Transcranial Magnetic Stimulation
An Introduction to Repetitive Transcranial Magnetic Stimulation (TMS)
At NAPA, we are now actively providing repetitive Transcranial Magnetic Stimulation (TMS) for the treatment of depression.
Just as the heart anatomically has mechanical, chemical and electrical functioning, so does the brain. We readily accept scientifically validated interventions on the full range of cardiac function. So, we should also consider this for the brain. Mechanical interventions – usually neurosurgery – are invasive and have a mixed history in psychiatry. Chemical interventions are mostly medications, which can be very effective in many cases, though can be fraught with potential systemic side effects, which can affect the entire body. Due to these limitations, certain neuroscientist clinicians have focused their efforts to find safe and effective electromagnetic based interventions.
For over a century, scientists have been exploring the use of electrical and magnetic interventions to assist in the treatment of neurological and psychiatric illnesses, with varying results. Effective, safe and tolerable treatment options continue to be honed. One theory is that using magnetic fields with appropriate shaping and parameters clinicians can intervene on the electrical activity of the brain without using physically invasive techniques. TMS was introduced into research in the mid-1980s, and the technology has been steadily refined since that time. TMS is not electroconvulsive therapy (ECT, or “shock therapy”), and may be performed safely in an outpatient setting, without anesthesia.
With research advances in diagnoses, one of the more consistent neuroanatomical findings in Psychiatry has been the association of a hypoactive (or slowed) portion on the left side if the brain, called the dorsolateral prefrontal cortex (DLPFC). It was postulated that TMS can be used to speed up that portion of the brain, and interrelated circuity. Through a series of repeated applications of TMS pulses over the course of weeks, this portion of the cortex can be normalized. I was privileged in 2004-2005 enough to be a treater in the original trials of this technology, developed by Neuronetics into what is now the NeuroStar device. In 2008 TMS was cleared for treatment of adults with Major Depressive Disorder (MDD) that failed to respond to pharmacotherapy – also known as Treatment Resistant Depression (TRD). Response and remission rates to TMS for TRD, though not guaranteed, have been shown to be significantly higher than for another trial of an antidepressant.
Although, TMS has been used to treat other neuropsychiatric conditions, Major Depression remains the single best studied indication for effectiveness and safety. The FDA recently cleared another device for the treatment of OCD, though by its nature being involved deeper in the brain, additional risks are involved with this. Currently, most health insurance plans usually reserve reimbursement for treatment to moderate to severe Major Depressive Disorder, using the protocols and devices cleared by the FDA. This is the treatment offered at NAPA. With changes to insurance coverage in Alabama in late 2018, TMS has become a practical office-based treatment option for insurance-based providers to offer.
For coverage approval, typically health insurers require documentation to (which may vary by insurer) include:
- Adult age
- A diagnosis of Major Depressive Disorder (MDD), Moderate to Severe severity
- Validation and measurement of the diagnosis and depression severity using a standardized rating scale (commonly the PHQ-9, which mirrors the DSM criteria for MDD)
- Failure of 3 to 4 antidepressants during the current episode, with documentation of dosages, start & stop dates, and response to each
- Failure of a course of validated psychotherapy during the current episode
- Prior authorization from the insurer before starting
The process for initiating rTMS treatment typically includes:
- Gathering preliminary information on prior treatment trials and health status for safety and insurance approval
- Having in place releases of information to communicate with all medical and mental health providers for continuity of care.
- Performing an assessment to verify appropriateness and safety of treatment
- Formulating a plan to manage any medical comorbidities, such as the existence of any implantable electrical devices or metal in the body
- The only firm contraindication to treatment with TMS is the presence of any ferromagnetically sensitive object in the head area.
- Obtaining informed consent for treatment, including a discussion of expectations and the known potential risks, side effects and benefits, including that effectiveness is not guaranteed
- The most medically concerning known side effect is the possibility of inducing seizures
Treatment typically requires:
- Commitment and dedication to your own recovery. Response, like many antidepressant treatments, is typically seen weeks into the stimulation.
- Daily transportation.
- Payment of associated fees and copays (our office will assist in clarifying this for you)
- Treatment is required almost every weekday for 9 weeks. This customarily includes 6 weeks of acute treatment 5 days per week, followed by a 3-week taper of thrice weekly for 1 week, twice weekly for one week, then once the last week.
- The first day of treatment lasts longer, because time must be taken to determine the motor threshold (MT) and map the appropriate treatment location
- Psychotropic medications are often maintained during and after treatment, especially of there has a been a partial response
- Near daily interaction with a, experienced, knowledgeable and supportive treatment team, and frequent monitoring by the administering physician, aids in safety and recovery
Untreated depression can be devastating for patients and families. It can steal lives through suicide, rob quality of life, and interrupt daily functioning in relationships, work, school, at home and hobbies. We welcome additional treatment options that have been proven safe and effective.
At NAPA, we are proud to use the NeuroStar device by Neuronetics, the only device proven efficacious in the treatment of MDD in multiple large randomized controlled trials required by the FDA. The NeuroStar device has a specially designed magnetic coil and core to better focus the magnetic field on the desired treatment area. The NeuroStar device has a patented sensor to keep the coil in contact with the treatment area to help ensure effective dosing. The response to NeuroStar TMS for MDD has been proven in several studies to be durable up to over 1 year in many cases.
I look forward to continuing to serve the North Alabama community with this new technology. Please contact our office for further assistance and information.
Heath R. Penland, M.D., F.A.P.A.
Board Certified in Psychiatry and Geriatric Psychiatry
North Alabama Psychiatric Associates, P.C.
Call to 256-322-6272 Today to Schedule an Appointment.
TMS Downloadable Resources
- Transcranial Magnetic Stimulation (TMS) Clinician Referral Form*
- Transcranial Magnetic Stimulation (TMS) Brief Clinician Referral Form*
- NeuroStar Patient Brochure
- NeuroStar Patient Consent fo Medical Procedure
- NeuroStar TMS Medication List
- NeuroStar Therapy Patient Guide to Treating Depression
- Patient Health Questionnaire (PHQ-9)
- TMS Patient Registration Packet*