Repetitive Transcranial Magnetic Stimulation (rTMS)

Repetitive Transcranial Magnetic Stimulation was approved by the FDA in October 2008 for patients with major depression who have failed one prior antidepressant trial.

Stimulation of the brain is accomplished by a pulsed magnetic field that is passed through a coil of wire encased in plastic and held close to the head. This magnetic field penetrates the scalp and skull. The stimulation is made at regular intervals, thus the term “repetitive” TMS.

In studies, rTMS appears to change brain activity beyond the duration of the actual procedure. Also, the procedure differs from Electroconvulsive Treatment (ECT) in that it stimulates the brain in a focal manner, thereby preventing the grand mal seizure and minimizing the transitory memory loss associated with ECT.

rTMS is performed on an outpatient basis, with a course of 20-30 treatments, each lasting approximately 40 minutes, and delivering 3,000 pulses. The most common reported side effect is mild headache. The cost per 40 minute session: approximately $400. Ouch!

The Alcohol and Antidepressant Use Conundrum

There are two factors to consider when assessing the combined use of alcohol and antidepressants: first, the likelihood that an antidepressant’s effectiveness will be altered by alcohol (will consuming alcohol prevent or diminish the potential positive effects of the antidepressant?); and second, the chance that there will be some untoward and unintended consequences between alcohol and antidepressants.

Given the complexity of individual biochemistry, the answer to the first question is difficult to nail down; but it more than likely depends on the quantity and frequency of alcohol use. There are a few studies indicating that any amount of alcohol – even just one alcoholic beverage – can lead to a diminished antidepressant response. I recommend to those using antidepressants that they consume no more than two (2) alcoholic beverages a week. Of course, many balk at that recommendation.

As far as the untoward and/or unintended consequences of combining alcohol with antidepressants, it largely depends on the actions of the antidepressant prescribed, particularly its capacity for producing sedation. For instance, there is much less concern about additive sedation if alcohol is ingested in combination with a non-sedating antidepressant. On the other hand, combining alcohol with a sedating antidepressant may lead the individual to become more intoxicated than would otherwise be anticipated.

In the end, anyone taking an antidepressant that is reluctant to significantly modify or even relinquish their alcohol use, has a decision to make. To them, I pose this question: What’s the positive intention for possibly sabotaging your improvement by continuing to engage in a behavior that is not in your best interest? Often enough I get the response, “well, I want what I want when I want it.” I always remind those that cling to such a belief system that they do so at their own risk – a risk that may very well compromise their physical and emotional health.

Saphris (asenapine): A New Entry Into the Ever-Growing Antipsychotic Mix

On August 14, 2009, the FDA approved Saphris (asenapine) as a new second-generation antipsychotic for the treatment of both schizophrenia and bipolar disorder. It is available only as a sublingual tablet, meaning that it is not effective if swallowed, and it must be left under the tongue to dissolve for it to be absorbed into the bloodstream. The available studies haven’t shown that Saphris (asenapine) provides any unique therapeutic advantage over other second-generation antipsychotics. The main contribution is that clinicians and patients will have yet another option, as if the clinical community needs another antipsychotic that is not special in any other way, and certainly not deserving of “novel” or “designer” drug status.

The manufacturer, Schering-Plough, is promoting the drug on the premise that it’s more effective at improving the negative and cognitive symptoms of schizophrenia compared to other atypical antipsychotics, and that Saphris (asenapine) has a better safety profile.

The safety profile issue has been used over and over before. While the drug demonstrated less weight gain compared to Risperdal ( risperidone) or Zyprexa (olanzapine), it has an elevated level (18%) of extrapyramidal symptoms (EPS) – comparable to first generation antipsychotics.

Schering-Plough’s specialty sales force is handling the detailing of Saphris (asenapine) – as opposed to its primary cast of sales representatives – targeting psychiatrists to prescribe this new antipsychotic.

Public Speaking: More Feared than Death?

I am often asked by new or aspiring speakers how to overcome the fear and sometimes downright paralysis associated with speaking in public. You may have read or heard about some people that fear public speaking more than death! Although this is utterly ridiculous, there are those that wouldn’t stand before an audience and utter a single word, phrase, sentence or speech under any circumstances or for any price.

Fear of speaking in public is considered a performance anxiety disorder. Of these disorders, public speaking is indeed the most feared. Others include test-taking anxiety and athletic performance when the game is “really on.” So if you’ve recently been tapped to deliver a first-ever talk to your garden club, PTA, or church social, here are a few tips for conquering your fear of public speaking:

• - Seek out speakers that you’ve heard before and believe to be competent, effective and enjoyable. Ask if you could send them a tape of a talk you’ve recently given or plan to deliver, or invite them to hear you in person if you’re speaking in their neighborhood. What you want is frank feedback that can be used to critically examine your progress. Ask these speakers what they believe you’ve done well, what should be further developed and what underwhelms them, which might be abandoned. Taking these steps will help build confidence.
• - Choose an association of professionals that is geared to provide feedback. Toastmasters is a good alternative because it offers speakers an opportunity to hone their skills in front of a supportive audience.
• - If possible, prior to the speech you’re giving, chat informally with some participants, particularly in smaller groups. Use these people as your “friendlies.” Their smiles and nods will quickly increase comfort levels.
• - When appropriate, speak with the use of visuals, this helps mitigate the feeling that the audience is “staring you down.”
• - Prior to the speech, do something or think of something that makes you laugh. Listen to a humor tape, think about some enjoyable times you’ve had, watch a good comedy. This will promote relaxation, and you want to feel as though you’re in a “fun mood” before you hit the platform.
• - Consider the use of “beta blocker” drugs (Inderal, for example) to help alleviate some of the peripheral manifestations of anxiety, such as trembling or excessive sweating. Beta blockers should only be used after consulting with your physician and should never to be considered a substitute for other ways of handling your fear.
• - Seek not to be perfect, but to be comfortable. Audiences don’t care if you’re perfect, but they will only be comfortable if you seem to be.
• - Understand that mature, motivated, and intelligent audiences want you to succeed.

Finally, take heed of the following: Your presentation will not mark a turning point for all of civilization. Prepare well, show up, deliver, and then go home. The Earth will continue to revolve around the Sun, no matter what happens to you on stage.