Edward Fruitman, MD
1451 Broadway
Hewlett, NY 11557
(516) 295-4867

Category

Brain

TMS Can Help Treat Root Causes of Depression & Anxiety

Dr. Edward Fruitman, Medical Director of South Shore Neuropsychiatric Center offers innovative genetically based treatment options for Depression and Anxiety. At South Shore Neuropsychiatric Center we offer a simple test that gives insight into our patients’ specific genetic profile which enables Dr. Fruitman to optimize medication regimen and/or offer alternative treatment options.

Recent studies suggest that early life experiences in combination with genetic predispositions are major contributors to treatment resistant anxiety and depression.  The amygdala is a region of the brain responsible for emotion regulation while the prefrontal cortex (PFC) is responsible for emotion processing. Fear inducing cues increase amygdala activity and cause the physiological responses to anxiety. The PFC regulates the amygdala effect by inhibiting autonomic and endocrine responses to stressors. In essence, the PFC controls the extent of an emotional response. Individuals that experience heightened anxiety and depressive symptoms are shown to have an inability to control and habituate responses to stressors.  Studies suggest that genetic factors may contribute to this effect. Researchers found that in “subjects carrying a substituted methionine in the BDNF gene, fear doesn’t extinguish as readily in response to repeated nonthreatening cues; in those with a valine, it extinguishes more easily. Using neuroimaging, the authors showed that polymorphism carriers exhibited more amygdala and less PFC activity with subsequent cue presentations.”  In these individuals the PFC is dormant and individuals may not respond to psychotherapy or medication.

Transcranial Magnetic Stimulation Therapy (TMS) is a noninvasive treatment option for individuals suffering from treatment resistant anxiety and depression.  TMS stimulates the PFC using noninvasive magnetic energy, which over time provides relief to depression and anxiety symptoms. Dr. Edward Fruitman is the pioneer provider of Transcranial Magnetic Stimulation (TMS) Therapy in the Five Towns area. Dr. Fruitman has successfully treated patients suffering from anxiety and depression with TMS since 2010.

PROBLEM: ADDED COST FOR MEDICAL PATIENTS WITH TREATMENT RESISTANT MAJOR DEPRESSION SOLUTION: TRANSCRANIAL MAGNETIC STIMULATION?

Behavioral Healthcare/ December 4, 2013

By Alison Knopf

neurostar-infoTranscranial Magnetic Stimulation (TMS) may be the best way to help patients with treatment-resistant major depression (TRMD) – people who have tried antidepressants at least once for the appropriate amount of time on the appropriate dose, according to Pete Mumma, Administrative Director of the Behavioral Health Service Line in the Department of Psychiatry at Lancaster General Health in Lancaster, Pennsylvania. But that doesn’t mean it’s easy to “sell” the TMS device to financial people in your institution.

Here’s how Mumma did it: 9.1 percent of the population has depression, and .05 percent has TRMD. These people are “superutilizers,” who consume 18 percent of a health system’s uncompensated or undercompensated spending. “It’s unsustainable,” he said. “We expect people who have extreme needs to be treated in pathway models that don’t meet their needs – what will we do with these patients, not just from a mental health perspective, but from a total medical perspective?”

For example, an individual with TRMD who also has cardiac disease or cancer is going to be very complicated to treat. “Any medical provider who is helping patients with TRMD is going to bump up against some or all of their issues,” said Mumma. Symptoms such as lack of energy, lack of concentration, and sleep problems create further distractions for the patient, he said. The recommendations of the cardiologist or oncologist won’t go as far as they would if the patient didn’t have depression.

The impact of mental health problems on physical treatment is more relevant now than it was in the past because of the way health systems are being reimbursed, said Mumma, citing in particular the penalty for readmissions within 30 days. If a patient fails cardiac treatment – perhaps because he didn’t exercise, something that is notably difficult for people with depression – and needs to be readmitted, that’s a ding to the hospital’s bottom line. “So cardiologists and every other doctor wants to make sure they eliminate barriers to good outcomes,” he said. Mental problems that make it difficult to follow through with physician recommendations are suddenly seen as very important – a good thing for both patients and the health care system.

“We can spend a little money up front to treat the depression, and the patient’s cardiac care goes farther, faster,” said Mumma.

The treatment

Typically, patients start with a daily course of treatment, which takes about 37 minutes. This would go on for four to six weeks. The treatment is painless and requires no sedation. Once the initial course is done, some patients may come back for a maintenance treatment. The treating provider will determine the exact treatment protocol and any maintenance needed.

Medications

The first line of treatment for depression is medication, but people with TRMD are patients for whom medication isn’t working. On the system side, the clinical benefit is important, but on the patient side, it’s crucial. “The tragic thing is these patients aren’t getting better,” said Mumma of TRMD.

Doing depression care differently – what Mumma is suggesting is avoiding the “shotgun approach” that most depression patients who have tried one medication after another have experienced. At Lancaster, before selecting a medication, the psychiatry department does “pharmacogenetic” testing via a cheek swab to at least narrow down the type of medication to try in the first place. “But many patients get agent after agent, and have had no other options over their lifetime.” Now, at least patients who have failed one course of medication with an appropriate dose and duration have another option.

“Through medications, we’re trying to light up some parts of the brain and quiet others,” said Mumma. That’s the same thing that TMS does – the magnet near the head “reaches deep into the amygdala, which scientists think is responsible for mood,” he said. “Instead of washing the brain with chemicals, this seems to isolate the problem.” Many patients continue to take medications while getting TMS but find they can reduce their medications over time, he added.

Another issue is the cost of medications. Abilify, the medication used for treatment-resistant major depression, is very expensive, said Mumma. “The health plan might be paying more than $1,000 per month” for Abilify, he said. “Add to that the costs of Celexa or other medications, plus the medication management.”

Tracking medical costs

Mumma also has scrutinized the literature, finding that one study showed that the most costly expense to employers was depression, at a cost of more than $350,000 per thousand employees. That isn’t only medical costs, of course, but aggregated costs of medical treatment, pharmacy, absenteeism, and “presenteeism” – in which employees are still at work but unable to function. “If we were to do depression care differently, that’s a huge savings,” said Mumma.

Patients paying

In clinical trials, suicidality was four times higher in the placebo group than the TMS group, said Mumma. (In the clinical trials, TMS was compared to sham TMS, not compared to medication.)

Major depression is a devastating disease for people who don’t get better, and 40 percent of the patients experience remission, said Mumma, who is not compensated by Neuronetics.

The big question is whether TMS is going to be as effective as electroconvulsive therapy (ECT), said Mumma. Clearly TMS is much more appealing to patients. “ECT is scary as hell, and it has ugly side effects like memory loss,” he said. ECT is effective, but many studies are showing comparable results for people with TMS, said Mumma.

“Nobody’s using the word, ‘cure,’” said Mumma. But TMS is different from medications, he said. TMS is non-medication based treatment, so there are no drug-drug interactions. “It’s difficult to get off of antidepressants once you get on, and antidepressants are basically a band-aid for a problem – just symptom improvement, not managing the illness.”  TMS does allow patients to return to functionality with fewer side effects than medication, said Mumma.

TMS Could Help Treat Chronic Dizziness

Researchers from the Johns Hopkins University School of Medicine believe that they have located a specific site in the human brain that could be one of the sources of dizziness and spatial disorientation.

While dizziness can also be linked to damage to the inner ear, or to other senses such as vision, neurology instructor Dr. Amir Kheradmand and his colleagues report that they have discovered a region of the brain that plays a vital role in our subconscious awareness of which way is up and which way is down.

Their study, which appears online in the journal Cerebral Cortex, found that some causes of dizziness, unsteadiness and “floating” could be linked to that region in the parietal cortex.

The study authors opted to focus their analysis on the right parietal cortex, as research on stroke victims with balance problems has suggested that damage to that region of the brain was directly involved with upright perception.

They recruited eight healthy subjects, placing each in a dark room and showing them lines that were illuminated on a screen. Dr. Kheradmand’s team then had the study participants report the orientation of each line by rotating a dial to the left, the right, or straight ahead.

The subjects then received (TMS) – an FDA-approved treatment for depression and which “painlessly and noninvasively delivers electromagnetic currents to precise locations in the brain.”

Each individual had a TMS coil placed behind the ear and against the scalp across the right parietal lobe. The subjects received 600 electromagnetic pulses over the course of 40 seconds, and at the end of each session, they were asked a second time to show the researchers which way the illuminated line was positioned. At the end of the study, all of the subjects reported that his or her sense of being upright had been altered in the same way after TMS was administered in the same location in the parietal cortex.

According to Kheradmand, his team’s findings suggest that this form of stimulation could be used to treat chronic dizziness. “If we can disrupt upright perception in healthy people using TMS, it might also be possible to use TMS to fix dysfunction in the same location in people with dizziness and spatial disorientation,” he said.

FDA approves TMS device to relieve migraine pain

FoxNews.com

694940094001_1409784734001_640-brain.jpgThose who suffer from debilitating migraines may soon be able receive an outpatient procedure that can help alleviate their pain, as reported by Nature World News.

The U.S. Food and Drug Administration (FDA) recently approved a TMS device for people who suffer from migraines that are preceded by an aura – characterized by a tingling sensation in the extremities and flashes of light or blind spots in a person’s vision. The device uses magnetic energy to stimulate the occipital cortex – an area of the brain involved in visual processing – in order to alleviate migraine pain.

In a trial conducted by the FDA, 201 migraine sufferers tested the device when they experienced head pain. Overall, 38 percent of patients using the device experienced relief from migraine pain within two hours, compared to just 17 percent of people who were given a fake version of the device.

While the TMS has not been proven to completely eliminate all migraine symptoms, it does help relieve migraine pain. The FDA noted that the device doesn’t provide relief for other symptoms of migraines, including  sensitivity to light, sensitivity to sound and nausea.

TMS SHOWS PROMISE FOR NEGATIVE SCHIZOPHRENIA SYMPTOMS

Medscape: Fran Lowry(May 2, 2013)— Bilateral prefrontal repetitive transcranial magnetic stimulation (rTMS) is a promising treatment for the negative symptoms of schizophrenia, new research shows.

Preliminary results from a double-blind, randomized controlled trial showed that patients with schizophrenia or schizoaffective disorder who were treated with rTMS had a significant improvement in their negative symptoms, as assessed on the Scale for the Assessment of Negative Symptoms (SANS), that lasted for 4 weeks post treatment.

However, after 4 weeks, this beneficial effect diminished.

The findings were presented here at the 14th International Congress on Schizophrenia Research (ICOSR).

Effective Treatment Urgently Needed

Effective treatment options for the negative symptoms of schizophrenia are urgently needed, said study investigator Jozarni Dlabac-de Lange, MD, from the University of Groningen, the Netherlands.

“The outcome for patients who are suffering from negative symptoms is much worse, and there has not been a lot of research in this subgroup of patients because they are very difficult to include in studies,” she told Medscape Medical News.

In addition, the few studies that have reported on the efficacy of rTMS treatment for negative schizophrenia symptoms have shown inconsistent results, Dr. Dlabac-de Lange said.

Each treatment lasted 20 minutes and was given in the morning and again in the afternoon. Patients were stimulated at 90% of the motor threshold.In the current study, the investigators randomly assigned 32 patients with schizophrenia or schizoaffective disorder and moderate to severe negative symptoms (Positive and Negative Syndrome Scale [PANSS] negative subscale ≥ 15) to receive either real (n = 16 patients) or sham (n = 16 patients) rTMS of the bilateral dorsolateral prefrontal cortex.

The researchers found that there was a significant improvement in the SANS measure of negative symptoms in the rTMS group compared with the sham group 4 weeks after the treatment sessions stopped (P = .04); however, the effects diminished by 3 months (P = .14).

Additionally, there was no significant difference between the 2 groups on the PANSS negative symptom score at 4 weeks (P = .38) and at 3 months (P = .32).

“Results were good at first, so the next step is to try and see how we can enhance these treatment effects, perhaps by combining rTMS with psychosocial interventions, discovering the optimal treatment parameters and learning which of the negative symptoms show a better response to rTMS,” Dr. Dlabac-de Lange said.

TRANSCRANIAL STIMULATION IMPROVES SYMPTOMS OF TOURETTE’S

By Helen Albert, Senior medwireNews Reporter-A month of daily transcranial magnetic stimulation targeting the supplemental motor area (SMA) results in lasting improvements in symptoms of Tourette syndrome, show study findings.

Repetitive transcranial magnetic stimulation (rTMS)… involves repetitive generation of a brief, powerful magnetic field by a small coil positioned over the scalp that induces an electric current in the brain,” explain Nong Xiao (Chongqing Medical University, Yuzhong district, China) and colleagues.

The technique is designed as a noninvasive treatment for a range of neurological and psychiatric disorders including migraine, stroke, and Parkinson’s disease.

In this study, the researchers tested the capacity of low-frequency 1 Hz rTMS applied at 20 daily sessions (Monday-Friday) over 4 weeks for treatment of the motor and speech neurological tics displayed by patients with Tourette syndrome, on the basis that low-frequency rTMS (≤1 Hz) inhibits and high-frequency rTMS (>5 Hz) promotes cortical excitability.

In total, 25 children under 16 years took part in the study. After 4 weeks of treatment, the team observed no improvements in tic symptoms in six children, but significant improvements in these symptoms that lasted until 3 months in 19 children, and until 6 months in 17 children (68%).

On average, significant reductions were seen in the scores obtained on various tests by the children at 4 weeks compared with baseline. These included the Yale Global Tic Severity Scale; Clinical Global Impression Scale; Swanson, Nolan and Pelham Rating Scale, version IV for attention-deficit hyperactivity disorder (SNAP-IV); Children’s Depression Inventory; Spence Children’s Anxiety Scale; and a novel Attention Test.

Overall scores for all these tests were lower at 6 months than at baseline, but only the SNAP-IV and Attention test scores were significantly lower at 6 months than at 4 weeks.

“Low-frequency (1 Hz) rTMS to the SMA significantly improved Tourette syndrome symptoms, suggesting that it is effective on tics, hyperactivity, attention deficit, depression and anxiety in children with Tourette syndrome,” write Xiao and co-workers in the Journal of Clinical Neuroscience.

“These collective results suggest the need for further studies using rTMS as a research and clinical therapeutic tool in psychiatric and neurological diseases, with particular attention to patients with Tourette syndrome.”

http://www.southshoretms.com/blog/

Transcranial stimulation improves symptoms of Tourette’s

Helen Albert, Senior medwireNews Reporter (Dec. 18, 2012)-A month of daily transcranial magnetic stimulation targeting the supplemental motor area (SMA) results in lasting improvements in symptoms of Tourette syndrome, show study findings.

“Repetitive transcranial magnetic stimulation (rTMS)… involves repetitive generation of a brief, powerful magnetic field by a small coil positioned over the scalp that induces an electric current in the brain,” explain Nong Xiao (Chongqing Medical University, Yuzhong district, China) and colleagues.

The technique is designed as a noninvasive treatment for a range of neurological and psychiatric disorders including migraine, stroke, and Parkinson’s disease.

In this study, the researchers tested the capacity of low-frequency 1 Hz rTMS applied at 20 daily sessions (Monday-Friday) over 4 weeks for treatment of the motor and speech neurological tics displayed by patients with Tourette syndrome, on the basis that low-frequency rTMS (≤1 Hz) inhibits and high-frequency rTMS (>5 Hz) promotes cortical excitability.

In total, 25 children under 16 years took part in the study. After 4 weeks of treatment, the team observed no improvements in tic symptoms in six children, but significant improvements in these symptoms that lasted until 3 months in 19 children, and until 6 months in 17 children (68%).

On average, significant reductions were seen in the scores obtained on various tests by the children at 4 weeks compared with baseline. These included the Yale Global Tic Severity Scale; Clinical Global Impression Scale; Swanson, Nolan and Pelham Rating Scale, version IV for attention-defict hyperactivity disorder (SNAP-IV); Children’s Depression Inventory; Spence Children’s Anxiety Scale; and a novel Attention Test.

Overall scores for all these tests were lower at 6 months than at baseline, but only the SNAP-IV and Attention test scores were significantly lower at 6 months than at 4 weeks.

“Low-frequency (1 Hz) rTMS to the SMA significantly improved Tourette syndrome symptoms, suggesting that it is effective on tics, hyperactivity, attention deficit, depression and anxiety in children with Tourette syndrome,” write Xiao and co-workers in the Journal of Clinical Neuroscience.

“These collective results suggest the need for further studies using rTMS as a research and clinical therapeutic tool in psychiatric and neurological diseases, with particular attention to patients with Tourette syndrome.”