Transcranial Magnetic Stimulation

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istillbelieve

istillbelieve

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Anyone in private practice planning on doing this? I have heard that it has been FDA approved for depression and bipolar disorder. Thoughts?
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I think it's an avenue that should get more consideration but from the data I've seen, I'm not a big proponent of it. It's expensive, not really more efficacious than antidepressants, not recommended for treatment resistant depression (so why even start if unless you want very quick results, but at a cost of what? Several thousands of $$$?), very few insurance companies will pay for it.

I'm an acquaintance of someone that does research on it and he does it at a local institution. I'm very happy he's doing it and I believe this can lead to bigger and better things down the road but for now...not something I'd recommend much if at all.

The initial hope years ago was it was going to be on the order of something as good as ECT minus the memory loss and need for all the anesthesia meds and anesthesiologist. It is nowhere near as good as ECT.

I have seen some data showing it could become much more efficacious with some modifications to the treatment but this is still being studied.
 
I know someone with a local practice who seems to use it to distinguish her practice from others. I agree with Whopper, though. The data isn't very exciting, and the cost is prohibitive for most.

Doing quality therapy would probably be cheaper and more effective, but not as enticing to those looking for an external fix.
 
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istillbelieve said:
Anyone in private practice planning on doing this? I have heard that it has been FDA approved for depression and bipolar disorder. Thoughts?
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There is a private practitioner in our area doing this. He describes it as being as effective as ECT. I don't know the data well at all, so I can't comment on that, but as to your question, there are definitely people in private practice doing this.
 
nitemagi said:
I know someone with a local practice who seems to use it to distinguish her practice from others. I agree with Whopper, though. The data isn't very exciting, and the cost is prohibitive for most.

Doing quality therapy would probably be cheaper and more effective, but not as enticing to those looking for an external fix.
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But therapy doesn't tingle your scalp and make clicky noises!
 
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We do a lot of it at my institution. I agree that it's expensive, but if you can afford it (and when insurance starts to cover it), I think there are some clear benefits. Working fast can be huge for some people - if somebody is actively suicidal, it may not be safe to wait 4-6 weeks for an antidepressant to kick in. In that case, the alternative is to hospitalize them for a month, which would be way more expensive than some TMS sessions.
 
shan564 said:
We do a lot of it at my institution. I agree that it's expensive, but if you can afford it (and when insurance starts to cover it), I think there are some clear benefits. Working fast can be huge for some people - if somebody is actively suicidal, it may not be safe to wait 4-6 weeks for an antidepressant to kick in. In that case, the alternative is to hospitalize them for a month, which would be way more expensive than some TMS sessions.
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If they are severely depressed and actively suicidal, why not just do ECT? Seems like that would be much safer and more efficacious, even with the higher side effect profile. Suicidality is more worrisome than temporary memory loss in my opinion.
 
well what about PERMANENT memory loss, which affects up to 1/3 of those who have ECT. that is worrisome, and has been associated with some suicides. Hemingway's suicide for example is thought to be associated with his ECT and no longer being able to write anymore. More recently, William Styron noted that ECT left him unable to write so this is not just a historical thing associated with ECT in the past.

Now I recommend ECT for select patients and have seen good results, but psychiatry has tended to vastly oversell the benefits of ECT (which RCTs show are shortlived) and underplay the significant adverse effects that can occur, especially with prolonged treatment, or successive courses. Historically, those who complained of persistent memory problems following ECT were dismissed as "cranks" or portrayed as unreliable narrators because of their mental illness. The idea that ECT is some benign lifesaving intervention is is just not true. If it really has significant benefits (which I believe it does), we must accept it has the potential for serious adverse consequences, which occur more frequently than are previously thought. It particularly irks me when people's cognitive troubles post-ECT are put down to "depression" or the underlying mental disorder when the patients were not reporting these difficulties before.
 
splik said:
well what about PERMANENT memory loss, which affects up to 1/3 of those who have ECT. that is worrisome, and has been associated with some suicides. Hemingway's suicide for example is thought to be associated with his ECT and no longer being able to write anymore. More recently, William Styron noted that ECT left him unable to write so this is not just a historical thing associated with ECT in the past.

Now I recommend ECT for select patients and have seen good results, but psychiatry has tended to vastly oversell the benefits of ECT (which RCTs show are shortlived) and underplay the significant adverse effects that can occur, especially with prolonged treatment, or successive courses. Historically, those who complained of persistent memory problems following ECT were dismissed as "cranks" or portrayed as unreliable narrators because of their mental illness. The idea that ECT is some benign lifesaving intervention is is just not true. If it really has significant benefits (which I believe it does), we must accept it has the potential for serious adverse consequences, which occur more frequently than are previously thought. It particularly irks me when people's cognitive troubles post-ECT are put down to "depression" or the underlying mental disorder when the patients were not reporting these difficulties before.
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Which RCT's? I'm not meaning to be difficult, I would really like to take a look at those studies because my institution pushes ECT pretty heavily and for a wide population and I've seen some great results (in my very short time on psychiatry services to date).
 
the best one was the Northwick Park ECT Trial.

In 2003 2 systematic reviews were published funded by the UK department of health the first in The Lancet looking at the evidence of ECT in mood disorders, and the second a qualitative study exploring memory loss etc following ECT and are recommended reading (I make all my med students have a read through before seeing ECT).
 
SteinUmStein said:
If they are severely depressed and actively suicidal, why not just do ECT? Seems like that would be much safer and more efficacious, even with the higher side effect profile. Suicidality is more worrisome than temporary memory loss in my opinion.
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The risk of anesthesia should never be under estimated. While still not the "ideal" treatment, TMS is still a viable alternative for those who have not been able to tolerate other medications, or other treatments. TMS shows promise, but we still have a long ways to go with it. And it is, in all respects, safer than ECT as the anesthesia risk is eliminated.
 
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Thanks for the study links, that's very helpful. Hopefully TMS will continue to make progress and will ultimately be an effective and affordable option for a select group of patients with depression.
 
istillbelieve said:
Anyone in private practice planning on doing this? I have heard that it has been FDA approved for depression and bipolar disorder. Thoughts?
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The evidence really isn't that great. See:

Hines JZ, Lurie P, Wolfe SM. Post Hoc Analysis Does Not Establish Effectiveness of rTMS for Depression. Neuropsychopharmacology 2009;34:2053-54.
Yu E, Lurie P. Transcranial Magnetic Stimulation Not Proven Effective. Biol Psych 2010;67:e13
Yu E, Lurie P. Randomized Controlled Trials, Not Meta-Analyses, Remain Standard for Assessing Depression Device Effectiveness. Biol Psych 2010;67:e29

And summarized here:
http://www.citizen.org/publications/print_release.cfm?ID=7712
 
shan564 said:
We do a lot of it at my institution. I agree that it's expensive, but if you can afford it (and when insurance starts to cover it), I think there are some clear benefits. Working fast can be huge for some people - if somebody is actively suicidal, it may not be safe to wait 4-6 weeks for an antidepressant to kick in. In that case, the alternative is to hospitalize them for a month, which would be way more expensive than some TMS sessions.
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If insurance ever starts to cover TMS, that will be very very sad.

It will also be open to abuse/misuse, and if insurance ever does start to cover it(again hopefully they wont) it will only last a brief period of time because entrep psychs who want to make a buck will be recruiting these new covered patients at record numbers and insurers will catch on.

Providers love the idea of TMS because it allows them to capture large amounts of revenue potentially. You can buy the machine and do it yourself. Whereas with ect, you can bill a code(and if you stack them my understanding is it can be pretty good revenue...but you may have collection issues in some cases), but the vast majority of the real revenue is unable to be captured...the real money is going to the people who already make real money...anesthesia and the hospital.

right now I think most people view TMS along the same lines as people view those fancy and expensive machines chiropractors try to put people in. Simply an attempt to capture revenue from the public.
 
nitemagi said:
I know someone with a local practice who seems to use it to distinguish her practice from others. I agree with Whopper, though. The data isn't very exciting, and the cost is prohibitive for most.

Doing quality therapy would probably be cheaper and more effective, but not as enticing to those looking for an external fix.
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also not as enticing to many psychiatrists who are looking for a quick buck
 
The TMS machine costs 70k. That is a lot of additional overhead for a private practice. You better have a good business plan. :)
 
well the numbers I've seen are a good bit less(like 25k)...given what is being charged for TMS, with even a small amt of volume you could make that up and then some pretty easily. Same concept for the fancy chiropractic machines....and yet saavy chiropractors spend more on them in some cases because of the income stream potential.
 
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vistaril said:
well the numbers I've seen are a good bit less(like 25k)...given what is being charged for TMS, with even a small amt of volume you could make that up and then some pretty easily. Same concept for the fancy chiropractic machines....and yet saavy chiropractors spend more on them in some cases because of the income stream potential.
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Do you know what the average cost per session is?
 
I think it's about $300ish per session. Cheaper than long-term Abilify...
 
I'd be okay using it as a research tool, but the evidence isn't there for recommending it as a reasonable treatment modality.

For me, the test is this: would I recommend a patient to a TMS system I didn't own? I sure don't now, and don't know anyone who does. I have a hunch that the only practices that enthusiastically recommend TMS are the ones that own a machine. What a coincidence!
 
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shan564 said:
I think it's about $300ish per session. Cheaper than long-term Abilify...
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If you consider cost-benefit ratio and not just the cost, the third gen drug would run circles around TMS.
 
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It is slowly being covered in my state. With some work with the insurance companies, TMS is starting to be covered by the welfare insurances. Two private insurance companies are already covering it. At one doctor's practice, he is being paid tons and tons of cash. It doesn't seem worth it.

I sure hope TMS is not being billed under the same CPT code as psychotherapy or meds. If it is and this doesn't work, the patient will really be in a bad position if she/he can't afford anything out of pocket. And psychotherapy and meds are expensive without coverage.
 
Cheaper than long-term Abilify...
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And so too are several other antidepressant augmentation agents such as Buspirone, Lamictal, thyroid hormone, another antidepressant of a differing mechanism.....

Not directed at anyone in this thread because I see this everywhere. Don't jump on the Abilify Kool-Aid bandwagon. Yes, there's a place for it in antidepressant augmentation, but IMHO it shouldn't not be first-line unless there's specific clinical indications for that med.

The problem is it's one of the only meds where drug-reps are "teaching" doctors about antidepressant augmentation. The other meds are generic so they have no drug rep spreading around their virtues.

And primary care doctors and psychiatrists of lesser quality are eager to jump on that bandwagon. The PCPs dont' know much about augmentation. The psychiatrists, I can't think of an excuse because this is something you ought to know about if you specialize in psychiatry.
 
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shan564 said:
I think it's about $300ish per session. Cheaper than long-term Abilify...
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The vast(and by vast I mean 99%+) of patients pay somewhere between $0 and $40 per month for abilify. Patients only care about out of pocket cost. I've never heard of a patient paying more than 300 dollars per month out of pocket for abilify. if that were the case Abilify would pretty much cease to exist.

It's a totally different ballgame than TMS, which patients do pay out of pocket for.

Additionally, I'd like to point out that comparing one cost-inefficient treatment with another very cost inefficient(and often worst case scenario) treatment is a pretty poor argument.
 
notdeadyet said:
I'd be okay using it as a research tool, but the evidence isn't there for recommending it as a reasonable treatment modality.

For me, the test is this: would I recommend a patient to a TMS system I didn't own? I sure don't now, and don't know anyone who does. I have a hunch that the only practices that enthusiastically recommend TMS are the ones that own a machine. What a coincidence!
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which is why it's the same as chiropractors and their fancy machines.......when we advocate for things like TMS, we are basically chiropractors(and NOT the good evidence based ones either)....
 
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vistaril said:
which is why it's the same as chiropractors and their fancy machines.......when we advocate for things like TMS, we are basically chiropractors(and NOT the good evidence based ones either)....
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I agree with this. Could change down the road, but we're miles away from being able to ethically recommend it at this point.
 
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Wouldn't it have a use for very treatment resistant depression? STAR*D showed the response rate for additional antidepressant meds after the 3rd were abysmal. Like 7 to 10% remission when you switch to a fourth, and likely worse if you switch to a 5th, 6th, etc. At what point would TMS cross that cost-benefit line? After the 4th med? 6th?
 
whopper said:
And so too are several other antidepressant augmentation agents such as Buspirone, Lamictal, thyroid hormone, another antidepressant of a differing mechanism.....

Not directed at anyone in this thread because I see this everywhere. Don't jump on the Abilify Kool-Aid bandwagon. Yes, there's a place for it in antidepressant augmentation, but IMHO it shouldn't not be first-line unless there's specific clinical indications for that med.
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Totally agree...
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001403
 
SteinUmStein said:
If they are severely depressed and actively suicidal, why not just do ECT? Seems like that would be much safer and more efficacious, even with the higher side effect profile. Suicidality is more worrisome than temporary memory loss in my opinion.
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I know this is an old thread, but I agree with this. I think ECT is for people who are actively suicidal. More than likely these patients have tried antidepressant medications that haven't been helpful, and to wait to see if TMS would work is to risky.
 
Caldwell-Luc said:
I know this is an old thread, but I agree with this. I think ECT is for people who are actively suicidal. More than likely these patients have tried antidepressant medications that haven't been helpful, and to wait to see if TMS would work is to risky.
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A lot of people don't want ECT.
 
shan564 said:
A lot of people don't want ECT.
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Plus you should also see if there suicidal thoughts are caused by depression or by bpd. I know a lady who had ect for bpd because her psychiatrist thought it would be good for her and it ended up making her worse.
 
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softballtennis said:
Plus you should also see if there suicidal thoughts are caused by depression or by bpd. I know a lady who had ect for bpd because her psychiatrist thought it would be good for her and it ended up making her worse.
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Well, that's true for everybody, regardless of if you're considering ECT.
 
shan564 said:
A lot of people don't want ECT.
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Sometimes it can't be helped especially if the patient attempted recently. I know this is anecdotal. But, I know of two cases were ECT was so helpful that these individuals are no longer in psychotherapy or having to take medication. However, there are longitudinal studies that indicate there are relapse rates.
 
notdeadyet said:
I'd be okay using it as a research tool, but the evidence isn't there for recommending it as a reasonable treatment modality.

For me, the test is this: would I recommend a patient to a TMS system I didn't own? I sure don't now, and don't know anyone who does. I have a hunch that the only practices that enthusiastically recommend TMS are the ones that own a machine. What a coincidence!
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Not necessarily, although anecdotal: in my area only one provider owns a machine. He is pretty well know in the community for TMS. In fact, his name is associated with TMS. He gets tons of referrals from other psychiatrists.
 
Caldwell-Luc said:
Sometimes it can't be helped especially if the patient attempted recently. I know this is anecdotal. But, I know of two cases were ECT was so helpful that these individuals are no longer in psychotherapy or having to take medication. However, there are longitudinal studies that indicate there are relapse rates.
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Of course, that's a given. But there's a large number of patients who are likely to benefit from ECT, but don't need it urgently, and are quite vehemently opposed to the idea.
 
softballtennis said:
Plus you should also see if there suicidal thoughts are caused by depression or by bpd. I know a lady who had ect for bpd because her psychiatrist thought it would be good for her and it ended up making her worse.
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An ECT provider actually mentioned that it can still be helpful no matter what the severe depression is caused by. However, this doesn't make sense. If the depression is situational, then it is likely to come back.
 
I have been told that there is research that shows that ECT can cause permanent brain damage as measured by decrease in FSIQ and that the more sessions you have the more the likelihood of this occurring. This was from my supervisors during my internship who were getting the data to stop the hospital from continually zapping a treatment-resistant patient with BPD (i.e., obnoxious, angry patient who wouldn't stop cutting even when staff told her to knock it off). The speculative cause they put forth was that seizures, regardless of their origin can lead to brain damage. As this is not my area of expertise, and I don't have time to research it personally, I am just putting that out there.

Also wanted to second the sentiment about the bells and whistles phenomena. That is why I am so against the flashing lights of a popular trauma treatment. We have real science that show that our treatments work including both medications and talk therapy and fad of the day treatments take away from our credibility.
 
Over the years, there have been a lot of device based therapies. They came and went with fair regularity and were so preliminary they aren’t in text books or many papers. TMS seems to be an exception. Medical device companies continue to pour research and development money into studies, and most text books now include TMS in their chapters on somatic therapies. Granted, it is very hard to create a real sham TMS arm; because it produces some sensations, and it is a real set up for inducing placebo responses, but it does seem to be of some use. The price really has to come down. Maybe someday there will be a black market and TMS bars will be replacing all of those ridiculous oxygen bars. :D
 
smalltownpsych said:
I have been told that there is research that shows that ECT can cause permanent brain damage as measured by decrease in FSIQ and that the more sessions you have the more the likelihood of this occurring. This was from my supervisors during my internship who were getting the data to stop the hospital from continually zapping a treatment-resistant patient with BPD (i.e., obnoxious, angry patient who wouldn't stop cutting even when staff told her to knock it off). The speculative cause they put forth was that seizures, regardless of their origin can lead to brain damage. As this is not my area of expertise, and I don't have time to research it personally, I am just putting that out there.

Also wanted to second the sentiment about the bells and whistles phenomena. That is why I am so against the flashing lights of a popular trauma treatment. We have real science that show that our treatments work including both medications and talk therapy and fad of the day treatments take away from our credibility.
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There is real science behind ECT and TMS. Ketamine injections however are not FDA approved.
 
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