Amanda Wilde (Host): UAMS is the first in the nation to offer groundbreaking therapy for treatment-resistant depression. It's called SAINT, and we'll hear next from psychiatrist, Dr. Amy Grooms, about this cutting-edge technology.

This is UAMS Health Talk, a podcast from the University of Arkansas for Medical Sciences. I'm Amanda Wilde. Dr. Grooms, thank you so much for being here.

Dr. Amy Grooms: Oh, thank you for having me.

Host: As a public health sciences university, it must be exciting for you to be first in the country to offer SAINT, and I know it's an exciting breakthrough, but what is it? What is SAINT? Is that an acronym?

Dr. Amy Grooms: It is. I mean, you can't have anything official in medicine unless there's a snazzy acronym. So, the SAINT protocol stands for Sequential Activation of Intermittent Neurostimulation and Transmagnetic Stimulation, which is a lot to say, but I think it's better encapsulated with the SAINT protocol is a new way of delivering a treatment called TMS, which stands for transcranial magnetic stimulation, and it's groundbreaking in that the current literature shows very promising results of taking what is usually a six-week course of an hour-long treatment, five days a week, and then kind of smushing all of those treatments into five days. And then, we're seeing some really promising results in terms of rapid antidepressant response.

Host: So, is SAINT a new delivery of a known kind of therapy?

Dr. Amy Grooms: So in the 1950s, we had this aha moment when we discovered kind of serendipitously that some medications can help treat depression. And so for a long time, the idea has been, well, depression is caused by a chemical imbalance of your brain. Fast forward 70 years and obviously, it's much more complicated than that and now when we think about depression, it is important to think about what's going on at the level of what's happening inside a single neuron and how those neurons talk to each other.

And as you kind of step back and see that 40,000-foot view of, well, how is the brain work and how does depression happen? You really start to think about depression more in that there's a disruption in the way different areas of your brain talks to each other. So, thinking about the brain in terms of neural circuitry rather than this is the depression spot.

Host: Now, SAINT is for especially treatment-resistant depression. How does it work?

Dr. Amy Grooms: So, as research has really kind of gone along and we've started to understand how these neurocircuits are implicated in depression and how they can be changed both with medications, but also with other treatments like psychotherapy, and these more modern neuromodulation treatments. And that's where TMS falls.

And so, in 2008, the FDA, that's when they first approved the treatment for treatment-resistant depression with TMS, transcranial magnetic stimulation, which applies stimulation to a specific part of your brain that kind of taps into that neurocircuitry, which is involved with depression. And using that neuromodulation treatment, we're able to kind of rebalance that and bring that back to a normal state. So, most of the time when my patients are feeling better from depression, it's this sense of, "I feel back to myself."

And so, what SAINT does is, since 2008, there's been a lot of progress looking into, well, how can we optimize the way that we deliver TMS? Thinking about all the different little variables. How can we optimize it so that maybe we can get some better results? So, that's where SAINT comes in. So, there's not like a depression spot in the brain as we would think about there's a spot for a bruise, or stimulate here and your leg moves. Depression is more complicated.

What this machine is using, what the TMS machine does, is it uses a high-powered magnet, and we place that over an area of the brain in the front, which is basically in the prefrontal cortex, and provide stimulation there, and like I said, that kind of goes into rebalancing those neural circuits.

With standard TMS, what SAINT does is it introduces the use of a neuronavigation system and really precise targeting so that when we're targeting that stimulation, we're actually targeting specifically for each person exactly where we need to provide that stimulus. And that's one of the differentiating factors between standard TMS and this new treatment modality. Another difference is the way that the pattern of that stimulation. So, it's delivered in a way that is more akin to your own neurobiology, and the way that neurons already talk to each other.

Host: And you also mentioned that the treatment is smushed together, I believe, was the technical term you used. How long does the treatment take?

Dr. Amy Grooms: So, standard TMS, the course of that is you're in treatment for 20 to 40 minutes for 5 days a week for 6 weeks. And in 2014, one of the classic meta-analysis found that this is an effective treatment, specifically for treatment-resistant depression, but still not as good as we would have hoped.

So, what SAINT does is, in addition to changing how the pulse pattern is, we're using functional fMRI imaging to identify a specific target for each patient. And then with advances in the way that we can deliver the stimulation, we're able to collapse those six weeks of treatments into five days. So, the way that looks for a patient is that the treatment courses, we would come in, see a patient in consultation. And if this seems like the right treatment for you, then the patient would have a special MRI where you're not just looking visually at how the brain is made, but how the different areas of the brain talk to each other, and then that data is fed through an algorithm that provides a very precise target for where we actually target the stimulation during treatment.

And then, once we have that target, then the patient would come in on Monday morning, around 7:00 a.m., and the treatment time is nine minutes and 40 seconds. And then, there's a 50-minute break, and then you come back and do another nine minutes and 40 seconds. So, you have 10 sessions in one day, and you do that for 5 days, and then the treatment is done.

One of the holy grails of Psychiatry has been how can we really find a treatment that can provide folks with more rapid relief from depression because the symptoms are uniquely debilitating and miserable for another technical term.

Host: Absolutely. I see now why this could be a giant leap forward for some patients. What are the sort of results you have seen so far?

Dr. Amy Grooms: So far, we've been seeing promising results. We decided to jump in as relatively early adopters for this treatment modality based on looking at their research. So in 2022, a group at Stanford who developed this modality published a double blind, randomized, controlled trial. What they found was they had an immediate response after five days for 70% of the patients. And then, 57% of the patients had remission after five days of treatment. And to put that in perspective, that's in the realm of ECT, which is typically regarded as the gold standard, most effective treatment we have. And then, they followed these patients out. And after four weeks, 64% of the patients retained their response rate and 42% percent of the patients were still in remission. So, with that kind of data out there, we felt like it was important to make this treatment available to Arkansans rather than having to wait and see at other places.

Host: Because this technology could really make a significant difference in people's lives.

Dr. Amy Grooms: Exactly. And it's an outpatient procedure, it doesn't involve any anesthesia. The side effects are, generally, some people may have a mild headache or discomfort at the stimulation site, but there's a theoretical risk of seizure. But looking at any form of TMS, the estimated risk of seizure is still really rare. So, I think this could be a real watershed moment for Psychiatry and how we approach treatment for depression.

Host: Looking forward to future results that prove that out. This is a complex subject, Dr. Grooms. Thank you for explaining SAINT and wishing you continued good results and success.

Dr. Amy Grooms: Thank you again for having me.

Host: That was Dr. Amy Grooms, Psychiatrist at the University of Arkansas for Medical Sciences. To learn more or schedule a consultation, contact the Interventional Psychiatry Program at PRI. You can visit their website at psychiatry.uams.edu/clinical-care/interventional-psychiatry or by calling 501-526-8614. If you found this podcast helpful, please share it on your social channels and check out the entire podcast library for other topics of interest to you. This is UAMS Health Talk, a podcast from the University of Arkansas for Medical Sciences.