So Where Has The Doctor Been??? . . . Some Personal Reflections on Depression, Health and Life In General

I had a few responses to my blarticle on providing TMS to patients in the Philadelphia area.  I actually thought there would be more . . . but articles on Vyvanse, Klonopin and Lamictal reign supreme . . . more on that another time.  Let’s start with two viewpoints and then I will get personal . . .

SCK writes in . . .

Why did you decide to offer TMS?

Are you aware of criticisms such as: http://www.citizen.org/publications/release.cfm?ID=7712&secID=1163&catID=126? Are you bothered that insurance carriers are not covering it?

My non-expert review of the available literature seems to show that effects of the treatment are small and unreliable. Given that, it may be good to have one more technique available.

The Internet is full of excitement for this product, but that excitement all seems to be generated by Neurostar’s PR machine. A strong PR push makes me raise more questions.

What kind of an investment is it to become an “Official TMS provider”?

. . . and Ruth writes in . . .

This is fantastic, Dr. Hartman! We at New Directions support group for folks w/mood disorders and their family members have at least one treatment-resistant woman so your willingness to try this new method is quite heartening. You have a good heart which is so wonderful for suffering individuals.

Becoming an “Official TMS Provider” really involves just a few steps.  You must be a Psychiatrist (ie, an MD who can prescribe) . . . and you must have $60,000 (which I did not) . . . or be able to borrow it (which I had to do).  You are then trained on how to use the machine intelligently and effectively.  Neuronetics provides great training and great support for those who are using their machines.  I had to rearrange my office so that I could have a room dedicated to the TMS process, including painting and decorations and sound insulation. And, I had to put an infrastructure in place to manage it (new phone line, staff time for delivering the TMS treatments and processing the treatment data).  Other than moving one of my offices, it is probably the biggest undertaking that I have done in my professional career.

Why did I do it?

Not because it works for everyone.  It is clearly no panacea.  I did look at the link that you provided and, in the interest of fairness and openness I am passing the link on to everyone who reads this site.  I made this investment of time and money because . . . it works for some people.  And it works for some people when everything else has failed.

Let’s face it.  Depression sucks.   I always knew that.  I talk to 5-10 people every day that are in the middle of their depression so I hear how it impacts on their life and the lives of their children and spouses.  I do my 15 minute pollyannafullofhopeencouragingthingsaregoingtobebettersomeday speech . . . and hope for the best.  And then go on to see my next patient.  When I see these folks, I’m not making my hopefulness up.  I mean it.  I am always hopeful that I will be able to find the right medicine, the right combination of medicine, or the right words to say that will spark recovery for each person that comes in to see me.  I genuinely LIKE my patients and I really, really want them to get better.  But some don’t.  Some linger in depression and  suffer.  But for me, the suffering has been distant.  More intellectual.  My personality allows me to feel empathy for people who are suffering without taking on their suffering as my own (otherwise, I could not do this work effectively).  People don’t come to me to share their suffering.  They can do that with their friends.  People come to me to share in my hope.  Big difference.  But I must be able to provide that hope for them.

As those of you close to me know, my last five or six years has been filled with significant losses and heartache.  I have written about some of these losses at various points in my blogging career, so even my loyal readers who live in the four corners know that, like their lives, my life is not always easy.  With the advent of the holidays this year, a family member with whom I am very close has suffered a very serious Major Depressive episode.  Not the “blues”.  Not melancholy.  Not the omnipresent dissatisfaction with the holidays that so many people refer to.  I mean Major Depression.  Seen it from a distance for years.  Never quite seen it like this.  Or lived it like this.  Nor felt the absolute devastation that runs through the lives of the person who is depressed and all the family members that it touches.  Because of my line of work, I did feel a twinge of shame . . . I should have been able to see this coming and have prevented it.  But that is like saying that the family members of a cardiologist are not allowed to have a heart attack.  I did feel a twinge of shame . . . the potential for stigma that comes from suffering serious mental illness.  All of these abstract and intellectual experiences became very, very real for me in the month of December.  As a “professional”, I had to step in and take some definitive action to care for my loved one.  As a family member, I felt devastated and frightened.  Overwhelmed.  Confused.  Alone.  I’m sure that many of you have felt that same way at various times in your lives.  I had to triage my responsibilities and, quite frankly, blogging took a back seat.  I tried to write, but my creative energies were not there.  This particular entry was started in mid-December.  I am only now getting to it.

So, why bring this up in the context of a blarticle about TMS.  Because I am lucky.  And my family member is lucky.  My family member is getting better.  But what if they did not?  What if they had to try another medicine . . . and another . . . and a combination . . . and another combination . . . and an augmenting strategy . . . and another and another and another and . . . what then???  If a person with Major Depression fails a trial of medication, the chances of improving with the next medication is less than the chance of responding to the first.  And the chances for the third are less than the chances for the second.  And so on and so on.  So my response to nay-sayers about TMS is . . . “so what”.

So what if not everyone responds.  So what if it is expensive.  So what if the insurance doesn’t cover it.  That cannot be the ultimate determinate for use of TMS.  Fact is, some people who have failed everything else respond to it and get better.  I would have sold my shoes and walked barefoot in the snow for a chance to get my family member better if nothing else was working for them.  I know it would be a difficult decision for anyone to give this a try.  But what choice is there?  Giving up?  Deciding to live the half life of the chronically depressed?  In my mind, you must always reach for the brass ring.  Even at the risk of failure.

So, there.  That’s my opinion.

Unfortunately, the stress level of the last month or so has taken a toll on me, personally.  On New Year’s Day . . . I finally broke.  I woke up with viral like symptoms . . . you know, the skin hurting, muscle aching sort of feeling.  New Year’s Day is the day my family gets together to celebrate the holidays . . . it is also the commemorative day of my father’s dying six years ago.  It was my turn to host the gathering, but as the day progressed, I became increasingly short of breath and had a vague chest discomfort that got worse.  After experiencing an episode of diaphoresis (sweating) and vomiting, I decided I was having a heart attack and it might be best for me to go to the hospital.  I had the pleasure of being carted out in an ambulance on New Year’s Day with my kids and grandkids watching and rushed to the local hospital where some minor EKG changes were noted.  I spent the night there and did r/o for an MI (doctor schpeek meaning I did NOT have a heart attack).  But as I lay in the ER, hooked up to monitors, BP cuff, pulse-ox and watching the look on my wife’s face and knowing that my daughters and my son were thinking that they might lose me . . . I changed my mind.

I decided that I couldn’t fix everyone and that I was not going to kill myself trying.

And . . . I was going to take better care of myself.

For me, that means getting more rest and eating better.  Getting more exercise.  Making sure that I take time to meditate daily.  Make sure that I spend time in prayer.  Make sure that I spend time creating . . . which for me is very much tied to writing on this blog (I LOVE to write on the blog).  And box in work so that it does not take over my entire life.  To do that I have already started to make some changes to my schedule.  I am sure that some people are going to be quite upset with me.  But I can’t please everyone all the time and I can’t please anyone if I’m pushing up daisies.  The good news for you readers is that you will likely have more to read.  And, if I have actual time to think, it might be of higher quality, too!

As a final note, I am currently recovering from a cardiac catheterization that showed that I had some minor blockages but no major blocks in my coronary arteries.  I will be modifying my diet somewhat (it has not been that bad, but I have never been one for portion control . . . until now), and losing some weight (hence portion control).  Controlling my stress better . . . and not saving the world.

Kudos go out to my cardiologist at Chestnut Hill Cardiology (Alison Branigan, MD) and the cardiologist that did my cath (Brad Lin, MD) both of which are just great.  Also, to Abington Hospital who, from the ER to the telemetry unit of my overnight stay to the cath lab where my cath was done, exhibited true medical professionalism and kindness to me and to my family.

See you all soon!

–Dan Hartman, MD