Transcranial Magnetic Stimulation

[FrasierMD]

Recent data is now showing TMS could work for treatment-resistant depression.

http://www.medscape.com/viewarticle/804736

This changes things.

Has this been published in a journal yet? This is first I heard of this data. Looks promising.

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[Frazier]

Has this been published in a journal yet? This is first I heard of this data. Looks promising.

I like your name.

 

[notdeadyet]

Recent data is now showing TMS could work for treatment-resistant depression.

http://www.medscape.com/viewarticle/804736

This changes things.

What does? It's a Medscape article from an APA presentation given over a year ago. The claim of 43% complete remission from treatment refractory depression would be very interesting, but I haven't seen that groundbreaking article get published.

A few things that were interesting about this:

• a quick pubmed of the lead investigator and TMS show recent publications using the data he is apparently referring to (42 sites, 250-300 patients, etc.). But the results aren't nearly as impressive as he claimed in the Medscape article (by my admittedly quick read of the pubs).
• the pubs were in CNS Spectrum and Depression and Anxiety. Not exactly what I'd expect for game-changer stuff.
• those involved with the research all list multiple disclosures with the device manufacturer whose system they are studying. In fact, Neuronetics, Inc is the project sponsor. I'm about as skeptical of this project as I would be of "Abilify Maintenna proven to cure psychosis... a study brought to you by Otsuka..."

 

[shan564]

There is real science behind ECT and TMS. Ketamine injections however are not FDA approved.

There's plenty of science behind ketamine too. It's not FDA approved yet.

Has this been published in a journal yet? This is first I heard of this data. Looks promising.

There's all sorts of stuff in journals about TMS for TRD, but as aforementioned, there are lots of problems with this study and with a large percentage of studies...

 

[whopper]

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 don't know what the person was thinking that kept wanting to zap the BPD (you mean borderline PD right?) because ECT isn't supposed to help it unless that person knows something I don't.

 

[whopper]

What does? It's a Medscape article from an APA presentation given over a year ago.

I'm likely being egocentric. Most of the data I've been seeing up to this point showed that TMS had no significant benefit for those treatment-resistant, and this procedure is darned expensive. So my original thought was if this is the case, why even bother with it? TMS vs $4 antidepressant? There's no comparison.

If it does work for treatment-resistant depression, on the other hand, this does create a reasonable place for it to be considered. I was being egocentric in the sense that I was thinking on my own original thought so the above data I found significant-to me. I saw similar data in a recent APA headline but erased that e-mail.

 

[shan564]

I don't know what the person was thinking that kept wanting to zap the BPD (you mean borderline PD right?) because ECT isn't supposed to help it unless that person knows something I don't.

Giving him the benefit of the doubt, he must have thought that the patient had a major depression complicating the BPD.

 

[whopper]

I treated a borderline PD patient on my unit a few months ago and within 3 days went from very suicidal to, in her own words, "completely fine." Seemed like emotional dysregulation to me. She wanted ECT thinking it would cure her of that emotional dysregulation. I told her this was not the case and since she felt fine at the moment it was likely not depression in the Axis I sense of the word.

Yeah I know, like she's going to understand that. Sometimes I don't think even several psychiatrists understand that. I spent what I believe was over 3 hours during her hospitalization trying to explain the difference between an Axis I MDD vs borderline PD and that the latter is better characterized by fluctuating and volatile moods that are often stress-related.

Her son called us, telling us he was a psychologist and insisted we have a family meeting with him and the patient. So we did that and I was expecting a Ph.D. psychologist. In comes a kid wearing a t-shirt and jeans, that looks like he's in his early 20s, calling himself a psychologist, and I asked him his level of education, and he told me he just completed his intro to psychology course and that he was a professional psychologist because he did some volunteer work at the Children's Hospital. (I wish I was joking on that one). He kept trying to browbeat us into doing what his mother wanted-ECT despite that she was feeling fine.

I discharged her. A colleague of mine took up her case a few weeks ago and I found out that since I last saw her, she went to every institution within a 50 mile radius that offered ECT demanding ECT despite that she told them she felt fine, and they all refused.

 

[Caldwell-Luc]

Wow! Just like drug seeking behavior!

 

[OldPsychDoc]

I treated a borderline PD patient on my unit a few months ago and within 3 days went from very suicidal to, in her own words, "completely fine." Seemed like emotional dysregulation to me. She wanted ECT thinking it would cure her of that emotional dysregulation. I told her this was not the case and since she felt fine at the moment it was likely not depression in the Axis I sense of the word.
....
since I last saw her, she went to every institution within a 50 mile radius that offered ECT demanding ECT despite that she told them she felt fine, and they all refused.

I'm reminded of an eloquent second opinion one of my mentors charted on a similar patient--I wish I had the actual quote, but in essence it read: "One suspects that the patient's insistence on receiving electroconvulsive therapy is based more on her desire to experience transient oblivion* as a relief for her symptoms than on any evidence of actual therapeutic response."

*(the phrase that made the note memorable to me.)

 

[xlithiumx]

That phrasing sounds awful familiar OPD. Was that mentor at U of MN?

 

[OldPsychDoc]

That phrasing sounds awful familiar OPD. Was that mentor at U of MN?

No, but she trained there--in the days before the Great Schism.

 

[wolfvgang22]

I'm reminded of an eloquent second opinion one of my mentors charted on a similar patient--I wish I had the actual quote, but in essence it read: "One suspects that the patient's insistence on receiving electroconvulsive therapy is based more on her desire to experience transient oblivion* as a relief for her symptoms than on any evidence of actual therapeutic response."

*(the phrase that made the note memorable to me.)

That is an awesome phrase, I'm stealing it.
Since somebody brought up ketamine, how about some good old LSD?

 

[whopper]

transient oblivion

Wow-two words with the punch of a paragraph.

 

[smalltownpsych]

I don't know what the person was thinking that kept wanting to zap the BPD (you mean borderline PD right?) because ECT isn't supposed to help it unless that person knows something I don't.

Correct. Borderline PD. As to what they were thinking, the staff were frustrated and "had to do something". One doc suggested that maybe the patient was really depressed and that is what led to her chronic self-harm and SI and then groupthink took over. Then after the patient had ECT they were more manageable for a couple of weeks so treatment was considered a success. Then when the patient began to reconstitute, they went back to familiar patterns of negative interactions with others and coping with that through same ways. Conclusion was drawn that she needed more treatment because obviously the depression had returned. The cycle went on for quite a while. For me it illustrated the danger of a purely medical model applied without considering psychological dynamics. It can get really scary and has historically led to some pretty abusive practices.

 

[smalltownpsych]

I treated a borderline PD patient on my unit a few months ago and within 3 days went from very suicidal to, in her own words, "completely fine." Seemed like emotional dysregulation to me. She wanted ECT thinking it would cure her of that emotional dysregulation. I told her this was not the case and since she felt fine at the moment it was likely not depression in the Axis I sense of the word.

Yeah I know, like she's going to understand that. Sometimes I don't think even several psychiatrists understand that. I spent what I believe was over 3 hours during her hospitalization trying to explain the difference between an Axis I MDD vs borderline PD and that the latter is better characterized by fluctuating and volatile moods that are often stress-related.

Her son called us, telling us he was a psychologist and insisted we have a family meeting with him and the patient. So we did that and I was expecting a Ph.D. psychologist. In comes a kid wearing a t-shirt and jeans, that looks like he's in his early 20s, calling himself a psychologist, and I asked him his level of education, and he told me he just completed his intro to psychology course and that he was a professional psychologist because he did some volunteer work at the Children's Hospital. (I wish I was joking on that one). He kept trying to browbeat us into doing what his mother wanted-ECT despite that she was feeling fine.

I discharged her. A colleague of mine took up her case a few weeks ago and I found out that since I last saw her, she went to every institution within a 50 mile radius that offered ECT demanding ECT despite that she told them she felt fine, and they all refused.

You had me worried for a minute until you said that the son was misrepresenting himself! I am glad to hear that the facilities refused. Unfortunately, in a city near our community there was a clinic and psychiatrist who specialized in ECT and espoused that it would do much more than what the research supported. I was just searching for him on-line and could not find it so maybe he closed up shop.

 

[wolfvgang22]

It's probably easier to get insurance to pay for ECT than it is to get them to cover DBT. It's sad.

 

[Indodo]

Okay, so let's say you have a patient with MDD that eventually has psychotic features. You have tried, faithfully, "the protocol" with SSRI, increasing the dose, adding another agent and then going through 5 more. You see some effect but not quite resolution. Now you have a patient on 2 antidepressants and an atypical who is "sort of okay" but doesn't particularly care to be depressed on 3 medications. Lets assume everything else, labs, physical health is without concern.

ECT or TMS? What if it was your parents, spouse, kids etc. What would you choose for yourself?

I think I would want to try TMS in this scenario. If the symptoms are bad, I would opt for ECT.

 

[smalltownpsych]

If the symptoms are bad, I would opt for ECT.

I am confused by what you mean by that. I don't think anyone would recommend ECT or TMS unless the symptoms were bad. In fact, an SSRI probably should not be used unless the symptoms are bad as there is evidence to show that medication tends to have more of an effect the more severe the depression. As I conceptualize it, psychotherapy is the least risky and least invasive procedure and should be first line of treatment for milder depressive symptoms, as severity increases, then medications should be considered, and finally ECT or TMS (if it is really effective which some are debating here). Unless you are making the point that TMS should be used earlier because it is less risky or invasive than medications?

 

[wolfvgang22]

Well, it really depends exactly on what has been tried and how impaired/ill the patient is. Depression related auditory hallucinations usually resolve with the successful treatment of the depression.

If the case is truly refractory, have other meds such as TCA's been tried? What about psychotherapy? What about adjunct medications such as levothyroxine or lithium, to name two? Is the patient doing his/her activities of daily living, going to work, etc? Is the patient suicidal or self harming?

I'd reserve ECT for severe refractory cases or acute patients just because of possible anesthesia side effects and adverse events (is the patient morbidly obese, have COPD, have other health problems?), and some possible memory loss, especially if bipolar ECT is used.

I don't think there are many contraindications to do TMS if money is not a big concern and the patient is not acutely suicidal, self harming, not eating at all, etc.

If it were for myself, for first episode of severe depression with unlimited funds, I'd jump for TMS plus SSRI and CBT/DBT at a nice well-staffed resort, keeping in mind it's probably going to take about 40 sessions of TMS to see same effect as 9 to 12 sessions of ECT. If that didn't work I'd consider ECT. My doctor might disagree.

 

[smalltownpsych]

Well, it really depends exactly on what has been tried and how impaired/ill the patient is. Depression related auditory hallucinations usually resolve with the successful treatment of the depression.

If the case is truly refractory, have other meds such as TCA's been tried? What about psychotherapy? What about adjunct medications such as levothyroxine or lithium, to name two? Is the patient doing his/her activities of daily living, going to work, etc? Is the patient suicidal or self harming?

I'd reserve ECT for severe refractory cases or acute patients just because of possible anesthesia side effects and adverse events (is the patient morbidly obese, have COPD, have other health problems?), and some possible memory loss, especially if bipolar ECT is used.

I don't think there are many contraindications to do TMS if money is not a big concern and the patient is not acutely suicidal, self harming, not eating at all, etc.

If it were for myself, for first episode of severe depression with unlimited funds, I'd jump for TMS plus SSRI and CBT/DBT at a nice well-staffed resort, keeping in mind it's probably going to take about 40 sessions of TMS to see same effect as 9 to 12 sessions of ECT. If that didn't work I'd consider ECT. My doctor might disagree.

I would vote for the well-staffed resort too!

 

[Indodo]

Well, it really depends exactly on what has been tried and how impaired/ill the patient is. Depression related auditory hallucinations usually resolve with the successful treatment of the depression.

If the case is truly refractory, have other meds such as TCA's been tried? What about psychotherapy? What about adjunct medications such as levothyroxine or lithium, to name two? Is the patient doing his/her activities of daily living, going to work, etc? Is the patient suicidal or self harming?

I'd reserve ECT for severe refractory cases or acute patients just because of possible anesthesia side effects and adverse events (is the patient morbidly obese, have COPD, have other health problems?), and some possible memory loss, especially if bipolar ECT is used.

I don't think there are many contraindications to do TMS if money is not a big concern and the patient is not acutely suicidal, self harming, not eating at all, etc.

If it were for myself, for first episode of severe depression with unlimited funds, I'd jump for TMS plus SSRI and CBT/DBT at a nice well-staffed resort, keeping in mind it's probably going to take about 40 sessions of TMS to see same effect as 9 to 12 sessions of ECT. If that didn't work I'd consider ECT. My doctor might disagree.

I agree that ECT is for severe cases where the patient is unable to function, on the cusp of being hospitalized, being hospitalized or needing involuntary commitment due to a mental illness. I have no experience with TMS and have never even considered it until recently although there are a few psychiatrists doing it around here. I would not consider it for anyone who was at risk to themselves because the data doesn't really look that promising.

I guess what I want to know is if other psychiatrists would consider it in an outpatient setting with patients that have partial response with meds and therapy, who can function but not at full capacity. I have a fair number of these patients although not all are as "clean" (no medical problems, good social support, no substance abuse etc) as the ideal picture I painted above. BTW, I try all the usual suspects including lithium, levothyroxine, buspar, atypicals, wellbutrin, remeron, blue light and am in the process of incorporating a cha-cha studio (only for the elderly).

Would you think about TMS in this patient type? Or is the cost too high and the possible benefit not worth it?
I am also suspicious about it being a good investment. None of the mega groups around here do it and they do all the other spammy stuff like vitamins, weight loss, med spa etc.

 

[smalltownpsych]

I agree that ECT is for severe cases where the patient is unable to function, on the cusp of being hospitalized, being hospitalized or needing involuntary commitment due to a mental illness. I have no experience with TMS and have never even considered it until recently although there are a few psychiatrists doing it around here. I would not consider it for anyone who was at risk to themselves because the data doesn't really look that promising.

I guess what I want to know is if other psychiatrists would consider it in an outpatient setting with patients that have partial response with meds and therapy, who can function but not at full capacity. I have a fair number of these patients although not all are as "clean" (no medical problems, good social support, no substance abuse etc) as the ideal picture I painted above. BTW, I try all the usual suspects including lithium, levothyroxine, buspar, atypicals, wellbutrin, remeron, blue light and am in the process of incorporating a cha-cha studio (only for the elderly).

Would you think about TMS in this patient type? Or is the cost too high and the possible benefit not worth it?
I am also suspicious about it being a good investment. None of the mega groups around here do it and they do all the other spammy stuff like vitamins, weight loss, med spa etc.

I think having the old folks cha-cha will probably be the most effective treatment so long as your malpractice insurance will cover the broken hips. lol