Our New York City Psychiatrist Robert D. McMullen, MD discusses:
How to Talk to a Psychiatrist?
What to Expect for Your First Visit with Your Psychiatrist
Hello there! I’m Dr. Robert D. McMullen, and I have been treating patients as a psychiatrist for over 35 years. I work mainly in psychopharmacology and Transcranial Magnetic Stimulation, TMS. I attended the Georgetown University for medical school and specialized in psychiatry at Columbia Presbyterian, both located in the USA. I currently see clients at my office in New York City. In this video, we will be discussing the best way to talk to your Psychiatrist and what to expect for your first visit.
It’s not Always About Your Mom
I once had a patient that was a sort of celebrity, in fact I saw him on television a few times after I worked with him. He visited me at the West Chester office. Contrary to popular belief, many celebrities and famous individuals suffer from depression. I did a thorough health and history interview with him and discovered he suffered from depression and Bipolar II Disorder. After we finished the interview, he confided in me that he had been extremely anxious and worried about coming in for this appointment and had even been dreading it for over two weeks. He now understood that there wasn’t anything to stress over, since I merely want to get to know you and your history during a first appointment.
Many individuals new to seeing a Psychiatrist believe that we will only discuss their parents and upbringing since that must be the primary reasoning for their current issues. The truth is, that while things that happened with our parents may have been an initial cause for a person’s depression or Bipolar Disorder, we are unable to change the past. Therefore, the initial interview focuses more on you and your symptoms.
What’s the Matter?
When you speak with your Psychiatrist at your first appointment, it’s helpful to consider the things that are bothering you and interfering with your life. Usually, these issues will be related to depressed moods, anxiety symptoms, excessive worrying, or perhaps problems with attention. You could have difficulty paying attention to things like your studies in high school or college and have a harder time staying on focus than your friends and family members. You are just as bright and intelligent as they are, it’s just harder for you to sit still and complete a task like homework or reading from a boring textbook.
As a client new to treatment, you should expect the discussion of many possibilities of diagnoses from depression to anxiety. Originally, I sometimes failed to ask patients about panic attacks and other forms of anxiety. It’s important to discuss these types of issues with the doctor so we can get a well-rounded idea of what is happening so we can make the correct diagnoses and begin to treat you.
Rome Wasn’t Built in a Day
As a seasoned Psychiatrist, I no longer consider the first visit to be definitive. Similar to an Internal Specialist Physician, you can’t always discover the cause of stomach pain in one visit, the same idea holds true in Psychiatry. Arriving at the right diagnosis will require patience both on my part and yours so you can receive the highest and best level of care possible. Sometimes it may also be beneficial to meet with family members of the client so they can give input since they can often notice signs and symptoms we ourselves can miss.
TMS Brain Care is our practice located in NYC, New York City. We hope this video has helped you to understand what to expect at your first appointment and the kinds of things you could be talking about. Please give us a call at 212 362-9635 to make an appointment at our NYC office. You can also visit us at https://tmsbraincare.com. Don’t forget to click the like button for our video and to subscribe to our channel. If you enjoyed this video, please forward it to your friends and family and leave us a comment with your thoughts and questions. Thanks!
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)
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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
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.
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.
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.
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