Bipolar Disorder and Bipolar Depression Treatment with TMS
I’m going to talk about treating depression and bipolar disorder. I’m Robert McMullen. I’m a psychiatrist in New York, practicing 36 years. I went to Georgetown Medical School and I went to residency at Columbia Presbyterian. Over those years, I concentrated on treating people with medication for various psychiatrist illnesses, panic attacks, depression, manic depression, schizophrenia, the whole gambit.
Five and a half years ago, we added a new modality in the office and that’s TMS, transcranial magnetic stimulation. It means exactly what it says. It pulses goes on and off and those magnetic field easily goes through the skull and that changes the electrical activity underneath the coil. We can either excite or inhibit under the area, and in different places. The response rate has been extremely high in depression where we have regular unipolar depression where people have been treatment- resistant and have not done well on medicine for many years. We have about 50% of people come all the way to normal and then they stay there a long time and when they relapse they don’t need another 30 treatments just five or six. Now the hardest thing to treat is often bipolar depression.
We are often really stuck with that because if somebody is bipolar, you can either be bipolar one where they have manias or they can be mild bipolars, bipolar two, where they can have mild highs. But in either case, sometimes it’s almost impossible to use a standard anti-depressant because it just fires things up. It’s stimulating them too much, it’s like putting gas on a fire and you may do better for a month when you add in Prozac or Zoloft or some anti-depressant but then a couple of months later they’re back down in the depression.
They may be having more depression in the next year then they would have if they had taken nothing so the anti-depressants can really be a negative with them. If the other medications we use for bipolar depression like Lamictal, Depakote, and Lithium and Seroquel, there’s many medicines, if they’re not working to being the person out, what is the next step? We found with TMS we can successfully treat them and not over stimulate them. Now, with one caveat, if we treat them the standard way, the standard treatment for depression is an excitatory treatment right here on the forehead, the left dorsolateral prefrontal cortex, but that treatment which has been done for 22 years now is often too stimulating in bipolar people, it’s just like giving them an anti depressant. It fires them up. They can start cycling and being worse than ever. When we’ve done it and they have cycled, if we stop it right away and shift to the other side usually we are okay.
But generally we don’t even try that. We do a right-sided inhibitory, a quiet treatment on the right dorsolateral prefrontal cortex and this was not researched as much and not done as much over the last 20 years because treatments started out here. So people just kept doing the same type of treatment with variations, higher intensity, more pulses, things like that. But it turns out that almost anybody with depression, a right-sided inhibitory treatment will work just as well as the standard left-sided excitatory treatment. It does not seem to cycle people who are bipolar. There may be a rare patient, but we have not seen them yet. With this treatment, you bring people out of the depression in the usual amount of time which is about 30 treatments but it can be anywhere from 15 to 50. Frequently, you can bring them all the way to normal and then hopefully they will stay on some sort of medication like Lithium and Lamictal and Depakote and not necessarily in very high doses.
With Depakote and Lithium we like to keep the doses as low as possible because of the side effects but thereafter the hope is that the medication will keep the person euthymic for a long period of time and then when they relapse they can come in and have a few treatments and their generally back up to where they were. I’ll give one example, I have a 29-year-old lady who I’ve treated since she was about 15. She had chronic depression and a lot of anxiety back then and then all her life she has fluctuating depression. On medication, she would be better but she was never quite up to normal. Even when she was in a period of life where everything was fine, she was living life overseas, she spoke the language fluently which she had learned, she had a circle of friends, a nice job, a nice boyfriend, everything was really pleasant and for all practical purposes perfect. She still felt depressed in the background. When she eventually moved back here after two or three years she happened to go into the world’s biggest depression, or at least the most severe depression she had ever had. She was really thinking about suicide and just the fact that it would hurt her family so much she didn’t do it. So I said, come on down tonight and we will start. We started to do these treatments. She was a little different because it took her a little longer so after 25 or 30 treatments she’d be completely normal but it would only last a couple of days.
Maybe even get suicidal. After a while I was doing treatment twice a week just to keep her head above water and I was beginning to worry, am I going to have to keep doing this her whole life, you know, giving her two treatments a week. Then, there was a treatment she had an unbeknownst to us that was the last one. She stayed fine. She did have one relapse six months later and needed one treatment. But that treatment I believe was number 51. I knew her mother very well, since before she was born. I talked to her mother on the phone and I asked how is she really different since the TMS, how is she different than she was before. And she said Robert, you’ve got to be kidding, she was depressed all her life and now she’s normal. I asked the young lady the same thing and she said just about the same response. And she stayed completely euthymic for 3 years and one month and then she began sinking into depression over a week or two. She was going through moderate depression. She came in right away. We did 5 or 6 treatments and she was back to euthymia.
This is frequently how it works that people who have never been up to normal we can often get them back to normal and they can stay there for a long period of time. Although usually they stay on some medications, it’s like you need the medication as maintenance medication to prevent the next depression. So in summary TMS works for a lot of different neurological and psychiatric disorders and we are finding more and more things that it may work for. But one of the big ones is depression in the context of bipolar disorder, which is a very hard depression to treat often.
This seems to be able to treat it without causing more cycling and also with having a long-term benefit.