
not going to have 15 times the money to
work with we have to work with what we
have so how do we get to effective care
for 1600 patients / md i'm going to
start off with treatment-resistant
depression because there is lots of it
four point seven percent of the
population in Canada will undergo an
episode of major depression in any given
year and the problem is that more than a
third of them don't get better on
conventional treatments two percent of
the population is not the population
with depression it's a number of people
with depression we can't treat that we
don't know how to treat and they're
walking around out there right now in
Ontario that's two hundred and
seventy-five thousand people so it's a
tremendous number and what sometimes
obscured as a human cost of that i
copied that circle there off of a
questionnaire that was done by a patient
in my clinic there are not many
disorders of Medicine where a person
actually says I'd rather be dead than
have this there are very few disorders
sometimes an end-stage kidney failure
and liver failure but very few disorders
where a person says I would rather be
dead than live with this illness and
there's two hundred and seventy-five
thousand people out there who are
thinking about this and we don't know
how to treat them you can't put a cost
on human suffering but you can put a
cost on the amount of foregone tax
revenue the direct expenses of hospital
and healthcare treatment for these
people the disability payments and
social assistant payments of these
people its twenty thousand dollars per
case of treatment resistant depression
so we're looking on the order of over
five billion dollars a year in Ontario
alone what are the options we have today
well not much if medications and therapy
have failed you the only thing that we
currently have left that's OHIP approved
is ECT electroconvulsive treatment I'm
not going to spend a lot of time talking
about
whether its effect is it certainly is a
very effective treatment it has a bad
Sigma associated with the memory effects
that are associated with
electroconvulsive treatment what I'm
going to say though is that that's the
percentage of those people who got UCT
last year in Ontario it's about 1,600
people it's less than 1% so whether you
like ECT or whether you don't like ECT
unless we scale it up by a factor of
over a hundred that will never be enough
ECT to treat everybody even if everybody
wanted it so we've still got 270 3400
people walking around out there and
that's that's the enemy that's what we
have to go after enter another kind of
brain simulation and this is what we
practice in our clinic repetitive
transcranial magnetic stimulation
hopefully some of you have heard about
this before it's a pretty say it's
actually a technique that's been around
since the 1980s and is being used for
depression since the 1990s that
butterfly shaped coil you see there is
about the size of two slice bagels stuck
together it's an electromagnet so
there's wiring inside it can deliver
finally focus magnetic field pulses to
anywhere in the brain to a depth of
about two or three centimeters in the
background you'll see an MRI up on that
computer screen is we can use an MRI to
guide it and by applying repeated pulses
over time you can strengthen or weaken
circuits in the brain that are
overactive or under active they're not
fridge magnets they're pretty powerful
if you place one of these over the area
that was your thumb of your finger and
Andre I think you had a chance to do
this yesterday that have you ever seen
that heritage moment were Wilder
Penfield the neurosurgeon was
stimulating on the brain and getting
people's thing we seen this so you can
do this with these coils you place it
over the air that moves your finger send
in a couple of pulses the person's whole
hand will move the person's whole foot
will move so you're directly stimulating
the brain and this is what it looks like
if you were to undergo rtms you're
sitting in a little chair there to look
a little dentist chair there's an MRI in
one corner there you can see there's a
little camera in the middle that's
tracking the person's head and the
stimulator so we can position these to
an accuracy of within two millimeters
anywhere on the brain that we want to
stimulate and that allows us to target
circuits in a much more finally focused
way than therapy
medications for people where therapy and
medications aren't doing the job it's
been around for depression since 1994 if
you give people 20 or 30 sessions of
stimulation you can actually get more
than fifty percent of them to the point
where you've knocked their symptoms down
by half you can get at least a third of
them to the point where they say I don't
feel depressed anymore I'm ready to go
on no long-term adverse effects there's
no memory problems with it it doesn't
wreck your attention or your memory or
anything like that all the effects are
short-term it feels like an elastic band
being slapped against your forehead over
again that's that's a that's one of the
downsides of it ninety-five percent of
people find it tolerable you can get a
headache afterwards for an hour to that
usually goes away after the first week
so one in ten thousand risk of seizure
which is about the same or less than you
would expect with antidepressant
medications and that's that's pretty
much it here's the strange thing about
it Health Canada has approved this since
2002 the FDA's approved it since 2008
and there are over 500 clinics buzzing
away down in the US treating tons of
people so why don't we have more rtms
clinics in Canada well I'm going to
argue once again that the economics have
not been favorable up until very
recently and everything that I focus my
research on is to make it a no-brainer
sorry for the pun to start funding this
treatment so the problem is with
conventional rtms there there's a
person's frontal lobe there and you're
seeing the left frontal lobe being
stimulated 30 sessions of treatment two
hundred and fifty dollars per session of
treatment is the going rate in private
clinics in Canada it's closer to 350 to
400 per session in the US so six to nine
thousand dollars per single course of
treatment and the other problem is that
each session is 38 minutes long that's a
bigger problem than it sounds it's a
problem for the person sitting in the
chair that's 38 minutes but the problem
is it also means that just like in
psychiatry one point oh I can only treat
about eight people a day per machine
that's a problem so what do we need to
do there are four things we need to fix
about our TMS to make it a no-brainer to
make it psychiatry three-point oh we
need the sessions to be faster than 45
minutes a lot faster we need the courses
to be shorter we can't
we don't want this to be taking four to
six weeks of the person's schlepping
into hospital every day for treatment we
have to get this down to one or two
weeks we need more responders fifty
percent is good but we want it to be
better than that and finally we'd like
to have a predictive test we've talked a
lot about biomarkers and one of the key
focus of the Ontario brain institute is
fine markers why can't you scan my brain
doctor and tell me whether this is going
to work or not well surprisingly we're
still trying to figure out how to do
that and that's one of the things that
with doctor said Kennedy and the other
folks at the OB I we're trying to work
on so I'm going to take these one at a
time first one and this is by far the
key what if we could make our TMS from
our 38th minute treatment into a
three-minute treatment the economic
benefits are tremendous of that first of
all I can schedule patients every 10
minutes I can do six times as many
patients treated on a single machine and
that means the cost of our TMS dropped
six fold plus the waitlist increase by a
dramatic factor of six fold as well
that's what the Toronto theta burst
trial it's all just Toronto anymore we
now have you bc getting involved
montreal make join us so we have a
larger network of clinics we're getting
hundreds of patients 202 maybe at this
point closer to 300 who have major
depression where medications and therapy
haven't helped rather than going for ect
half of them are going to get the
standard conventional protocol they're
using in the state's this sort of nine
thousand dollar one with the 38th minute
treatments the other half are going to
get a different thing this is what I do
as a clinician scientist we comb through
the research and we look for things that
might be helpful it turns out that if
you repattern the pulses so they mimic
the natural theta rhythms of the brain
it's the theta rhythms that the brain
uses to change its own wiring and if you
make the pulses look like the same
pattern the brain uses a change its
wiring it turns out that at least in
some areas of the brain there's evidence
you can get the same job done in three
minutes with just six hundred pulses you
don't need the 38 minutes to do it so
what happens if we get out some standard
scales measure their symptom severity
and say can the three-minute treatment
do the same job as 38-minute treatment
so I'm going to show you a graph with
two little curves on it it's the curve
of improvement in symptoms of each
person
average with a 38 minute treatment
versus the three-minute treatment now
here's the thing we haven't finished the
trial yet so we're still in the blind
I've treated we've done about a hundred
people so far i'm going to show you our
preliminary results here are the two
curves I can't tell you which is which
but it actually doesn't matter the
outcomes look identical and if we look
at the percentage of people who are
getting better here's what we're seeing
again I can't tell you which is which
but it really doesn't matter the two pie
graphs look the same same proportion of
responders same proportion of remitters
same proportion of non-responders so
this is looking really promising and
there are other more more evidence
coming out that these three minute
treatments are doing the same job we've
been using them for more than two years
we've probably treated over 200 300
people with them at our clinic and the
three minute treatments are working just
as well as the old 38 minute treatments
so that's transformative and it's a
different way of thinking I have to
thank Tina buqun and she'll Marceau from
the edge stone foundation for pointing
this out that we've been chasing how to
get that number forty odd percent up to
forty five percent and they're saying
what if it doesn't work any better what
if it's just faster and more
cost-efficient and improves access and
I'm now a full convert to this belief
that improving access is the central
problem improving advocacy is a
secondary problem there's only one thing
I'm not happy about eighteen to twenty
percent of people are saying I feel all
better now I'm not happy with that
number that number needs to be better i
want i want more remitters we want our
team us to be more powerful we want it
to be able to do a lot more things than
it currently does so let's go on to
problem two what if we can make our TMS
work for twice as many patients and for
this I have to turn it back again to the
neuroscience this is where you put on
your clinician scientist hat and say are
we really stimulating the right brain
area now here's the funny thing about
the rtms literature that left frontal
lobe area that I showed you is the only
area that's been systematically studied
in 20 years of research so there were
really nobody had ever tried any of the
other areas the frontal lobe now that
area was a really good guess for what we
knew about the brain in 1994 but it's 20
years later we've had tremendous
advances in neuroscience and they're
actually pointing to a different area
not on the left side but tucked away
right in the middle it's called a dorsal
Nexus it's a little area where three
different networks of
main activity to intersect there's a
network of area that generates bodily
visceral emotional responses that's the
feel behind feelings there's a reason we
call emotions feelings they have a body
feel to them and there's an area of the
brain that generates those feelings
there's another network that is
responsible for things like thoughts and
inner speech when you say oh I'm so
clumsy why am i late why do i do what i
always make these silly mistakes that
sort of thing and there's a third area
that's involved in rumination and
self-reflection so when you're whenever
you're not in a moment if at any point
while I've talked any one of you is
tuned out and I'm sure this is having to
everybody in this entire audience
whenever you tune out from what I'm
saying to you right now that's that
middle network there the
self-referential network you're thinking
about something else and that those
networks should be on a little bit they
should be on some of the time but in
depression they're on a lot of the time
so you can't focus on what you're doing
is you're lost in thought and what's
worse is these three networks are all
tangled up together in depression
they've intersected so your thoughts
your feelings your emotions are all
wound up together in a vicious cycle
that you can't get out of the area
that's supposed to shut that process
down is that little dorsal Nexus area in
that red spot in the middle there that's
tucked away in the middle and what's
interesting is you take that same dorsal
Nexus area and then you look at hundreds
of people with depression and you look
at your MRI scans it turns out that
there's actually a loss of gray matter a
very subtle loss of gray matter in that
area in people with depression so if you
ask you know when we scan people for a
stroke we can see where the stroke is
when you scan someone for depression you
can't see where the depression is unless
you scan hundreds of people and then
hundreds of people who don't have
depression and compare them you can see
a very subtle thinning of the gray
matter in that area it's actually been a
little bit damaged it does grow back if
you get better don't worry about that
but it's in the same area here so this
is the neuroscience we had in 2011 I
said well why don't we start simulating
this area this area is potentially a
little more linked to it finally one
last thing the prophet is to do this at
Toronto Western Hospital you may know
that they implant deep brain stimulators
for things like Parkinson's disease
they're like little pacemakers they can
turn on and off circuits in the brain
there's a woman who came in for
Parkinson's disease treatment and the
surgery is very tricky to do sometimes
the wrong brain area gets
and off this area got turned off and
within seconds she started crying
uncontrollably she had lapsed into a
depression that she hadn't suffered for
from years as soon as they turned off
the switch she recovered from the
depression you could literally turn the
sadness on and off with a switch in her
case and that was the area that was
being turned on off when they went into
the scan so so let's not turn it off
let's get a coil on that let's turn that
area back on again now you need a
special coils to do that you see it's
bent it's sort of can you see it's bent
over so it sits on the forehead like
that but those coils can go deep they
can go very deep within the brain they
can get down to that area it's got a
terrible name it's called the DMP FC we
were trying to come up with something
better for it i was speaking of somebody
at a conference down in san francisco
and they said honey you need to call
this the d spot or something like that
and i wasn't prepared to tell patients
we needed to stimulate their d spots so
who agree so we left that one out then
but what happens if we do stimulate this
is a funny thing it's not that you get
more responders the number of responders
doesn't change but the difference is
that it if it works it works all the way
so if you're going to respond to this
you remit it's much closer to the action
it's much closer the Centers for emotion
regulation so when we stimulate this
area oh and by the way we did do the
three-minute treatment as well as the
longer treatments and yes we got the
same outcomes on both so we tried both
there's the same issue again but
stimulating this other area definitely
gives you more room ITER's it gives you
more people getting better I wasn't very
happy telling a patient they only had a
20 percent chance of feeling all better
at the end but for a patient with
treatment-resistant depression I do feel
happy you're telling them that there's a
50-50 chance that they're going to get
better and at least a forty percent
chance that they're going to say I don't
even feel depressed anymore that I'm
willing to work with there's the two
curves for that by the way you'll notice
the upper curve the white one is the
three-minute treatment you'll notice it
just by chance our patients having the
three minute treatments actually started
off more severely ill than the ones who
had the conventional treatments and yet
they both ended up in the same place
after four weeks so these three minute
treatments are really doing the job and
we can now say that these three minute
treatments I can get you a forty percent
chance of remission fifty percent chance
that you're going to feel at least half
way better of course nobody wants to be
in the blue pile everybody wants to be
in the red pile don't they
so doc can't you do a test can't you
scan my brain and tell me whether it's
going to work or not this is
surprisingly elusive we've been scanning
the brain for a really long time it's
been we've been able since the early 90
is to demonstrate group differences
between people who have depression
people that don't but to take an
individual person it's like I don't know
if you looked at say hair length you
could say there may be group differences
between males and females in terms of
hair lengths but I can't look at one
person's hair and say if there's a woman
or a man just based on looking at hair
like that's that's completely unworkable
so what we've all been struggling to do
in the biomarkers field is to say can I
take one individual persons scan and
maybe their genes and maybe their
protein the others and figure out
whether it's going to work or not this
is still in its infancy but what we're
trying to do is look at their resting
state brain activity what I'm showing
you right now is a movie sped up of
somebody's brain activity over about 10
minutes of lying in the scanner those
are those networks that I was telling
you about so there's about twenty twelve
of those different networks each one
does a different job what I mean the
brain is a network the way the City of
Toronto is a network and if you've ever
looked at a google maps of Toronto that
shows you all the traffic does anyone
ever use the traffic maps that find
their way around and so on you'll notice
those traffic patterns change and if you
look at Friday p and you'll notice
recurring patterns every day of Friday
around 5pm there's this funny pattern on
the network we're going to call that
afternoon rush hour every day at 9am
there's a morning rush hour on Friday
and Fridays there's a cottage pattern on
you know on game day there's that
there's a rogers centre pattern there's
all these different patterns going on
and so the city runs different patterns
to get different jobs done and the brain
runs different patterns of activity to
get turnt jobs done what depression
looks like on a brain scan is not a
chemical imbalance what it looks like is
gridlock that doesn't go away we all
know there are cities that get
dysfunctional their infrastructure that
have Gridley it's happened in Mexico
City Sao Paulo Beijing lately in toronto
since they worked on the gardener that
we've got you know we've got these long
and during rush hours and this is what
depression looks like it's a network
that's jammed up and we've got to get it
unjammed so can we see that if we look
at certain patterns of brain activity
this is really preliminary it's really
new I'm going to share it with you
anyway
but I had one of my graduate students
pull out five people who had not done
well with the symptoms fact they'd even
got a little bit worse during the course
of the treatment so they declined so
let's look at what's going on in the
area we stimulate what's neat is that it
turned out you didn't need a PhD in
their imaging to be able to figure this
out so I'm going to circle the area in
green can everybody see those areas
circled in green so that's where we
stimulated and if you look at the top
one you'll see it's orange / connected
to the brain's reward circuitry next one
orange / connected the brain's reward
circuitry and down in the lower three
rolls again orange orange orange every
one of them over connect it if you have
that pattern and I see that on your scan
before treatment it looks like this
treatment is going to do the job we
should go and think of something else if
we can confirm this is really
preliminary so I'm sharing this with you
early on but it's it's looking like it
may become a reliable pattern if we
confirm this and we can elaborate this
with you know the person's genetics and
maybe with machine learning artificial
intelligence algorithms to read these
patterns and new pattern recognition we
may be getting close to a reliable
predictor what about people who do get
better let's look at what their pattern
looks like so here's five people who got
a lot better can we see they're
completely different so orange brains
over here blue brains over here blue is
under connected these are the folks who
are lacking in the brakes right there
having dysregulation when they try to
snap out of things they just get
derailed by them you need this area to
be on in order to snap yourself out of
your depression if you have a blue brain
that means you're not going to get
better no it's as you have a blue brain
that means there's out there's a thing
to fix that means that if we stimulate
you we can turn your blue brain into
orange brain you can actually get better
notices one problem down here this
person here can you see the last one
here uh uh orange brain so my graduate
student showed me this and said well I
guess our system isn't very good because
this person shouldn't be getting better
but they this scale said they did and
then she told me the person's names i
remember that patient this person got
better on the scales but only because
the treatment made her completely manic
she started spending tons of money this
happens about one percent of the time
and our TMS about one percent of the
time it does the opposite what
especially the person became completely
manic spent tons of money had a romantic
entanglement with somebody who wasn't
her husband it almost ended her
relationship
she came in she said I will never do our
TMS again I said was unfortunately you
were one of the one percent of people
worked in what so the scales were wrong
on the scam was right this person should
not have had our TMS so it's funny it's
the exception that proves the rule
alright that's three out of four here's
the biggest one the biggest thing people
complain about with our TMS is not that
it hurts it's not that it's expensive
they say why do I have to drive in from
Ajax every single day for 20 to 30 days
to get this treated and what we really
want to do is accelerate it down to
about phaya down to about two weeks so
what if we gave more than one session a
day this is something a lot of places
are looking at right now I think in a
year's time I'll be able to show you
several groups that have studies
underwear in this and it looks like
giving more than one session does really
accelerate it we gave one person who
previously gotten better on our TMS you
know about 30 sessions we got her better
over 30 sessions of treatment and then
we said she came back about a year later
she said I'm starting to slip again but
I have to go to school in a week so we
offer five sessions a day her depression
on the scale so this is her on Monday so
on day one here she is up at the top 37
on the back inventories pretty severe
depression that was monday morning next
bar is Tuesday morning next bar is let's
see where are we here next bar is
Wednesday morning next bar is thursday
morning Friday morning Saturday morning
so she got better in five days tougher
test we had another person this is a
physician who was admitted severely
depressed and suicidal to the hospital
did not want to undergo ECT his beck was
a 54 now the scale only goes to 63 so
that's sort of off the charts in terms
extreme symptoms monday morning tuesday
morning wednesday morning thursday
morning friday morning knocked it down
to 27 down in half and five days by the
end of the two weeks he was also
intermission that's we've done this
about 25 times down we see about thirty
forty percent of the time we're able to
do this so it looks like our TMS isn't
necessarily going to take four to six
weeks we may be on to a treatment that
can get people better in five to ten
days and that's the future I'm
envisioning for it an accessible
inexpensive rtms treatment for all
Canadians treatment resistance in less
than ten percent of people once we've
screened them whether
or I remission in one to two weeks and
using brain imaging for treatment
selection I'm going to wrap up saying
that I don't want you to think of this
is just something for depression the
circuit we stimulate here is just
generally one that's involved in thought
regulation and the funny thing is it's
involved in lots of other disorders as
well so if you look at the same brain
scans where they look at the thickness
of the gray matter it turns out that
that area is also thin and people who
have binging and purging behaviors that
you see in bulimia nervosa and sometimes
disorders like anorexia nervosa binge
purging obsessive-compulsive disorders
same area it turns out to be affected
and most importantly post-traumatic
stress disorder which is people are now
realizing a major problem among veterans
among police officers and when people
have undergone trauma one out of three
people who undergoes a serious trauma
doesn't get out of their PTSD using
medications or therapy it's the same
issue there are veterans who come to my
clinic who are veterans of Bosnia there
are veterans who come who are veterans
of Rwanda they've been stuck for 20
years nothing is getting them better and
what we're finding is that when you do
our TMS at this area this is completely
by accident all we were doing was
treating the depression but they come in
and spontaneous to tell us my binge and
purge behaviors are gone so it works on
your depression it also clears up the
impulsivity that drives binging and
purging behaviors OCD here's a person
than severe contamination fears you had
to wash her hands hundreds or dozens of
times a day and that's her hand at the
bottom I'll share your story she says
after a day of feeling absolutely
defeated she sent me this picture and
said I pull off this stunt for the first
time in several years and there she is
holding one of those grimy subway poles
no sweater wrapped hander napkin and
some random guys hand is pretty much
making out with mine or the very least
flirting so her depression and her OCD
both got better when did this treatment
I don't want to claim what works for
everybody we still haven't gotten past a
fifty-fifty problem but when it works it
covers all of the above all right final
issue where do Canadians get this
treatment so where can canadians
currently get publicly funded treatment
with our TMS it's been approved by
Health Canada since 2002 here we are 12
years later this is where you can get
our TMS in Canada as of today under
public health care saskatchewan and
quebec saskatchewan approved it i
believe in 2008 easy decision they
didn't have
rTMS clinics at the time so they said
there was an easy funding decision for
them they have a couple running now
Quebec has a number of clinics and they
are now funding it there are two other
provinces where it is as we speak under
consideration Alberta as of April
twenty-eighth 2014 released a report
recommending its implementation we hope
to see that coming to Alberta Ontario it
is before the same committee as we speak
being considered with a decision
hopefully expected within the next month
so I'm hoping to say that we'll be able
to deliver effective and affordable to
the system treatment for our TMS I'm
hoping that this will be the future
brain simulation I'm hoping it won't
look like this that it won't be science
fiction but that it will be something
that everyone in this room or a loved
one who needs it would be able to access
should they ever do so so that's the
final message and for anybody who has
loved one with depression one final
message or for anyone who's been through
depression the last thing I want to
leave you with is that things are moving
everyone says don't lose hope but I want
to give you hope what it showing you
today is going to give you some concrete
reasons to say things are moving along
we know more today than we did a year
ago we know more today than we did three
years ago we have better treatments
today than we did three years ago there
are a lot of new treatments in the
pipeline not just our TMS there's a
non-invasive version a milder electrical
version that you may be able to take
home with you it's about the size of a
pager that's under development I'm
looking at that coming in the next three
to five years there are a couple of new
medications that look like when they
work about half the time they clear up
depression in 24 hours those are
currently being under study there are
new options that work by completely
different mechanisms than everything
we've had for the last 60 years so
remember that that this is a moving
field we are not stuck with what we have
I'm sorry it's taking so long we're
doing the best we can but we are going
to hope to have more for you every year
than we did the year before thanks very
much
very compelling I saw the data yesterday
and I got to buzz your brain with a
magnet and stuff that was great fun but
I think people in the audience like me
are saying well this is compelling
worked half that at least half the time
it's as good as drugs which is what most
people use now what's the holdup why
don't we have this what's the holdup
here I think to be honest we as I say
there there's a funding issue so our TMS
has been expensive up until now and the
numbers haven't been there it's been
hard to persuade people that we should
be doing a 7,500 dollar treatment when
it's only got a twenty percent chance of
working so everything I've been working
on here is the trends say let's get it
to work for more people more quickly you
know fifty to sixty dollars per course
for treatment rather than 250 working
for a larger proportion of people and
with a test that tells us whether it's
going to work or not so we to be honest
we as clinicians scientists we had more
work to do to really make the economic
argument for our TMS but I think it's
been made now so how far away are we
from that tipping point well it's tipped
in Saskatchewan it's it's tipped in in
Quebec I'm hoping this summer we'll see
Alberta and we'll see Ontario also
joining this and hopefully this will
come across Canada one of the nice
things about doing research in this
field is it all the Canadian labs the do
rtms there are very collegial bikes
which seem to be happy working together
in larger communities we're not
competing for funding and that sort of
thing brain Canada and the other
government bodies are actually been very
good about encouraging grants where
people collaborating in fact forcing
their work across sites rather than
against each other to do these big
studies these 300 patient 500 patient
studies that are really going to prove
that three minute treatments work better
that really going to prove these
technical advances so when a government
thinks about introducing a new treatment
they think well are there going to be
saving so we're going to be able to pay
for this so if i can get this magnet
online
can I stop taping drugs can I stop
therapy is it just going to magically go
away with a little bit of magnetic field
so what what our TMS does we believe is
first of all everybody who comes to see
me in the clinic is try between three
and twenty medications without success
nobody comes and having not tried
anything most of the tribe therapy if
they can get it and so our TMS gets them
unstuck it's a great acute treatment
once they get unstuck when I tell them
first of all is now is the time to go
and do therapy to unlearn the habits of
thought that have puts you there in the
first place now's the time to address
those stress towards now is the time to
go and find that job now is the time to
go and sort out the relationship that's
got you stressed up now is the time to
leave the abusive partner who's been
putting you into this state for the last
five years so we try and strengthen
people's ability for self-control we're
not pushing a happy button we're
improving their own ability to regulate
their own thoughts and we then encourage
them to work with that so it's a synergy
rather than a replacement I would say
okay so our TMS is going to fix the
circuits in your brain for a while but
it's not going to fix your marriage
magic exactly what we're trying to do is
get you to the point where you can climb
the stairs yourself it's on an escalator
ride it's a stair climb okay and you
know how much further can we take this
you give us a little hint at the end
that maybe we will be able to do this at
home are we going to get to the point
where we can eliminate the clinic and
people can just do a self treatment it
sounds wacky but well so this is just in
a perfect world you wouldn't have to
come into hospital get these done we'd
have a safe technology where we could
apply stimulation to these areas even
without using a much cheaper device that
a person could apply at home it looks
like such a technology may be available
approved by Health Canada 2012 there are
a couple of different manufacturers out
there you can make these things for
about 250 bucks they run off of double-a
batteries and rather than blasting the
brain with so much stimulation that the
neurons fire they exploit the fact that
neurons are always firing all by
themselves and all of you all this does
is nudge them with a very mild
electrical current feels like a little
tickle so that these the brains own
activity then induces the changes all by
itself and so that's called transcranial
direct current stimulation or tDCS we
really need better acronym
wait a bit so T spot yeah the taste and
again it's the same issue like we really
were still optimizing the parameter so
we're and then we're not sure we have
the right brain area for tDCS we're not
sure if we have the right simulation
parameters I'd say that that technology
is 10 to 15 years behind our TMS in
terms of figuring but it will get
figured out and it's easier to teach
someone how to use it than it is to
teach someone with diabetes how to do
their own insulin injections so we think
that this technology could potentially
be transformative and really cost
effective in fact potentially cheaper
and welcoming of the medications but
doesn't doesn't some of this stuff lend
itself to clacker II you know I've seen
don't gamers have things they can stick
on their head and it's going to make you
smarter and better better killing people
online yes is we looked at it so this
transcranial direct current stimulation
technology can do a lot of things have
been studied for 20 years they've
noticed that it improves people's
reaction times in their working memory
capacity so one company decided that it
would be cheaper to just sell it to
video gamers and not make any medical
claims about it them to go through the
expense and trouble of a clinical trial
so it's officially so oh we're not it's
not for your depression it's just to
help you play video games but whether
some people end up using a depraved play
depression was not something I police of
course right and you know we're joking
about this but you can't just take a
magnet and and make yourself better
write these there these are powerful
sophisticated machines you have in your
cliq well so this is just it if you if
you do it incorrectly the nice thing is
surprisingly there's not a huge downside
so it's not like with some other
treatments where if you do it wrong
you're going to drastically cause
massive problems what you'll probably do
is more give yourself a headache and so
on people are not going to be able to
buy these and just take them home they
they cost about a hundred and fifty
thousand dollars for the whole suite of
treatment so if you want to buy one of
these and take them home unless unless
you've got a pretty large expense
account that's going to be it's going to
be a bit troubling but one of the things
that we're trying to look at here is to
make it safe enough that people can use
it at home and furthermore to finish
doing the studies that show people how
to use it safely and show people and do
it under medical supervision so that the
treatment is doing the job it's supposed
to do and not causing you adverse
effects so you you have four important
things you have to do
once you have to do to make this ready
for prime time what's the most important
of the four is it targeting who it'll
work for best is it doing it faster is
it doing it quicker which one is the
most right so again if I listen to my
patients the biggest problem they talk
to me about is access they're not saying
make it five percent faster what they're
saying is can I get in in less than
three months and we've tried to stick
with a referral time of two weeks and
what the reason we move to these theta
burst treatments is because our clinic
filled up very quickly once we opened
when a year our machine was completely
full and there's a lineup starting I
don't like lineups so we said let's see
if we can get away with the three minute
treatments and it turns out they work at
least as well if not better so that's
enable us to squeeze and that's enabled
us to treat between 30 and 50 patients a
day with one md working fifty percent in
the clinic and fifty percent on research
so I think the central problem is to get
the treatments quicker so that we can do
them in accelerated fashion multiple
times a day and so that we can get
people in there and not have wait lists
but you're really just touching the tip
of the iceberg you're treating very few
people is it realistic to get a bunch of
these hundred and fifty thousand dollar
machines into the offices of
psychiatrists in in near future so so we
looked at that and we wrote our economic
analysis that we place before the
technology assessment committee here in
Ontario and we propose there are 50
hospitals in Ontario the current provide
currently provide ECT services we went
and did the mathematics we said you
could treat you know several you can
treat in every one of those hospitals a
thousand to fifteen hundred patients per
year if you run if you open a clinic
like the one that's at Toronto Western
or like the one that's over can makes
operating a clinic like that costs about
eight hundred thousand dollars for all
expenses together so for between 40 to
50 million dollars in a healthcare
budget of 14 billion dollars we can
offer this to forty to fifty thousand
Ontarians every year so that would make
a reasonable so it's point two percent
of the budget to treat two percent of
the population so we think we think
that's a winner and these are the true
you're talking about people with
treatment-resistant very expensive
patients they don't tend to work there
in the emergency room a lot a lot of
self-harm so these are very expensive
patients what I was and that was the
in the mid even I mean there are some
treatments we do on humanitarian grounds
because you want to have them we don't
have transplant programs because they
save the province money we have prints
pump progress because if it's your aunt
or uncle yourself and needs a transplant
we want to have that service available
for depression there is so much of it
that we really have to make an economic
argument as well and what we're trying
to say is that here leading somebody
untreated even aside from the human cost
has a financial cost to twenty thousand
dollars a year to the system as a whole
treating them costs at least with the
newer treatments more like two or three
thousand dollars per remission achieved
so no matter how you do the calculations
for every two or three thousand dollars
the government spends on this you will
get someone to remission right and so we
think that it's cheaper to treat them
not to treat even human considerations
aside and you didn't in your talk you
didn't use the c-word we didn't talk
about a cure so people have to come back
and get booster shots if you will is
that right so as I said depressions like
a traffic jam powder on the brain it's
not a chemical imbalance is a brain
arrhythmia if you want to think of an
abnormal rhythm in the brain some of you
will notice someone who has an abnormal
rhythm in their heart extra beats or
skip beats and that's a recurring
condition if you take medication for it
you come off the medication the abnormal
rhythm will creep back in there and the
brain is the same way so in terms of we
have treatments that will put things
right but unless you want to physically
go in and structurally all for the
entire brain then doing these treatments
is going to be a treatment for it rather
than an outright cure where you just
take the condition away and we know the
brain is a sophisticated we can develop
you know people can be resistant to
treatments to drug treatments after a
while is their resistance to develop to
this does the depression say ah I know
what you're up to I'm going to I'm going
to take a different route that's that's
actually the good bit so if it works it
seems to keep working our TMS does not
last forever it's more like exercise
than like surgery so you'll do it a
course of it and then usually somewhere
between the average is about ten months
the person may say it's coming back
again I need to come back in so we'll do
a booster treatment in that case the
boost of treatments seem to get further
and further apart over time but it does
work over
again now there's a couple of mics if
people I want the public here to get to
their word in so lift your hand if you
have a question and while the mics are
running around and ask you one other
thing how much does that stigma play
into this where this is notion add it
just shake yourself out about your a bit
down you'll get better we don't have to
spend all this money do you see that
unstated or subtly well so thanks for
asking we all say three things on that
the first thing is that we when a person
says snap out of it that's because they
can do it they can do it because that
circuit is on they have orange brain
they don't have blue brain that circuit
is engaged when they turn it on they can
regulate their emotions but I mean I
have a motor cortex I can lift my arm up
and down because i haven't had a stroke
that's taken out that area so did that
with the manga yes that's right your arm
going so the first thing is that the
stigma in part comes from a need to get
the word out there that this really is a
brain disorder nowadays we can really we
can really see it on the scans we can
see what circuits involve what needs to
be turned back on but I think that's
only half the battle the other side of
fighting stigma is to actually have
better treatments if you're an employer
if you're a system you can say look I
get and you have an employee who gets
depression is off work nine months a
year you can say look I completely
sympathize with your condition I'm still
not going to hire you right and that's
you know it's it's not right but it's
also not I think it's naive to think
it's not going to happen so the second
half of fighting stigma is to make the
thing treatable I think that's really
important we have to fix it and if we
can find ways to make depression
something it's rapidly treatable and
reliably treatable then the Sigma part
goes away oh you have depression just go
to the doctor get it sorted out take a
couple of weeks off not oh you have
depression I don't want you to talk
about it I need to hide this and I can't
tell my employer because I'll get fired
it's a treatable thing the stigma goes
away if and so that's the second half of
fighting stigma okay and a big part of
it is the recognition that it is a brain
disease like any other physical disease
just like you saw in the pictures yeah
so weird that might get you I know I
and hands can't go ahead yes you you
mentioned it might be effective in a few
other disorders unfortunately didn't
mention schizophrenia psychosis any
think to suggest it might work there so
like so my goodness are the question is
whether our TMS might be helpful for
psychosis or for other tricular sees
different schizophrenia Nuria right and
schizophrenia is a notoriously tough one
looking at the brain it's not just a
rhythm problem or a traffic jam there is
a lot of shrinkage and sort of atrophy
that goes on in the brain one of the
early study of schizophrenia called it a
precocious dementia almost like a sort
of a dementia that sets in and your
early 20 is rather than later down the
line so you have to overcome not only
sort of a traffic problem but also a
structural problem there I think our TMS
is so far and answer your question no
one's figured out how to treat psychosis
delusions and hallucinations using our
TMS my good colleagues over at can makes
are using it to fix some of the things
about schizophrenia the medications
don't seem to be helpful with
medications can be helpful with things
like delusions and hallucinations in
schizophrenia but the lack of attention
the apathy the difficulty focusing and
concentrating those so-called negative
symptoms there are air is the brain that
could help with that and CAMH is
studying that so there are people
working on that part of it but one of
the most exciting conditions you're
looking at next is PTSD we have a lot of
soldiers a lot of police officers
firefighters who suffer from PTSD this
is really promising yeah so that's one
of the areas where we're quite excited
about it for depression when standard
therapies don't work there are a number
of things you can do for PTSD if
medications and therapy if you're doing
those and you're still stuck as many
people are then there really is nothing
else you can't give ECT it doesn't do
the job it doesn't fix it so for our TMS
what we're seeing is fifty to sixty
percent of people are having fairly
dramatic improvements we had a person
who was a vet who had been taken hostage
in Bosnia who underwent the treatment
and he got a lot better in the first
five days on Monday he came in and
looked much worse and I said well what
did you know what's going on is it slip
you said well no I went out to sea
captain Phillips this weekend I thought
it test
so it's a movie where a person was taken
hostage we gave him another week of
treatment and he looked fine and then
the next day he confessed the following
Monday that he went with his wife and
saw it again and this this and the
second time after 10 sessions of
treatment he was able to withstand that
so receipt we're cautiously optimistic
that I think if I had to look ahead in a
crystal ball what's our team is really
going to be the so-called killer app for
I think that PTSD may turn out to be the
thing that our team s is really
recognized as being helpful for okay I
think next time take away his scotiabank
simcard a good treatment so is another
question over here yes what's the root
cause of depression and can it be
treated by just medication so you guys
are what are the roots of depression yes
what's the root cause okay well that's a
tricky thing I'm going to say the state
of depression on a brain scan looks like
a traffic jam that won't go away it
looks like gridlock the brains and
network the way that the city is a
network of streets this traffic of
pulses in the brain the way that there's
traffic cars on the street thank you all
for doing different functions when the
brain gets stuck in a particular traffic
pattern and can't get out of it like
gridlock that's that's a lot like
depression the reasons why brain can get
in that are many fold and much like a
city could get gridlock for many reasons
a brain can get that way too if you
damage the network and I blocks of
structural damage potholes and that sort
of thing a person can become prone to
depression early childhood experiences
that miss wire the brain or cause
abnormalities can create that traffic
jam genetics can make some brains more
likely to slip into that just as some
cities by nature of their road network
are more likely to slip into gridlock
and can't handle as much traffic but I
think the important lesson is that any
brain can fall into this pattern it's
not something it just happens to the
week just like any city if you put
enough cars and it will lapse into
gridlock some cities can handle more
than others but you put too many cars in
the road any city will shut down and the
same thing as true and depression so
it's that complex mix of genetics and
environment and triggers and we don't
know whose oh it's dropped all of that
lays the foundations for what the
network of each person's brain looks
like as unique as a fingerprint is
unique as a city with its own
personality but it's the traffic on that
network that determines whether the
person is depressed at that moment or
not
now for a long time we've been saying oh
depression mental illness is a chemical
imbalance you don't use that terminology
you talk about circuits going awry is
the the chemistry notion is that gone
well so it certainly changes in the
brain chemistry can remedy depression
certainly we do see some chemical
changes of the brain of people who have
depression but at the end of the day
what really matters is how those neuro
chemicals in the brain alter the brain
activity I mean we sometimes hear about
say serotonin and serotonin dancing
Medicaid but serotonin isn't mood right
it's not like these little serotonin
molecules have little happy faces and
float around a brain and cheer you up
they don't do anything in the brain
until they can persuade a neuron to fire
its activity differently and what they
do depends on which neuron if they if
they tickle your visual cortex you'll
see things if they ticularly brainstem
they'll give you nausea or they'll take
away nausea and if they affect the ears
to bring they're involved in regulating
emotions then they may alter your
emotional state if you skip the neuro
chemistry and go straight to the
circuits themselves then the near
chemistry becomes a sort of a separate
issue so I don't wanna think of it just
as a chemical imbalance I'd think of it
more as a traffic problem the brain
stuck in gridlock well that's something
I torontonians can understand another
question yes here you can you please
comment on how your technique might be
applied to other brain diseases such as
Parkinson's okay so that's a great
question so the question is whether our
TMS might be helpful in Parkinson's
disease neurologists invented TMS and
one of the leading TMS researchers in
Toronto the one who trained almost
everyone else is dr. Robert chen he's a
movement disorders neurologist who works
with TMS in Parkinson's disease up until
recently it's mostly been a research
tool I think that there are areas of the
brain that could be very useful in
Parkinson's disease I think we can get
to them there are a handful of trials
coming out suggesting it may potentially
be helpful so I don't think it's a
terrible idea to try it in Parkinson's
disease there need to be a few more
studies over the next year or two to see
how promising it is but I do think that
that is a potential application it may
not cure it but again I think it could
be helpful in relieving symptoms once a
person's already gone as far as they can
with the medic
patience and they already use deep brain
stimulation for Parkinson and for
depression this is just a different
that's implemented that's exactly it so
by simulating deeply within the brain
you can you can you can alter the
activity in some of the circuits that
are abnormal and Parkinson's disease
with a TMS stimulator we can't get as
deep in the brain where we can still get
to the circuit because there are bits of
the circuit there up near the surface
and so I think we may be able to alter
that circuit and potentially achieve
some improvements not what we do in the
psychiatry clinic but I think if the
neurology clinic were to build an rtms
Center them they could also do quite
well okay yeah so over here on the right
so you talked about the the portion
they're still treatment-resistant after
the rtms and using an fMRI to identify
them is that fMRI built into your cost
analysis yeah so that's that's actually
a good point so if you build and what I
mean if we have to do f MRIs and all
these people would it be worth it the
cost of doing one of those fMRIs is
between 200 and 250 dollars and that is
to make a yay or nay decision on a
treatment that's going to cost you two
or three thousand dollars so for every
two of those you do you're going to save
yourself one futile treatment save the
patient a lot of costs coming back and
forth so I think the economics work out
there you're looking at four or five
hundred dollars to decide whether or not
to do a two-thousand-dollar treatment
for the system and a whole heck of a lot
of parking lot fees for the patients so
maybe maybe it harder than that soon and
so that that's good that makes a lot of
sense and for those treatment-resistant
who are still treating resistant org
wouldn't benefit from the rtms what are
these like treatments that are in the
pipeline what do you offer what can you
offer them okay so that's so there are
two parts of that question first of all
what we're learning from these scans is
that I hope I can say all those people
that showed you were depressed by
standard diagnostic criteria what's
interesting is that depression doesn't
look the same and everybody there's more
than one kind of depression out there
and when we see what we call a bimodal
distribution where you give a bunch of
people a treatment and half of them get
better and half of them get nothing what
that means is you had more than one kind
of person in your group not all
depressions the same by simulating in
this one area we're sorting out one
group of them what I think personally is
going on in the other group is that it's
a deeper brain area and in fact we did a
study suggesting the non-responders
don't have a dorsal Nexus
they've got a ventral maxis it's down
deep in the brain it's in the brain's
reward circuitry itself the people who
seem to be good at treating that are the
neurosurgeons they can get to that
circuitry and they seem better at
helping those patients by tunneling down
into the branding and planting a
simulator deep in the brain we can't get
to it with a coil yet there is a
Canadian company that's building a new
coil that I think might be able to do
the job we haven't been able to test
that yet so if we get that new coil we
may start offering it and seeing whether
we can help the other half of the people
without requiring them to undergo an
invasive neurosurgical procedure