TMS Info from the Second MD

Unlike the first MD, this individual is in private practice. That is, he’s not a clinical researcher. There are several individuals in the practice and they share a TMS machine.

There was almost complete agreement on the topics of overlap between the first doc and this one. There were, however, a number of other interesting bits of info to share.

The second doc believes a more accurate response rate is 70-80% with folks like me (multiple anti-depressants and combinations tried) with 40% getting full remission, i.e., no drugs needed. For folks who are bipolar or have had ECT the numbers are lower, but he doesn’t have the data to quantify how much. These stats are based on his results and others he works with across many practices.

An open research question is the need and value of ongoing maintenance treatments. His gut feel is a follow-up session may be needed as often as every three weeks for some people. He has patients who call in as the depression returns and they get a maintenance session that does the trick for awhile.

He generally follows the standard 20-30 sessions, 5 times a week, but thinks it may be better to add more sessions at the end to taper off. Along those same lines he expects there will be more breakthroughs in this area. The current procedure only treats the left side of the brain. He is fairly certain benefit will be shown eventually to treating both sides.

On the topic of folks who don’t respond, his experience is if someone is not going to get any relief you know it by 20 sessions and can stop. In fact if there’s no noticeable improvement after 3 sessions, they do a realignment just in case there was a problem.

As with the first doc, the lack of insurance coverage is a major problem getting patients. At $400 per session it just isn’t affordable for most people. His practice has had their machine since Jan and they have treated 15-20 people. (That’s, very roughly, about 1 session per day on average.) If insurance covered it, he’s convinced they would have treated at least 100 patients. Of the patients mentioned above, the doc treated 8 of them. One failed to get any benefit, 3 were partial successes and 4 experienced total remission.

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TMS Info from the First MD

On the TMS front, I finally got to speak with a TMS practitioner and got a bunch of questions answered. He's a researcher, though, who runs clinical trials with drugs primarily. It's been months since he's had a TMS patient, because there are no more clinical trials his group is involved in now. Several places I've read the most powerful predictor of a successful outcome for a given doc for most non-trivial procedures is the number of times they do the procedure. As a result, I'm going to pass on this provider, but the stats sound worth trying it somewhere else, at least for me.

The procedure is typically one session a day, five days a week for three weeks. Each session is about an hour long with 45 minutes of actual treatment. It is important that the sessions run consecutively – no week or two week breaks for a vacation in the middle of the procedure. Cost is about $12-15K and insurance rarely covers it.

The most recent data shows about 50-60% are able to reduce their meds by half and 30% are able to go off their meds all together. Folks who have failed with multiple anti-depressants taken alone or in combination have lower success rates, but they don't have hard numbers for that. Same is true if someone tried ECT and it failed. Longer term about 30% of the people have a relapse of depession and require booster treatment. The total data available for this is limited, though, as they've only been tracking it for two years.

The most common side effect is minor irritation at the site where the magnetic coil rests. They recommend taking Advil or Tylenol prior to each treatment to minimize the effect. There have been incidents of seizures, but they are apparently very rare. He told me that the frequency is at or below what one gets with anti-depressants and no one at his organization has ever had one. Regardless, he said it's a good idea for an MD to observe the entire first treatment session just in case. He also recommends that the initial alignment/placement be done by an MD. It needs to be accurate to within about a millimeter for best effect.

If one is already on anti-depressants, he does not recommend stopping their use prior to treatment. They do find, though, that it may be desirable to lower dosages as the treatment proceeds. The treatments have a tendency to increase the potency of the anti-depressants one is taking, so scaling back may be appropriate. Prior to every session one fills out a depression scale and there's a brief consultation to determine if a meds adjustment is appropriate.

Stay tuned for info from my next data collection session from a different doc next week.

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Promising Earlier Use of Drug

Johnson & Johnson may have a real winner on their hands. Their drug Zytiga is already approved for use in very late stage prostate cancer – after Casodex/Lupron and chemotherapy fail. On average it extends life a few months.

They ran a clinical trial where the drug was used much earlier, before chemotherapy was started. The results were so good they halted the clinical trial to give the control group Zytiga as well. Pain levels were significantly reduced and life was extended considerably (because they halted the trial early they were unable to estimate with precision how much longer life was extended).

Definitely will be discussing this with my oncologist. My impression is I would start about the time bone pain from the cancer starts.

Bloomberg’s report of the drug can be found here.