# Depersonalization treatment with rTMS in Hungary



## teal (Oct 9, 2019)

As we know, there is no cure for DPDR, but rTMS has shown promise, especially when targeted at the right VLPFC. I have been in touch with the Flash Clinic in Budapest (hat tip @curiousmind), and they say the have the required equipment and such and can perform neuronavigated rTMS treatment upon request.

They need a special kind of MRI that costs 35.000 HUF. So if you already have an MRI it may not be the type they're looking for. The 20 sessions of rTMS at the right VLPFC would cost 300.000 HUF. They have short waiting lists, so it's (in most cases) possible to get an appointment a few weeks ahead in time.


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## teal (Oct 9, 2019)

Risk-reward. No treatment is harmless, but luckily rTMS seems to be less harmful than many other treatments. See this thread. The reward, you just don't know how it would affect you. It could have no positive effect at all, and it could be it works just great. In the small study that's been done on the right VLPFC the symptoms were reduced by 44 % on the CDS scale. There are two CDS symptom scales, and it's this one they used in the study with regards to treatment response.


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## curiousmind (Oct 31, 2019)

Great to see that you've made advances to get this treatment. If your in town let me know


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## curiousmind (Oct 31, 2019)

Also, I reckon you wait until the French Trial is published. The right angular gyrus may be the better treatment for you depending on your symptoms.


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## teal (Oct 9, 2019)

The right VLPFC treatment seems fairly harmless, so I won't wait and wait for something that might or might not work in France. I've sent you a message.


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## 35467 (Dec 31, 2010)

Their prises are extremely fair. I think it is around the same price as in Poland. rTMS is extremely overpriced in westeurope SMART TMS in England charges 250.pund pr. session and they don't have neuronavigation. It is very likely that one has to come for new treatments to avoid setbacks every 9-12.months with 10.sessions.


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## 35467 (Dec 31, 2010)

A MRI scan for neuronavigation has to take all of the brain surface and then the file has to compromise into a format that is compatible with the program they use. So if one has a MRI scan it is very unlikely it can be used because it might not be of the whole brain or be in a format that is not compatible to their system.


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## 35467 (Dec 31, 2010)

teal said:


> The right VLPFC treatment seems fairly harmless, so I won't wait and wait for something that might or might not work in France. I've sent you a message.


The right VLPFC is for the emotional numbing of the disorder. The right angular gyrus or the right TPJ is for the rest of the symptoms. Depersonalisation symptoms likely is related to different stages of cognitive emotional regulation where the emotional numbing is related to the prefrontal cortex and angular gyrus to the embodiment of regulated emotions. rTMS at angular Gyrus will likely have no effect on emotional numbing. That was also seen in those who responded to the right TPJ.


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## teal (Oct 9, 2019)

Mayer-Gross said:


> Their prises are extremely fair. I think it is around the same price as in Poland. rTMS is extremely overpriced in westeurope SMART TMS in England charges 250.pund pr. session and they don't have neuronavigation. It is very likely that one has to come for new treatments to avoid setbacks every 9-12.months with 10.sessions.


Living expenses is probably what'll cost the most. I see the Danubius Hotel is five hundred meters from the clinic, where it costs 34 USD per day. With AirBNB it's slightly cheaper. But curiousmind, I guess you know more about this. Let's say one would need to stay in Budapest a month or two, is there a place where you can rent a flat for an extended period, for a better price?

But the prices, it's good they don't overcharge for rTMS, which highly indicates they are in it for doing good, and not making off like bandits.

Yeah, getting a new MRI would be very sensible. Even if the old could perhaps maybe work, it doesn't cost much to take a new one, and it makes it much more smooth and easy for the people who perform the treatment, to get the MRI from the machine they normally use.


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## curiousmind (Oct 31, 2019)

teal said:


> But the prices, it's good they don't overcharge for rTMS, which highly indicates they are in it for doing good, and not making off like bandits.


Well the clinics in Hungary are first and foremost selling their services to local citizens, and the average monthly salary here is low when compared to salaries in Western Europe. In order to keep their business alive, clinics need to keep their prices confined to ranges that are appropriately in line with the expenditure capabilities of Hungarian customers. Very few people living in Budapest would go through with an rTMS treatment that costs as much as it does in England/US. Similar situation in Poland.



teal said:


> But curiousmind, I guess you know more about this. Let's say one would need to stay in Budapest a month or two, is there a place where you can rent a flat for an extended period, for a better price?


Airbnb is probably your best bet, you can book superb apartments in the heart of the city at a very low price. Prices usually seem very low to visitors of Budapest especially if you are coming from the "western world". Keep in mind that this will also depend on the season in which you decide to come. Fall and spring are the best times because this is when tourism is the lowest. Summertime and wintertime are usually busy and likely the prices are also higher.


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## 35467 (Dec 31, 2010)

The prizes for rTMS in Italy is 120.euros pr.session. They use theta burst and that might increase the patient they can take 3-4.times pr. day compered with normal rTMS. The only private provider in Danmark takes 25000. danish kroners/3345 euros for 30.sessions with 2.consultations with a psychiatrists-so close to 100.euros pr session. They only treat depression at the right and left DLPFC. All rTMS clinics in the UK have similar prizes like SMART TMS and i have the impression of market without competition in the UK at prizes close to 350.euros pr. session. The prizing in western Europe ought to be around 100.euros. Could be lower with the use of theta brust as session is reduced from 35.min to 3.min or 40.sec. Location of the coil is what takes time. Smart TMS says that the expensive equipment is the reason for their prizing. Funny that others can have a prizing 70% lower with the same equipment.


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## 35467 (Dec 31, 2010)

In the american market the prizing is also close to 3-400.dollars for those not covered by insurance. But, in reality most with depersonalisation are not covered by insurance because health insurance only covers depression and rTMS locations for depression. So, north americans with depersonalisation disorder also have to pay all expenses.


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## 35467 (Dec 31, 2010)

There have been done some trials with rTMS at the angular gyrus with stimulation of the area with rTMS in normal people. It affects one biographical memory so it becomes less ego-centric. There will be a distance in ones memory of personal experiences as if it did not happen to oneself. It can also give a sense of loss of agency over ones movements. The symptoms in depersonalisation of being a robot is likely to be related to angular gyrus overactivity. Angular gyrus is in a network with the right VLPFC in cognitive relation of emotions, it is a central hub in the "default mode network" that is the brains resting state where it is connected to the medial prefrontal cortex that is also very overactive in emotional suppression in DP, it is central on self- awareness, it is central frontoparietal network related to attention . Stimulation of angular gyrus here.https://www.frontiersin.org/articles/10.3389/fnhum.2014.00471/full


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## curiousmind (Oct 31, 2019)

Mayer-Gross said:


> it is central frontoparietal network related to attention


the medial prefrontal cortex?


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## 35467 (Dec 31, 2010)

No, most searchers says dorsal location. But, the overactivity found in depersonalisation disorder in the prefrontal cortex like medial, dorsal are likely all to have been activated by the VLPFC that finds a need for cognitive regulation emotions. So, by normalising the right VLPFC it should affect other areas in the prefrontal cortex too.


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## teal (Oct 9, 2019)

Comparing prices. Quick and dirty, Mayer-Gross, just to contrast England and Hungary.

*SMART TMS in London*

5000 £ for rTMS (given that the price would stay the same if/when they'd get neuronavigation)

395 £ for an MRI (this is quick and dirty)

2800 £ for living at a hotel (it costs about 100 £ per night for hotels that are hard by SMART TMS London)

= 8195 £ for all that.

*Flash Clinic in Budapest*

763 £ for rTMS

150 £ for likely consultation and control fees

89 £ for an MRI

728 £ for living at a hotel just by the clinic

= 1730 £ for all that (using today's HUF/GBP exchange rates, naturally)

So even if they'd get neuronavigation in England, which I think they should, even if they'd get it, I think London would be a poorer choice. They seem more professional, more skilled and frankly more dedicated in Hungary.

For the sake of simplicity I set the stay to four weeks, even though the study lasted ten weeks. Hotels only include breakfast, so other living expenses and air plane tickets must also be taken into account. It's probably possible to get it for cheaper, if staying outside the city and taking public transport to the center every «treatment day».

Another way to cut costs could be to rent out the place where one currently lives on AirBnB while in Budapest. But I guess that would be way too stressful for most, myself included. So I'm just mentioning it.


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## teal (Oct 9, 2019)

Mayer-Gross said:


> It is very likely that one has to come for new treatments to avoid setbacks every 9-12.months with 10.sessions.


Is this empirically or theoretically based? I was thinking, with depression, if the reasons why someone got depressed in the first place are still there they'd prolly need new rTMS treatments every once in a while. But with DPDR, if the reason why things went awry is no longer present (say there was a psychological trigger, or the illness was triggered by cannabis use), perhaps new treatments wouldn't be required? Just thinking aloud now, not saying it is this or that way with DPDR.

I guess the cases we have to build on are mainly those from England.


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## 35467 (Dec 31, 2010)

We know from Diffusion tensor imaging (DTI) and structural studies with MRI scans that the longer you have had depersonalisation disorder, the more it affects the brain. The networks that have made depersonalisation have made a psychical imprint on the brain -perhaps also on the body. In the french study they are also looking for structural changes after TMS and looking for setbacks in a follow up to see how long the affect lasts. In all other conditions treated by rTMS like depression, addiction there are a need for a follow up ever 9-12.months with 50% less session than the first time. I think it will also be the case for depersonalisation disorder for those who have had the disorder for years. That is also why i have consider being part of a trial pointless. Often it will be a placebo and only 50% will get the real thing. Those who have a reduction will like see setback but cannot get treatment again because they where a part of a trial of a non-approved treatment. It will still be non-approved and setbacks can not be treated.

The pricing of rTMS in some places like the UK, US, Schweiz have done that i have never considered those places as an option for a treatment.


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## 35467 (Dec 31, 2010)

Here is the pricing of a "competitor" to SMART TMS in the UK;

"Treatment for depression using rTMS is short but intense. You will have five sessions each week. The average treatment length is four to six weeks. Some patients have reported benefits from the first week.

The cost of the initial assessment with the psychiatrist is £500 and rTMS is £2,000 per week. You will also require a review appointment with the rTMS consultant each week to re-prescribe your treatment and review your progress, which costs £270. Indeed, because of the cost of this state of the art equipment and the level of expertise involved, rTMS cannot be a 'cheap' treatment. But, when we consider the benefits, the cost pales in comparison."

2000.punds a week or 400.punds pr. session or 470.euros pr session. No, neuronavigation there either and that is why people have that "hat" on for location of the right DLPFC on the picture.

https://www.psychiatrycentre.co.uk/repetitive-transcranial-magnetic-stimulation-rtms-clinic/how-much-does-rtms-cost/


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## 35467 (Dec 31, 2010)

In depression some can give 2.daily rTMS session a day. They do that in Italy , Nederlands and a clinic in Germany for depression and addiction. I hope the same can be done in depersonalisation over time when we and they have more experience with the condition so 10.sessions can be giving in 5.days.


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## teal (Oct 9, 2019)

Mayer-Gross said:


> We know from Diffusion tensor imaging (DTI) and structural studies with MRI scans that the longer you have had depersonalisation disorder, the more it affects the brain. The networks that have made depersonalisation have made a psychical imprint on the brain -perhaps also on the body. In the french study they are also looking for structural changes after TMS and looking for setbacks in a follow up to see how long the affect lasts.


Pity to hear. Oh well. Could you point me to good info on this?



Mayer-Gross said:


> Those who have a reduction will like see setback but cannot get treatment again because they where a part of a trial of a non-approved treatment. It will still be non-approved and setbacks can not be treated.
> 
> The pricing of rTMS in some places like the UK, US, Schweiz have done that i have never considered those places as an option for a treatment.


I can relate. It would be awful to be unable to get follow up treatments. I am no rich man, so every dollar counts. But on the other hand, even if there were no follow up, God how good it would be to get better, albeit temporarily. It would be like getting my head above water for the first time in decades. Oh, how good that would be. Just a single session where I'd get somewhat better, would really infuse me with hope.

I am seriously considering getting the MRI scan in Hungary and meeting and talking with them, and then heading back for a full treatment later. Right now I am going to try klonopin for the first time. Naloxone too. But Hungary is really my best bet.


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## 35467 (Dec 31, 2010)

You can see that depersonalisation disorder is a more potent disorder if you look at the response rate for more psychological approaches like CBT. They are close to or below depression. Some have said that it is 3.times more difficult to treat depersonalisation with CBT that OCD. These conditions also have a high relapse rate when it is so inflexible. There is something more than just networks and psychological cognition at work.

DTI scans/structual changes in DP;

"In patients with DPD, the structural connectivity between brain regions crucial for multimodal integration and emotion regulation may be altered. Aberrations in fibre tract communication seem to be not solely a secondary effect of local grey matter volume loss, but may present a primary pathophysiology in patients with DPD."https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6158023/


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## 35467 (Dec 31, 2010)

When i started in the spring of last year for a rTMS treatment i was looking for;

1) a place with neuronavigation for location

2) a place with fair prizing pr. session,- the UK was out of the question already then.

3) a place with fair prizing to live in for some weeks until a month.

4) a place with people willing to read into the disorder than just the abstract of a trail.

5) place that might take a broader interest into depersonalisation disorder for a systematic treatment.

When i looked at rTMS Italia they had neuronavigation, normal TMS and theta burst at two location out of four in Italy, a price of 120.euros pr. session, they would likely take two session a day, their location would likely be Cagliari, Sardinia that have low prices for stays out of the turist season like 50.euros pr. day. They also had people who have done research into particularly cocaine addiction and they also do testing of patients for it and do publications. So, my hope was they would look into depersonalisation like they do with addictions and might be open for testing, collect data on patients as they do for addiction so it could be made for publications about depersonalisation . Such data would open up for more trails in depersonalisation with rTMS so it could be a more formel treatment given in the public health system or covered by insurance in the near future . But, a prof. who responded me who is also their advisor said he would look into the disorder and take it seriously. They never replyed me and i think the owner has turned it down. 70% of their patients get treated for addictions and they likely have a profitable business running with their capacity. I hope that they might come into the game at some point in time they have the ambition to have locations in all 20.regions and larger cities in Italy. Other rTMS providers in Italy are also coming into the game. So, Italy might also be an option in the years to come.


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## 35467 (Dec 31, 2010)

There are some cost that might be missing. They have consultation fees with a psychiatrist of 20000Ft/60.euros and a control fee of 10000 ft./ 30.euros. I think that at least two consultation and likely 1-2.controls are likely unavoidable as a start up for a treatment.It could be slightly more as the condition as so unknown by most and the first patients they have with depersonalisation . So, add 150-200.euros to 900.euros for rTMS


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## teal (Oct 9, 2019)

I put in 175 EURO of consultation and control fees.

I think I speak for the whole boards when I say we're grateful for the effort you've put in. Making cases available for the public, like you've thought of in Italy, would hugely benefit the community.


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