Deep TMS, Effective Treatment for OCD
I’m Robert McMullen. I’m a psychiatrist in New York City for 36 years. I went to Georgetown Medical School, which is a wonderful medical school and I did my residency at Columbia Presbyterian in New York.
I have during my entire practice concentrated on using psychopharmacology to treat psychiatric illnesses from manic depression to mild bipolar disorder to depression to schizophrenia to panic attacks, the whole range. Five and a half years ago, we added a new modality in part because I wanted to have another option when people failed on all kinds of medications.
This is transcranial magnetic stimulation. It’s transcranial it goes across cranium. It’s magnetic and it’s stimulation. The beauty of it is that a magnetic field is not blocked by the skull at all it just goes through it very easily. Whereas, if you try to run electricity from one side of the head to the other it really doesn’t want to go through the skill and it will tend to go over the top of the head, so it doesn’t get into the brain that easily. But this was a very easy way to intervene in the brain both for research purposes and for treatment.
It was developed by Tony Barkley in England in 1985. It’s been used for depression for over 20 years now. It’s been FDA approved for depression since 2008. It works for treatment resistant depression in just about 50% of people, bringing them all the way to normal and often with a long-term benefit. But it works for many other things and the thing I want to talk about is OCD, obsessive-compulsive disorder, which is a very common disorder and several percent of us suffer from this currently or at some time in our life.
It’s very hard to treat. We have medications, mainly SSRIs, serotonin medications that significantly help but it’s very hard to improve somebody more than 50% percent or even to improve them 25%. I have one patient, I will use as an example, she is a woman in her early 50s who has suffered from depression and OCD all her life. Her main complaint was the OCD because it just tortured her that she would be worrying about her health all day long. It could be some new thing that she was worried about and she would look it up on the Internet and find out all sorts of details. Sometimes, or often, there was a grain of truth in what she was worrying about But this took up so much of her time that it was interfering with her ability to work well at her job. Plus, it just made her life a little miserable.
We decided to do a TMS treatment with a TMS machine called Brainsway from Israel and it’s a helmet and the cooper coils in it are arranged in such a way that it goes much deeper than other TMS machines. We have another one that’s the standard figure eight but this company developed a helmet especially for OCD. So we use this on her for 30 treatments. What was surprising was that both her depression and her OCD really improved. For depression, her scores were fairly severe like her score was 30 to 40 came down to the normal range. That was really a big transformation that she did not feel depressed anymore. The OCD score was about 23- 24 when you’re getting up that high the white box, it’s called the Yale Brown Obsessive Compulsive scale, once you are getting up that high you are getting close to where somebody can’t work that they are too dysfunctional to work. That score went down to 10 from a high of 23-24 sometimes a little higher.
When they do research on OCD with medications they call it a response if you get a 25% improvement, with depression you have to have a 50% improvement. But OCD is so difficult to treat that the researchers are satisfied with a 25% improvement and there’s no placebo responders anyway. The people who get the fake pill, that looks like the medicine and they don’t know who gets what, the doctors or the patients. Those patients, very few of them get much benefit. So 25% is considered a response, so she had an over 50% response and it persisted for six months. She did really well for six months. Then I think she backslid a little bit, you know, the OCD has come back a little she should probably get a few touch up treatments. But that’s pretty phenomenal to have that much benefit and last that long. She was happiest about the relief from the OCD than she was from the depression even though the depression worked 100% because OCD was no longer torturing her all day long. She could stop herself from thinking about things. She could spend time thinking about other things. It was quite a transformation. This is going to be, it already is a revolution in psychiatry. It’s not as big of a revolution as it could be because so few people are getting treated.
There’s many reasons for this, I think one of them is to tell other psychiatrists that I can get 50% of your treatment resistant patients all the way to normal sounds too good to be true, so it must not be true. If you failed at five medicines, then odds that the next one is making you 100% is way below 5%, maybe lose to 0. When we get about 50% that’s final. Also I think it’s hard to convince the patients that it sounds weird to be putting a big magnet on your head. It involves going over to a doctor’s office several times a week for weeks. It can be expensive. All of these things inhibit the wide spread use of this. But as it’s getting used more widely and more people see the dramatic responses, then there’s more and more people coming for treatment. This is much safer than ECT, Harold Sackeim was the head of research at Columbia for 20 years in shock treatment and he really discovered many important things about where to place the electrodes for the shock treatment to get the maximum benefit and minimum side effects. He said that TMs is much better then shock treatment because it’s safer, you don’t have anesthesia, and it’s more comfortable. Generally, you can have the treatment and then get up and go to work that day whereas with ECT you have to undergo anesthesia and so on.
He also said that TMS was longer acting. It lasts longer.
You don’t relapse, or when you do you don’t need to full gamut of sessions again so TMS works very well in OCD.