TMS
Started by PA-CtoMD
Personally, I haven't seen the data to support it. At this point, I'll view it as a fad and insurance companies are reluctant to reimburse for it.
Be sure to check with your malpractice carrier before signing up for this.
I think that there are two major issues with the literature on TMS:
1. Many of the studies only look at treatment-resistant depression, so it would be expected for it to be moderately effective.
2. All of the studies treat depression as a homogeneous illness, and they use essentially the same methodologies. This works when you're testing a drug, since most drugs nonspecifically target a downstream effect (decreased serotonin in the synaptic cleft) of the neuroplastic malfunction that's led to the phenotype of depression. But when you're talking about an intervention that's working directly on action potentials, you should expect that there will be different wiring malfunctions that are causing the same phenotypes with similar downstream effects. TMS studies generally haven't considered this factor because we don't have a good way to do that yet, and so they all target the prefrontal cortex. When it becomes more widely accepted, I think we'll have more research on finding different brain regions to target based on different clinical presentations. An easier thing (but still difficult to study) might be to do trials of TMS in 2-3 different locations for the same patient... I think that such a study would be expensive and difficult, but it would show that different people with similar phenotypes will respond to different forms of TMS because their underlying brain dysfunction is different. Our current approach is akin to treating all leukemia with cytotoxic chemotherapy rather than treating CML with imatinib.
1. Many of the studies only look at treatment-resistant depression, so it would be expected for it to be moderately effective.
2. All of the studies treat depression as a homogeneous illness, and they use essentially the same methodologies. This works when you're testing a drug, since most drugs nonspecifically target a downstream effect (decreased serotonin in the synaptic cleft) of the neuroplastic malfunction that's led to the phenotype of depression. But when you're talking about an intervention that's working directly on action potentials, you should expect that there will be different wiring malfunctions that are causing the same phenotypes with similar downstream effects. TMS studies generally haven't considered this factor because we don't have a good way to do that yet, and so they all target the prefrontal cortex. When it becomes more widely accepted, I think we'll have more research on finding different brain regions to target based on different clinical presentations. An easier thing (but still difficult to study) might be to do trials of TMS in 2-3 different locations for the same patient... I think that such a study would be expensive and difficult, but it would show that different people with similar phenotypes will respond to different forms of TMS because their underlying brain dysfunction is different. Our current approach is akin to treating all leukemia with cytotoxic chemotherapy rather than treating CML with imatinib.
I think the problem with these sorts of concepts is how difficult they would be to achieve in most typical community settings. Even if there is something to the research and it specifies treatment options in a more targeted approach, who is going to *accurately* tease out the 'different clinical presentations' and then effectively tie it back to the pertinent research? I'm going to see psychopharm followups at 45 minutes a pop and I don't have confidence I can do that very well for many patients. So I seriously doubt some psych np who is running through 98023's as fast as the cmhc cracking the whip who found her through an agency will allow is going to do it all that well....
I agree... it'd have to be done by a subspecialist. And we don't yet have the knowledge required to do specific brain-region-targeted interventions routinely. The same way that the oncologists weren't ready to use specific protein-targeted monoclonal antibodies 20 years ago, but now imatinib and trastuzumab are standard treatments.
Since we're talking about TMS, what about biofeedback?
There is stronger evidence that supports biofeedback. I have read through only a little of the literature however. I go to a neuropsychologist for neurofeedback. It is used more for anxiety, performance, insomnia. The percentage of getting help for depression is about 20%
psychologists/other providers sure make a lot of money doing this. A provider can see a whole bunch of patients at the same time.
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Not FDA approved.
I think I'm in the wrong business....
