"Best" TMS Device?

[FlowRate]

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Hi All,

We're looking at potentially starting a TMS service line. I'm working through various resources to try and learn more about the differences in price and features between different devices. That said, I would greatly appreciate if anyone has some recommendations from their own experience or research.

Thanks!

A good source for a higher level overview that I found: The complex landscape of TMS devices: A brief overview - PMC.

 

[mistafab]

Which indications will you all be using it for?

I've had experience with neurostar and brainsway. Currently we do rtTMS but it requires the FMRI. Previously we just did the headcap landmark-type interventions. Had good experiences with both but the fMRI guided rtTMS has definitely been higher level in terms of %response/remission.

I've had no experience with the tms for nicotine use disorder, but was really interested in seeing that.

 

[splik]

Magventure is the one that is most commonly used by the reputable practices around here (including the academic centers and Kaiser). Some of them also have Brainsway as well.

 

[FlowRate]

Which indications will you all be using it for?

I've had experience with neurostar and brainsway. Currently we do rtTMS but it requires the FMRI. Previously we just did the headcap landmark-type interventions. Had good experiences with both but the fMRI guided rtTMS has definitely been higher level in terms of %response/remission.

I've had no experience with the tms for nicotine use disorder, but was really interested in seeing that.

That's really interesting. Are you doing research or are people paying out of pocket for fMRI? (I'm assuming insurance doesn't cover fMRI.)

Would primarily be for MDD although would like the option to try other indications as they become more evidence-based/FDA-approved/insurance covered.

Magventure is the one that is most commonly used by the reputable practices around here (including the academic centers and Kaiser). Some of them also have Brainsway as well.

Thanks. I imagine people usually opt for the devices that are TBS capable?

 

[Stagg737]

That's really interesting. Are you doing research or are people paying out of pocket for fMRI? (I'm assuming insurance doesn't cover fMRI.)

Would primarily be for MDD although would like the option to try other indications as they become more evidence-based/FDA-approved/insurance covered.

Thanks. I imagine people usually opt for the devices that are TBS capable?

Our academic center uses Brainsway for mostly MDD (occasionally OCD). I don't currently do TMS, but am trying to get into it in the next few months, so curious about others' thoughts on devices as well.

 

[mistafab]

That's really interesting. Are you doing research or are people paying out of pocket for fMRI? (I'm assuming insurance doesn't cover fMRI.)

Would primarily be for MDD although would like the option to try other indications as they become more evidence-based/FDA-approved/insurance covered.

Thanks. I imagine people usually opt for the devices that are TBS capable?

Currently it is cash only for treatment. The data is so compelling for MDD (even TRD) though that I don't think insurance will be able to block the fMRI -> rtTMS pathway for long.

 

[psydocc]

From a practical standpoint, any FDA approved machine will work for an insurance based practice using the machine for regular MDD protocol. "Best" would utilize fMRI but that isn't covered by insurance. Some might feel that faster (SAINT/TBS) is better, but again that wouldn't be covered by insurance. I have no doubt that newer/better protocols will become FDA approved in the future, but by the time that happens it will likely be the end of life expectancy for a machine that you buy now anyways. I'd avoid any pay per click offers (neurostar does this I think?)

 

[Merovinge]

Has there been anymore f/u to the SAINT style TMS efficacy.

 

[mistafab]

Has there been anymore f/u to the SAINT style TMS efficacy.

From the very limited sites doing it (including where I am), the data seems to be supportive of the original data. I think there is ongoing debate and exploration regarding what to do regarding maintenance afterwards.

 

[Merovinge]

From the very limited sites doing it (including where I am), the data seems to be supportive of the original data. I think there is ongoing debate and exploration regarding what to do regarding maintenance afterwards.

Pardon my ignorance but what is keeping this from more widespread use? That would be the largest breakthrough in the treatment of depression across the history of mankind. Is it due to patents or some other force limiting the widespread studies/adoption?

 

[mistafab]

Pardon my ignorance but what is keeping this from more widespread use? That would be the largest breakthrough in the treatment of depression across the history of mankind. Is it due to patents or some other force limiting the widespread studies/adoption?

It is (currently) extraordinarily expensive, and not covered by insurance. It requires the FMRI which many places just dont have access to. It requires a psychiatrist involved to personally read the FMRI to calibrate the machine. It takes a week straight of treatments which take most the day, which requires staff and supportive relationships to be available for this.

Based off my biased, skeptical perspective - insurance will put off approving this for as long as humanely possible.

 

[Merovinge]

It is (currently) extraordinarily expensive, and not covered by insurance. It requires the FMRI which many places just dont have access to. It requires a psychiatrist involved to personally read the FMRI to calibrate the machine. It takes a week straight of treatments which take most the day, which requires staff and supportive relationships to be available for this.

Based off my biased, skeptical perspective - insurance will put off approving this for as long as humanely possible.

That's really helpful for my understanding. Is there a real pathway for reducing the extraordinary costs? I recall how much fMRI was running 10 years ago and it was absurd, I presume this has come down some but then requiring so much coil time as well...

 

[clozareal]

I'm looking into expanding my practice into a TMS practice as well now that two devices have FDA clearance for adolescent depression as 1st line, which I think is excellent as the side effect profile of SSRIs (suicidality, manic switch, sexual side effects during a time of rapid sexual development/exploration, weight gain) are much worse than TMS in this age group and the efficacy seems similar. We can debate whether it separated from placebo for the TMS trials although only one SSRI separated from placebo for adolescents anyways because the high placebo response rate, which might not be the case with TRD.

I spoke with MagStim who told me that their neuronavigation doesn't require fMRI data although you can definitely get an add on to upload that MRI data into the system (not sure if they can do fMRI). They said that they can do it based on external landmarks but I'm not sure how that is any better than the F3 measurement system or if it's anywhere near as accurate as MRI data. It looks like non-MRI-guided < structural MRI guided < fMRI guided from here.

Looking into MagVenture, Brainsway, and NeuroStar too. Anyone else have any guidance here? @FlowRate did you get one?

 

[psych_0]

It is (currently) extraordinarily expensive, and not covered by insurance. It requires the FMRI which many places just dont have access to. It requires a psychiatrist involved to personally read the FMRI to calibrate the machine. It takes a week straight of treatments which take most the day, which requires staff and supportive relationships to be available for this.

Based off my biased, skeptical perspective - insurance will put off approving this for as long as humanely possible.

How much is your all-in cost to patients (including the fMRI and all treatments)?

 

[mistafab]

How much is your all-in cost to patients (including the fMRI and all treatments)?

Ballpark is 25-30k

 

[Merovinge]

I'm looking into expanding my practice into a TMS practice as well now that two devices have FDA clearance for adolescent depression as 1st line, which I think is excellent as the side effect profile of SSRIs (suicidality, manic switch, sexual side effects during a time of rapid sexual development/exploration, weight gain) are much worse than TMS in this age group and the efficacy seems similar. We can debate whether it separated from placebo for the TMS trials although only one SSRI separated from placebo for adolescents anyways because the high placebo response rate, which might not be the case with TRD.

I spoke with MagStim who told me that their neuronavigation doesn't require fMRI data although you can definitely get an add on to upload that MRI data into the system (not sure if they can do fMRI). They said that they can do it based on external landmarks but I'm not sure how that is any better than the F3 measurement system or if it's anywhere near as accurate as MRI data. It looks like non-MRI-guided < structural MRI guided < fMRI guided from here.

Looking into MagVenture, Brainsway, and NeuroStar too. Anyone else have any guidance here? @FlowRate did you get one?

Really agree to disagree that side effect profile of SSRIs in adolescents is anything like you are making it out to be. Suicidality increases the most in places with the lowest SSRI prescriptions and lowering sexual drive for adolescents is both almost never impairing and likely a positive with outcomes from early sexual intercourse being anything but good. Weight gain is possible but very rare on Prozac and Lexapro, and still relatively rare on Zoloft (and realistically those are the only 3 you would ever prescribe an adolescent except for rare instances of treatment refractory OCD).

TMS requires so much time that scheduling it for an adolescent can cause harm if you are impairing the ability to go to school or do extracurriculars. I am very pleased about having TMS in the arsenal, but if you are suggesting replacing the first SSRI script for every adolescent with TMS I think that's a wild decision based on available evidence.

 

[clozareal]

Really agree to disagree that side effect profile of SSRIs in adolescents is anything like you are making it out to be. Suicidality increases the most in places with the lowest SSRI prescriptions and lowering sexual drive for adolescents is both almost never impairing and likely a positive with outcomes from early sexual intercourse being anything but good. Weight gain is possible but very rare on Prozac and Lexapro, and still relatively rare on Zoloft (and realistically those are the only 3 you would ever prescribe an adolescent except for rare instances of treatment refractory OCD).

The risk of suicidality with SSRIs in adolescents isn't negligible. When the FDA black box warning came in, the lack of treatment has driven up depression and suicdiality in places where prescriptions of SSRIs decreased for teenagers, but that's correlational rather than causal. That trend reflects the consequences of undertreatment rather than proving that SSRIs themselves cause/worsen suicidality in depressed teens. We know that untreated depression correlates with higher risk. The meta-analyses show a real increase risk of suicidality compared to placebo and I'm not one to ignore the black box warning.

I have a big problem with discouraging sexual exploration in teenagers being a seen as a positive outcome as a side effect of medication. I disagree that it's "almost never impairing" but rather it's not discussed as thoroughly or evaluated systematically in clinical practice.

Weight gain isn't "very rare" either. Fluoxetine tends to be more weight neutral but I've definitely had patients gain significant weight on it.

I prescribe SSRIs often for depressed, anxious, OCD teens. I have many treatment resistant teens as well. It's nice to have something in the arsenal, even as a first line before medication. I agree that it's not a benign intervention and can be time intensive, but much less than an IOP program which I do frequently recommend for those who are significantly impaired in school and extracurriculars anyways.

I'm not saying it should replace SSRIs, but it should be part of our armamentarium of options we can consider earlier on in the course of treatment, as early as first line depending on patient preference.

 

[splik]

Really agree to disagree that side effect profile of SSRIs in adolescents is anything like you are making it out to be. Suicidality increases the most in places with the lowest SSRI prescriptions

A lot of people used observational data to claim that reduced SSRI use increased suicidality, but RCTs which are far superior consistently show an increased risk of suicidal ideation (but not completed in suicide) in adults and younger adults. Also the observational data is mixed, while the RCTs and meta-analyses are quite consistent. It is really an abuse of data to claim otherwise. Even in healthy people without a mental disorder there is an increased risk of suicidal ideation compared with placebo. The risk is low with a NNH of 143. So while the risk has probably been overblown, the strength of the evidence for this is quite strong.

 

[calvnandhobbs68]

I'm looking into expanding my practice into a TMS practice as well now that two devices have FDA clearance for adolescent depression as 1st line, which I think is excellent as the side effect profile of SSRIs (suicidality, manic switch, sexual side effects during a time of rapid sexual development/exploration, weight gain) are much worse than TMS in this age group and the efficacy seems similar. We can debate whether it separated from placebo for the TMS trials although only one SSRI separated from placebo for adolescents anyways because the high placebo response rate, which might not be the case with TRD.

I spoke with MagStim who told me that their neuronavigation doesn't require fMRI data although you can definitely get an add on to upload that MRI data into the system (not sure if they can do fMRI). They said that they can do it based on external landmarks but I'm not sure how that is any better than the F3 measurement system or if it's anywhere near as accurate as MRI data. It looks like non-MRI-guided < structural MRI guided < fMRI guided from here.

Looking into MagVenture, Brainsway, and NeuroStar too. Anyone else have any guidance here? @FlowRate did you get one?

Uh are you aware of what the actual clearances are?

Neurostar
The FDA reviewed this data set alongside clinical literature and concluded that NeuroStar TMS, when used as an adjunct to antidepressant therapy, is substantially equivalent in terms of safety and effectiveness compared to antidepressant therapy alone in this population.

Magstim
For Adolescents: Horizon 3.0 Transcranial Magnetic Stimulation Therapy Systems are indicated as an adjunct for the treatment of MDD in adolescent patients (age 15-21).

I also said this when the Neurostar clearance came out last year but it seems to be based on mostly internal data from, guess who, these companies that I can't find easily anywhere. If someone has the actual data that led to these clearances, that would be interesting because I've found it pretty difficult to figure out what these were actually based on.

 

[Stagg737]

A lot of people used observational data to claim that reduced SSRI use increased suicidality, but RCTs which are far superior consistently show an increased risk of suicidal ideation (but not completed in suicide) in adults and younger adults. Also the observational data is mixed, while the RCTs and meta-analyses are quite consistent. It is really an abuse of data to claim otherwise. Even in healthy people without a mental disorder there is an increased risk of suicidal ideation compared with placebo. The risk is low with a NNH of 143. So while the risk has probably been overblown, the strength of the evidence for this is quite strong.

Sources? I've explored this pretty intensively and found the data to be very dubious, especially considering the rates of reported SI with SSRI use dramatically increasing after the black box warning was added because of reports from phase 4 trials. I would go so far as to say in practice the ONLY times I see patients start SSRIs and develop significant SI are in those with significant personality dysfunction (where everything causes side effects). Maybe 1 or 2 rare cases where starting SSRIs or significant dose changes led to manic symptoms. Also, worth noting the difference between SI and suicidal behaviors, the latter of which I'm even less convinced of.

 

[clozareal]

Uh are you aware of what the actual clearances are?

Neurostar
The FDA reviewed this data set alongside clinical literature and concluded that NeuroStar TMS, when used as an adjunct to antidepressant therapy, is substantially equivalent in terms of safety and effectiveness compared to antidepressant therapy alone in this population.

Magstim
For Adolescents: Horizon 3.0 Transcranial Magnetic Stimulation Therapy Systems are indicated as an adjunct for the treatment of MDD in adolescent patients (age 15-21).

I also said this when the Neurostar clearance came out last year but it seems to be based on mostly internal data from, guess who, these companies that I can't find easily anywhere. If someone has the actual data that led to these clearances, that would be interesting because I've found it pretty difficult to figure out what these were actually based on.

There's no need to be condescending—especially when your confidence might be misplaced since you might be wrong about what you are "aware of."

The actual language is "adjunct to treatment of depression." It's an adjunct to the standard of care, which includes both psychotherapy and oral medications, but not necessarily both. It doesn't explicitly say anywhere that they have to fail a medication or be on a medication at the same time, which is different than the indication for adults.

The proposal that NeuroStar submitted is here including some of their data.

 

[calvnandhobbs68]

Are you? The actual language is "adjunct to treatment of depression." It's an adjunct to the standard of care, which includes both psychotherapy and oral medications, but not necessarily both. It doesn't explicitly say anywhere that they have to fail a medication or be on a medication at the same time, which is different than the indication for adults.

The proposal that NeuroStar submitted is here including some of their data.

Lol falling for the intentionally vague language are we? Their actual data is:

"In summary, the large real‐world data set from the TrakStar database and available published data demonstrates substantially equivalent treatment effect of TMS therapy as an adjunct to antidepressant therapy over antidepressant therapy alone in reducing depression in adolescents that is consistent within and across all studies based on a total of 1,812 adolescents."

I saw the clearance information. That's what I mean, "some" of their data with lots of very important information conveniently left out (like idk for starters literally anything about prior or current concurrent treatment or actual detailed demographic information lol). Lets keep in mind that this is the TMS company that found that 77% of their patients (whose parents were probably paying thousands of dollars for this off label use of TMS and coming to their users clinics multiple times a week) showed improvement after 6 weeks (with no further followup or analysis and no even attempt at any control groups).

The other clearances don't seem to have any sort of data or documents, which makes me think they're just piggybacking off the Neurostar one and stating that their systems are substantially equivalent for adults same way that Neurostar is, so why can't they be used for the same age ranges?

 

[FlowRate]

I'm looking into expanding my practice into a TMS practice as well now that two devices have FDA clearance for adolescent depression as 1st line, which I think is excellent as the side effect profile of SSRIs (suicidality, manic switch, sexual side effects during a time of rapid sexual development/exploration, weight gain) are much worse than TMS in this age group and the efficacy seems similar. We can debate whether it separated from placebo for the TMS trials although only one SSRI separated from placebo for adolescents anyways because the high placebo response rate, which might not be the case with TRD.

I spoke with MagStim who told me that their neuronavigation doesn't require fMRI data although you can definitely get an add on to upload that MRI data into the system (not sure if they can do fMRI). They said that they can do it based on external landmarks but I'm not sure how that is any better than the F3 measurement system or if it's anywhere near as accurate as MRI data. It looks like non-MRI-guided < structural MRI guided < fMRI guided from here.

Looking into MagVenture, Brainsway, and NeuroStar too. Anyone else have any guidance here? @FlowRate did you get one?

Re: Manic switch. I am still not convinced that is actually a thing. Activation syndrome? Absolutely. But one implies latent bipolar disorder and the other goes away on retrial if you treat concurrently with a benzo for week or two.

I determined that it wouldn't be a value added service to spin up right now. The TMS clinics locally are pretty aggressively priced compared to other regions and have the scale that comes with taking multiple insurers and cash patients.

Really agree to disagree that side effect profile of SSRIs in adolescents is anything like you are making it out to be. Suicidality increases the most in places with the lowest SSRI prescriptions and lowering sexual drive for adolescents is both almost never impairing and likely a positive with outcomes from early sexual intercourse being anything but good. Weight gain is possible but very rare on Prozac and Lexapro, and still relatively rare on Zoloft (and realistically those are the only 3 you would ever prescribe an adolescent except for rare instances of treatment refractory OCD).

TMS requires so much time that scheduling it for an adolescent can cause harm if you are impairing the ability to go to school or do extracurriculars. I am very pleased about having TMS in the arsenal, but if you are suggesting replacing the first SSRI script for every adolescent with TMS I think that's a wild decision based on available evidence.

Re: Weight gain. IIRC that's what some early data/Stahl's says about escitalopram, but my clinical experience is that escitalopram is probably 50% more likely to cause weight gain than sertraline. I think it has more in common re: sedation and appetite with citalopram than previously recognized. (Although not nearly as significant.)

 

[aim-agm]

Also, worth noting the difference between SI and suicidal behaviors, the latter of which I'm even less convinced of.

In these discussion I like to note that it is actually quite trivial to induce SI. Just command someone "Don't think about killing yourself" and they will usually automatically think about it. No one would assign any clinical significance to that SI because there is no expectation that it would lead to a suicidal behavior. That reinforces that the question that matters with SRI-induced SI is if it will lead to suicidal behavior, because otherwise it's clinical significance is rather limited.

 

[Merovinge]

Re: Manic switch. I am still not convinced that is actually a thing. Activation syndrome? Absolutely. But one implies latent bipolar disorder and the other goes away on retrial if you treat concurrently with a benzo for week or two.

I determined that it wouldn't be a value added service to spin up right now. The TMS clinics locally are pretty aggressively priced compared to other regions and have the scale that comes with taking multiple insurers and cash patients.

Re: Weight gain. IIRC that's what some early data/Stahl's says about escitalopram, but my clinical experience is that escitalopram is probably 50% more likely to cause weight gain than sertraline. I think it has more in common re: sedation and appetite with citalopram than previously recognized. (Although not nearly as significant.)

Interesting, not at all my experience with Lexapro. I find it firmly in between Prozac and Zoloft in terms of activation/sedation and weight gain. The faster onset makes it quite relevant in IP/PHP/IOP situations so it is often my go to for anyone with comorbid depression and anxiety sx. I still prefer Prozac in depression without significant anxiety, particularly with low energy/anergia and Zoloft for primary anxiety without comorbid depression and particularly with any OCD symptoms.

 

[FlowRate]

Interesting, not at all my experience with Lexapro. I find it firmly in between Prozac and Zoloft in terms of activation/sedation and weight gain. The faster onset makes it quite relevant in IP/PHP/IOP situations so it is often my go to for anyone with comorbid depression and anxiety sx. I still prefer Prozac in depression without significant anxiety, particularly with low energy/anergia and Zoloft for primary anxiety without comorbid depression and particularly with any OCD symptoms.

Here's some stuff:

Weighing in on weight gain from antidepressants - Harvard Health

If you're struggling with depression, the most important question about taking an antidepressant is whether it will work. But another question on your mind may be whether it will fuel weight gain. ...

www.health.harvard.edu

Or this is what openevidence came up with. I only have the screenshot and haven't vetted the sources (it was posted in a chat the other day and I was sent the picture.)

 

[Merovinge]

Here's some stuff:

Weighing in on weight gain from antidepressants - Harvard Health

If you're struggling with depression, the most important question about taking an antidepressant is whether it will work. But another question on your mind may be whether it will fuel weight gain. ...

www.health.harvard.edu

Or this is what openevidence came up with. I only have the screenshot and haven't vetted the sources (it was posted in a chat the other day and I was sent the picture.)
View attachment 404331

I would strongly keep in mind that data on adolescents or children are not equal to date on adults, particularly when we already know of large outliers (e.g. Abilify). That being said the data is already pretty scant both in effect size and in observational study when the majority of patients were not even taking the medication that were included. Clearly an area that needs more research.