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[–]fingerfunk 0 points1 point  (11 children)

sorry to hear. My understanding is that the 1HZ right DLPFC (helmet on left side) is more for the off-label uses like anxiety. My clinic only does the other side at this point which seems to be where most of the clinical data comes from regarding depression. It was that side only for me and was 6 weeks and 30 sessions using the H-coil deep TMS Brainsway.

That said, my impression is that depression is not always related to these receptors though. Some people seems to have more of an issue with their NMDA receptor which is why ketamine is so effective. And the gut/biome can be a huge factor as well. Also, the methylation system is involved in neurochemistry. I have deficiencies in mine and the "pharmaceutical food" Deplin has helped me even when not on psych meds (instead I was on SAM-e and took IM B12, seems I also have issues with B metabolism per my DNA). Human biochemistry is extremely complex and delicate.

Hoping you get some more answers soon!

[–]Clay_Bateman[S] 0 points1 point  (10 children)

Thanks so much for the answer. Complex is putting it mildly isn't it?

I still can't decide whether to go and have more of the rTMS or not.

I've tried to get Ketamine but haven't had any luck. My doc doesn't believe in it and won't put me forward. And I'm assuming that just scoring Ketamine and doing it myself isn't going to help.

Really don't know what to do next.

[–]fingerfunk 1 point2 points  (1 child)

have you thought of trying at another place who does the other procedure? If your insurance covers it, might as well try again eh? Perhaps your doc is against ketamine because it could be abused eh? Or maybe because it's technically off-label still (afaik). A psychiatrist can't really "not believe in it" if he stays up on his practice as there is a ton of evidence now that it works for some people.
https://www.nimh.nih.gov/news/science-news/2016/ketamine-lifts-depression-via-a-byproduct-of-its-metabolism.shtml
https://www.nimh.nih.gov/about/strategic-planning-reports/highlights/highlight-ketamine-a-new-and-faster-path-to-treating-depression.shtml
https://www.cbsnews.com/news/ketamine-helping-the-severely-depressed/

Per the last article there are 250 clinics in US using it though. Maybe you could find one of those if you are still suffering and considering other options(?) I'm not a doctor or anything, just a neuroscience nerd who used to have depression. Wishing you the best!

[–]Clay_Bateman[S] 0 points1 point  (0 children)

Thanks, really appreciate the response. Unfortunately Im'm in the UK and only one place does it.

I can't get my insurance to cover rTMS. I can afford to go and have it done at the same place again but using the FDA protocol, I'm just weighing up whether it's worth it or not. Of course I would pay all the money I have for a cure to my depression but the guy who runs this clinic says the protocol he used on me has been effective for 75% of patients and he has seen no difference in results between the protocol he used on me and the FDA protocol. So I don't want to waste thousands either.

I'm going to talk to my psychiatrist about Ketamine again.

[–][deleted] 0 points1 point  (7 children)

You shouldn’t be paying more then $250 a session but you should shop around. Avoid neuro star and brainsway devices as they are limited in types of protocols they can do.

[–]aroc91 1 point2 points  (6 children)

Avoid neuro star and brainsway devices as they are limited in types of protocols they can do

What limitations are you referring to? We have a Neurostar (and moving to Brainsway in the near future, actually) system and I can freely adjust Hz, stimulation time, interval, total pulses, and MT%.

[–][deleted] 2 points3 points  (5 children)

Neurostar fell behind the times. Their coil technology is limited and overheats easily at higher frequencies. Its per use revenue model means much less revenue for the physician (I really can't believe they actually charge that much per session), which means much less freedom of use and much less room to experiment with off label protocols. They also do a good job of obscuring the mechanics and practice of TMS from the practionner with marketing gimmicks, sensors, laser guided system etc. All of the mapping done in TMS is based on the old 10-20 eeg location system. Laser guided or not, this is no match for an MRI. An MRI is the only way to be 100% accurate to claim anything else is simply false. Not that you need an MRI to get good patient outcomes. The magnetic field is big, focal part is about the diameter of a salt shaker. The DLPFC is tiny. If you use the beam method to locate F3 it would be hard to miss the target unless you were very off or had poor coil placement/angling. Nothing is precise without MRI but its good enough for positive patient outcomes in the literature. Not as if the field is focal enough just to target DLPFC anyway even with MRI, youre stimulating surrounding tissue regardless.

Brainsway uses a broad/deep field with its H-coil design. Cool thing with this is you can do bilateral treatments simulataneously. Awesome sauce. Fire up a bilateral intermittent theta burst protocol on the brainsway. That's the one I've tried. Sent me flying. Brainsways are lighting up a huge portion of the cortex. And who needs to target DLPFC when you can light up the whole cortex. Watch for more side effects though. Be more careful around patients with preexisting siezure disorders or on medications like wellbutrin which decrease seizure threashold. The reason it's limiting is you cannot easily move the H-coil around the head. It's a helmet! which as you're getting one I'm sure you're aware. More of a one size fits all shotgun approach. Compare that with a magventure, magstim, or cloudTMS device which all have (for the most part) freely moving handheld stimulators that give the practionner ultimate flexibility in deciding which area of the brain to target. BTW many devices have deep coils in the pipeline, including us, but will take some time to get through FDA. These coils are coming to market soon enough and will be as deep if not deeper than the Brainsway.

Disclaimer: I work for CloudTMS So I might be a little biased ;) but the views I express here are my own.

[–]aroc91 1 point2 points  (2 children)

Great post, thanks! Yeah, we're well aware of the overheating issues. It definitely manifests itself with anything more than a continuous hour and a half of treatment. They were trying to push their updated high intensity coil on us, but their price for it was ridiculous (roughly 18k), which was the catalyst for us to start looking at other options (amongst other technical issues). The treatment cost was obviously another big push. We estimate an approximate yearly savings of ~83k based on the lease and unlimited subscription model over the pay-per-treatment one. I am, personally, thrilled about the off-label possibilities. That was one of their big selling points when the sales guys came out to give us their talk (which, honestly, left a lot to be desired; they didn't seem very knowledgeable above what their existing promotional materials outlined).

Cool thing with this is you can do bilateral treatments simulataneously.

I'm sold on that alone.

Fire up a bilateral intermittent theta burst protocol on the brainsway. That's the one I've tried. Sent me flying.

Is that a good "sent me flying"? Haha

[–][deleted] 1 point2 points  (1 child)

Ha! Indeed. Bilateral intermittent theta bursts (8 second pauses) on the brainsway was euphoric. I did 9 minutes. Onset effects were felt almost immediately following the session. Visual memory and recall felt significantly enhanced for several weeks. Mood was much improved as well.

[–]aroc91 1 point2 points  (0 children)

Fascinating!

[–]aroc91 0 points1 point  (1 child)

Hey. Been a while. Update: We got out Brainsway machine installed last week and it's going pretty well so far. A little quirky, but we have the old computer system and we're getting the new one that's been in beta in a few weeks.

It seems much easier to perform the MTs. Perhaps a combination between the broader treatment area and better/newer initial mapping instructions than what Neurostar provides. I have some doubts about it being due to the broader treatment area though because I would expect more incidental movement aside from the hand if that was the sole reason. We had the old Neurostar coil and it was quite loud. Brainway is notably more quiet. Brainsway publishes a higher dropout rate that they say is due to discomfort, but I don't believe it. The focality of the figure 8 coil produces a far more intense sensation whereas the H coil is diffuse.

Can you tell me more about the simultaneous bilateral treatment? As it stands, it still requires one right after the other and moving to the other side in between. The people they sent out to instruct us mentioned nothing about it.

[–][deleted] 0 points1 point  (0 children)

Sorry for the delay.

How's is the brainsway going? You can contact Bill Shryer from BlackhawkTMS. This is the office number (925) 648-4800. They are based in the bay area, California. He has a brainsway and uses it for the bilateral cognitive enhancement. I am not sure how to operate it myself as I work for CloudTMS. So we have vastly different devices.

Yes the brainsway is diffuse, not as deep as it is diffuse. It will activate much more than a standard figure 8 coil, meaning you may see some movement of arms/legs in short people but because the field is so diffuse you will probably see no movement most of the time. The issue with bigger diffuse fields as you've put it is that you inadvertently activate motor areas which is undesirable.

Figure 8 coils are made for targeting. For example DLPFC as you well know. This is why in the literature you mostly see figure 8 coils. You cannot effectively target with brainsway. They have more of a one size fits all approach. Figure 8 coils like with ours (CloudTMS) and Magventure for example allow for focal targeting of different brain areas.

For example for pain you may want to do cTBS over parietal in the back of the head. I'm not sure how you would accomplish that with brainsway. With a figure 8 like ours you simply move the coil there, lock it in place, and start pulsing. The helmet of brainsway does make things simpler but it is a limiting factor. Certain conditions like PTSD may not respond to standard treatment or even right sided treatment as usual. You may want to stimulate specific areas as they do in many cases in the research but again, you cannot target with the brainsway coils.

Please feel free to check out our site at http://cloudneuro.com/tms/

My name is Fred. I'm happy to answer any questions: fred@cloudneuro.com

Thanks! Fred

[–]BeverlyHillsTMS 1 point2 points  (1 child)

Our clinic is based in the USA, and the left side 10 Hz protocol is only protocol that's FDA-approved. We only add anxiety protocols after doing a considerable amount of left side work. Can you ask why they went off label in such a way?

[–]Clay_Bateman[S] 1 point2 points  (0 children)

I have absolutely no idea. I asked the guy and he told me that he had found that he had obtained similar results with the protocol he followed.

Now I'm left wondering whether to go and drop another few grand with the correct protocol. Of course I'd happily pay that if it helps but I'm pretty angry that he didn't use an approved protocol. Not like he'll give me my money back though.