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Reducing medications with TMS treatment

Do you recommend patients to end their current medications through their treatment?

Medications are a very interesting and complex question and patients have different responses to them. There’s a certain group of patients who have not had any benefits from medications at all. You can’t necessarily listen to them say that but you can look at the record to see if they benefited from them or not. Many of those patients have a certain signature on their EEG that tells you that they’re not going to respond to medications very well.

For the patients that didn’t benefit from the medications, it doesn’t really matter if or when it comes off. I usually do that around about the second or the third week just so we don’t have too many changes all going on at once. The majority of patients have a partial response. To get them off their medications during TMS has to be done very carefully. It raises the issue as of when patients come in, their medication often can be adjusted.

Many people who do TMS are often very competent psychopharmacologist also, so antidepressants can be augmented. The doses can be changed. The timing that a person takes it at – morning or evening – can be changed. It can be split up. So many adjustments can occur and I like to do that right when the TMS starts. I like to maximize the medications and optimize them so that we’re doing everything we can do to help the people.

Some people ask, “Why would you do that right when TMS is starting because then you don’t know what it was that helped the person?” If we were scientists only, that is perhaps what we would do. We would isolate factors and vary them one at a time so we could at least make some kind of correlation. We use science but we’re helpers. We want to help people. So our prime directive is to get people better. What exactly gets them better, we can figure out later as the things come off. It’s my opinion that we should do everything possible right away.

So do you find that most people, at the very least, lower their dosage of medication and that some people come off them completely?

Yes, so there are three groups. Some people who stay on the same meds, only they’re not depressed anymore. Some people who get by on fewer medications afterward and some people who are completely off them, for better or for worse.

An example of somebody who is on lower medications is a forty-three-year-old attorney who had depression and dysthymia (called double depression). He was one of the people who had a complete response, meaning that not only did the depression get better, but his dysthymia was gone also. His medications we tapered very carefully and he had been on Vyvanse, fifty milligrams, and Remeron (Mirtazapine), 45 milligrams. The Vyvanse came down to 10 milligrams. The Remeron came down to seven and a half milligrams. If we tried going lower than that, he started to have some symptoms come back and after several attempts, we just left it at those lower doses instead of the higher doses.

One of the things that we note is that when people need less medications and you reduce the dose, it actually feels better to take less.