Questions about DBS, TMS, and ECT?

[Tom4705]

Who administers deep brain stimulation and transcranial magnetic stimulation? Is it the Psychiatrists themselves or some other MD? Does it require some sort of separate training outside of a Psych residency? Is it more lucrative than pharmacotherapy or psychotherapy? Can you speak to it's efficacy?


Can any of these be incorporated in a private practice? Genuinely curious.

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[Stagg737]

DBS is a device surgically implanted by neurosurgeons. A psychiatrist can refer a patient to neurosurgery for this, but outside our academic center Idk anyone who does them. TMS is a larger machine that can be used in PP offices. The psychiatrist would do the initial mapping but afterwards the individual sessions can be done by a tech or nurse if they're trained on how to do it. From what I know the only training "required" is from the company who supplies the machine on how to use it, but obviously I would advise against providing any therapies you're not trained in. ECT can be done "outpatient" but requires a surgical suite with anesthesiology present. You should be trained in ECT in residency and I'd give a yellow flag to programs that don't train residents in ECT.

There's a separate thread about if TMS is lucrative. Bottom line is that it can be if you've got the patient volume for it, which many outpatient psychiatrists won't due to the time requirement to complete a course of TMS. ECT is typically not lucrative compared to general outpatient or cash-only psychotherapy, but it is arguably the best treatment we have in psychiatry other than stimulants for true ADHD.

 

[Merovinge]

Psychiatrists that do ECT on a regular basis are universally rockstars. Outside of the rarest of circumstances it is a low reimbursing, high complexity situation that makes no financial sense if the doc was just worried about their bottom line. People do it because it is so life changing and should be praised for it.

 

[comp1]

It's weird to think of ECT and TMS being compared with DBS. DBS is still very much investigational for anything mental health related. But yes, regardless, psychiatrists won't do much more with that than refer out to a surgeon if it ever did progress beyond research. I always thought of ECT as very high reimbursing, but also...there are very few people who do ECT around me, so it might make more sense for it being low reimbursement.

 

[Stagg737]

It's weird to think of ECT and TMS being compared with DBS. DBS is still very much investigational for anything mental health related. But yes, regardless, psychiatrists won't do much more with that than refer out to a surgeon if it ever did progress beyond research. I always thought of ECT as very high reimbursing, but also...there are very few people who do ECT around me, so it might make more sense for it being low reimbursement.

Fair point about DBS. OP is a UG student who may have minimal actual exposure to psych treatment irl, so makes sense that they'd group procedures together. Asking about ketamine would probably fit better with TMS and ECT, but wouldn't expect a UG (or pre-clinical med student) to know that.

ECT can be expensive for patients, but considering the need for a facility/cost, cost of the machine and equipment, and need for anesthesia (both the med and the docs, lol), the psychiatrist isn't going to be seeing most of what the patient pays. I do ECT several days a month and estimate I get around $175/treatment. My metro has 4 locations that do ECT, one is a VA and the other 3 are hospitals all of which have psych units attached/affiliated.

 

[Sushirolls]

Patients might be very late for traffic, or they miss an appointment, or stop treatment and didn't communicate timely.
Gaps in treatment schedule implode any prospect of big money.
Then there are other schedule issues, some places might need to block time for the anesthesiologist/anesthetist and if you match that schedule block, not having it filled is big loss. But its not as though you can just conjure up patients to fill that potential open schedule. It ebs and flows, just like inpatient, and just like outpatient service inquiries, too.

Other nuances with CMS hard start/stop times pushes back against the classic PACU set up with curtains and moving machine from patient to patient. Anesthesiology can't be working on the the next case until the first case is concluded. That means at most 15min turn over, but a more realistic is 20min. [when I did a PACU based ECT in past, I was doing 30 min blocks, and trying to shave things down to get to 20 min, but just wasn't happening] Some places also push back in OR / PACU giving preference to Ortho or whatever surgical specialist for their patients. So then you risk less time availability for your cases or at minimum idle/down time simply waiting for a bed or room to open up. More than half of ECT is medicare population, so right there income is limited, and a notable chunk can be medicaid too.

So in summary as noted above, the vast majority of ECT services are not a money making service line that's going to get hospital admin to tell ortho they need to wait. In their eyes its at best an opportunity to infill space/personnel underutilization.

The only way to make ECT profitable is some how be in an area with a better payer mix, having enough volume to support 4 or even 5 day service, and have per day treatments that exceed 4 hours of time to mitigate those gaps/cancelations, and if able, have a treatment rate that is faster than every 30 minutes. <--All of this is hard, very hard to achieve.

ECT =/= money. It is a labor of love for the intellect of the procedure, and substantial positive impact it has on patients for drastically improving their function.

*Think you can pull off ECT in ASC? Nope. CMS and many private insurance companies won't reimburse if facility code reflects ASC location. This is its own long story. They have no interest in changing that bureaucratic hiccup.

 

[sloh]

*Think you can pull off ECT in ASC? Nope. CMS and many private insurance companies won't reimburse if facility code reflects ASC location. This is its own long story. They have no interest in changing that bureaucratic hiccup.

I'd like to hear the story

 

[Tom4705]

DBS is a device surgically implanted by neurosurgeons. A psychiatrist can refer a patient to neurosurgery for this, but outside our academic center Idk anyone who does them. TMS is a larger machine that can be used in PP offices. The psychiatrist would do the initial mapping but afterwards the individual sessions can be done by a tech or nurse if they're trained on how to do it. From what I know the only training "required" is from the company who supplies the machine on how to use it, but obviously I would advise against providing any therapies you're not trained in. ECT can be done "outpatient" but requires a surgical suite with anesthesiology present. You should be trained in ECT in residency and I'd give a yellow flag to programs that don't train residents in ECT.

There's a separate thread about if TMS is lucrative. Bottom line is that it can be if you've got the patient volume for it, which many outpatient psychiatrists won't due to the time requirement to complete a course of TMS. ECT is typically not lucrative compared to general outpatient or cash-only psychotherapy, but it is arguably the best treatment we have in psychiatry other than stimulants for true ADHD.

Thank you for the information! Is DBS commonly used for Psychiatric disorders or is it more for neurological issues? Also, is TMS or ECT efficacious for more serious conditions like schizophrenia or bipolar disorder?

 

[Tom4705]

It's weird to think of ECT and TMS being compared with DBS. DBS is still very much investigational for anything mental health related. But yes, regardless, psychiatrists won't do much more with that than refer out to a surgeon if it ever did progress beyond research. I always thought of ECT as very high reimbursing, but also...there are very few people who do ECT around me, so it might make more sense for it being low reimbursement.

I see. What has the research shown for DBS on Psychiatric illness?

 

[DOswag]

I don’t do ECT or DBS. But the group I work for does a lot of TMS. We got trained on how to do the initial mapping and the rest was about the background of TMS, the different coils and types of the specific machine we use, the science of TMS and how it works. Pretty fascinating stuff. Studies show it is significantly more effective at treating depression than meds, symptom burden reduction (with many getting full resolution of symptoms) is around 60+%, and the side effects are much less than meds with the most common thing being a mild headache. It does require high volume to keep the machines running to be very lucrative but it is certainly possible. I know psychiatrists within our group in other states that are pulling 5-700K, I’m on pace for 400K this year. I love TMS and would refer more patients to it but it is a time commitment for the patient and insurance requires multiple med trails/failures before they’ll approve it

 

[tr]

I see. What has the research shown for DBS on Psychiatric illness?

Deep Brain Stimulation for Obsessive-Compulsive Disorder and Depression | Annual Reviews

The field of stereotactic neurosurgery developed more than 70 years ago to address a therapy gap for patients with severe psychiatric disorders. In the decades since, it has matured tremendously, benefiting from advances in clinical and basic sciences. Deep brain stimulation (DBS) for severe...

www.annualreviews.org

Deep brain stimulation for refractory major depressive disorder: a comprehensive review - Molecular Psychiatry

Deep brain stimulation (DBS) has emerged as a promising treatment for select patients with refractory major depressive disorder (MDD). The clinical effectiveness of DBS for MDD has been demonstrated in meta-analyses, open-label studies, and a few controlled studies. However, randomized...

www.nature.com

 

[Stagg737]

Thank you for the information! Is DBS commonly used for Psychiatric disorders or is it more for neurological issues? Also, is TMS or ECT efficacious for more serious conditions like schizophrenia or bipolar disorder?

TMS is not, primarily just for depression and OCD at this point. ECT can be helpful for schizophrenia or bipolar disorder, but more often used for depression and catatonia.