Transcranial Magnetic Stimulation (TMS) Around the Country: Dr. Denise Lin's Experience in Santa Barbara

Update on Transcranial Magnetic Stimulation (TMS):  

WEST COAST TMS DIRECTOR DR. KIRA STEIN INTERVIEWS SANTA BARBARA PSYCHIATRIST AND TMS SPECIALIST DENISE LIN, MD:

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Denise Lin, MD of           Advanced Psychiatric Care and TMS Center in Santa Barbara

Denise Lin, MD is owner and medical director of Advanced Psychiatric Care and TMS Center, located in the coastal town of Santa Barbara, California. She has been practicing psychiatry for eleven years.   With an undergraduate degree in Nutritional Sciences from UC Berkeley, Dr. Lin graduated medical school at the University of New Mexico. She was initially interested in endocrinology, the medical management of hormonal illnesses, but developed a passion for psychiatry that compelled her to switch her training program from internal medicine to psychiatry. She enjoys exploring the role of nutrition in psychiatric illness in her studies through the Institute of Functional Medicine, and in line with her earlier training in the nutritional sciences. She has specialized certification by the American Board of Physician Nutrition Specialists.

Dr. Lin has been treating patients with transcranial magnetic stimulation TMS for about two years and kindly agreed to share her experiences by being interviewed here by West Coast TMS Institute’s medical director, Dr. Kira Stein.

West Coast TMS Institute:  First, I want to thank you for taking the time to discuss with us your experiences as a psychiatrist who practices transcranial magnetic stimulation.  Please tell us a little bit more about your background and philosophy.

Denise Lin, MD: I really feel a calling to work with people with mental illness because it seems their disorders are more likely to be misunderstood by patients and medical professionals alike. I strive for a comprehensive approach to diagnosis and treatment, addressing mind, body and spirit as much as possible.  Over the past several years, I have worked with the underserved chronically mentally ill population with Santa Barbara County mental health, running the CARES clinic, which is essentially a psychiatric urgent care clinic. It is challenging and often fast paced, and I have learned a lot! One thing I see more clearly than ever is that there is definitely some overlap as far as the root causes of mental and medical illnesses.  Sometimes diet and lifestyle changes can reduce risks for both by affecting the level of inflammation in the body and even modifying gene expression.

West Coast TMS Institute:  What is the name of your center, its location, and what prompted you to found it?

Dr. Lin: I opened up Advanced Psychiatric Care and TMS Center here in Santa Barbara in order to provide interested patients with the latest information about diet and lifestyle for good mental health. Transcranial Magnetic Stimulation fits in perfectly in my practice because it is an effective treatment that doesn’t involve taking drugs that we know can sometimes have negative physical effects.

West Coast TMS Institute:  How do explain TMS in layman’s terms, such as those without a background in medicine?

Dr. Lin:  I say it is great treatment option that works with or without medications to relieve depression and anxiety. It utilizes a rapidly pulsed magnetic field to stimulate brain cells in a specific area of the brain that we know is associated with mood and anxiety symptoms. It is performed in our office while you are awake and alert (perhaps while watching a good movie from our DVD library). You can drive to and from treatments and there is no downtime, nor any negative effect on memory. Each patient has a customized treatment plan but it is typically prescribed 5 days a week for 5 or 6 weeks followed by a tapering down phase. Some people opt for monthly maintenance to sustain their improvement. Each treatment lasts between 37 and 60 minutes. I often provide specific nutritional supplements to take during the treatment course if I feel that is appropriate.

Reason for turning to TMS: “I was also getting a bit frustrated by the limitations of medications…..” 

West Coast TMS Institute:  When did you first get interested in transcranial magnetic stimulation and why? Do you remember the moment when you first become intrigued by the potential of TMS?

Dr. Lin:  I heard of TMS about 7 years ago in a journal article and soon thereafter someone showed me a flyer from a TMS Center in Vancouver, Canada where it had been approved for treating depression years before it was approved in the States. I was very excited to learn that it was a way to stimulate brain cells non-invasively and without medical complications or memory deficits. I was also getting a bit frustrated by the limitations of medications. Sometimes patients did wonderfully on medications and they were literally lifesaving for them. But with some people, it seemed that every medication we tried caused uncomfortable side effects, like weight gain and sexual side effects. Or the medications just didn’t help, or only helped temporarily. 

West Coast TMS Institute:  What was the turning point in your practice of medicine that prompted you to actually start offering TMS?

Dr. Lin: I think it was when I spent a week at the Medical University of South Carolina with TMS researchers Dr.’s Mark George and Ziad Nahas. They showed me their research and I had a chance to practice with it, even though the device they used back then was different than the much more efficient and user-friendly NeuroStar we use now.

West Coast TMS Institute:  On initially learning of TMS, it can sound kind of strange to some, how to deal with that initial apprehension some people have?  Some people even mistaken it is for electric shock therapy (ECT).

Dr. Lin: I probably experience this reaction more from mental health professionals than from the public. Some people hear “magnet” and maybe it conjures up the notion of something wacky and non-scientific.  Not long ago I had a conversation with the medical director of a local HMO asking him to authorize a course of TMS for a nearly suicidal depressed patient who had not experienced relief after many antidepressant medications. This unenlightened physician called TMS “voodoo” medicine!” I just hope he learned the error of his thinking when the patient he authorized responded beautifully to TMS with complete remission of his depression!

It is pretty easy to dispel the idea that TMS is in any way similar to ECT (electroconvulsive therapy). We show prospective patients our comfortable TMS room with our DVD library and reassure them that they can drive to and from treatments. I had a patient who was an engineer in a very high tech and demanding job who would pop in over on his lunch break to get his TMS treatment. In contrast, people undergoing ECT may have significant memory deficits. They have to take time off work and are actually barred from driving because of the severe cognitive effects.

“…I think we have just barely scratched the surface of ways transcranial magnetic stimulation (TMS) can improve quality of life in people suffering from many hard-to-treat conditions.”

West Coast TMS Institute:  What kind of symptoms and conditions have you found TMS to be most effective at treating?

Dr. Lin:  I have used TMS successfully to treat depression from mild to severe cases. I find it very effective especially for younger people. The patients I have treated who are in their 20’s seem to respond very quickly, while the older patients seem to respond more slowly. One patient in his early 80’s had a course of TMS that didn’t seem to be very helpful, but then two weeks after his treatment, he called, excitedly saying the TMS had “kicked in!” He hadn’t felt that well in years and he was very happy with it. We checked in with him a few months later and he was still doing very well.  It can be somewhat activating so that people who are in a very low energy or lethargic, melancholic-type of depression may experience a pretty rapid improvement in energy and motivation. 

I also treated someone a while back with long-standing chronic depression and chronic neck pain*. Her depression improved and her neck pain completely went away. She was delighted and surprised by this as she had been told she would have to live with her neck pain forever.

I treated a patient for with migraine* who improved rapidly as well. Given these results and the recent exciting research using TMS for migraine, fibromyalgia* and other forms of chronic pain* I think we have just barely scratched the surface of ways transcranial magnetic stimulation can improve quality of life in people suffering from many hard-to-treat conditions.

West Coast TMS Institute: Have you treated patients with TMS who suffer from bipolar episodes of depression?  If so, are they the milder (bipolar type II) or more severe (biplar type I) forms?**

Dr. Lin: I treat depressive episodes associated with both type 1 and type 2 bipolar disorder*, but I keep people on mood stabilizers during TMS treatment and of course, monitor closely for signs of mood switch towards mania. I have had a couple people with bipolar disorder get slightly hypomanic during TMS treatment, and so I conducted a few right-sided TMS treatments until the hypomania subsided, and then went back to left-sided TMS stimulation.  Since TMS patients already come in daily, I can monitor them carefully and quite frequently, even if it’s just for a few minutes–another benefit of TMS.

West Coast TMS Institute: How have your patients responded to TMS?  Any case examples that can illustrate their experience, as well as your observations?

Dr. Lin: I recently looked at all of my patient data and found that 2/3 of my TMS patients have had either full remission or a significant improvement from TMS. I think this is a good statistic because I know that most of these folks have been battling unusually tough, stubborn cases of depression. Many had not responded to 5-10 medication courses.

I think one of my favorite cases is that of a physician patient who had been a professor at a medical school. She had to stop working due to a severe, long-standing bout of depression which didn’t respond to medication and therapy.  At the depth of her depression she could not maintain her concentration enough to read a page in a novel or even do the simplest of puzzles, even though she had a PhD in Mathematics in addition to her medical degree. She couldn’t motivate herself to change her clothes or bathe and she was beginning to contemplate suicide when she came to me. She made a complete recovery after 20 TMS treatments! She is back at work as a physician and has taken up oil painting.

West Coast TMS Institute:  Do you think TMS should be a treatment routinely offered to patients?  If so, at what point in treatment?

Dr. Lin: I seem to have developed a reputation for taking care of people with treatment-resistant major depression. But honestly, TMS is effective for many people with depression, in people who have not tried multiple antidepressant medications.  I often offer it to people who are depressed with or without anxiety, and with or without bipolar disorder

“….depression is so disabling, we cannot afford not to treat it appropriately and aggressively. TMS is a powerful weapon in our armamentarium that should not be denied anyone who is suffering.”

West Coast TMS Institute:  Is TMS worth the financial up-front costs patients need to invest nowadays?  How do you analyze the costs versus the benefits of TMS?

Dr. Lin: I think that when a person who is suffering from depression takes a moment to really assess the impact that depression has on all aspects of their life, when they see the toxic effect depression has had on their relationships, their work and productivity, their level of creativity, and even the quality of life of their children—it becomes very hard to justify not treating depression. We have a great deal of data showing the medical effects of prolonged depression. Untreated depression increases the risk of

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Kira Stein MD of Los Angeles' West Coast TMS Institute

diabetes, cardiovascular disease, stroke and even of having a heart attack. Given all these profoundly detrimental effects of depression, even the most calculating of bean-counters would have to see, I believe, that depression is so disabling, we cannot afford not to treat it appropriately and aggressively. TMS is a powerful weapon in our armamentarium that should not be denied anyone who is suffering.

West Coast TMS Institute:  Thank you very much, Dr. Lin, for taking the time to help people learn more about transcranial magnetic stimulation and your positive experiences with the procedure.

 

 

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* TMS Therapy is FDA-Approved for treatment resistant depression.  Use of TMS for the treatment of other conditions is currently considered off-label.

**For our readers:  Bipolar disorder is a chronic mood disorder that involves episodic periods of clinical depression alternating with full-blown manic episodes (elevated, extremely intense or agitated mood, racing thoughts, pressured speech, excessive self-esteem, impulsivity, boundless energy, with decreased need for sleep).   Bipolar I disorder is diagnosed when there is a history of a clear and extreme period of manic symptoms.  Bipolar II is diagnosed when the history of manic symptoms are relatively mild and less dysfunctional.

For TMS in the Santa Barbara area, Dr. Lin can be reached at the Advanced Psychiatric Care and TMS Center; For TMS in the Los Angeles area, Dr. Kira Stein can be reached at the West Coast TMS Institute.

 

 

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