TMS for OCD

[keolu hills]

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I have just learned that TMS can be used to treat patients that are suffering from OCD. Is anyone planning on doing this for their patients or referring them to a psychiatrist that does?

Thanks

 

[whopper]

Yes and no.

Of course I want some patients to try it. I've had a few where nothing worked well on them and have even considered cingulotomy to treat their OCD.

The problem is that insurance yet hasn't caught up with the FDA approval and won't pay for it.

Oddly, and I never expected this to happen, I've had several patients with very extreme treatment resistant OCD (tried on several SSRIs, SNRIs, Clomipramine, Luvox, a few atypicals, Buspirone) respond well to Vraylar even when other atypicals were tried and failed. What's going on there I do not know.

 

[TexasPhysician]

Is this like finding a leprechaun?

An OCD patient that has failed multiple meds at actual OCD treatment doses that simultaneously has insurance that covers TMS for OCD probably exists somewhere, but I’ve never seen one.

 

[whopper]

TMS as we all know existed for several years but it was only until recently that the majority of insurance companies were open to paying for it.

I remember years back the guy doing it at U of Cincinnati mentioned something to the effect of they finally had 1 insurance company paying for it and it was one no one ever heard of ever. Almost all the patients had to pay out of pocket.

At the TMS place I'm affiliated with they've done a few OCD TMSs but each person had to pay out of pocket cause insurance wasn't paying.

Due to the above this pretty much eliminates anyone from even considering TMS for OCD unless they are wealthy.

 

[keolu hills]

TMS as we all know existed for several years but it was only until recently that the majority of insurance companies were open to paying for it.

I remember years back the guy doing it at U of Cincinnati mentioned something to the effect of they finally had 1 insurance company paying for it and it was one no one ever heard of ever. Almost all the patients had to pay out of pocket.

At the TMS place I'm affiliated with they've done a few OCD TMSs but each person had to pay out of pocket cause insurance wasn't paying.

Due to the above this pretty much eliminates anyone from even considering TMS for OCD unless they are wealthy.

So, they paid for TMS for depression and not for OCD? Just recently TMS for OCD has been FDA approved. So that is strange.

 

[splik]

So, they paid for TMS for depression and not for OCD? Just recently TMS for OCD has been FDA approved. So that is strange.

The FDA allows marketing of brainsway deep TMS (not any other device or kind of TMS) for OCD. While FDA approval can pave the way for insurance coverage, this is not necessarily the case and can take years. For example, TMS for depression was FDA-approved in 2008, but it wasn't until about 2014 that insurance companies were routinely covering it for refractory depression (typically you would have to fail at least 4 medications and 1 course of evidence based psychotherapy), and it took about 10 yrs for medicare to cover it in many parts of the country. Insurance companies can still commission their own reviews, and deem this indication "investigational" in order to deny it, given there isn't great data to support the use of deep TMS for OCD. Even if they do cover it, it is likely that the same criteria as for DBS for OCD would be used, i.e. failure of at least one SSRI and clomipramine at therapeutic doses, and failure of a trial of exposure and response prevention. Most patients with OCD still do not get access to high quality ERP, the gold standard treatment, which is more of an issue than access to deep TMS.

Personally I find it more odd that insurances wont typically cover bipolar depression, only unipolar depression. so you often see TMS psychiatrists fudging bipolar diagnoses to unipolar so patients can get it covered.

 

[whopper]

Yep answered it for me.

Something concerning depression and TMS that they're currently not covering is there's data showing the maintenance TMS could be very useful for treatment resistant patients where TMS did work, but for whatever reason the benefits went away with time. Most of the time insurance only pays for 1 series of treatments without maintenance treatments.

 

[keolu hills]

Thank you all for your responses.

This doesn't sound too hopeful for even patients suffering from OCD. It our area, it is almost impossible to get Exposure and Response Prevention treatment for patients. This patient did one round of CBT. It might be a good idea for her to try CBT with another psychologist.

 

[WisNeuro]

Is there more data backing up the TMS for OCD thing. Last I saw, there were a few very small n studies, and many of those lacked a sham condition. Have there been some good studies on this in the last year or two?

 

[whopper]

Yes.
One printed in the Green Journal.

Efficacy and Safety of Deep Transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A Prospective Multicenter Randomized Double-Blind Placebo-Controlled Trial - PubMed

High-frequency dTMS over the medial prefrontal cortex and anterior cingulate cortex significantly improved OCD symptoms and may be considered as a potential intervention for patients who do not respond adequately to pharmacological and psychological interventions.

www.ncbi.nlm.nih.gov

 

[clausewitz2]

Thank you all for your responses.

This doesn't sound too hopeful for even patients suffering from OCD. It our area, it is almost impossible to get Exposure and Response Prevention treatment for patients. This patient did one round of CBT. It might be a good idea for her to try CBT with another psychologist.

There are also ACT-oriented approaches to OCD that seem to work reasonably well although not addressing the same phenomenology as ERP. If you live in an area where ACT is more popular this is an option.