Transcranial Magnetic Stimulation (TMS) Therapy
Dr. Duzyurek has been utilizing TMS at his practice since March 2009, 5 months after its FDA clearance, as one of the pioneering psychiatrists in the country specializing in the clinical application of transcranial magnetic neuro-modulatory treatment as a formally trained practitioner of NeuroStar TMS Therapy System. This new treatment alternative, also known as repetitive Transcranial Magnetic Stimulation (rTMS), has been available internationally since the turn of the century. It has been cleared by the US Food and Drug Administration (FDA) for the treatment of Major Depressive Disorder in adult patients who have failed to achieve satisfactory improvement from prior antidepressant medication, and it is now covered by most insurance companies. For info on other conditions for which TMS shows promise, or where it may be utilized off-label, click here.
As the first practitioner to offer office-based rTMS in the greater Washington, DC area, and one of the most experienced, Dr. Duzyurek performs this medical procedure on an outpatient basis in the comfort and full confidentiality of a private practice setting using his own TMS device. Unlike "TMS clinics" and most other facilities or practices, he personally conducts all treatment sessions with one-on-one attention without delegating any procedural task to other staff or trainees, with minimal administrative hassle, and without extra layers of cost, such as facility fees.
WHAT TMS THERAPY IS NOT
TMS Therapy is non-invasive, meaning that it does not involve surgery or insertion of any material, such as a needle, into the body.
It does not require anesthesia or sedation, as the patient remains awake and alert during the treatment, allowing for prompt return to daily activities following each treatment session.
TMS Therapy is non-convulsive, meaning that it does not involve induction of seizures in order to work.
TMS Therapy is also non-systemic, meaning that it does not involve administration of any chemicals or pharmaceuticals that circulate in the blood stream throughout the body.
HOW DOES TMS THERAPY WORK?
Through a treatment coil, the NeuroStar TMS Therapy device generates highly focused, rapidly pulsed magnetic fields, similar in type and strength to those produced by an MRI machine. These pulses of magnetic fields are directed to the dorsolateral prefrontal cortex, an area of the brain involved in mood regulation via complex functional connections it makes with other parts of the brain. As the pulses of magnetic fields move into the brain, in a specified pattern, they induce very small electrical currents. This micro-level electrical activity physiologically activates brain cells. This is thought to beneficially modify the release of neurotransmitters, functioning of certain neural networks, and gene expression, consequently producing lasting improvements in symptoms of clinical depression. In preclinical scientific studies, TMS therapy has been shown to possess the hallmarks of desirable and effective antidepressant treatments including induction of genes involved in neuron and synapse formation and maintenance, normalization of abnormal stress hormone responses, increases in brain monoamine (serotonin, norepinephrine, and dopamine) turnover, normalization of cerebral blood flow and glucose utilization in the mood circuitry of the brain, and efficacy in animal models of depression.
NeuroStar TMS Therapy was evaluated for efficacy and safety in the acute treatment of major depression in patients who had failed to receive satisfactory improvement from prior antidepressant medication. A six-week, randomized, placebo-controlled triple-blind study conducted at 23 premier research institutions around the world established the efficacy of NeuroStar TMS Therapy in the treatment of depression.
In clinical trials, half of the patients had been treated with at least 4 medication treatment attempts, one of which was at an adequate dose and duration. Approximately half (54%) of the patients treated with NeuroStar TMS Therapy® experienced significant improvement in depression symptoms. About a third of the patients treated with NeuroStar TMS Therapy® experienced complete symptom relief (full remission) at the end of six weeks. In a 6-month follow-up study, less than 10% of patients who benefitted from TMS Therapy experienced relapse.
Demonstrated Safety and Tolerability
Treatment with NeuroStar TMS Therapy caused few side effects and was generally well tolerated by patients. The most common side effects reported during clinical trials were headache and scalp pain or discomfort, generally mild to moderate and occurring less frequently after the first week of treatment.
Less than 5% of patients discontinued treatment with NeuroStar TMS Therapy due to adverse events through the primary study endpoint (4 weeks).
Over 10,000 active treatments were performed safely across all NeuroStar clinical trials submitted to the FDA. In clinical trials there were:
No systemic side effects (unlike medications)
o No weight gain o No loss of libido, sexual dysfunction, or negative impact on male or female fertility
o No drowsiness or insomnia o No nausea, loose stools, constipation, or dry mouth
No cognitive side effects, such as adverse effects on concentration or memory (unlike ECT)
No emotional side effects such as emotional flatness, detachment or apathy (unlike some medications)
No increase in anxiety, agitation or suicidality (no black-box warning by FDA regarding increase in suicidality, unlike medications)
No device-drug interactions
WHAT DOES IT ENTAIL IN TERMS OF TIME COMMITMENT?
The typical initial treatment course consists of 5 daily treatments per week over a 4-6 week period, for an average of 20-30 sessions, normally followed by additional 6 sesions distributed in a taper period of 3 weeks. Each treatment session involves application of intermittent trains of magnetic pulses for a total duration of about 40 minutes. However, the total duration of a session is about an hour, including other tasks such as preparations and assessments. The first TMS therapy session lasts considerably longer (up to 2 hours) during which Dr. Duzyurek will locate the area of your primary motor cortex that governs the right hand muscles and determine the minimal amount of magnetic energy required to activate the neurons in that region. This amount of energy is called your 'motor threshold' (MT). Then he will adjust the magnetic energy level typically to 120% of your motor threshold and navigate a laser-guided coordinate system to locate the treatment application site over your left dorsolateral prefrontal cortex. All these are conducted using single magnetic pulses, guiding systems of the device and the TMS software painlessly and without causing any adverse effects. These and other treatment parameters will then be programmed into the device for use during subsequent sessions. These parameters may need to be recalibrated at times during the course of treatment per Dr. Duzyurek's monitoring and assessment.
USEFUL LINKS ON CLINICAL DEPRESSION
ADJUNCTIVE LIGHT THERAPY DURING DAILY TMS THERAPY VISITS
WHAT IS THE PROCESS FOR RECEIVING TMS THERAPY WITH DR. DUZYUREK?
Patients can receive TMS Therapy from Dr. Duzyurek in one of two ways:
- If referred by another psychiatrist specifically for TMS Therapy, patients will maintain their doctor-patient relationship with their referring psychiatrist during and following the course of TMS treatment for ongoing, overall psychiatric care and treatment. In those cases, Dr. Duzyurek's involvement will be limited to conducting an initial evaluation and consultation to determine if the patient is a clinically appropriate candidate for this form of treatment, as well as conducting the actual TMS sessions, necessary periodic assessments, and clinical collaboration with the attending (referring) psychiatrist. Dr. Duzyurek will ask the referring psychiatrist to provide clinical information on the patient's prior and current diagnoses, treatments (including a detailed past medication history), and the treatment responses observed.
- Patients who do not have an ongoing doctor-patient relationship with a psychiatrist, such as certain self-referred patients or those referred by a non-MD mental health professional, or by an MD who is not a psychiatrist, will need to first see Dr. Duzyurek as a general psychiatrist for a comprehensive diagnostic evaluation and treatment planning. If this assessment reveals that TMS Therapy is indicated and the patient is an appropriate candidate, TMS would be included in the treatment plan. An important piece of this assessment is the patient's past and current psychiatric medication history. In order to facilitate this task, Dr. Duzyurek encourages all of his patients to utilize PastMeds.com, a free service for patients and physicians to assist them in organizing and recording prior psychiatric medication experiences and history. Dr. Duzyurek is registered with this service under the provider code DUZYUREKMD.
TMS THERAPY IS PRO-COGNITIVE
Data analysis presented at the American Psychiatric Association's annual meeting in San Francisco on May 19, 2009 demonstrated that Transcranial Magnetic Stimulation (TMS) Therapy improved key areas of cognition in patients whose depression improved with this procedure. Cognition is the collective term for mental faculties involved in acquisition, processing, reorganization, retention and recall of knowledge and information, and includes comprehension, inference, decision-making, planning, reasoning, thinking, perception, alertness, awareness, attention, concentration, learning, and memory. TMS Therapy produced significant improvements on both overall cognitive function and short-term verbal memory. These positive cognitive (nootropic) effects could not be fully accounted for by the improvement in mood alone. In other words, in contradistinction with treatments such as electroconvulsive therapy (ECT), or experimental tDCS, TMS Therapy is not associated with negative effects on cognition, on the contrary, it is associated with cognitive improvements that appear to go beyond what is simply expected from improvement of depressed mood. For example, in this study, within the TMS group only, there was a statistically significant improvement on the Buschke Selective Reminding Test in the TMS responders compared to TMS non-responders for both short-term recall (P = 0.0116 at four weeks; P = 0.0038 at six weeks) and delayed recall (P = 0.0463 at four weeks; P = 0.0012 at six weeks). This difference in cognitive function was not seen among sham (placebo)-treated patients.
TMS THERAPY HAS A LARGER EFFECT SIZE COMPARED TO ANTIDEPRESSANT MEDICATIONS
In a cardinal study, outcomes observed for NeuroStar TMS Therapy compared favorably with outcomes observed for antidepressant medications. In an analysis of effect sizes from controlled trials, NeuroStar TMS Therapy was compared to a meta-analysis of antidepressant medication clinical trials. NeuroStar TMS Therapy produced an effect size (Hedges’ g) of .52, which indicates a clinically significant, moderately strong effect, compared to .31 for antidepressant medications, which indicates a weaker effect. Click here to learn what an Effect Size means.
Visit Some Leading Centers That Have Adopted rTMS as a Treatment Option for Their Patients:
Unlike certain portable and AA battery operated so-called CES devices sold by various companies (CES is short for "Cranial Electrotherapy Stimulation", not to be confused with transcranial Direct Current Stimulation or tDCS), TMS therapy has been studied internationally and in the US, including at NIMH, in high quality, multicenter studies, and is endorsed via Category I CPT codes by the American Medical Association and the American Psychiatric Association (APA), and it is included in the APA Practice Guidelines for the treatment of Major Depressive Disorder. Dr. Duzyurek does not endorse the afore-mentioned portable devices, as well as tDCS as reasonable alternatives due to a lack of acceptable-quality, replicated and convincing evidence with regard to their efficacy and safety in depression. For example, tDCS may reduce IQ.
OTHER CONDITIONS WHERE TMS THERAPY SHOWS PROMISE
There are numerous other psychiatric and neurological conditions where TMS therapy shows promise based on basic science research and early clinical studies and experiences. These continue to be active areas of research, and some clinical experience in some of these applications has already started to accumulate. Some of these other clinical disorders in which TMS shows promise include: Bipolar Depression, PTSD, ADHD, Fibromyalgia and various other Chronic Pain Disorders, Generalized Anxiety Disorder, Traumatic Brain Injury (TBI), Mild Cognitive Impairment (with or without Vascular Depression), Tourette's Syndrome, Dysexecutive Function Disorders, Auditory Hallucinations, Deficit (Negative) Symptoms, and Executive Function (e.g., working memory) Deficits in Schizophrenia, Addictions, Certain Sexual (e.g., Orgasmic) Dysfunctions, Emotional Regulation Disorders including Borderline Personality Disorder (with or without associated clinical depression), Parkinson's Disease, Dystonias and other Movement Disorders, Tinnitus, certain forms of Epilepsy, Aphasia, and various comatose conditions, among others.
Links on Various Other Current and Promising Uses of TMS Therapy:
Click on the image above for an informational video demonstrating the NeuroStar system.
In most cases, the key to enhance the odds of success with TMS to well over what is generally reported is accurate technique and (when appropriate) knowing how to integrate TMS with a well-designed and correctly-timed advanced psychopharmacological treatment. Incorrect choice or timing of medications may reduce TMS efficacy. As an advanced psychopharmacologist, Dr. Duzyurek pays particular attention to achieving a synergistic integration of the two modalities, and to the crucial technical details for a correct and effective application of TMS treatment at every session. He is able to offer personalized enhancements in the application of rTMS for increased efficacy, and an integrated delivery of other aspects of psychiatric treatment during TMS sessions for time and cost efficiency. With this approach, he has successfully treated patients with TMS after their failed attempts at high-volume TMS clinics.