Chapter 34: Transcranial Magnetic Stimulation

 

 

 

My psychiatrist at the Amen Clinic believes I would be a good candidate for Transcranial Magnetic Stimulation.  My brain scans showed decreased activity in the left and right inferior orbital prefrontal cortex on both studies (concentration & rest), more severe at rest.  SIDE NOTE:  When there is decreased activity in the inferior orbital prefrontal cortex during a resting state and it improves with concentration, it is often associated with depressive disorders, and may be responsive to antidepressant medication.

Transcranial Magnetic Stimulation reaches the prefrontal cortex areas of the brain very well.  It does not stimulate the deeper areas of the brain.  That is why my doctor believes I would be a good candidate.  I also have problems with activity in deeper parts of my brain.  If you are interested in seeing my brain scans, go to Chapters 11 & 13.

My medical insurance company believes TMS is experimental and will not help pay for the therapy.  The Neuropsychiatric Institute near the city where I live offers TMS treatment and have had the necessary equipment since January 2010.  I know they have a patient assistance program and I would need to get the details to see if I could afford the therapy at this time.  I think doing the research for this blog chapter will help me decide if I could make this treatment happen!

NEUROSTAR TMS DEPRESSION THERAPY SYSTEM 

FIRST TO BE GIVEN FDA APPROVAL

  

Sean Fallon, author of this post, at GIZMODO

"Last year, Neuronetics' NeuroStar TMS (Transcranial Magnetic Stimulation) Therapy system became the first device of its kind to be cleared by the FDA for treating depression. Although, the similarity to a dentist chair was probably not a great idea.

Nonetheless, trials on 164 patients with unipolar, non-psychotic major depressive disorder using the device proved that treatment with short magnetic field pulses to the left prefrontal cortex can be a viable alternative to medication. After 30 40-minute daily sessions, half of the patients in the trial experienced significant improvement, while a third reported complete resolution. Plus, the only statistically significant side effect was mild discomfort in the treatment area. Currently, patients can receive NeuroStar treatments in a psychiatrist's office while remaining completely awake and alert.

Given all of the uncertainty and danger surrounding many psychiatric drugs, NeuroStar seems like it's worth a shot for people suffering from serious bouts of depression. It could also be a sign of things to come. Perhaps technology like this will one day be implanted directly into our brains—making us feel awesome all the time."

http://gizmodo.com/5403423/neurostar-tms-depression-therapy-system-first-to-be-given-fda-approval

Transcranial Magnetic Stimulation requires the following:

1. Prescription by a Psychiatrist
2. 20-30 Outpatient Treatments, Usually Daily
3. Treatment for 4-6 Weeks
4. 37-40 Minute Sessions
5. Patient is Awake, No Anesthesia or Sedation
6. Usually $325.00 or More For Each Session (Depends on the treatment facility) 

This is the link to the NeuroStar TMS Therapy website.  It will give you more detailed information about the treatment:

http://www.neurostartms.com/Patient/Home.aspx

I thought the video on the NeuroStar website was educational and encouraging.  To watch it, go to this link:  (Sorry it was not possible to embed the video)

http://www.neurostartms.com/NeurostarTMSTherapyforDepression/NeurostarTMS-Video.aspx

GOOD BASIC INFORMATION ON TRANSCRANIAL MAGNETIC STIMULATION 

FROM THE MAYO CLINIC

By Mayo Clinic Staff

RISKS
Transcranial magnetic stimulation is the least invasive of the brain-stimulation procedures used for depression. Unlike vagus nerve stimulation or deep brain stimulation, transcranial magnetic stimulation doesn't require surgery or implantation of electrodes. And, unlike electroconvulsive therapy, it doesn't require seizures or complete sedation with anesthesia. However, transcranial magnetic stimulation does have some risks and can cause some side effects.

Common side effects
Transcranial magnetic stimulation often causes minor short-term side effects. These side effects are generally mild and typically improve after the first week or two of treatment. They can include:

• Headache
• Scalp discomfort at the site of stimulation
• Tingling, spasms or twitching of facial muscles
• Lightheadedness
• Discomfort from noise during treatment

Uncommon side effects
Serious side effects are rare. They can include:

• Seizures
• Mania, particularly in people with bipolar disorder
• Hearing loss due to inadequate ear protection during treatment

More study is needed to determine whether transcranial magnetic stimulation may have any long-term side effects.

  

HOW YOU PREPARE

Before having the procedure, you may need a medical examination to make sure it's safe and a good option for you. You may be asked a number of questions about your depression. Tell your doctor or health provider if:

• You're pregnant or thinking of becoming pregnant.
• You have any metal or implanted medical devices in your body. Transcranial magnetic stimulation usually isn't recommended if this is the case.
• You're taking any medications, including over-the-counter medications, herbal supplements or vitamins. Bring a list of what you're taking to your doctor's appointment and include dosages and how often you take them.
• You have a history of seizures or mania. Tell your doctor about any past injuries or surgeries and about any other physical or mental health problems you have.

Little preparation is needed. Transcranial magnetic stimulation isn't invasive, doesn't require anesthesia and can be performed in a doctor's office. You don't need to arrange for someone to drive you home after treatment. Before considering treatment, however, check with your health insurance company to see whether transcranial magnetic stimulation is covered. Your policy may not cover it. 

 

WHAT YOU CAN EXPECT

Transcranial

Your first treatment
Before treatment can begin, your doctor will need to identify the best place to put the magnets on your head and will need to find the best dose of magnetic energy for you.

This is what will most likely occur during your first appointment:

• You'll be taken to a treatment room. You'll be asked to sit in a reclining chair, and you'll be given earplugs to wear during the procedure.
• An electromagnetic coil is placed against your head. The electromagnetic coil is switched off and on repeatedly, up to 10 times a second to produce stimulating pulses. This results in a tapping or clicking sound that usually lasts for a few seconds, followed by a pause. You'll also feel a light tapping sensation on your forehead. This part of the process is called mapping.
• The amount of magnetic energy needed is determined. Your doctor will increase the magnetic dose until your fingers or hands twitch. Known as your motor threshold, this is used as a reference point in determining the right dose for you. During the course of treatment, the amount of stimulation can be changed depending on your symptoms and side effects.
• Once the coil placement and dose are identified, you're ready to begin. The treatment itself will last about 40 minutes. The entire appointment typically lasts about one to two hours.

During transcranial magnetic stimulation
Here's what to expect during each treatment:

• You'll sit in a comfortable chair. The magnetic coil is placed against your head.
• The machine is turned on. You'll hear clicking sounds and feel tapping on your forehead.
• Each treatment session lasts about 40 minutes. You'll remain awake and alert.
• After treatment, you can return to your normal daily activities.

There are different ways to perform the procedure. Techniques may change as more is learned about the most effective ways to perform treatments.

  

RESULTS

Some research showed that transcranial magnetic stimulation improved depression symptoms, while in other studies it didn't seem to help. If transcranial magnetic stimulation works for you, your depression symptoms may improve or go away completely. Symptom relief may take a few weeks of treatment.

Transcranial magnetic stimulation may be less likely to work if:

• Your mental illness causes detachment from reality (psychosis)
• Your depression has lasted for four or more years
• Electroconvulsive therapy (ECT) has not worked to improve depression symptoms

It's not yet known if transcranial magnetic stimulation can be used to treat depression for the long term, or whether you can have periodic maintenance treatments to prevent depression symptoms from returning. The effectiveness of transcranial magnetic stimulation may improve as researchers learn more about techniques, the number of stimulations required and the best sites on the brain to stimulate. 

http://www.mayoclinic.com/health/transcranial-magnetic-stimulation/MY00185

If you are interested in reading a more in depth article on the background, development, practical implementation, and applications of TMS go to:  

http://www.scholarpedia.org/article/Transcranial_magnetic_stimulation

I am also considering going to Newport Beach (Amen Clinic) to have TMS done.  The doctor there does one TMS treatment and an EEG on the brain.  There needs to be a day in between, and then another TMS treatment is performed and another EEG on the brain.  The EEG's results give the doctor information to help him predict if TMS is going to be effective for that particular patient.  I will find out if this procedure is still being used, and if it is used at the Neuropsychiatric Institute near my home.

I think affordable medical treatment should be available to anyone who might benefit from it!

Chapter 15: Clonazepam The Beast, Effexor XR

During the past month since I posted on my blog I have been trying to eliminate the withdrawal symptoms from clonazepam (generic for Klonopin).  I have not made much progress!  The main symptom being extreme anxiety. Starting Wellbutrin also increased anxiety.  On the fourth day the anxiety was so extreme I did not take anymore.  I took regular Wellbutrin, instead of SR or XL which was what my psychiatrist at the Amen Clinic recommended.  I think that was a mistake!  I was disappointed, but I didn't want to try Wellbutrin again!  The anxiety makes my body feel like it is going to explode from the inside.  This feeling is a new one to me, very uncomfortable, and I am weary!

I was first prescribed clonazepam for the anxiety caused by the antidepressant Zoloft.  I did not feel anxious until I started on the medication, and the anxiety was mild.  There was evidence at this time of clonazepam causing scalloping on the brain and of it being highly addictive.  There was also evidence the anticonvulsive class of drugs helped with anxiety.  My psychiatrist at the time didn't know this information about clonazepam (or maybe he didn't agree with it), but he helped me recover from a major depression more than once.  Now I want to come back to the "present" and not spend any more time in the past.

One bright spot in the past month was talking to my psychiatrist at the Amen Clinic by phone on June 16.  He was happy to hear I had been off clonazepam for over 5 weeks.  He was positive and supportive and boosted my spirits.  He reminded me what an accomplishment it is to be off this drug!  He said I had been on clonazepam for so long it could be causing depression!  He recommended I wait until my body had been free of the drug for 8 weeks before we decide to change or add medications to my treatment.  I did add 5-HTP, also known as oxitriptan (INN), a naturally-occurring amino acid, chemical precursor and a metabolic intermediate in the biosynthesis of the neurotransmitters serotonin and melatonin from tryptophan.  I will talk to my psychiatrist again on July 7 after being off the beast (clonazepam) for over 8 weeks.

I have not noticed any difference in how I feel after adding 5-HTP, except maybe a little nausea.  I am ready to take the next step in my treatment plan, adding Effexor XR.  This is what my treatment plan from the Amen Clinic says about Effexor XR:  "At low dosages, Effexor XR will help anxiety, depression and obsessive thinking, and at high dosages will help ADHD symptoms.  An antidepressant with action at multiple receptor sites, Effexor XR will enhance prefrontal cortex function and decrease anterior cingulate and limbic hyperactivity.  Effexor XR has a starting dosage of 37.5 mg daily, increasing by one every 7 days as tolerated, to the therapeutic target dose of 75 mg to 350 mg.  It should be taken with food to avoid upset stomach.  Effexor should not be stopped abruptly because it has been associated with a discontinuation syndrome in some patients.  At higher dosages, blood pressure should be monitored.  If Effexor XR causes more irritability, I would increase the anticonvulsant to stabilize the temporal lobes, enhance mood stability, and decrease anxiety or irritability."

I was on Effexor (not Effexor XR) about 10 years ago.  The nausea it caused didn't stop, so I changed to Zoloft.  The problem with nausea could have been caused by going on the medication too quickly.  This time I will increase the dosage more slowly.  I experienced the discontinuation syndrome mentioned above when coming off Effexor.  At this point, I expect to be on an antidepressant for the rest of my life so I am not concerned about discontinuing the drug.  I will need to lower the dose of Luvox as I add Effexor XR.  I have a positive attitude and will discuss the treatment plan with my psychiatrist next week.

I am ready to have a normal day not based on surviving!  "Normal day, let me be aware of the treasure you are." (by Mary Jean Iron)

Chapter 13: My Brain Scans; Inside Active View

I have been off clonazepam for 15 days.  I am still taking extra Neurontin for the anxiety, I am more irritable, but I am sleeping well.  I visualize my brain healing, and I am starting to get excited about being able to start the last part of my medication treatment plan.  As soon as the anxiety calms down I will begin taking Wellbutrin.  It is important for me to wait until the anxiety calms.  The 100 milligrams of Luvox I am taking per day is helping to calm the increased activity in the deep limbic system.  The 1200 milligrams of Neurontin per day is helping calm the anxiety in the basal ganglia.  Wellbutrin will help increase the activity in my prefrontal cortex.

Here are SPECT scans of a healthy brain when it is active.  This is a 3D Active rendering, looking at the most active 15% of the brain where fluid (Ceretec) injected into an artery reached the tissues.  A normal scan shows increased fluid in the tissues of the cerebellum, with all else being relatively quiet.  Pictures are from the Amen Clinic.
                                    

                                    

                   Here are my SPECT 3D Active rendering scans after rest:  R=rest.

These are my SPECT 3D Active rendering scans after concentration:  C=concentration

                           

                                                                           

My SPECT Study Findings Report from the Amen Clinic is 4 pages long.  Here is a brief overview of what was found on my scans.  The most significant finding is decreased activity bilaterally (both sides) of the temporal lobes on the rest and concentration studies. 

Decreased activity was found in the following areas:

• Bilateral inferior orbital prefrontal cortex, worse at rest.
• Bilateral parietal lobes, worse at rest.
• Medial parietal lobe, on both studies.
• Left and medial dorsal prefrontal cortex, at rest.
• Bilateral occipital lobes, at rest.
• Anterior medial prefrontal cortex pole, on both studies.
• Internal cerebellar activity, worse at rest.

Increased activity was found in the following areas:

• Thalamo-limbic system, worse on concentration.  The basal ganglia are a group of large nuclei that partially surround the thalamus.
• Anterior cingulate gyrus, on both studies.

Below are pictures of the anatomy of the brain.  PFC=prefrontal cortex; FC=frontal cortex; TL=temporal lobe; PL=parietal lobe; OL=occipital lobe; BG=basal ganglia; ACG=anterior cingulated gyrus; PCG=posterior cingulate gyrus; R=right; L=left.  These photos were included in my notebook from the Amen Clinic.

                                                              

I am not well yet, but I am making progress toward feeling better.  Having SPECT scans done did not cure anything, but they gave my psychiatrist at the Amen Clinic more information which helped him write a treatment plan that is working for me!

Chapter 9: Three Days At The Amen Clinic

Wednesday morning I had my first SPECT brain scan.  The IV was inserted with ease and I had no bruising later.  The concentration scan is done first and I did an activity to get my brain focused.  The radioactive isotope was put into my IV during the activity.  I did not have any sensation in my body when it was injected.  After the activity I laid down on my back on the scanning machine.  I needed to hold still, but the the time went quickly; it took about 15-20 minutes.  A band was wrapped around my forehead to help me keep my head still.  The scanning machine made a noise, but it wasn't irritating.  Part of the machine went around my head, but I did not feel claustrophobic like I have during an MRI.

Wednesday afternoon I had an appointment with one of the historians.  She had read my intake questionnaire and asked me questions to clarify, or give her more details on my answers.  This was a calm, deliberate process. She gave me plenty of time to add any information to what was included in the questionnaire. She compiled a well written history for the psychiatrist I had an appointment with later in the week.

Thursday morning I had my second SPECT brain scan.  After the IV was in place I was taken to a dim lit room to prepare for the resting scan.  I was asked to let my mind wander or daydream, but not to think about any specific subject, meditate, or fall asleep.  A short time into my resting the isotope was injected.  There was an interesting rug in the room with geometric shapes on it.  I wanted to see how the pattern repeated itself, but I didn't, I kept resting.  There was also a picture of Dr. Amen with information about his work in brain imaging I wanted to look at.  I didn't, I kept resting. After 15-20 minutes, I laid down on the scanning machine for my second scan.

On Thursday afternoon, my husband and I had a delectable seafood lunch at a restaurant called Rusty Pelican.  It is on 2735 West Coast Highway, Newport Beach, CA 92663-4798, (949) 642-3431.  http://www.rustypelican.com/

On Friday afternoon I met with a psychiatrist.  He showed me my brain scans and went over what was found on them.  It was awesome to see the scans!  He showed me rippling, called scalloping, on the surface of my brain.  For me, it is probably caused by taking the drug clonazepam. I have not abused or been exposed to drugs, alcohol, or environmental toxins. I have used this drug for approximately 8-10 years and the Amen Clinic uses it only for short periods of time for severe cases of anxiety.  I am in the process of coming off clonazepam so the scalloping on my brain can heal!

Other Findings:

1. Luvox has been helping calm the activity in my deep limbic system; where depression originates. 
2. There is too much activity in my basal ganglia; causing anxiety. 
3. I have an atypical depression needing to be treated in layers.  This is why I haven't achieved a more complete remission of symptoms in the last year and a half.  The basal ganglia (anxiety) must be calmed down first. 
4. My prefrontal cortex is not functioning effectively.  After the anxiety is calmed down I will need to take a drug to stimulate the prefrontal cortex.  If I take this drug too soon, it will over stimulate the basal ganglia and cause too much anxiety.

I now have an extensive treatment plan giving me hope I can get feeling better!