Bleeet . . . Memories

When I was a kid, my parents would periodically get us all together in the living room, pull out the slide projector, wrestle with the screen and give us a slide show.  My brothers and I got such a kick out of this, laughing at the pictures of when we were babies, our first communion, confirmation, May Processions, Christmas, summer vacations . . . pictures of all those pivotal moments in a family’s life.  The times spent together doing things.  When you think about it, that is what makes a family a family of friends.  Doing things together and having fun.  Otherwise, a family is just a bunch of genetically related strangers.

Back then, a slide show was state of the art.  My parents never got into the “super-8″ movies (if you remember super-8 you are old), so the static pictures of us smiling, running, building sand castles or standing stiff-backed by the statue of the Virgin Mary was what we had.  Little did I know how important those slide shows were.  The repetition of those slides over time gave me continuity.  It allowed me to think of myself as a long living person.  I can’t say I remember my first birthday, but I remember the slide of my first birthday.  And the repeated looking at that slide gives me the memory of having that first birthday.  Through those slides, the memory of my youth and the time spent with my brothers and parents are reinforced.

Jump forward twenty or thirty years and slide shows are a thing of the past.  You couldn’t get a slide projector if you wanted to, and every catalog has a slide-to-digital converter box for sale.  But are we missing something here?  Maybe your home is different, but the opportunity to sit around and look at old movies/old pictures on the computer screen just doesn’t happen.  I think that has led to a bit of a disconnect for my kids.  They talk about not remembering their childhood so much (can you imagine that).  When I show them pictures of their “youth”, it brings such a smile to their faces and I get a . . . “I remember that!!!”.  Memories are memories because they are relived.  Left to their own, they get dusty and disappear.

So, my advice for the week:   Slow down, pull out some old pictures and have a few laughs with the kids.  It helps them to remember themselves.  It helps them remember happy family times.  It gives them perspective.  And it will do the same to you, too.

–Dan Hartman, MD

Bleeet . . . some thoughts on stuff

I have too much stuff.  It is clogging my life like plaque in an artery.  My life has seemed clogged and cluttered at times and my surroundings seem to mimic that as well.  As if a lifetime of collecting stuff has not been enough, my parents death in 2002/03 has resulted in my inheriting of a third of their stuff.  At first, I kept this stuff close, cause it was like a piece of them.  But now, it has just become part of the clog.  I am not a hoarder.  My home is reasonable neat.  But all available spots for stuff have been filled and I have had enough.  It is like a metaphor of my life.  My life is equally full and there is not room for more.

I recently came across this verse from the Tao Te Ching:

You own nothing and no one

All that is composed will decompose

All that is yours will leave and become someone elses

Take pleasure in what you possess

Without being attached to these things

Let go of your identification with your stuff and with your accomplishments

I am not my things.  My parents are not in their things.  When my parents died their things became my things but they are not really my things because they will be passed along to someone else at some point.  If I am just temporarily holding these things and will have to give them up sooner or later, why not make it sooner so that there is less to be concerned about now?  I have begun to gain appreciation for the empty spots in my life.  The room that has little in it.  The time that is not scheduled.  The air that carries only silence.  It is in those moments where I find my mind most settled and my heart most free.

–Dan Hartman, MD

Mood Instability . . . PMDD or Bipolar Disorder . . . Or Both?

I am a 29 yo mother and was diagnosed as being bipolar at approximately 25 yo. I have taken a variety of medications(lamicatal, fluoxetine, topamax, lithium) and respond but i have always had “flare-ups” of exaggerated moodiness(rage, sadness, etc) about 2 weeks before my period. Since I have been married my husband has been able to predict my moods based on my the timeframe of my periods and I had NO symptoms of my mood disorder while pregnant. In fact, I felt better moodwise pregnant than I did at any other point of my life, period! So my question is, do u think I could have PMDD vs. bipolar? Is that a viable misdiagnosis?

Veeeeerrrryyyy interesting question.  At the root of this is the question of what exactly is a Bipolar Disorder and is ALL mood instability a flavor of Bipolar or can it be something else.  The problem with thinking of all mood instability as Bipolar Disorder is that it “waters down” and makes the diagnosis less meaningful.  The diagnostic criteria for Bipolar Disorder come from the “Diagnostic and Statistical Manual” or DSM (currently in the 4th edition–treatment revision or . . . DSM IV-TR).  The criteria are supposed to be diagnostic, but also statistically relevant.  By this I mean that meeting the criteria will statistically predict your response to a specific treatment and predict what the course of the illness will be.   If the criteria are too broad, it lessens the DSM’s effectiveness as a predictive tool.  Establishing a diagnosis for someone can be quite difficult, however.  When I do an evaluation, I get a slice of time in that person’s life.  The diagnostic criteria are longitudinal criteria . . . that there is a progression of symptoms over time.  A waxing and waning.  And the timing of the ebb and flow of symptoms plays a strong role in deciding what the ultimate diagnosis is.  There is big danger in not keeping this in mind.  For example, there is nothing to distinguish the depression of Major Depression from the depression of Bipolar Disorder, Most Recent Episode Depressed (yes, Virginia, that is the official name of the disorder).  It is only looking at the progression of symptoms over time that one can see the presence of manic or hypomanic symptoms that then changes the diagnosis to one of Bipolar Disorder.

With that in mind, what would we call someone who has symptoms of Bipolar Disorder only in the last two weeks of her cycle?  If it was, indeed, true symptoms of Bipolar Disorder (ie, meeting the specific criteria of Mania or Hypomania), then we would call it a Bipolar Disorder.  Regardless of the specific cause.  The intervention, however, might be quite different.  Certainly there is room for use of a mood stabilizer in this circumstance, but that would seem to be a band-aid to me.  People’s brains are very heavily influenced by hormonal factors . . . men and women . . . and probably more than we understand at present.  It would seem to me that the better intervention for someone with this specific pattern of mood instability would be to treat this hormonally. Some birth control pills are quite effective at reducing late cycle mood instability, especially that characterized by irritability and sadness.  In fact, as you describe, your symptoms are more consistent with a PMDD picture rather than Bipolar Disorder.  Unfortunately, you are allowed to have both.  If you meet criteria for Mania or Hypomania, you have a Bipolar Spectrum illness.  Anger/irritability, however, is not sufficient to meet criteria for Mania or Hypomania, so unless you have other features of these disorders, you may have been misdiagnosed.

–Dan Hartman, MD

Bleeet–Striving For Health

Trying to keep the momentum going . . . trying to eat right, exercise, sleep, relax.  Quite frankly it is hard to get all that self care into a day when you have to work!  I have been meditating on and off for years, but just went to my first formal meditation “class” last night (great way to spend the anniversary!).   It was good.  I really liked it.  Tonight, I didn’t want to exercise but did it anyway.  Now I feel better (I was a little tense after work).

What have you done today to be healthier?  What have you done for your own betterment?  It is not too late!  Go do something good for you!

–DH MD

Bleeet–26 years and counting

So today is my 26th wedding anniversary. I always take time off so we can spend some time together. The year has been very difficult with all the loss and stress. Having made it to this day is significant. True commitment can overcome adversity if patience and Love are present. Have a good day, all.

Bleeet . . . a new invention

Sometimes I don’t want to write a whole blarticle but I want to write. Get some thoughts out. Vent a little. I don’t tweet so I will instead bleeet. I define that as a quick little blog entry that should take no more than a minute to read. Sometimes, I have no time and no interest in writing a big entry. Sometimes, you have not interest in reading one but want to see something new. Here you go!

Obsessive Ruminations Embedded In A Mood Disorder

Sharon writes in . . .

My son has just started Seroquel XR for bipolar depression. However, he is suffering with repetitive thoughts, for example he recently was emptying a bag of trash that contained old light bulbs and in carrying it outside he lifted it over an ottoman in his living room, that was 4 days ago and all he can talk about is “what if there was a small piece of glass that somehow went onto the ottoman and even tho he vacuumed the ottoman several times, he still thinks there could be a microscopic piece of glass that could get on his shoe or hand or sofa, or his eye, mouth, what if… He realizes that it is pretty close to absolutely impossible for that to have happened, but the thought just won’t leave his mind and just keeps repeating over and over and over. This happens quite often “the what if” episodes, could involve the conveyor belt at food stores, what if someone ahead of him just bought soap or soap products and then he put is milk carton down in the same spot, and it goes on and on. What kind of medication would address this situation? This has been happening for over 10 years, it wears him down and tears me apart. Nothing I say helps, sometimes I even get angry because it may seem ridiculous to me but it is torture for him. I am not asking you to prescribe or diagnose, but a list of medication that would help so I can present that to his physician. We are in the process of looking for another psychiatrist. My son recently stopped all of his medication, he was on Geodon 80 mg 1 to 2 times a day, PaxilCR 37.5 mg 2 @ bed time, Xanax XR 2 mg, 2 in am and 1mg, 1 in am (5mg), Remeron 15 mg. @ bed, Trazadone 100mg 1 to 1 1/2 @ bedtime and Lamictal 100-150 mg and he was like a zombie and one day he just stopped all meds abruptly, a nightmare ensued and I am trying to get him back on track which is difficult since I need his attention and we need to communicate and he is too preocuppied with these repetitive thoughts. I need some help here and I know it is just an email away. Please help me to help my son. Thank you so much.

Yikes!!!  That was a long introduction to this blarticle, but it was meaty and seemed like it needed to all be there to tell this story.  Really sounds like your son (and you) have been suffering with this for quite some time.  There are many levels to the issues that you present, but I will try to make my answer straight forward and helpful.  As always, I must make some assumptions here.  I will assume that your son’s diagnosis of Bipolar Disorder is correct and that there is no psychosis going on here.  The issue that occupies most of your letter is not related to depression or to mania, however, but to the anxious repetition of fear thoughts . . . the “what ifs” that plague him and at times paralyze him.  What are they?   And more importantly, what can we do to make them go away?

First off, as you describe them, they are not a feature of depression or of Bipolar disorder.  The sort of ruminations that are described above are best thought of as being in the anxiety disorder family.  But, unlike the usual “what ifs” that we all fall prey to at times, these are completely unreasonable and odd and cannot be let go.  The “what ifs” can show up as Generalized Anxiety (“what if I lose my job and I don’t have any money and I lose my house and my wife leaves me to live with her family and I am left alone on the street for ever and ever and ever . . . .”) or as Social Anxiety (“what if I go into that room to do my presentation and I start stumbling over my words and everyone finally realizes what a dork I am and they are going to be talking about me and laughing about this and I will never be able to live this down and my career with be destroyed and I will get sick on my shoes in the middle of the presentation and on and on and on and on”).  The sort of ruminations that you describe above are ODD and STRANGE and are possible in a fantastic sort of way, but . . . not really.  This presentation is much more consistent with a Obsessive-Compulsive spectrum illness, rather than any of the other anxiety disorders and, certainly, lies outside of the standard diagnostic criteria for a mood disorder.  This sort of obsessive rumination can occur by itself or it can be embedded in another psychiatric condition.  I think it is important that the pattern of it be clearly identified and characterized to see if it does meet true Obsessive Compulsive Disorder criteria.  Regardless, the treatment of it will be similar.

The medicines that work to decrease such obsessive ruminations (and true OCD) are the medicines that work to increase serotonin levels . . . the SSRIs. Interestingly, medicines that work on the serotonin system but also on the norepinephrine system (such as Cymbalta and Effexor) do NOT work as effectively for OCD spectrum illness.  Adding an SSRI agent such as Zoloft or Prozac (or the Paxil he was taking) may be helpful for reducing the above ruminative symptoms.  The complication here is that your son is also diagnosed with Bipolar Disorder.  Using medicines like the SSRIs in a patient with Bipolar Disorder runs the risk of inducing manic or hypomanic symptoms.  To reduce that risk, it I strongly urge that he be on a mood stabilizer.  There are so many potential mood stabilizers that I do not want to go into that here (I have multiple blarticles on this in the archives) but he MUST be on one before starting the SSRI.  It is not clear how the presence of the Paxil he was taking impacted on the pattern of symptoms.  While most people do respond to any of the SSRIs, some do better on one than on the other.  Compliance is also key.  Are you sure that he was taking the medication as prescribed?  If he was compliant with the Paxil and he was on that dose for at least three months, it would be reasonable to try another one of the agents in that class.  Important here is the need to take a high enough dose for long enough.  It is common to need very high doses of an SSRI (often over the standard “high dose” that is give for depression) for a long time (at least three months) before you can call a trial a failure.  If he did have an adequate trial of the Paxil and then goes on to fail an adequate trial of another SSRI, then augmenting strategies can be used.  Lithium is a common adjunct to the use of antidepressants to help make them work more effectively.  And again, he must be on adequate mood stabilization for this treatment to be done safely.

There is also plenty of research showing that concomitant implementation of good cognitive-behavioral therapy for OCD improves the outcome of treatment.  It must be very specific CBT with exposure and response prevention in order for it to be adequate treatment for this sort of condition.

My best wishes go out to you and to your son.

–Dan Hartman, MD

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

Generic Woes, Anxiety Shows and Sarcastic Doctor Blows

I am a 23 year old male, am currently on Adderal XR 30Mg bid, Xanax 1Mg bid, and Remeron at bedtime. I have been on Adderal XR for five years. (at 60mg) The last few months the pharmacy has given me (unbeknownst to me) generic adderal XR, and I noticed (without knowing it wasn’t the ‘name brand) a substantial change in my productivity and overall, an increase in ADHD symptoms. (honestly it feels like taking 30mg alone) And have finnally the last week, got out and old bottle of immediate release 30 Mg Adderal (not XR) and have taken 30mg(XR) AND 30mg (regular) in the morning and 30mg of the XR in the afternoon, and have done well. The doctor I am seeing has already lowered the xanx dramatically. (my other doctor had me on 4mg qid wich was a lot but I most days only took 2mg 2 or 3 times a day) And has sarcastically made comment about me being on “all the good stuff” and “great combination” I take he is very biased when it comes to sched. medications. Any way, I am very apprehensive to tell him about the Adderal problem as, I was doing great on 3mg of xanax and still he lowered it, I don’t want the same thing to happen with Adderal, If he did, I would be a more unfocused MESS. Also, I have been reading about Vyvanse. Is that possibly a good thing to switch to? (70mg bid?) (and what about 2mg xanax XR in the AM and 1 mg regular prn?) Does this seem like a logical request to ask a very closed minded doctor? (I can’t switch doctors for 6 months).

Your situation brings up many different issues that I think will be helpful to others.  Let’s start with the Adderall issue.  A number of months ago (can’t remember exactly when), Adderall went generic and everyone started getting “mixed amphetamine salts” instead of their brand name stuff.  Anytime this happens, there is a segment of the population that does not get the same benefits as they do from the brand name drug.  This switch to generic Adderall is no different.  I have received what I feel are credible complaints about it not lasting as long, “kicking in” too strongly, not getting the “boost” from the second half of the medicine, etc., etc. You identify the perfect scenario where you didn’t even realize that there was a change (they look very similar to each other).   The best solution for you would be to go back to the brand-only Adderall.  It worked for you for years and you had no difficulty with it.  You were not seeking more of it over time or playing with the dosages.  It will likely cost you more and your doctor may have to advocate for you (more about him later), but it would be the logical thing to do.  I would not switch to Vyvanse because Adderall was working for you in the first place.  Just go back to what worked.  I worry that Doctor Sarcasm would view a request to switch to Vyvanse as drug seeking, since Vyvanse is “the good stuff” now.

Now, the Xanax.  You don’t describe what role the Xanax has in your life.  Did you have severe anxiety in the past?  Has that been better lately?  Have you had the re-emergence of anxiety as the dose of the Xanax has been reduced?  These are all very important questions that need to be answered.  Most doctors (myself included) like to get people on the lowest possible dose of Xanax and, if clinically appropriate, off this class of medicine.  Xanax, in particular, has a nasty reputation of being addictive and abusable.  But the tapering of medicine should be clinically driven and not based on population based fear.  And it should never be accompanied by sarcasm.  You go to the doctor for help and advice.  If you want sarcasm, go talk to your family.  That is actually the most concerning issue raised by your letter.  Given how you seem to feel about the relationship you have with your doctor, I would say that 6 months can’t pass too quickly.  Try talking to him in a straight forward manner and address his sarcasm if he slips into that again.  You can try saying something along the lines of . . . “I hear by the tone in your voice that you don’t trust me with these medications.  I can assure you that I take only what is prescribed and only take these medicines to control my symptoms.”  Maybe the doc will listen, maybe he won’t.

Good Luck!

–Dan Hartman, MD

Transcranial Magnetic Stimulation–Part II

Sorry for the lack of writing folks, I been biiiiiiizzzzzzzzzyyyyyyy!

I am proud to announce that I am an official TMS provider!  My NeurostarTMS machine was delivered the first week of November and I spent the better part of last week being trained on how to use it in real-life situations.  From a professional standpoint it is awesome.  For the standard psychiatry part of my practice, the most technically challenging aspect of the day is clicking the top of my pen so I can write prescriptions.  Using TMS is a whole other world.  For those who have little understanding of what TMS is (which I would guess is most of you since this is brand new technology), it involves stereotactically mapping out the part of the brain that sends signals to your right hand, and then using those coordinates to estimate the location of the prefrontal cortex that would be most likely to cause mood improvement if subjected to a series of magnetic pulses.  The machine itself is amazingly awesome in how it is set up to make this doable.  That fact that it works to help people who are suffering feel better?  I cannot describe how that makes me feel.

The persistent suffering of my patients with non-responsive depressive symptoms is very difficult.  I am very skilled at not letting their sadness become my sadness, but I develop a very nice relationship with these people over time and it IS sad for me to see them suffer.  I have depression in my family, so I know first hand how frustrating it is for patients and their families to spend month after month not getting better.  I know how my decisions with the medicine can impact on lives and families and make or break them.  To have a new hope to give these people . . . brings tears to my eyes.  I have one patient already receiving active treatment and I have several more who are in the pipeline ready to start by the end of the month.  I will let you know how things go over time.

So, I’ll be back to writing soon.  I still have organizational issues to address to get TMS fully integrated into my practice.  If you want to learn more about TMS, go to the company website and see for yourself . . .www.neurostartms.com.

–Dan Hartman, MD