"Christine Curtis of Sterling says she is a happy mom again crediting her recovery from debilitating depression to an expensive treatment that sends magnetic pulses into the brain. I cant put a price on it said Curtis  who said she feels better than she has in a decade after completing  days of the procedure called repetitive transcranial magnetic stimulation or rTMS. An increasing number of psychiatrists and hospitals  as well as entrepreneurs opening rTMS centers around the country  are betting that there are millions of people like Curtis discouraged by depression treatments that have proved unsuccessful and willing to pony up thousands of dollars for the possibility of relief. The treatment which has been approved by the Food and Drug Administration is covered by Medicare in five states but few private insurers pay for it routinely. While rTMS has ardent supporters its effectiveness is still debated and there is little evidence showing how long the results last. The technique has been shown to work better than a placebo but the proportion of patients who show complete relief ranges widely from as few as  percent to as many as  percent according to various studies. The debate has huge implications not just for many of the  million Americans who suffer from major depression every year but also for businesses eyeing a potentially lucrative market and insurers weighing whether to cover it. About half of those  million Americans seek relief through psychotherapy and prescription drug treatment according to an evaluation  http_CER_.pdfby the federal Agency for Healthcare Research and Quality. But studies show that antidepressants provide complete cessation of symptoms only about a third of the time. Magnetic stimulation is aimed at patients with such treatmentresistant depression. Supporters say rTMS is worth the cost  between  and  for the fourtosixweek treatment  because it enables people such as Curtis to resume productive lives. Skeptics question the price tag in light of uncertain benefits. The majority of studies that evaluated rTMS failed to find evidence of an enduring treatment effect after the initial response ... and some ... failed to find any significant treatment effect concluded Health Plan of Nevada a UnitedHealthcare insurer which rejected coverage in March. With the nations healthcare spending expected to top . trillion this year the battle over paying for rTMS http demonstrates why it is so difficult to rein in healthcare costs. New technology is generally allowed into the market after studies show it is reasonably safe and more effective than placebos. But thats not the same as showing it works better than current approaches. Experts differ over whether its smart to cover new techniques if they havent proved superior to established methods. And they can also disagree over the medical research itself Was a study done well Were there enough patients enrolled Did it ask the right questions Insurers often call for more research while doctors and patients  many desperate for help  warn against delay. And costs are rarely discussed publicly. What did I have to lose  In December when Curtis first had a magnetic coil placed on her scalp while a  machine sent pulses into part of her brain she had already spent a decade trying seven different prescription medications in her battle with depression. Getting no relief but gaining weight and feeling sluggish and out of it because of the drugs side effects she eagerly agreed to the monthlong series of fivedayaweek treatments. Most patients have between four and six weeks of near daily sessions. Curtiss psychiatrist Niku Singh who is also the medical director at TMS NeuroHealth suggested that she try the procedure. I was all for it said Curtis whose insurance did not cover the treatment. Its a matter of nothing else had worked so what did I have to lose As the very first patient treated at the Tysons Corner facility which opened in December Curtis paid only  because the center needed a test patient to meet the requirements of the device manufacturer. The fee is generally about  but officials say they work with patients who cant afford that. Founders of the center compare rTMSs potential to that of the nowubiquitous laser eye clinics they aim to open a chain of centers nationally that will take walkins and accept referrals from physicians. Walkin patients without a doctor referral would be screened by the centers medical director to determine if they are in fact appropriate candidates for rTMS treatment. We looked at the Lasik model and said Can we do this with depression Can we do this with TMS said Bill Leonard president of the company. During a treatment a patient sits in a chair like one in a dentists office while an electromagnetic coil is placed against her head. The machine sends four seconds of magnetic pulses into the brain in second intervals making a woodpeckerlike tapping noise. The whole procedure takes about  minutes and is monitored by a technician. Patients say it does not hurt. Studies have shown that side effects are few and generally minor such as headaches and scalp irritations. Singh said rTMS works by having the pulses stimulate a region of the brain that helps control mood researchers say the pulses help depression by activating the release of neurotransmitters such as serotonin norepinephrine and dopamine. Singh who owns two psychiatry practices in the region says he does not have an investment interest in TMS NeuroHealth. The use of rTMS for altering mood or affecting the brain has been studied since at least the early s. After reviewing data from a study of  patients the FDA cleared the device  http_docspdfK.pdfin  for the treatment of major depression in adults who had failed to improve after at least one round of drug therapy. That study was funded by the devices manufacturer Neuronetics a company based in Malvern Pa. It found httpdepression.wustl.eduOReardonPivitaltrial.pdf that up to  percent of patients treated with the device for six weeks became symptomfree about twice as many as those treated with a sham rTMS machine. Subsequent studies have shown a range of results with about a third of patients reporting complete relief. One  study http of  moderately treatment resistent patients funded by the National Institute of Mental Health found that rTMS was four times as likely to get patients symptomfree as was a sham procedure. Patients in that study were treated five times a week for three to five weeks. One key measure  known as the number needed to treat  found that one patient became symptomfree for every  who were treated. Five percent of the patients in the sham group became symptomfree.  Supporters such as those at TMS NeuroHealth say they are seeing better results than that among their patients who can continue taking antidepressants along with their treatment. Curtis for example still takes a daily antidepressant four months after completing her treatment but she has been able to sharply reduce the dosage. Curtis said she noticed no change in her depression at the very start of her rTMS treatment but she began feeling better after about two weeks of treatment. Im not up and down anymore she said. For patients who dont respond to prescription drugs and talk therapy the other major option is electroconvulsive therapy or ECT in which an electrical current is sent through the brain to deliberately cause a seizure. The procedure which is more widely used than rTMS requires two to three treatments a week for three to four weeks and is effective for many patients. But it requires anesthesia and sometimes causes memory loss or confusion. rTMS does not require anesthesia and its side effects are generally mild. A few small studies have looked at its effects on cognitive function and found either no effect or slight improvement according to the AHRQ analysis. The costs of ECT  typically about  for four weeks of thriceweekly treatments according to AHRQ data  are covered by most private insurers as well as by Medicare and Medicaid. The cost is higher however if a patient must be admitted to the hospital. Comparable to drug therapy  Linda Carpenter an associate professor of psychiatry and human behavior at Brown University who has conducted medical studies using rTMS for depressed patients says the treatment is effective for some patients possibly even better than simply trying another medication. But she says questions remain about how long the effects last and how often a patient should return for additional sessions. Whats the range of booster treatments people need she asks. Is it once a week or every couple of years Theres a huge range in my clinical experience. Carpenter a physician says research has not found any safety issues for patients returning for additional treatments but cost is a factor. Uncertainty about its longterm effectiveness is why most insurers do not routinely cover rTMS. Medicare also has mainly rejected coverage though in January the administrator of the programs New England region became the first to approve it citing the AHRQ report and an assessment httpcepac.icerreview.orgwpcontentuploadsFinalReportTRD_FINAL.pdf from an independent regional advisory board. That member panel voted  to  last year that studies of the treatment showed it to be as good as or better than usual care for depression. Six of the  said it represented a reasonable value for its cost four saw it as a low value. The same panel voted  to  that rTMSs health benefit was equal to that of ECT. A similar coverage decision proposal is being considered by the Medicare office serving the Washington region. Even with limited insurance coverage about  patients have had the treatment and the number of treatment centers has doubled to a total of about  nationwise since  according to reports by the devices maker. Centers include some big names such as Johns Hopkins in Baltimore and the Mayo Clinic in Rochester Minn. Still some are not convinced. The initial treatment with rTMS is  Thats a lot of generic Prozac or Effexor which are costeffective antidepressants with long track records said Joel Rubinstein associate medical director of Harvard Pilgrim HealthCare an insurer that does not cover rTMS. Managed care has an obligation to a population. Youre shepherding a fixed amount of resources across a large population and trying to do it according to some sort of evidencebased system. Kaiser Health News http is an editorially independent program of the Henry J. Kaiser Family Foundation a nonprofit nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente."