Robert D. McMullen, MD, a psychiatrist in NYC who has been working with people suffering from TRD for over 30 years, reports that there are a variety of options that can be used to try to bring patients to 100% mood normalcy. Call (212) 362-9635


What Can Be Done for TRD

When a patient has their first, second and maybe even third major depression and they are placed on a good anti-depressant medication, 15% of patients can be expected to go all the way to normal within 6 weeks. As for the remaining 85% of the patients, as many as 80% may reach a normal mood if additional treatments are added.

The goal is to get everyone to feeling normal. This is done by adjusting dosages, adding treatments and changing the combinations until a good result is reached. It may take months or even years to reach the best possible results but alleviating a person from the symptoms is well worth the effort.

Here are a few of the augmentation treatments that are used and proven effective for many sufferers:

Depression Treatment Device
Transcranial Magnetic Stimulation (TMS)

If anti-depressant medication does not bring a person’s mood all the way to normal, TMS is one of the most beneficial augmentation strategies available.

This treatment relieves symptoms in 50% of the patients who try it and the benefits are long lasting, up to three or four years – even for people who have never had normal moods before. If a person has a relapse, just a few treatments will restore the good moods again.

TMS uses magnetic field pulses that stimulate or inhibits activity in the brain, depending on the setting and placement of the magnets. It is a comfortable treatment that does not interfere with a patient’s work or school schedule. The risks are minimal and there is no memory loss.


Robert D. McMullen has found that just 1/50 mg of lithium can give some people excellent results within one to two weeks. Some people, who have been treated for decades using other medications, have dramatic improvement with just this very small dosage of lithium.

People who don’t respond immediately, may respond if they take lithium over a long period of time. This low dose has no side effects at all and no monitoring of the blood is required.

Some people, such as those suffering from bi-polar disorder, need higher dosages of lithium. If they show relief but then have a relapse, the dosage can be increased. Many show improvement in just one week.


Other medication that people respond well to is N-acetylcysteine (NAC), a medication often used as an antihistamine. It is an amino acid. Four grams are taken per day.

It allows the body to make more of the main antioxidant needed to clear out poisonous free radicals.

Glutathione is made up of three amino acids – glycine, glutamine and cysteine. When you provide the body with this, including the cysteine, the body can make about 50% more glutathione than it normally makes.

Tests done by a psychiatrist in Austrailia showed that many people who were depressed either too many free radicals or too little glutathione. After giving them NAC for four and a half months and increasing the dosages from two grams to four grams, many people improved. Their bodies made more glutathione, which in turn cleaned up the free radicals.

EPA in Fish Oil

Another beneficial augmentation is fish oil, which is mainly composed to two types of fats – EPA and EHA. Patients usually take six to eight pills a day for a month to see if there is a benefit.

There are some new brands on the market with just EPA, which are smaller capsules with 500 mg. If a patient has to take a lot of EPA, he may prefer this brand.

What’s more, fish oil reduces inflammation, which has been shown to have a correlation to depression.


Another augmentation is taking statins, often used to reduce cholesterol. A test was done on patients who had suffered from heart attacks. Those on statins were 50% less likely to be seriously depressed after a heart attack.

The statins that seem to help the most are those that are lipid/fat soluble because they into the brain more easily, such as Zocor and Crestor. Robert D. McMullen is an advocate of taking statins because people with depression have a higher risk of heart attacks.

People with these factors are at a higher risk for heart attacks:

* Family history of heart attacks
* De.pression
* Having diabetes
* Having high cholesterol
* Smoking

So if you suffer from being depressed, you have an extra reason to take a statin. The modern theory is that a person with these factors should be on the highest dosage of statins that they can tolerate because the higher the dose, the fewer heart attacks occur.


Another augmentation strategy is diet. The vegan or the Mediterranean diet may be the best because it reduces inflammation. Since reducing inflammation is beneficial to people who are depressed, they should avoid white rice, white bread and white potatoes. The Mediterranean diet has been shown to reduces incidences of heart attacks.

Asprin – N-saids

NSAIDs are nonsteroidal anti-inflammatory drugs. Taking these is another augmentation measure people who are depressed can try. Mainly Celebrex has been used but not recommended for long-term use. However, if someone is extremely depressed, it is good in the short term.

Behavioral Strategies

Here are two non-medication strategies that have been shown to reduce symptoms – exercise and light therapy:

Exercise – One Hour a Day

Exercise reduces the incidences of heart attack, cancer, and other illnesses. Exercise is a tremendous anti-depressant. Studies have proven that if someone exercises vigorously for one hour a day, five days a week, they will get the same benefit as taking popular antidepressants, such as Prozac.

Light Therapy

A person can receive significant anti-depressant effect if he gets up early in the morning, such as at 7:00 AM, and immediately goes outside for half an hour. It’s important to be under a full sky, even if the sun is not shining brightly.

In the winter, a depressed person can use a light box, which contains fluorescent lights. The amount of light that is needed is 10,000 lux. It’s necessary to sit really close to the box for half an hour when first getting up in the morning.

Machines and Parameter Used with TMS

Since transcranial magnetic stimulation therapy has been so successful, it deserves further mention. TMS has a 50% chance of bringing people who have never had normal moods in their lives all the way to normal.

Several TMS machines can be used. One has two copper coils that touch each other, making a figure-eight electromagnetic field. Different parameters can be use with TMS, such as adjusting the pulses and placements of the coils on the head. Various combinations can be tried until the individual get the optimal results.

There are other augmentation strategies that can be used. Trying one treatment after another can be frustrating and take a great deal of patience on the part of the individual who are depressed. He must trust his psychiatrist and be willing to wait a length of time to determine if a treatment is working or not. It may require trying many different treatments until the right combination is found.

Treating depression can be complicated but reaching 100% mood normal is well worth the effort.

Call (212) 362-9635 for an appointment in New York City. Offices in Manhattan and Mt. Kisco, NY, USA

Is TMS therapy FDA approved?

Yes, TMS therapy was approved by the FDA for trials and treatment back in 2008. TMS therapy had proven and continues to prove itself as an effective treatment for patients suffering from a number of disorders. Although our technicians specialize in treating patients suffering from treatment-resistant depression, we have also used TMS therapy to treat patients with all kinds of disorders, including, but not limited to:

Obsession-compulsive disorder (OCD)
Parkinson’s Disease
Movement disorders
Bipolar disorder
However, although we have seen success in treating patients with the above disorders, TMS therapy has only officially been FDA-approved for treating depression. We believe there is a good chance that the FDA will approve the trials for treating other kinds of patients with TMS therapy, which we hope will allow more insurance companies to give in and accept coverage for this treatment, enabling more patients in need of help to receive the treatment they need.

Call our offices today to schedule a consultation or to ask any more questions we have not covered in our FAQ.

Can I stop using anti-depression drugs if I do TMS therapy?

We have very few patients who have decided to stop taking their regular medication following TMS therapy, although we know of patients who have done so. It is entirely possible to stop taking any kind of antidepressants after TMS therapy, but maintenance sessions would essentially be a guarantee.

Maintenance sessions are necessary because stopping the use of antidepressants will result in chemical changes in the brain as it returns to its normal function, and there is no way to guarantee that the patient will not simply return to a depressive state once this change occurs. With maintenance, the patient can continue receiving some form of treatment for their condition without running as big a risk of relapse.

With this in mind, it is often a good idea to continue taking antidepressants after TMS therapy, provided the medication worked somewhat before. This is because you’ve just completed treatment based on a certain brain structure, so maintaining that structure with the same antidepressants will ensure the best long-term results.

Can I also take antidepressants if I am receiving TMS therapy?

Yes. If you are already taking a course of antidepressants that are already working to some degree, even if they alone are not bringing the brain to normal, it is a good idea to keep taking them even while undergoing TMS therapy.

As always, there are possible exceptions. For example, a patient with severe bipolar disorder likely should not only be taking antidepressants. Rather, these patients should take a mood stabilizer, a component of which antidepressants should make up. This is because bipolar patients suffer from mood changes beyond depression, and treating one without the other will not be nearly as useful as treating the problem as a whole.

Our technicians have experienced success with bipolar patients taking the correct medications while applying TMS therapy to the right side of the brain instead of the left. We have recently begun the process of publishing a paper regarding our findings.

Call our offices today to discuss your medications with our doctors and learn how they could interact with TMS treatment.

Is TMS therapy uncomfortable?

TMS therapy is delivered as a low-intensity procedure that lightly penetrates the skull and brain but without using invasive measures to alter the structure of the brain. It is designed to require little of the patient, both in time and healing energy. Having said that, TMS therapy would only be uncomfortable at higher intensities due to the tension of the scalp muscles. We take every precaution to begin our pulses at the lowest possible intensity while increasing it as necessary depending on how the brain responds to the magnetic pulses.

If the patient feels uncomfortable with the feeling of the pulses, we will dial back the intensity and consider increasing it down the road after the patient becomes more accommodated to the pressure. Headaches are the most common side effect, but these are usually temporarily reported, noting that the headaches seem to stop after the first week of treatment.

Some patients have experienced discomfort even at the lower levels of intensity. When this occurs, we either switch machines or attempt to use the other side of the scalp instead.

Does TMS therapy cause memory loss?

No, there is absolutely no memory loss known to correspond with TMS therapy. The only known side effects with TMS therapy are the rare risk of grand mal seizure and the rare risk of fatigue.

In fact, as we have learned through hundreds of patients in the last few years, it is almost a challenge just to cause any kind of harm on TMS therapy, proving its safety for most patients suffering from depression. If the technicians fail to place the pulses in the correct parts of the brain, the pulses do not seem to adversely affect those parts of the brain, making them a pointless wait in an expensive chair in the worst case.

Although memory loss will not occur from TMS therapy, the other potential risk involved comes with bipolar patients; sometimes, stimulating the dorsal lateral pre-frontal cortex can overstimulate the patient and trigger a temporary manic episode that eventually crashes back into a depressive episode. We have recently engaged in research that suggests we can avoid this complication by providing the pulses on the right side of the brain instead of the left.

What are the side effects of TMS therapy?

The most serious risk involved in TMS therapy is the possibility of experiencing a grand mal seizure, but this is a rare side effect. Only 1 in 10,000 patients will experience a grand mal seizure during transcranial magnetic stimulation therapy.

Otherwise, the most common side effect is experiencing headaches after the first two or three treatments. This is because the brain is not used to experiencing targeted magnetic pulses, much less many pulses over consecutive days. It is also not used to feeling copper coils pressed against the scalp, causing the muscles to tense up and become achy for a few days. After the first week of treatment, however, the vast majority of patients stop experiencing headaches as the scalp becomes accommodated to the twin coils and pulses.

Our technicians have had three patients out of several hundred experience fatigue as a side effect of TMS therapy. One patient experienced mild sleepiness and the other two developed extreme but temporary fatigue for a day following the procedure.

What are the potential risks of TMS therapy?

The most serious risk involved in TMS therapy is that the procedure could trigger a grand mal seizure in the patient undergoing the process. However, the likelihood of suffering from this side effect is as little as 1 in 10,000. The risk increases substantially in patients who have a prior seizure disorder, raising the odds to 1 in 200. This is why it is important to discuss this disorder with the practicing physician; treatment must be applied much more carefully, if at all.

Our office has experience with treatment-resistant patients, including patients with epilepsy, but we have not had a patient suffer a grand mal seizure during our TMS therapy sessions. To combat the risk of seizure, we take extra precautions when appropriate, including, but not limited to, taking care of the pulse intensity as well as the location of the pulses delivered to the brain. However, if a patient were to experience a grand mal seizure during treatment, the side effects would be minimal as the patient is seated in a chair and not in a life-threatening environment

What is a typical course of TMS treatment?

As with all kinds of medical treatments, it is important to note that all patients are unique with individual differences that can alter the parameters of the treatment course. With that in mind, it is common for most patients to average about 30 treatments over the course of a month and a half; usually, the treatment involves a session every weekday, five times a week, for six weeks.

In our office’s experience, patients who undergo 30 TMS therapy treatment sessions will have about the same beneficial effect as someone who has undergone 10 electroconvulsive therapy treatments, but without having to deal with invasive procedures that run the risk of damaging brain tissue. In addition, it is common for ECT patients to relapse down the line and require the 10 treatments all over again. While TMS therapy isn’t a one-off permanent solution, it allows patients to go on for much longer periods of normalcy before experiencing depression again. Not only that, but we find patients who relapse after TMS do not need a full 30 sessions when they return.

Is TMS therapy like electroconvulsive therapy (ECT)?

Considering the nature of the process and the fact that patients who experience seizures may not be suitable for treatment, it is understandable to think of TMS therapy and electroconvulsive therapy as one and the same. In truth, there are several key differences between these two types of treatments; in fact, the only thing they really have in common with one another is that they are both types of treatments designed to stimulate and regulate electrical activity within the brain.

However, as stated, there are plenty of differences to note. For one, ECT relies on a heavy usage of electricity because most of it encircles the skull since electricity doesn’t want to penetrate the solid surface. The amount of electricity applied induces intentional seizures, whereas TMS therapy is considerably less invasive and doesn’t run the same risk of damaging the brain. Nowadays, patients undergoing ECT are put under so the seizures aren’t very visible. However, in TMS therapy, no such seizures are necessary; magnetic pulses easily penetrate the skull without going very deep.

Does Medicare cover TMS treatment?

Medicare is a form of federal health insurance available primarily to elderly folks over the age of 65, first established back when Lyndon Johnson was the President of the United States. Currently, Medicare does cover TMS therapy treatment in patients with Medicare who are suffering from depression. It is necessary to keep alert for any potential changes in coverage in Medicare from year to year, but because TMS therapy continues to prove itself over time, it is unlikely that Medicare will cease coverage of the treatment.

There are also many TMS therapy practitioners available throughout the country who accept Medicare as a form of insurance. This means American patients with Medicare should have little difficulty finding a center that will provide treatment for a low, affordable cost. Compared to patients on other forms of insurance, patients with Medicare save a substantial amount per treatment and overall, saving thousands of dollars over 30 sessions.

Is TMS therapy covered by my insurance?

The short answer is that it depends on the patient’s insurance policy as well as the state in which the procedures will take place. As time goes on and more patients successfully undergo TMS therapy, more and more insurance companies begin to open up their policies to include TMS therapy treatment to qualified patients.

The treatment has been FDA-approved since 2008, which makes it more difficult for insurance companies to deny the effectiveness of the treatment and to deny making payments towards it. Some still try to deny the procedure, unless the patient and their doctor are able to prove that it is medically necessary for the patient to receive TMS therapy to combat treatment-resistant depression.

Call our offices today to schedule a consultation and to find out whether or not we can accept your insurance. Even if sessions aren’t fully covered, they may be partially covered.

Who cannot get TMS therapy?

For the most part, just about any type of patient is capable of getting TMS therapy. There are a few exceptions, however. The following types of individuals may not qualify for TMS therapy:

Patients who have undergone brain surgery and still have magnetic metals in the brain
Patients who have never responded to other depression treatments
Very elderly patients
Patients who have seizures
The reason leftover magnetic metals in the brain can prevent TMS therapy candidacy is that the process is based on magnetic stimulation. The treatment operates under the assumption that there are no other magnetic presences in the brain, which is true unless a patient has undergone certain types of surgical procedures. During TMS therapy, the metals would heat up and result in more harm than heal.

Having metals in the body may not necessarily disqualify a patient. Our office has experience working with a patient with stainless steel in her body away from the treatment site. Stainless steel contains very mild magnetic properties, but the far proximity makes her a suitable candidate for TMS therapy regardless.

What is the difference between regular TMS therapy and deep TMS therapy?

The simplest answer is that deep TMS therapy affects a deeper part of the brain compared to its standard counterpart; in fact, it goes about twice as deep.

With regular TMS therapy, we rely on a two-coil device to deliver electricity through copper wires, creating a magnetic reaction. This reaction is strongest at the point where the coils touch. The magnetic spot is put on the dorsal lateral pre-frontal cortex, either the left or the right side depending on the nature of the patient’s depression. The magnetic pull stimulates an area of the brain comparable to an American silver dollar and as deep as 2 to 3 centimeters.

Deep TMS therapy, developed by a physicist in Jerusalem, differs considerably: In this process, the coils are designed in such a configuration that it enables the magnetic stimulation to reach as deep as 6 to 7 centimeters into the patient’s brain. It also affects the diameter of the affected area, covering a substantial amount of the brain with every pulse.

What is the difference between TMS and rTMS therapy?

When our offices discuss rTMS therapy, we are referring to a similar practice called repetitive Transcranial Magnetic Stimulation therapy. Technically speaking, all TMS therapy treatment is considered repetitive; that’s because one session isn’t sufficient to treat any patient, which is why we prescribe multiple scheduled sessions for treatment.

However, the separation in the two terms comes down to academia: Researchers seeking to run trials to learn more about TMS therapy will have patients who actually undergo the process, but they will usually only receive one or two pulses per trial. Even if they were to receive two or three pulses each time, it’s not really considered to be repetitive. After all, just compare this to our standard treatment process, which includes multiple pulses on various key points across the scalp — something truly repetitive, especially as it must be done over and over again over multiple sessions over time.

In other words, TMS refers to the academia, whereas all TMS treatment is technically rTMS. For simplicity’s sake, we refer to all treatment as TMS therapy.

Do I need to be hospitalized for a course of TMS therapy?

No. TMS therapy is a mild outpatient course of treatment that involves very few tools to accompany the high level of necessary skill to achieve. Undergoing TMS therapy includes receiving a prescribed number of pulses of varying strength to key areas on the head, jolting the brain and exciting or depressing synapses as needed to work more efficiently than before — or as healthy synapses should, as the case may be.

As a mild treatment, TMS therapy only affects about 3 centimeters deep into the brain. When stronger pulses are prescribed, even the deeper course of treatment will only reach about 7 centimeters into the brain. Although we require multiple pulses across multiple points on the head, each pulse lasts just a fraction of a second and offers very little discomfort, if any. Because the procedure is not invasive and doesn’t require any hospitalization, most patients should be able to resume normal activities immediately.

Who will benefit the most from TMS therapy?

TMS therapy was developed in an effort to combat ineffective depression medication and continues to serve as a pioneer in the industry. Patients who suffer from hard-to-treat depression are therefore some of the best candidates for TMS therapy, as they are most likely to notice short- and long-term benefits.

When antidepressants fail to work for several years, there’s a strong case to make that the next antidepressant won’t be the lucky charm. It may work better than the last one, but if the others couldn’t achieve a state of normal, then why should we think the next ones will? As our offices report a 50 percent success rate, TMS therapy provides, at worst, a coin toss of a treatment option. At best, it can bring you back to feeling normal and back in your own body. Our own Dr. McMullen recommends that patients who recognize themselves in this description to schedule a consultation to learn more about TMS therapy and whether or not they’d be a suitable candidate.

Who administers TMS therapy?

At our office, Dr. McMullen takes charge in determining the necessary course of action regarding TMS therapy sessions and who may qualify as a candidate. In general, the TMS practitioner prepares all the variables in the treatment, including:

Whether or not the patient is a suitable candidate for TMS Therapy
Where to administer treatment
Treatment parameters
The number of sessions the patient will need to undergo for successful treatment
Number of pulses
Although the primary physician must be the one to make the final call on treatment variables, which involve more than the above, we employ technicians who are specially trained to carry out the actual procedure according to strict guidelines. We establish a precise step-by-step guide for our technicians to follow every single time they administer the treatment, regardless of the patient. This process includes:

Placing the cap on the patient before treatment
Marking the points where magnetic stimulation will be applied
Working with the physician to adjust treatments over time

Does TMS therapy work?

Although we do not yet fully understand the full breadth of the science behind the treatment, we can say with absolute certainty that TMS therapy not only works, but it works very well. While most people suffering from depression are eligible to undergo TMS therapy, there are a few characteristics that significantly improve a patient’s reception to the treatment:

Either male or female
Ages 20 to 75
Still occasionally experiences normal moods
Occasionally responds to other medications
In a longer-than-usual-lasting depressive episode
The prognosis is better in this situation: Meeting the above criteria gives you some of the best chances to respond positively to TMS therapy. However, patients who have never responded well to alternate medications, such as antidepressants, and remained in a constant depression may not benefit from TMS therapy. Naturally, patients who fall somewhere in the middle of these two extremes face an average prognosis.

What is the TMS therapy success rate?

Currently, TMS therapy is performed by some doctors across the country, with each one reporting different results. We can expect a variation in success rate depending on the physician performing the procedure and his or her skill, as well as the health of the patient. Some doctors report an 80 percent success rate, although there are a few caveats to keep in mind here: Most of the patients these doctors saw were receptive to treatment, and they may not take in quite as many patients.

Our office reports a 50 percent success rate, which is a rate we feel is more realistic to strive for. This is because many of our patients are treatment-resistant, meaning they’ve turned to several other solutions already, including multiple medications for many years, and never quite reached a state of “normal.” However, even these folks, who were beginning to or had already lost hope, were able to achieve regular status with the help of adding several TMS therapy sessions.

How does TMS therapy work?

Short for Transcranial Magnetic Stimulation therapy, TMS remains a mystery at this point, though we currently have some theories that involve understanding the biology of depression. The left side of the brain isn’t as active during the depression, resulting in reduced blood flow. Normally, this is treated using excitatory treatments that stimulate further brain activity, which means the patient receives therapy that directly targets the inactive side of the brain. This procedure can be likened to TMS therapy, which explains why we’ve been able to rely on it to successfully treat patients.

Of course, as relevant as this link may be, there is inevitably something more complicated going on, as is the typical case with brain activity and treatments. The reason we know there’s something extra happening in the brain is that after 45 minutes of therapy, the brain activity level in a depressed patient returns to the low value it was before the treatment. Because the patient does improve, however, we are confident that excitatory treatments are on their way to becoming truly even more effective.