y p o
play

Y P O Clinical Applications C of TMS T & O Evidence in - PowerPoint PPT Presentation

Dec 21, 2022 •258 likes •828 views

Y P O Clinical Applications C of TMS T & O Evidence in N O Depression D Adam Stern, M.D. 2553480 E Director of Psychiatric Applications S A Berenson-Allen Center for Noninvasive Brain Stimulation, BIDMC E L Instructor in

  1. Y P O Clinical Applications C of TMS T & O Evidence in N O Depression D Adam Stern, M.D. 2553480 E Director of Psychiatric Applications S A Berenson-Allen Center for Noninvasive Brain Stimulation, BIDMC E L Instructor in Psychiatry Harvard Medical School P

  2. Y P O Overview C T O • TMS Basics in Psychiatry N O • TMS studies in depression D E • Treatment program at BIDMC S A E L P

  3. Y P O Disclosures C T O Research has been supported by N Harvard Catalyst / The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for O Advancing Translational Sciences, National Institutes of Health Award UL1 TR001102) and financial contributions from Harvard University and its D affiliated academic health centers. The content is solely the responsibility of the author and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, E or the National Institutes of Health. S NARSAD Young Investigator Grant from the Brain and Behavior Research A Foundation E L P

  4. Y P O Disclosures (cont.) C T • TMS has been approved for treatment in O treatment-resistant depression though we N may discuss other uses which have not been FDA approved. O D • Some portion of the material has been E shared by other members of the BA-CNBS S A and are used with permission. E L • I have no financial conflicts to report. P

  5. Y P What is the need for non-invasive brain stimulation? O C T O N O D E S A E L P

  6. Y P O Developments in Medical C Treatment of Depression T O 1900 N 1 st century ’30s ’40s ’50s ’60s ’70s ’80s ’90s O D E S “Black Bile” ECT TCAs MAOIs SSRIs A Heterocyclics E Lithium Pharmacologic L Refinements P Courtesy of: ASCP Psychopharmacology Curriculum: “Electroconvulsive Therapy” 6

  7. Y P O What about Electroconvulsive therapy (ECT)? C • Many decades of safety T and efficacy data O • Gold Standard for N treatment-resistant O depression D • Invasive stimulation E requiring anesthesia with S frequent cognitive adverse A effects E Image courtesy of: http://www.nimh.nih.gov/health/topics/brain- L • Enormous stigma stimulation-therapies/brain-stimulation- P therapies.shtml

  8. Y P O C T O N O D E S A E L A.T. Barker P 1984

  9. Y P Electro-Magnetic Induction O C “ I think I got hold of a good thing ” T O N O D E S A E M. Faraday L 29 August 1831 P

  10. Y P Stimulation Coils O C T O N O D E S A E L P

  11. Y Equipment P O Repetitive Stimulators C T O N O D E S A E L P

  12. Y P O Topographic resolution C T O N O D E S A E L P

  13. Y P O C T O N O D E S A E L P Stern AP, Cohen D. Neuropsychiatry 2013.

  14. Y P Scalp to Brain Relation O C T O N O D E S A E L P

  15. Y P TMS Parameters O C T O N O D E S A E L P

  16. Y P rTMS: O Lasting Modulation of Cortical Activity C TMS Sham T TMS O N O 1 Hz D TMS E S A 20 Hz E TMS L P Valero et al. 2002

  17. Y Therapeutic Applications of P O rTMS C • Depression • PD T • Bipolar Disorder • Focal dystonia O • OCD • Epilepsy N • PTSD – Myoclonic epilepsy O • Schizophrenia – Focal status • Auditory Hallucinoses D epilepticus • Pain • Stuttering E – Visceral pain • Tics S – Atypical facial pain A • Neurorehabilitation – Phantom pain E – Neglect L – Aphasia P – Hand weakness

  18. Y P Potential Adverse Effects O C • Common: T – Headache O – Auditory effects N • Rare O – Seizure induction D – Effects on Cognition – Mania E – Endocrine effects S A Safety Guidelines E L Monitoring P

  19. Y P O C T O N O D E 2013_______ Brainsway S DeepTMS A E FDA L cleared P

  20. Y P rTMS in Depression O C T • Kolbinger et al. 1993, 95 O • Grisaru et al. 1994 • George et al. 1996 N O D • Pascual-Leone et al. 1996 – Double Blind E – Multiple Control Conditions S – 17 patients A – 9/17 with ∂HDRS > 50% E L P Lancet 1996

  21. Y rTMS for depression treatment P O Efficacy - Review C T O N O D E S A E L P Gershon, Dannon and Grunhaus (Am J Psychiatry 2003; 160:835–845)

  22. Y P O C T O N O D E S A E L P

  23. Y P O Sen-Star Treatment Link C 4 key functions: T O * Contact sensing to ensure N treatment coil is positioned correctly O * Magnetic field confirmation D to ensure patient receives desired treatment E * Surface field cancellation to S reduce stimulation of the A scalp E * Charge approximately $100 L per treatment P

  24. Y P O Stimulation Parameters C T O 10 pulses/sec N 120% of motor threshold O D 3000 pulses/session E 4–6 weeks S A Iron-core coil E L P

  25. Y P O C T O N O D E S A E L P

  26. Y P O C T O N O D E S A E L P

  27. Y P O Study 101 Trial Design C Randomized, Double-blind, Sham-Controlled T Phase I Phase I I Phase I I I O Drug-Free Acute Treatment Phase Taper Phase 6 weeks 3 weeks Lead-I n N 7-10 days NeuroStar TMS Therapy O (N= 155) [TMS Taper D + Open-label n= 325 AD Mono-Rx] E Sham TMS S (N= 146) A Randomization E Primary Timepoint @ 4 weeks L Secondary Timepoint @ 6 weeks P Durability of Effect @ 9 weeks

  28. Y P O C T O N O D E S A E L P

  29. Y P O C T O N O D E S A E L P

  30. Y P O C T O N O D E S A E L P

  31. Y P O C T O N O D E S A E L P

  32. Y P O How does TMS compare to other approaches C for treatment-resistant depression? T O N • Olanzapine/Fluoxetine (Thase, 2007): 0.33 O • Aripiprazole (Marcus, 2008): 0.34 D E • Neurostar TMS Therapy (Demitrack, 2009): 0.52 S A • Brainsway DeepTMS (Levkovitz, 2015): 0.76 E • Electroconvulsive Therapy (UK ECT Review Group, 2003): 0.91 L P

  33. Y P Brainsway DeepTMS: A New Device O C T O N O D E S A E L P

  34. Y P CONSORT O C T O N O D E S A E L P

  35. Y P O DeepTMS HDRS Change C T O N O D E S A E L P Levkovitz, et al. World Psychiatry 2015;14:64–73

  36. Y P O C T O N O D E S A E L P

  37. Y P Is this as good as it gets? Probably Not. O C T O N O D E S A E Oliveira-Maia A, Press DZ, Pascual-Leone A. (preliminary/submitted): L Modulation of motor cortex excitability predicts antidepressant response to P prefrontal cortex repetitive transcranial magnetic stimulation.

  38. Y P What about Stim. Target? O C T O N O D E S A E L P

  39. Y P Patient Referral O C T • For patients with O medication resistant N depression O • Must be under care of D psychiatrist E • Referral form on S tmslab.org or call: A E 667-0307 L P

  40. Y P Initial Evaluation O C T • Referral from treating psychiatrist O • Neurology N – Contraindications O – Effect of medication on TMS D • Psychiatry E – Caution if: Psychotic depression, bipolar, personality disorders S A – At least one adequate trial of antidepressant medication E L P

  41. Y P O C T O N O D E S A E L P

  42. Y P Consent O C T • Discussion of on-label vs. off-label treatment O N • Explanation of side-effects O – Seizure D – Headache E – Neck pain S – Scalp pain A E L P

  43. Y P Initiation Phase O C T • Treatments daily (excluding weekends) O • Various mood assessments N daily/weekly/monthly O • Minimum 2 weeks D • Maximum 4-6 weeks E S A E L P

  44. Y P Assessment tools O C T • Beck, Hamilton, Analogue scale O • Target symptoms N • Clinician evaluation of patient O • Other sources of information (e.g. family, referring psychiatrist) D • Side effects questionnaire E S • Weekly meeting of all staff to discuss progress A E L P

  45. Y P Alternatives being investigated O C T • Choosing protocol on clinical parameters O (anxiety, risk of mania/sz) N • Using rs-fMRI guidance for targeting O • Using anatomical MRI to help with intensity of D stimulation (particularly in elderly) E • Plasticity measures as guide S A • Others: mood induction, more than one E session/day L P

  46. Y P O C T O N O D E S A E L P

  47. Y P Maintenance Phase O C T • Minimal evidence (absence of evidence, not evidence O of absence) N • Relapse prevention O – Start with weekly treatment D – Gradually space out sessions E • “Watchful Waiting” S – Patient presents when feeling worse A E L P

  48. Y P Cost O C T • Insurance coverage depends on location O – Medicare jurisdiction N – Private payers O • Additional fee for assessments D • Helping with billing, talking with payers E S A E L P

  49. Y P O C T O N O D E S A E L P

Recommend

More recommend