Archive for February, 2012

West Coast TMS director Dr. Kira Stein’s Presentation on Transcranial Magnetic Stimulation (TMS)

Transcranial Magnetic Stimulation, or TMS, is an entirely new direction in psychiatry that focuses directly on stimulating specific areas of the brain that are part of neural networks responsible for brain dysfunction.  This is entirely different from medication because transcranial magnetic stimulation does not effect other areas of the body with side effects since there are no systemic exposures with TMS, as seen with medication.  This makes TMS a viable alternative for depression treatment in people who are not responsive to medication, who can’t tolerate medication, or who feel it is necessary to avoid medication.  Since transcranial magnetic stimulation is a relatively new treatment option, Dr. Stein delivered a lecture to therapists and therapists-in-training at the Phillips Graduate Institute in Chatsworth, California to help them understand where TMS  fits in the algorithm for the treatment of major depressive disorder.  The reception was very enthusiastic, and Dr. Stein appreciated the excellent questions and discussion generated by the audience.

Topics on Transcranial magnetic stimulation that were covered were:

1. The Importance of psychotherapy as the first line treatment of clinical depression.
2. The diagnostic criteria for major depressive disorder.
3. The epidemiology of clinical depression.
4. Current Treatment options for clinical depression when lifestyle changes and psychotherapy are insufficient, including: Medication, Transcranial Magnetic Stimulation (TMS), ECT, VNS.
5. The effect size of TMS versus placebo (sham) versus medication.
6. Risks and benefits of transcranial magnetic stimulation.
7. The TMS experience, including a video demonstration of TMS with narration by Dr. Stein.
8. Discussion of possible future uses of TMS for the treatment of other psychiatric an neurological conditions.

If you are interested in having Dr. Stein present a speech or lecture on Transcranial Magnetic Stimulation, clinical depression, reproductive psychiatry, or other issues in psychiatry please contact West Coast TMS Institute at 818-855-1694.

To learn more about transcranial magnetic stimulation check out our website on What is TMS?

"YOU CAN'T STOP THE WAVES, BUT YOU CAN LEARN TO SURF" - Jon Kabat-Zinn

Does Successful Depression Treatment Really Mean Perpetual Happiness?

“I just want to be happy.” Cynthia* shrugged her shoulders wearily.  “I mean, why is my depression treatment not working any more?

Cynthia had two prior severe depressive episodes but had been pleased over the past 3 years that her psychotherapy and medication were keeping her in check, enabling her to function well and enjoy her family and career.  In her mind depression treatment was working — until now.

“Lately, I feel this sense of despair, on the verge of tears and so worried. I thought the medication was supposed to make me happy.  What’s wrong with my depression treatment?”

I suggested that in order to understand what may be causing a worsening of her depression, she consider if there was anything going on in her life that might be causing her to worry and be more upset.

Cynthia tensed up and started wringing her hands nervously. “Oh things were going pretty well, but two weeks ago I lost my job and now that I’m home more, I’ve discovered that my son Charlie has been smoking marijuana  – I can’t believe he is using pot after all our warnings!  What else is he getting into!”?

“What would you think if you were not uncomfortable with your son’s behavior or you were okay with losing your job?” I asked.

Cynthia paused and looked around. “I guess that wouldn’t be normal…whatever that means.”

“Exactly.  Feeling upset and sad when you are faced with the loss of your job and problems with your son is understandable.”  I then asked, “Even though you’re upset and sad, are you doing what you need to adjust?

Cynthia paused.  “Well, my husband and I plan on meeting with Charlie for a talk.  And I’m sending out my resume daily and am already going to interviews.”

Is Depression Treatment Really Not working?

“So why do you think your depression treatment is not working?” I pressed.

“Because I’m not happy anymore,” tears were gradually falling down her cheeks. “I’m just so sad about this.”  She then went on to clarify that, while she was sad about her family and career situations, she was grateful that she had the support of her husband and her friends, and she was able to laugh and feel like her normal self most of the time.

All things considered, she was actually functioning quite well!

Successful psychiatric depression treatment, whether through psychotherapy, medication or an intervention such as transcranial magnetic stimulation (TMS), makes it possible to once again experience renewed energy, motivation and interest in life.  Nevertheless, when faced with life stresses and transitions, depression treatment should still allow patients to experience a full range of emotions — including appropriate sadness and worry in response to life’s challenges.  With successful treatment comes the ability to function productively and emerge intact and fully functional.

Authentic Living With Depression Treatment:  Surfing, Not Skating

The purpose of psychiatric treatment is to experience life healthfully, not to numb people against feeling the normal discomforts and challenges of life.

To expect life to be a simple skate across the lake is unreasonable.  Like an ocean, life involves waves of challenges, without which we would not appreciate happiness from good fortune or success.

Successful depression treatment — and mental health in general — is being able to ride the waves of life and to appreciate and enjoy life when given the opportunity.

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*Cynthia is a fictitious name.  This post reflects a common interaction I have had with multitudes of patients.

If you liked our post on depression treatment goals, check out our other blog posts.

There Is Hope

DEPRESSION NEEDS APPROPRIATE CARE

Unrelenting depression can destabilize a person’s family life and career. Yet only about 60% of people suffering from depression get treatment, and only half get appropriate, adequate care for depression.

Why would someone not get appropriate care?  There are many possible explanations, including:

• Clinical depression tends to cause people to think hopelessly, and they become resigned to living a limited life.
• People who are depressed often have such low self-esteem that they do not feel worthy of treatment.
• Excessive guilt is a common symptom of depression, and patients often see themselves as burdens to their families. This further dissuades them from pursuing appropriate healthcare, since good healthcare can cost time and money.
• Many who experience deep clinical depression feel that they can “pull themselves together,” even though their mental condition has become so dysfunctional that they are both emotionally paralyzed and unable to get the energy and motivation that they need to make necessary changes or even go to psychotherapy.

Don’t Let Depression Undermine Its Own Treatment

Because depression affects the brain, the very organ of the body that is supposed to help us solve problems, people who suffer from depression often get stuck, unable to choose the next best steps for their own treatment.  This is why it is so important for close friends and family to recognize when a loved one is suffering from depression.

Close family and friends can help depression sufferers realize that they actually need – and are worth — treatment.  They need to reach out to help sufferers understand that the risks of depression are far more costly than the treatments and, then, urge them to accept help.

The Cost of Depression

Depression almost always comes at a cost to sufferers. Unlike physical illnesses that people tend to treat right away, mental health problems can take a while to recognize. Rather than seeking treatment, it is not uncommon for people with depression to try to make themselves “feel better” through large purchases, expensive trips, or cosmetic treatments. Yet these expensive diversions do nothing to alleviate the emptiness and dysfunction of depression, which can persist or even worsen without appropriate care.

• Melinda, for example, has been suffering from serious depression for three months and believes that getting away on a three-week trip will cheer her up and make her happy again. Flying to Italy and spending over $8,000, she finds that she doesn’t enjoy her vacation and, on many days, finds it difficult to even get out of bed. When she returns home, her depression has only worsened.

• John was laid off from his job about a year and a half ago, and his depression has caused him to withdraw from his friends and family, while his lack of energy prevents him from finding another job. He remains unemployed and is now estranged from his wife and two children.  His inactivity has led to weight gain and elevated cholesterol levels, and his depression has increased his risk for heart disease.

• Cynthia, who recently had a baby and has been looking forward to spending her maternity leave with her new family, is suffering from postpartum depression and feels oddly disconnected from her baby,even when she’s breastfeeding. In addition, her relationship with her husband is suffering, and she also cannot sleep, even when the baby is napping, making her irritable, anxious and, of course, depressed.  Her depression worsens, making her unable to return to work and, now, because she is unable to focus or cope, she needs a nanny to help her manage her children. Not only is she losing her monthly income of $4000 per month, but now she needs to pay a nanny to help the family.
  

  Missed Opportunities

  In addition, her relationship with her husband is suffering, and she also cannot sleep, even when the baby is napping, making her irritable, anxious and, of course, depressed.  Her depression worsens, making her unable to return to work and, now, because she is unable to focus or cope, she needs a nanny to help her manage her children. Not only is she losing her monthly income of $4000 per month, but now she needs to pay a nanny to help the family.

Look at the costs associated with each person’s depression:

Estrangement due to untreated depression

Depression’s Challenges:  Mental – Physical – Financial

Depression not only takes a mental toll but a physical and financial toll, as well. Leaving these conditions untreated can cause serious problems amplified by a reluctance to seek treatment because they feel it is too expensive or too much of a risk (if treatment does work).

There are options!

Depression can be treated. If lifestyle changes and psychotherapy are not effective, then medication is an excellent option, and it can really help a person overcome the symptoms that are preventing them from reaching their full potential. However, many people cannot tolerate the side effects common to medications, including emotional “blunting,” weight gain, loss of appetite, and sexual problems, and at least 15% of people simply do not respond to antidepressant drug treatment.  Others, such as pregnant or breast-feeding women, are so concerned about medication‘s effects on their baby that they won’t even consider medication treatment. That’s where Transcranial Magnetic Stimulation (TMS) comes in.

Transcranial Magnetic Stimulation (TMS) treatment for depression

TMS is an FDA-approved treatment for clinical depression that uses non-invasive magnetic fields to improve the function of very specific parts of the brain. TMS has been proven to help patients with clinical depression, is at least as effective as medication, and has much milder or no side effects compared to medication. Research also reveals that people who remain on medication after a successful course of TMS tend to stay in remission more fully than people treated with medication alone.

The Investment in Good Mental Health

TMS also has costs associated with it, often in the range of $6,000-$9,000 for a four week course of treatment, depending on the number and type of treatments required. While the cost of TMS is significantly more than a month of medication, in the long run the final financial burden can be much less, especially when insurance provides reimbursement and when treatment jump-starts recovery.  Time is also an important factor. While it can take months to determine the correct dosage for medication, the usual full course of TMS treatment lasts only four to six weeks.

You ARE Worth It — You CAN Get Better

People often waste time and money on tactics that do not work because their depression convinces them they are not worth the investment.  This is an example of depression getting in the way of its own treatment. However, in addition to the financial ramifications, the price of ongoing depression includes serious interpersonal and occupational consequences.  That makes TMS a worthwhile investment, especially when compared to the costs of being MIA at home and at work, the expense of “self-help” treatments, and the price of medication that is insufficient or undesirable.

TMS can be either a standalone treatment or one that is used as a supplement to traditional medication. We have found that it works well for people who are already on medication but are not getting the results they need. Medication can also continue after TMS treatments are complete, if necessary.

The help you need to treat depression is well worth it in the end because there is no substitute for recovery.

If you liked this post on  the importance of investing in mental health, then stay  tuned for our upcoming blog on the cost-benefit analysis of TMS.

Update on Transcranial Magnetic Stimulation (TMS):  

WEST COAST TMS DIRECTOR DR. KIRA STEIN INTERVIEWS SANTA BARBARA PSYCHIATRIST AND TMS SPECIALIST DENISE LIN, MD:

Denise Lin, MD of           Advanced Psychiatric Care and TMS Center in Santa Barbara

Denise Lin, MD is owner and medical director of Advanced Psychiatric Care and TMS Center, located in the coastal town of Santa Barbara, California. She has been practicing psychiatry for eleven years.   With an undergraduate degree in Nutritional Sciences from UC Berkeley, Dr. Lin graduated medical school at the University of New Mexico. She was initially interested in endocrinology, the medical management of hormonal illnesses, but developed a passion for psychiatry that compelled her to switch her training program from internal medicine to psychiatry. She enjoys exploring the role of nutrition in psychiatric illness in her studies through the Institute of Functional Medicine, and in line with her earlier training in the nutritional sciences. She has specialized certification by the American Board of Physician Nutrition Specialists.

Dr. Lin has been treating patients with transcranial magnetic stimulation TMS for about two years and kindly agreed to share her experiences by being interviewed here by West Coast TMS Institute’s medical director, Dr. Kira Stein.

West Coast TMS Institute:  First, I want to thank you for taking the time to discuss with us your experiences as a psychiatrist who practices transcranial magnetic stimulation.  Please tell us a little bit more about your background and philosophy.

Denise Lin, MD: I really feel a calling to work with people with mental illness because it seems their disorders are more likely to be misunderstood by patients and medical professionals alike. I strive for a comprehensive approach to diagnosis and treatment, addressing mind, body and spirit as much as possible.  Over the past several years, I have worked with the underserved chronically mentally ill population with Santa Barbara County mental health, running the CARES clinic, which is essentially a psychiatric urgent care clinic. It is challenging and often fast paced, and I have learned a lot! One thing I see more clearly than ever is that there is definitely some overlap as far as the root causes of mental and medical illnesses.  Sometimes diet and lifestyle changes can reduce risks for both by affecting the level of inflammation in the body and even modifying gene expression.

West Coast TMS Institute:  What is the name of your center, its location, and what prompted you to found it?

Dr. Lin: I opened up Advanced Psychiatric Care and TMS Center here in Santa Barbara in order to provide interested patients with the latest information about diet and lifestyle for good mental health. Transcranial Magnetic Stimulation fits in perfectly in my practice because it is an effective treatment that doesn’t involve taking drugs that we know can sometimes have negative physical effects.

West Coast TMS Institute:  How do explain TMS in layman’s terms, such as those without a background in medicine?

Dr. Lin:  I say it is great treatment option that works with or without medications to relieve depression and anxiety. It utilizes a rapidly pulsed magnetic field to stimulate brain cells in a specific area of the brain that we know is associated with mood and anxiety symptoms. It is performed in our office while you are awake and alert (perhaps while watching a good movie from our DVD library). You can drive to and from treatments and there is no downtime, nor any negative effect on memory. Each patient has a customized treatment plan but it is typically prescribed 5 days a week for 5 or 6 weeks followed by a tapering down phase. Some people opt for monthly maintenance to sustain their improvement. Each treatment lasts between 37 and 60 minutes. I often provide specific nutritional supplements to take during the treatment course if I feel that is appropriate.

Reason for turning to TMS: “I was also getting a bit frustrated by the limitations of medications…..” 

West Coast TMS Institute:  When did you first get interested in transcranial magnetic stimulation and why? Do you remember the moment when you first become intrigued by the potential of TMS?

Dr. Lin:  I heard of TMS about 7 years ago in a journal article and soon thereafter someone showed me a flyer from a TMS Center in Vancouver, Canada where it had been approved for treating depression years before it was approved in the States. I was very excited to learn that it was a way to stimulate brain cells non-invasively and without medical complications or memory deficits. I was also getting a bit frustrated by the limitations of medications. Sometimes patients did wonderfully on medications and they were literally lifesaving for them. But with some people, it seemed that every medication we tried caused uncomfortable side effects, like weight gain and sexual side effects. Or the medications just didn’t help, or only helped temporarily. 

West Coast TMS Institute:  What was the turning point in your practice of medicine that prompted you to actually start offering TMS?

Dr. Lin: I think it was when I spent a week at the Medical University of South Carolina with TMS researchers Dr.’s Mark George and Ziad Nahas. They showed me their research and I had a chance to practice with it, even though the device they used back then was different than the much more efficient and user-friendly NeuroStar we use now.

West Coast TMS Institute:  On initially learning of TMS, it can sound kind of strange to some, how to deal with that initial apprehension some people have?  Some people even mistaken it is for electric shock therapy (ECT).

Dr. Lin: I probably experience this reaction more from mental health professionals than from the public. Some people hear “magnet” and maybe it conjures up the notion of something wacky and non-scientific.  Not long ago I had a conversation with the medical director of a local HMO asking him to authorize a course of TMS for a nearly suicidal depressed patient who had not experienced relief after many antidepressant medications. This unenlightened physician called TMS “voodoo” medicine!” I just hope he learned the error of his thinking when the patient he authorized responded beautifully to TMS with complete remission of his depression!

It is pretty easy to dispel the idea that TMS is in any way similar to ECT (electroconvulsive therapy). We show prospective patients our comfortable TMS room with our DVD library and reassure them that they can drive to and from treatments. I had a patient who was an engineer in a very high tech and demanding job who would pop in over on his lunch break to get his TMS treatment. In contrast, people undergoing ECT may have significant memory deficits. They have to take time off work and are actually barred from driving because of the severe cognitive effects.

“…I think we have just barely scratched the surface of ways transcranial magnetic stimulation (TMS) can improve quality of life in people suffering from many hard-to-treat conditions.”

West Coast TMS Institute:  What kind of symptoms and conditions have you found TMS to be most effective at treating?

Dr. Lin:  I have used TMS successfully to treat depression from mild to severe cases. I find it very effective especially for younger people. The patients I have treated who are in their 20’s seem to respond very quickly, while the older patients seem to respond more slowly. One patient in his early 80’s had a course of TMS that didn’t seem to be very helpful, but then two weeks after his treatment, he called, excitedly saying the TMS had “kicked in!” He hadn’t felt that well in years and he was very happy with it. We checked in with him a few months later and he was still doing very well.  It can be somewhat activating so that people who are in a very low energy or lethargic, melancholic-type of depression may experience a pretty rapid improvement in energy and motivation. 

I also treated someone a while back with long-standing chronic depression and chronic neck pain*. Her depression improved and her neck pain completely went away. She was delighted and surprised by this as she had been told she would have to live with her neck pain forever.

I treated a patient for with migraine* who improved rapidly as well. Given these results and the recent exciting research using TMS for migraine, fibromyalgia* and other forms of chronic pain* I think we have just barely scratched the surface of ways transcranial magnetic stimulation can improve quality of life in people suffering from many hard-to-treat conditions.

West Coast TMS Institute: Have you treated patients with TMS who suffer from bipolar episodes of depression?  If so, are they the milder (bipolar type II) or more severe (biplar type I) forms?**

Dr. Lin: I treat depressive episodes associated with both type 1 and type 2 bipolar disorder*, but I keep people on mood stabilizers during TMS treatment and of course, monitor closely for signs of mood switch towards mania. I have had a couple people with bipolar disorder get slightly hypomanic during TMS treatment, and so I conducted a few right-sided TMS treatments until the hypomania subsided, and then went back to left-sided TMS stimulation.  Since TMS patients already come in daily, I can monitor them carefully and quite frequently, even if it’s just for a few minutes–another benefit of TMS.

West Coast TMS Institute: How have your patients responded to TMS?  Any case examples that can illustrate their experience, as well as your observations?

Dr. Lin: I recently looked at all of my patient data and found that 2/3 of my TMS patients have had either full remission or a significant improvement from TMS. I think this is a good statistic because I know that most of these folks have been battling unusually tough, stubborn cases of depression. Many had not responded to 5-10 medication courses.

I think one of my favorite cases is that of a physician patient who had been a professor at a medical school. She had to stop working due to a severe, long-standing bout of depression which didn’t respond to medication and therapy.  At the depth of her depression she could not maintain her concentration enough to read a page in a novel or even do the simplest of puzzles, even though she had a PhD in Mathematics in addition to her medical degree. She couldn’t motivate herself to change her clothes or bathe and she was beginning to contemplate suicide when she came to me. She made a complete recovery after 20 TMS treatments! She is back at work as a physician and has taken up oil painting.

West Coast TMS Institute:  Do you think TMS should be a treatment routinely offered to patients?  If so, at what point in treatment?

Dr. Lin: I seem to have developed a reputation for taking care of people with treatment-resistant major depression. But honestly, TMS is effective for many people with depression, in people who have not tried multiple antidepressant medications.  I often offer it to people who are depressed with or without anxiety, and with or without bipolar disorder

“….depression is so disabling, we cannot afford not to treat it appropriately and aggressively. TMS is a powerful weapon in our armamentarium that should not be denied anyone who is suffering.”

West Coast TMS Institute:  Is TMS worth the financial up-front costs patients need to invest nowadays?  How do you analyze the costs versus the benefits of TMS?

Dr. Lin: I think that when a person who is suffering from depression takes a moment to really assess the impact that depression has on all aspects of their life, when they see the toxic effect depression has had on their relationships, their work and productivity, their level of creativity, and even the quality of life of their children—it becomes very hard to justify not treating depression. We have a great deal of data showing the medical effects of prolonged depression. Untreated depression increases the risk of

Kira Stein MD of Los Angeles' West Coast TMS Institute

diabetes, cardiovascular disease, stroke and even of having a heart attack. Given all these profoundly detrimental effects of depression, even the most calculating of bean-counters would have to see, I believe, that depression is so disabling, we cannot afford not to treat it appropriately and aggressively. TMS is a powerful weapon in our armamentarium that should not be denied anyone who is suffering.

West Coast TMS Institute:  Thank you very much, Dr. Lin, for taking the time to help people learn more about transcranial magnetic stimulation and your positive experiences with the procedure.

______________________

* TMS Therapy is FDA-Approved for treatment resistant depression.  Use of TMS for the treatment of other conditions is currently considered off-label.

**For our readers:  Bipolar disorder is a chronic mood disorder that involves episodic periods of clinical depression alternating with full-blown manic episodes (elevated, extremely intense or agitated mood, racing thoughts, pressured speech, excessive self-esteem, impulsivity, boundless energy, with decreased need for sleep).   Bipolar I disorder is diagnosed when there is a history of a clear and extreme period of manic symptoms.  Bipolar II is diagnosed when the history of manic symptoms are relatively mild and less dysfunctional.

For TMS in the Santa Barbara area, Dr. Lin can be reached at the Advanced Psychiatric Care and TMS Center; For TMS in the Los Angeles area, Dr. Kira Stein can be reached at the West Coast TMS Institute.