TMS Therapy - new hope for depression sufferers

TMS: New Hope for Depression Sufferers

no anesthetics or systemic drugs used

Sessions last a little less than an hour

awake, alert and comfortable throughout the session

uses technology that is similar to MRI

non-invasive and non-systemic

TMS: New Hope for Depression Sufferers

By Donna Farris, Writer/Editor, Avera McKennan Hospital & University Health Center

Because millions of depression sufferers do not respond well to traditional treatment, transcranial magnetic stimulation (TMS) is another tool psychiatrists can employ. At Avera, this novel technology is surpassing expectations, with up to 80 percent of patients experiencing improvement.

Avera opened its new TMS clinic in early 2013. While Avera psychiatrist Matthew Stanley, DO, hoped it would help patients, he was surprised to see this non-invasive, non-systemic treatment significantly elevate the mental health status of numerous difficult-to-treat cases. “To say that I’m pleasantly surprised would be putting it mildly. I have been incredibly impressed with this technology.”

TMS has been in development for over two decades. “Early in my practice of psychiatry, I realized that medications don’t work for every patient. We were not able to help every patient with depression return to health and wholeness. I felt like I needed more tools,” Dr. Stanley said.

Dr. Stanley went to Emory University in Atlanta for training on electroconvulsive therapy (ECT), and Avera subsequently became home to state-of-the-art ECT technology. ECT has been used successfully at Avera to treat severe depression for a number of years.

Dr. Matthew Stanley is Vice President for Avera’s behavioral

Also at Emory, research was ongoing with TMS. “I had the opportunity to talk to practitioners in the early stages of its development, and I have kept track of it ever since,” Dr. Stanley said.

health clinical service line. He is also Medical Director of Avera Behavioral Health Services in both Sioux Falls, S.D., and Marshall,

He watched it as it became cleared by the FDA as a treatment for depression, and eagerly awaited results from early adopters of this technology. “When TMS was showing very good clinical success, I started working with leaders at Avera to bring TMS to Sioux Falls. It was an opportunity to treat more patients with cutting-edge technology,” Dr. Stanley said.

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Minn., and is a board-certified psychiatrist with Avera Medical Group University Psychiatry Associates.

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Case after case of patients with complex depression show significant, positive results

Dr. Stanley believes this difference can be attributed to cognitive behavioral techniques and life coaching that accompany the treatment.

A national study reported that 68

TMS involves 30 sessions – every day Monday through Friday for six weeks. During that time, behavioral health technicians teach cognitive behavioral techniques to help improve pathways of thinking.

symptomatic improvement one

“People with depression tend to fall into ruts, and we try to reframe that thinking,” Dr. Stanley said. Life coaching involves improvements in exercise, diet, and sleep and wake patterns.

“We have a captive audience while the patients are receiving their TMS treatment. We use that time to do whatever we can to add to its success.”

It’s common that providers of TMS allow patients to read, watch TV or even sleep. “We keep them engaged from day one,” Dr. Stanley said. “If the brain is kept active during TMS, we see better results.”

Because of frequency of treatments and the length of the treatment course, patients form a connection to staff, and are invited to return for support group sessions, where they share their stories and stay current on cognitive behavioral techniques and life skills.

“Some of our patients would tell you that they are not sure if the counseling and life coaching helped them more, or the TMS. We don’t care, as long as they are getting better,” Dr. Stanley said.

For the past year and a half, TMS has been used at the Avera Behavioral Health Center to treat patients who are not improving on antidepressant medications, or those patients who cannot tolerate medications due to side effects.

“Depression” is an umbrella term that covers a wide range of illnesses. “It’s used to describe everything from prolonged sadness after the death of a spouse, to the after-effects of childhood abuse or neglect, to an inherited chemical imbalance,” Dr. Stanley said.

A lot of people respond well to traditional treatments of medication and counseling, just like a number of people with type 2 diabetes experience successful management with oral medications and lifestyle changes.

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Yet just like there are cases of “brittle diabetes,” when blood sugar is difficult to control despite all efforts to manage it, there are people with depression that’s difficult to impact for the long term.

“There is a form of recurrent, severe disease. It’s almost like the depression actively fights the medications. Medications work for awhile and then seem to fail,” Dr. Stanley said.

percent of TMS patients achieved year post treatment. One in two improved significantly, and one in three were free of symptoms.

At Avera, up to 80 percent of patients are seeing improvement with TMS.

Long-Term Results for TMS Therapy Medication and ECT studies:

TMS study:

Antidepressants also have side effects such as headache, nausea, weight gain, decreased sex drive, fatigue, insomnia and constipation.

In the past, Dr. Stanley has reserved ECT for the very complex and difficult cases of depression. “TMS is not equal, yet it treats a much more difficult depression far better than I anticipated,” he said.

“The patients we are treating are very complex.” These patients have dealt with depression for an average of 20 years, and have tried an average of eight different antidepressant medications.

Patients who have tried and failed with four medications have only a 7 to 13 percent chance of seeing success with a different medication.

After achieving remission through medications or electroconvulsive therapy

257 patients went through acute TMS therapy

68%

achieved symptomatic improvement one year after treatment

45%

reported complete remission one year after treatment

13%

remained in remission one year after treatment

Source: TMS for Resistant Depression: Long-Term Results Are In (Caroline Cassels; May 24, 2013)

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As is the case with many new treatments, not many insurance companies are providing coverage for TMS yet. Avera Health Plans is among insurance companies that do cover this treatment.

“Today’s world is more complex in terms of insurance, with people having to make choices about what types of treatment they can receive based on what insurance will and will not cover,” Dr. Stanley said.

Depression often is not well understood by those outside of the specialty of behavioral health. “People with depression keep walking and talking. They don’t look sick, so the disease goes untreated, or it’s not treated as aggressively as other physical conditions that lay you flat on your back,” Dr. Stanley said.

Are You Covered?

Several insurance companies cover TMS. Call Avera Medical Group TMS Therapy at 605-322-4363 today to see if your insurance provider covers it.

“There’s promise that in the future, more insurance companies will recognize its benefits and cover TMS. This treatment has greater acceptance on the coasts, and it will work its way to the Midwest,” Dr. Stanley said. Once this treatment has greater acceptance by payors, Dr. Stanley says he will prescribe it to more patients.

A course of TMS treatment typically costs around $10,000. Yet TMS can actually end up costing less than trying to treat patients with medications, when medications are not effective.

One Avera Patient’s Story With TMS Therapy 18 months pre-TMS

18 months post-TMS

BHS inpatient hospitalizations

3

Zero

Electroconvulsive therapy treatments

8

Zero

Emergency room visits

3

Zero

Careflight

2

Zero

Suicide attempts

3

Zero

Billed to patient 18 months pre-TMS

Billed to patient 18 months post-TMS

ECT

$32,000

$0

Careflight

$13,100

$0

Emergency room/BHS inpatient hospitalizations

$35,500

$0

TMS

$0

$8,000

Total

$80,600

$8,000

If patients end up being hospitalized due to a suicide attempt, or have an emergency room visit due to an overdose, the cost could reach as high as $50,000 or more.

“There are societal costs, as well as costs to the individual, such as missing work and being unable to reach your full potential,” Dr. Stanley said.

“What is it worth to the individual to be able to be at your peak once again?”

Comments heard from patients include: “I am sleeping better, have more energy, can focus, have the ability to think through how I feel, and am able to keep up with work and family.”

Patient Abby Erickson believes TMS saved her life. She would become frustrated and stop taking her medication, and her ongoing struggle reached such depths that she considered suicide. After her treatment, her outlook on life was a stark contrast. “I was happy and healthy.

I discovered who I was all over again.”

This does NOT include medication and psychological/psychiatric therapy expenses.

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Clinical Results

Weekly depression scales, such as the PHQ-9 and IDS-SR, and the Zung anxiety scale can help measure patients’ progress during TMS therapy.

PHQ-9 at Six Weeks 30

SCORE

25

Total score Depression severity

20 15 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

PATIENTS First Visit Score Six-Week Visit Sore

IDS-SR at Six Weeks

1-4 5-9 10-14 15-19 20-27

Minimal depression Mild depression Moderate depression Moderately severe depression Severe depression

Average initial score: 17.15 Average six-week score: 6.26 Average reduction in score: 10.89

Total score

Depression severity

1-4 5-9 10-14 15-19 20-27

Minimal depression Mild depression Moderate depression Moderately severe depression Severe depression

Avera’s average TMS patient is in the moderately severe range. Avera measured the response of 27 TMS patients. On a scale of one to 27, one to four being minimal depression and 20-27 being severe depression, the average patient scored 17.15. After the six-week treatment, that average score dropped to 6.26, with an average improvement of 10.89 points.

Another TMS study Pre-TMS: 18.3

Post-TMS: 9.6

30 25

SCORE

Comparative PHQ-9 Study

Total score Depression severity

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0-5 None 6 -10 Mild 11 -15 Moderate 16 - 20 Severe 21 - 27 Very severe

15 10 5

Avera TMS study Pre-TMS: 17.15

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

PATIENTS First Visit Score Six-Week Visit Sore

Zung at Six Weeks

Average initial score: 15.19 Average six-week score: 6.22 Average reduction in score: 8.96

Post-TMS: 6.26

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Source: TMS for Resistant Depression: Long-Term Results Are In

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Total score Anxiety level

60

20 - 44 45 - 59 60 - 74 75 - 80

SCORE

50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

(Caroline Cassels; May 24, 2013)

Normal levels Mild to moderate anxiety Moderate to severe anxiety Extreme anxiety

Average initial score: 53.78 Average six-week score: 40.04 Average reduction in score: 13.74

PATIENTS First Visit Score Six-Week Visit Sore

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Facts about TMS 03

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Patients hear a clicking sound and feel a tapping sensation on the head

• The most common side effect is mild to moderate discomfort at or near the treatment area, and this symptom lessens as treatment continues.

• There is a rare risk of seizure (one in 30,000 treatments).

05 Patients are awake, alert and comfortable throughout the session, and in fact engage with behavioral health technicians for cognitive behavioral teaching and life coaching.

Patients are seated in a specialized chair.

• These neurons communicate to deeper brain neurons.

• The only exclusions for treatment are implanted or non-removable metallic objects in or around the head.

• Stimulation of deeper brain neurons causes a secondary effect on remaining portions of the brain involved in mood.

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Sessions last a little less than an hour.

What TMS treatment is like: 01 Patients come to the TMS clinic at the Avera Behavioral Health Center five days a week – Monday through Friday for six weeks.

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How TMS works:

Patients can return to their regular activities immediately following the session. There are no restrictions on driving, work or other activities.

• TMS is non-invasive and non-systemic. It uses technology that is similar to MRI. • During treatment, a magnetic coil is placed against the head.

• The coil stimulates neurons in the pre-frontal cortex.

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There are no anesthetics or systemic drugs used.

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Avera Medical Group TMS Therapy 4400 W. 69th St., Suite 200 Sioux Falls, SD 57108 605-322-4363 Avera.org/tms

BHCS-48070-REVAU2514