When did you first hear about Brainsway Deep TMS, and what made you try it?
I heard about Brainsway Deep TMS on the day the FDA approval was issued. I was already a strong believer in TMS, and had been using surface TMS since 2009. Ever since I was a young psychiatrist, I've been closely following TMS technology, thinking it was very exciting, so I always kept one eye on the field. When Brainsway's Deep TMS was launched, it was not a Me-Too device, but one that claimed to have technical advantages, so I was avid to try it and gain hands-on experience. I've been working with Deep TMS since 2013, when it became available in the US.
How do you recruit patients?
The majority of our patients, around 55%, are self-referred, and find us online, as they're looking for depression treatments, or have heard about TMS and are looking for providers in the San Diego area. The rest are referred by psychiatrists.
What fears do patients usually express prior to the treatment?
Many are well educated about TMS, having researching the internet. Some are concerned about how uncomfortable treatment would be, but their biggest fear is that it's not going to work. These people put a lot of hope into each new treatment, because everything else has failed for them.
How do you handle skeptical patients?
I don't face a lot of skepticism. When patients contact me, they have already made the effort to reach out and are motivated. Actually, I believe skepticism is appropriate, as refractory depression is a tough enemy. Therefore, I let patients know that, at this point in their depression, every treatment has a limited statistical chance of working, but TMS is their best option, while yet another medication trial has exceedingly low chances.
What differences do you see between surface TMS and Deep TMS?
One of the first things we noticed is that patients are more comfortable with Deep TMS. Usually the first sessions are uncomfortable, and afterwards, patients get used to the treatment. With surface TMS, some patients never get comfortable, especially if they are treated with high amplitude, due to a high motor threshold.
We also noticed that with Deep TMS, we have more effective outcomes, and patients express a greater degree of satisfaction with the outcome. Since Deep TMS sessions are shorter than those of surface TMS, we actually achieve better outcomes in less total time. Moreover, even if patients do experience discomfort, tolerating the treatment for 20 minutes, with Deep TMS, is much better than tolerating it for 40 minutes, with surface TMS.
What are the differences between the effect of Deep TMS and that of other forms of treatment, in your experience?
Medication: Deep TMS candidates have already experienced medication, so their options are either another medication trial, or Deep TMS. We know from comprehensive studies, such as the Star D study, that after 3 trials, getting a response through medication becomes a long shot. The chances of response to TMS are much higher than those of another trial of medication.
ECT: When we deliberate between ECT and Deep TMS, we consider the potential for efficacy, versus the side effects. Deep TMS is definitely more benign, while ECT, until proven otherwise, is more efficacious. ECT has been around for decades, and since TMS is a relatively new treatment, I suspect we don't yet have enough experience to truly maximize its potential. Maybe over time we will discover unknown protocols that will achieve results comparable to ECT.
Currently, it makes a lot of sense to try Deep TMS before ECT. I always tell patients that if they respond to Deep TMS, they're much better off than with ECT, which is the next step, and entails many risks. Many patients are apprehensive about ECT. Before we had TMS, there was an enormous gap in escalating from medication to ECT. TMS has bridged the gap, so fewer people need to resort to ECT.
Describe the most dramatic change you saw in a patient.
We often see dramatic changes with Deep TMS. Just a few days ago, we had a patient who showed a high degree of suicidality. He was a fairly young man with a good job, educated, but suffering from profound hopelessness. We treated him with Deep TMS, but nothing was happening. I was getting a bit worried about his disappointment with the treatment, and how he would react to it. Suddenly, after 18 treatments, something started to change. He reported feeling better and having less of a struggle with negative thoughts. Then, gradually, he became less morose and silent, started to show a more positive outlook, and had motivation to do things. He began to loosen up and was interested in socializing. Then, within four treatments, he went from high to zero suicidality. This is not uncommon, and often happens toward the latter part of the treatment course. This really proves that the improvement is an effect of Deep TMS, rather than a placebo effect.
How long does it take before you actually see a change?
Of the patients that respond, we typically see a change after 12-13 treatments. Sometimes we have to work hard to convince patients that TMS takes time. We learned never to give up. It's like sitting on a boat and waiting for an iceberg to pop up out of the water. You think nothing's happening, but below the surface, every day, another layer of ice is being built up. You may not be aware of it, but it's still happening. Similarly, the brain changes every session, and gets closer to the breakthrough. Psychiatry takes time. We may wish we had instantaneous treatments, and clear markers that tell us that we're on the right track, but we're not there yet.
What cases surprised you most?
We've had patients who completed the treatment without improving, so we diagnosed them as having failed the treatment. Suddenly, they contacted us two weeks after the treatment, saying that over the last 2-3 days they experienced a huge spontaneous change in their depression. These people tried everything for many years, so it's no coincidence. Sometimes we set changes in motion, and after completing the daily treatments, they continue on the path on their own, and the iceberg breaks the surface only after the treatments ends.
What is your view on combining Brainsway Deep TMS and medication?
When patients arrive with an existing medication regime, I usually have them continue with it throughout the treatment. Even if the medication has not helped, ceasing to take it could create changes in the brain, and I don't want to generate any new conditions during the treatment. If patients do well after the treatment, and their improvement is stable over a length of time, then we consider going off the medication.
What estimated percentage of your patients respond well to the treatment?
Around 50%-60% have a significant improvement, with the burden of their symptoms significantly reduced. 35% experience remission, with a very low level of depressive symptoms, and virtually no depression.
Describe a problem you encountered during the treatment and how you overcame it.
We had a patient that was close to a level of psychosis, very paranoid and skeptical, who had to be convinced to be treated. We had to fight hard to keep him in the treatment, with his wife's help. Throughout the treatment, he improved significantly, but could not recognize it in himself or feel it internally. I had to point out his improvement, and reflect his positive symptoms, such as his telling jokes, in order to make him believe that things were really happening. After finishing the treatment, he sent us a note, thanking us for not letting him stop. Sometimes we have to work hard to keep people optimistic and motivated not to give up.
How does the patient's family respond to the treatment?
If the treatment is successful, is has a huge impact on the family, and they're very grateful. Depression has a terrible effect on all the surrounding people. Often a family member is the one who motivates the patient to undergo the treatment, and usually the family is all on board.
How do patients feel during the Deep TMS session? Do you usually have to calm them, and if so, how?
At first, the repetitive tapping on their skull is feels strange, and patients are focused on it, but after 2-3 sessions, it becomes a routine, so they take the time of the treatment to meditate or think. For some, it's even a time for social contact.
About Dr. David Feifel
Dr. David Feifel earned a Bachelor of Science, Master’s Degree and a Ph.D.(neurobiology) from the University of Toronto, Canada, where he also earned a Medical Degree. After completing an internship in Internal Medicine at the Toronto General Hospital, Dr. Feifel completed his residency training in Psychiatry at the University of California, San Diego, where he served as Chief Resident for the UCSD Outpatient Psychiatry Services in 1994. In 1995 he joined the faculty of the Department of Psychiatry in which he currently holds the rank of full Professor. He is also a faculty member in the UCSD Neurosciences Graduate Program. Dr. Feifel is the Director of the Adult Psychiatric Services at UCSD Medical Center, and the senior attending psychiatrist on the Neuropsychiatry and Behavioral Medicine Inpatient Unit (NBMU). In addition to being a Diplomate of the American Board of Psychiatry and Neurology in General Psychiatry, he is also certified in the subspecialties Psychosomatic Medicine, Behavioral Neurology and Neuropsychiatry. He has authored or co-authored numerous original scientific research papers, abstracts and book chapters.
Dr. Feifel’s clinical focus is the diagnosis and treatment of psychiatric disorders stressing a biological orientation. He is Director of the Adult Psychiatric Services at UCSD Medical Center, which includes the Neuropsychiatry and Behavioral Medicine Unit (NBMU), an 18-bed inpatient unit and the Consult / Liaison service. The Psychiatry service at UCSD Medical Center, was ranked among the nations' best by US News and World Report in Dr. Feifel is founder and Director of the UCSD Adult ADHD Program and the UCSD TMS Center. In addition to seeing patients, Dr. Feifel lectures and supervises medical students, residents and fellows at UCSD and he is a national lecturer on topics in psychopharmacology. Among his distinctions, Dr. Feifel is an elected member of the American College of Neuropharmacology, he has been elected by his peers for inclusion in ‘Best Doctors in America’, and he is cited in the Castle Connelly list of “Top Doctors:”