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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by twinleaf on May 6, 2008, at 15:56:12
showed statistically significant results with treatment-resistant MDD patients with one or more failed drug trials. The maker of the TMS device, Neuronetics, is resubmitting their application for FDA approval now, and they expect to hear whether or not it is accepted within a few months. A number of psychiatrists in my area have already taken training courses in its use from the University of South Carolina, where much of the research has taken place, and they are just waiting for its approval to begin offering it.
As someone who has been flying to Atlanta twice a year for TMS for the last five years, I am SO THRILLED!! In the studies, it gave remissions for 50% of patients for whom one, or often many drugs had not worked. From our perspective, that is really good! Also, other than being painful during administration, it is free of unwanted side effects.
I am SO HAPPY because it has faithfully worked every time I have gotten it...nothing else has.
Posted by Bob on May 6, 2008, at 16:14:25
In reply to rTMS data presented at APA Conference....., posted by twinleaf on May 6, 2008, at 15:56:12
Would this treatment be indicated for someone who has comorbid obsessional and OCD type problems?
The treatments are painful?
Posted by twinleaf on May 6, 2008, at 16:21:47
In reply to Re: rTMS data presented at APA Conference..... » twinleaf, posted by Bob on May 6, 2008, at 16:14:25
The studies they did were all on Major Depression only. I remember reading that there were trials of TMS for OCD at NIH a few years ago, but I haven't read anything about that recently.
As to the pain...everyone is slightly different, it appears. Some people feel no pain whatsoever, some feel a little, but are not bothered, and then there are people like me for whom it feels like a jabbing icepick. I absolutely need codeine to tolerate it.
Posted by Bob on May 6, 2008, at 16:47:20
In reply to Re: rTMS data presented at APA Conference..... » Bob, posted by twinleaf on May 6, 2008, at 16:21:47
> The studies they did were all on Major Depression only. I remember reading that there were trials of TMS for OCD at NIH a few years ago, but I haven't read anything about that recently.
>
> As to the pain...everyone is slightly different, it appears. Some people feel no pain whatsoever, some feel a little, but are not bothered, and then there are people like me for whom it feels like a jabbing icepick. I absolutely need codeine to tolerate it.
"... jabbing ice pick" sounds pretty harsh.I'm worried that rTMS might exacerbate my obsessional problems.
Posted by twinleaf on May 6, 2008, at 16:57:13
In reply to Re: rTMS data presented at APA Conference..... » twinleaf, posted by Bob on May 6, 2008, at 16:47:20
I personally don't mind at all, as long as I have taken codeine. It is so very helpful. For OCD, I don't think it would presently be offered as a treatment. They will probably initially stick to patients with MDD, as, so far, that's the only condition it's been proven effective for. For other situations, once there are doctors skilled in using it, it will undoubtedly be tried eventually "off-label"
Posted by Phillipa on May 6, 2008, at 17:02:29
In reply to Re: rTMS data presented at APA Conference..... » Bob, posted by twinleaf on May 6, 2008, at 16:57:13
Ouch!!!!! not good for anxiety either then? What is the criteria for MDD? Phillipa
Posted by Sigismund on May 6, 2008, at 19:06:35
In reply to rTMS data presented at APA Conference....., posted by twinleaf on May 6, 2008, at 15:56:12
>I am SO HAPPY because it has faithfully worked every time I have gotten it...nothing else has.
TwinleafHow long did it work for?
For which of your symptoms was it most helpful?
And anything else you would like to add.
Posted by twinleaf on May 6, 2008, at 20:09:25
In reply to Re: rTMS data presented at APA Conference..... » twinleaf, posted by Sigismund on May 6, 2008, at 19:06:35
For the past five years, I have been going approximately twice a year to Atlanta to have TMS, given by Dr. Mark Hutto. It always leaves me completely depression-free for at least two weeks, with mild depressive feelings for the next two weeks, and then a gradual return of a moderate to major depression by two months post-treatment. I usually have either four or six treatments each time I go; I always notice a lot of lifting of depression after one treatment, and by two treatments, I'm always depression-free. The additional treatments are sort of "insurance" since I have to come a long way.
If and when it is approved, I think I would do best having either two or three treatments once a month, or two treatments every two weeks, although even one might be adequate..
A word on how it works: it is known to increase blood flow to the left cerebral cortex (often reduced in severe depression) . It also reduces the levels of circulating cortisol- probably the most important precipitating factor in depression. It also restarts the growth of CA3 neurons in the hippocampus, and increases the levels of BDNF in the brain.
Posted by twinleaf on May 6, 2008, at 20:19:34
In reply to Re: rTMS data presented at APA Conference..... » twinleaf, posted by Sigismund on May 6, 2008, at 19:06:35
what symptoms got helped. I have Major Depression, but with a lot of anxiety also. I always notice that, as the depression disappears, the anxiety does too, probably because of the lowered cortisol. I have a wonderful endocrinologist who has been very interested in measuring my cortisol, before and after TMS treatments. There is an enormous drop right after treatment, with the levels slowly becoming elevated again during the next two months.
Posted by clipper40 on May 6, 2008, at 23:45:57
In reply to Oh, I forgot to say..... » Sigismund, posted by twinleaf on May 6, 2008, at 20:19:34
Interesting. So those of us with depression, anxiety and low cortisol apparently wouldn't be candidates. I'm disappointed.
Posted by twinleaf on May 7, 2008, at 12:21:32
In reply to Re: Oh, I forgot to say..... » twinleaf, posted by clipper40 on May 6, 2008, at 23:45:57
Well, I don't think anyone knows yet. One of the things we found out was that the TMS restored the diurnal variation in cortisol (highest in AM, lowest in the evening). Before treatment, mine was staying high all day. Also, about 50% of people with normal cortisol levels who are dexamethasone non-suppressors become suppressors after treatment.
And there are actions unrelated to cortisol- brain blood flow, cell growth in the hippocampus, higher BDNF levels.
Posted by clipper40 on May 8, 2008, at 1:12:16
In reply to Re: Oh, I forgot to say..... » clipper40, posted by twinleaf on May 7, 2008, at 12:21:32
Posted by BGB on May 8, 2008, at 20:08:40
In reply to Re: Oh, I forgot to say..... » clipper40, posted by twinleaf on May 7, 2008, at 12:21:32
Are you still seeing Dr. Hutto regularly? What do you think of him? He is starting to scare me. I hope he isn't a quack! Everyone (including my psychologist, who referred me to him, and my former psychiatrist) thinks that he is god's gift to psychiatry but I'm not convinced.
I'm not having rTMS treatments, I just see Dr. Hutto for my routine psychiatric care (his office happens to be on my way home from work). I've been seeing him for 5 months, and I've done nothing but get even more depressed. Each time I see him, he ups the dosages of everything, or "augments". Currently, he has me taking:
Trileptal 1800mg
Lamictal 200mg
Remeron 60mg
Cymbalta 120mg
Wellbutrin 600mg
Trazodone 150mg
Cytomel 50mcg (just for AD augmentation, thyroid is normal)
Valium 5-10mg prnIf he wants to go up on one more thing or add one more drug, I'm walking. He really has me questioning him now, but everyone says he's so great, so maybe it's just me. All I know is that if I were my own psychiatrist, I would throw out all of those AD's and try for one that works.
Sorry for venting! I would just like one more person's opinion, so I don't think I'm crazy.
Peace,
BGB =)
Posted by twinleaf on May 9, 2008, at 8:20:30
In reply to To Twinleaf, posted by BGB on May 8, 2008, at 20:08:40
Gosh. That's a HUGE amount of medication. I would be worried, too.
I have been flying to Atlanta - usually twice a year- for the TMS only. I have another pdoc at home who prescribes medication, so Dr. Hutto has never been involved with that aspect of things. I actually haven't had any TMS since last August because I've been doing better than usual.
If I were taking as much medication as you are, I would be very worried, too. This is a side to Dr. Hutto that I'm not familiar with. I'm assuming that none of the medications are working all that well, either. Is that right?
I think it would be a very good idea to let him know how you are feeling about the medications- that you do not want to keep on going up in dosages and adding new ones. Is giving TMS a trial something you would consider?
It's true that other doctors think highly of him. As you probably noticed from the certificate on the wall of his office, he was named Georgia's "doctor of the year" several years ago. Still, this does not sound like good medical judgement on his part. I would definitely follow your own instincts in this situation; mine would be exactly the same as yours.
Good luck! I hope you'll let me know what happens.
Lithium 300 mg.
Synthroid .05 mg.
Cytomel 5 mcg.
TMS, usually twice/year
Posted by Molybdenum on May 15, 2008, at 6:34:47
In reply to Re: To Twinleaf » BGB, posted by twinleaf on May 9, 2008, at 8:20:30
Hi,
Here's the article for those who don't otherwise get them:
How Does TMS Work in Treating Refractory Depression?
Posted 05/05/2008Joel Lamoure, RPh, BSP, FASCP
Author Information
Question
Transcranial magnetic stimulation (TMS) seems to be a much needed treatment for patients with major depressive disorder who are treatment resistant. What is the pharmacologic mechanism of TMS?Response from Joel Lamoure, RPh, BSP, FASCP
Assistant Professor, Department of Psychiatry, University of Western Ontario, London, Ontario, Canada; Mental Health Pharmacist, London Health Sciences Centre, London, Ontario, CanadaTMS is a noninvasive technique that uses magnetic fields to induce weak electric currents in brain tissue. As a result, brain neurons can be excited without the need for external electrodes. Instead, a coil is placed near the head of the human or animal over part of the brain, such as the dorsolateral prefrontal cortex.[1]
TMS can be classified into different types. The focus of this article will be rTMS, where the "r" represents a repetitive cycle. There are 2 different subtypes of rTMS: high-frequency and low-frequency. High-frequency rTMS may be defined as a 3- to 20-Hz application to the left prefrontal cortex, and low-frequency rTMS is defined as 1 Hz or less applied to the right prefrontal cortex.[2]
Pure unipolar depression is defined in the literature as having an incidence of 1.5% to 19%.[3] Despite effective treatment options that include medications to reregulate the balance of neurotransmitters in the brain (eg, serotonin, dopamine, monoamines, and norepinephrine) and behavioral interventions (eg, cognitive behavioral therapy), there are numerous treatment failures secondary to side effects: accessibility, adherence to the medication, or onset of action.[3]
The overall estimated incidence of treatment-refractory depression increases with the number of episodes a patient experiences. For example, the rate of recovery (sustained remission) in treated patients with only 1 major depressive episode is about 50%, whereas patients who have suffered 3 episodes experience a recurrence of their symptoms about 90% of the time.[4] When considered from the perspective of patient morbidity and quality of life, if remission is not achieved initially with treatment, 67.6% of patients will relapse within 2 years vs 15.2% of patients who initially achieved remission of symptoms.[4]
In patients with treatment-refractory depression, options such as electroconvulsive therapy (ECT) may need to be considered. Although biweekly ECT has a shorter onset latency than rTMS, it requires interventions using anesthesiologists and is associated with memory loss (secondary to the length of the seizure as 1 variable) and actual induction of a seizure.[3] As such, it is important to determine whether the patient is on any medications that may impact seizure threshold, as this can lead to complications and present a therapeutic challenge.
Analysis of the literature from May 2003 to the present yielded 14 studies of rTMS. However, several of those studies involved concurrent pharmacotherapy arms that may serve as a confounder, due to the efficacy of monotherapy using rTMS. Gershon and colleagues[2] conducted an analysis of the literature where pharmacotherapy interventions were removed (as defined by medication resistance); they found that 4 in 10 subjects were partial or full responders to rTMS vs no responders in the "sham" rTMS group. A sham group is similar to a placebo arm, where the magnetic coil has been shielded to minimize the amount of magnetic emissions from the coil. These numbers held true in other nonpharmacotherapy treated groups where George and colleagues[5] identified significantly more patients responding to rTMS (9 in 20) than in the placebo arm (0 in 20), with a P < .01 rendering it statistically significant. Treatment was provided each weekday for 2 weeks.
With this evidence, the question is revisited as to what impact the rTMS has on the brain. There are noted changes in the prefrontal cortex and paralimbic activity, even after a 2-week course of rTMS, analogous to the study conducted by George and colleagues.
In another study, Teneback and colleagues[6] identified increased activity at the cingulate and increased paralimbic blood flow after 2 weeks of treatment. This finding is important as the cingulate effect has been demonstrated to be blunted in depressed patients; intriguingly, antidepressants such as fluoxetine have also been shown to increase cingulate activity.[6] The researchers hypothesized that patients who responded to rTMS had increased inferior frontal activity at baseline, which may serve as a predictor of rTMS response.[6]
From a neurotransmitter perspective, rTMS had an impact on upregulation of the beta-adrenergic receptors in the frontal cortex, on downregulation of the serotonin (5-HT2) receptors in the frontal cortex, and on monoamine levels.[7,8] Thus, there are alterations in brain physiology and neurochemistry that may be unique to rTMS.[7]
From a safety perspective, rTMS was originally thought to be generally well-tolerated. However, mild adverse effects were identified, including slight discomfort due to facial muscle twitching (14%) and mild-to-moderate headache (9%), compared with no identified adverse effects in placebo arms.[9] Management of these adverse effects may include reduction of the stimulus intensity by 10% for the facial twitches, and analgesics, if tolerated, for headaches.[9] Unlike with ECT, there were no reports of memory impairment, concentration problems, or cognitive changes.[9]
This is the end of the thread.
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