I’m Robert McMullan. I’m a psychiatrist.

I went to Georgetown Medical School which was a wonderful place and I did my residency in psychiatry at Columbia Presbyterian hospital which is also a very good place with a lot of great research going on.

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or the past thirty-six years I’ve been doing primarily psychopharmacology.  And then, when TMS Transcranial magnetic stimulation came out, I very soon wanted to acquire a machine because this would be an extra modality to treat people who we couldn’t get all the way better with medicines. I got my first machine and I [inaudible] of 2010, and now we have four machines. Two machines in two different locations and two different types of machines.

Now, how does one treat depression with TMS? The basic treatment is to do an excitatory treatment on the left forehead, which is called the left dorsolateral prefrontal cortex. It is the point of the brain right here. The way one does this is there are copper coils through which electricity is being pumped in a very-, at a very high intensity. This pulse of electricity causes the copper coil to turn into a magnet. And so we’re putting a very powerful magnetic field over this spot of the brain. And a magnetic field can go through the skull very easily whereas electricity cannot. But, it’s not stopped by the skull at all so this magnetic field when it goes on and off, you can excite the brain or you can quiet the brain down.  And the main anti-depressant treatment for 20 years has been to do an excitatory treatment on the left, and this takes about half an hour. There’s usually 20 pulses per second for two seconds and then there’s a 10 or 15 second interval where there’s no pulses at all which is mainly to allow the machine to stay cool. It’ll overheat if you do too many pulses together.

he entire treatment takes about 30 minutes and it can feel a little funny like a woodpecker pecking on your forehead, and if you turned the intensity up enough since it’s causing the muscles on your scalp to tighten up it could be uncomfortable. If anybody gets uncomfortable we just don’t go up any higher, we stay lower, and then you accommodate to this over a few days and then usually you can go up to the desired treatment intensity.

Occasionally somebody will have a headache, usually just the first two or three treatments and we’ve had two or three people, out of hundreds who became very fatigued from the treatment and would stay fatigued for a day or two. That’s about the extent of the side effects. The one side effect we don’t want is to cause somebody to have a seizure. We’ve never had one, and it only happens in about one out of ten thousand treatments. It would be more likely to happen in someone who’s got a history of bad head injury, or a history of seizures. And, if you did the treatment instead of doing it here, you did it further back on the motor strip, that’s the easiest place to induce a seizure. So we avoid doing that.

Transcranial Magnetic Stimulation - focal field pattern

By MistyHora at the English language Wikipedia, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=5152920

Usually by 12 or 15 treatments we’re seeing some benefit that the person is beginning to improve. We have them fill out scales, self-rating depression scales, and then I also do a scale. If the people are steadily improving then it’s probably working. Sometimes the patient doesn’t feel any better and they say, you know, ‘It’s not helping me’, even though their scores are getting better, even though they are doing their own scales and the scores are getting better. And, that’s because sometimes the last thing to get better is how you feel. The depressed feeling is the last to get better, so even though they’re concentrating better, doing a few more things, and they have a little more energy and they’re enjoying food a little better, and their appetites a little better, they’re not feeling better. And, we explain this and then we continue on the way we are going.

Usually we think of about 30 treatments as being the amount most people need for their treatment. Some people get completely to a normal mood in 15 or 20 treatments, and then we may just stop there. Or, we may decide to do a few more treatments with the idea of cementing in the benefit. If there’s no benefit by 12 or 15 treatments then often we think of changing the parameters, and doing the treatment differently, for example, beginning to do treatment on both sides, or to switch from an excitatory treatment on the left to doing an inhibitory treatment on the right. And there’s a few other new parameters that have been introduced, different places and ways of treating depression. So, we have quite a few alternatives. If someone is overly stimulated by a left excitatory treatment, their [inaudible] begin to raise, and they can’t sleep, and they’re feeling kind of hyper, then they’re probably a little bipolar, and then we switch and do an inhibitory treatment here.

Over the years the treatments were mainly done left excitatory and that’s primarily because the first treatments were done that way so everybody continued to do it in the same place in the same way with some changes, like, doing more pulses per second or doing more total pulses. So, the parameters were improved over time, and there weren’t that many studies on using the right-sided inhibitory treatment, but it turns out that the right-sided inhibitory treatment works just about as well as the left excitatory.

I have treated a large number of bipolar patients, bipolar one, and then people with a mild bipolar problem called bipolar two with just the right-sided inhibitory treatment, and it’s helped their depression, and we haven’t caused anyone to cycle on them. We haven’t made anyone cycle up into a mania, or another thing that a stimulating anti depressing treatment does, whether it’s medicines or TMS, that stimulating treatment can cause people to cycle more. Maybe they don’t go into a high, but they start having more depressions and more agitation, and you’re actually making them worse over time.

In fact, you see this frequently in bipolar two people, who have had very few highs and very mild highs, so no one has really, recognise that they’re bipolar. So they’re put on an anti-depressant and the anti-depressant works really well and in a month or two they’re doing great and the psychiatrist thinks he’s a genius and-, but then in a few months the medicine poops out, and they raise the dose and it doesn’t help much, in fact the person might get worse. So then they take the patient off that medicine, they try another antidepressant, and the same thing might happen. Initially some benefit and then lose the benefit. And eventually, they’re getting no benefit at all, from any anti-depressant they had. That person is not responding because they are a little bipolar, and so they should be put on lamictal lamotrigine, which is an anti seizure medicine that has a great anti depression effect, and maybe a small amount of lithium, I always go very low, and then when you use TMS you use a right sided inhibitory treatment. We’ve had the experience that not only do we bring them out of the depression, but we stop their cycling so that people who are cycling between moderate depression and agitated depression and up and down, or cycling from depressions into mild highs, that the cycling has seized as well as bringing them out of depression. That’s quite an improvement.

What’s really important is not only to get them to normal, and the goal always has to be to get to a completely normal mood, where they feel a hundred percent. And, to maintain that you need to stay on the anti depressants usually, or some medication rather whether it’s lamictal or a tiny amount of lithium, or some combination of anti depressants. So usually the medicines that are working partially, we leave them on them, on those medicines, during the treatment, and that seems to raise the odds that they’ll come out of the depression. Now if you-, and we also use this to treat Parkinson’s disease and OCD obsessive compulsive disorder and a few other things such as migraines and chronic pain syndromes. These are off labelled treatments, but they often work extremely well.

If you have any other questions call me at 212-362-9635, 212-362-9635