35 years ago, Robert McMullen, MD opened his private practice in general psychiatry on the West Side of New York City. In 2010, he added
TMS depression treatment to his long list of treatments. Being a psychiatrist, Dr. Robert McMullen found himself looking for a way to treat his many patients suffering from major depressive disorder who did not respond to the medication he prescribed to them. To Dr. McMullen, TMS was the solution. “I was first interested in TMS because I had been reading about its benefits for years, and I needed an alternative for the many patients who failed to achieve full remission from antidepressants,” says Robert Mc-Mullen of his decision to finally invest in TMS equipment to make the – at the time – novel treatment available to his many patients.
No per-use fee
“The purchase price of the TMS equipment that I first bought was very expensive, and it has actually cost me a lot of money that I had to pay a fee to the company for every treatment I did. I am therefore very pleased that it is now possible to get FDA cleared TMS equipment from other manufacturers such as MagVenture who do not operate with a ‘per-use fee’. That makes a big difference to me and my practice,” says Robert McMullen.
TMS is worth travelling for
So far, around 300 patients with major depressive disorder have undergone TMS treatment at TMS BrainCare. “What has sustained us has been the enormous benefits, as well as long acting benefits, for so many of my patients,” says Robert McMullen, who in the past five years since he first began to offer TMS has been treating men and women of all ages from all over New York City and even further away.
MD Robert McMullen graduated from Georgetown University
Medical School in Washington DC in 1976.
He is founder and owner of TMS BrainCare in New York.
For 35 years he has had a private practice in general
psychiatry. He treats patients with a wide range of mental
illnesses. He specializes in the treatment of mood disorders
and anxiety disorders and is particularly experienced
with the treatment of resistant depression.
In 2010, he began offering TMS treatment.
More information at: www.tmsbraincare.com
Dr. John O’Reardon, Professor of Psychiatry at Rowan University and noted researcher of neuromodulation techniques, welcomes the FDA clearance of MagVenture’s MagVita TMS Therapy system for the treatment of Major Depressive Disorder in adult patients who have failed to receive satisfactory improvement from prior antidepressant medication in the current episode.
In July 2015, MagVenture was the fourth and thus the latest TMS manufacturer to receive an FDA clearance. Dr. John O’Reardon, who has extensive research experience within the field of TMS, sees this as a positive development, both from the perspective of a researcher and a clinician. He believes that the clearance will not only provide a healthy competition to the market, but will also further encourage insurance companies to provide meaningful reimbursement for the procedure.
On a global scale, John O´Reardon believes that the FDA clearance could also impact the dissemination of the TMS technology, both within clinical practice as well as in research. “More psychiatrists will start doing TMS and when good clinical results are observed this will create a strong word of mouth effect which will also encourage research specific to this particular device,” he says.
Potential pricing advantages, reliable cooling and low noise
John O´Reardon has been using MagVenture’s TMS equipment for the past 7 years. “From a psychiatrist’s point of view, MagVenture has some advantages,” he explains. “There are no extra costs for disposables. This will encourage other psychiatrists sitting on the sidelines to get into the marketplace. Furthermore, the cooling system has been very effective and reliable. It never overheats. The operator places the magnet directly on the scalp thus having a lot of freedom of movement in placing it accurately. Since everybody’s skull is shaped differently this is helpful. The noise level is reasonable. Also there has been little in the way of technical glitches, in my experience. It is important not to have these problems as you have a patient standing there waiting for treatment. The last thing you want is not to be able to do the session,” John O´Reardon stresses.
ECT research led to TMS interest
John O´Reardon’s interest in TMS emerged in the mid 90’s while doing a fellowship in Psychopharmacology and administering ECT. He read a report in Neuro Report which described the treatment of 6 patients using a new technology called TMS written by Mark George MD [see interview here]. It piqued his interest as for the first time it appeared possible to do brain stimulation in the office. “I saw the potential advantages over ECT which included time efficiency, convenience for the patient and lower side effects, including the absence of cognitive impairment,” he says.
In O´Reardon’s view, TMS will remain complementary to ECT but will not replace it. “ECT has the advantages of being more rapidly acting, more efficacious overall, and better if there Dr. John is marked suicidality. TMS, however, will be earlier in the treatment algorithm than ECT with fewer side effects and may in fact work if ECT has failed. We found [Connolly et al, 2012 J Clin Psy, ed.] that there was 40% chance of success with TMS if ECT had already failed,” he says.
New TMS modalities
Theta Burst, a patterned form of rTMS, is another treatment modality which John O´Reardon believes may ultimately have more promise than the standard 10Hz TMS protocol and further mentions sTMS (synchronized TMS) which is currently in trials and offers the potential of EEG-based TMS. According to Dr. O´Reardon, the possibility of at-home treatment may become a new frontier in treatment delivery as it would, obviously, be enormously convenient for the patient.
Combination and augmentation approaches
Another important issue will be the development of combined medication and psychotherapy strategies. There are two basic approaches here, combination and augmentation approaches. With a combination approach, an antidepressant and TMS are started together at the same time in the hope of a more complete result. In the augmentation approach, in the case of non-response or non-remission, TMS is added at 6 weeks to augment or enhance the antidepressant effect. Cognitive therapy can also be used to activate the prefrontal cortex immediately prior to TMS delivery to enhance its efficacy. This is a type of augmentation strategy for TMS but these approaches have yet to be studied, according to Dr. O´Reardon.
TMS ‘dream machine’
When asked to define his ‘TMS dream device’, John O´Reardon describes it this way: “It would be more compact, cheaper, provide an all-in package including theta burst, with a coil curved better to fit the shape of the head, with guidance from research as to how to optimize the TMS effect with medications and psychotherapy, and ability to deliver a treatment protocol in 1/5th of the time
Dr. John O’Reardon received his medical degree from University
College Cork in Ireland in 1984. He is board-certified in primary care
in Ireland and the UK.
He completed his residency in Psychiatry at the University of Pennsylvania.
Post-residency he did Fellowships in Psychopharmacology
and Cognitive Therapy.
His areas of interest clinically are treatment-resistant mood disorders
and neuromodulation therapy (ECT, TMS, DBS, VNS, dTMS,
sTMS and tDCS). Research wise his main interest has been the
development of new neuromodulation treatments.
He has been involved in large scale trials in TMS, VNS, DBS, sTMS
and tDCS. He has over 100 scientific publications, including 29 in
the TMS field.
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Link to FDA clearance
Caution: US Federal law restricts this device to sale by or on the order of a physician. The treatment may not be effective or appropriate for all patients, and additional side effects may occur. Please see the complete instructions for use, including warnings, precautions, and side effects, prior to use. Licensed physicians considering the application of rTMS must consult MagVenture Inc. and the relevant scientific literature to learn more about the treatment and potential risks.