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An Introduction to Transcranial Magnetic Stimulation in the Veterans Administration PowerPoint Presentation

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An Introduction to Transcranial Magnetic Stimulation in the Veterans Administration Presented by: Megan Reif, RN On February 21, 2018
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Be able to explain what TMS is and who may benefit from treatment Describe the VA rTMS National Clinical Program Know how to contact your local TMS provider and the national team Discuss how Suicide Prevention and Reach-Vet Coordinators could partner with TMS clinics to help Veterans. Objectives:
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Repetitive Transcranial Magnetic Stimulation Non-invasive therapy for treatment resistant Major Depressive Disorder FDA approved since 2008 Daily treatments in outpatient setting over approximately 1 month What is rTMS?
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The Brain an Electrochemical Organ Chemical Side: Medications Electrical Side: Neurostimulation Examples: rTMS, ECT Lattimore et al., 2005.
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TMS Modulates Excitability in a Frequency Dependent Manner Cortical Excitability Chen et al, 1997; Wu et al, 2000 Low 1 Hz or less More than 1 Hz
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Brain Networks Targeted
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How do ECT and TMS differ?
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rTMS is focal Jalinous, 1995
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Dec 2008, FDA approval TMS treatment for “Major Depressive Disorder in adult patients who have failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode". July 2011, FDA classified the rTMS system into class II (special controls) "in order to provide a reasonable assurance of safety and effectiveness of these devices". FDA Approval:
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When is TMS used?: Treatment-Resistance Continuum Kessler RC et al. Arch Gen Psychiatry. 2005;62(6):617-627; Kessler RC et al. JAMA. 2003;289(23):3095-3105; Herrmann RC. Am J Psychiatry. 1995;152(6):869-875.
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3 minutes TMS Video:
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Daily outpatient procedure. Ok to drive afterwards. Allows for frequent monitoring of patient. Low side-effect profile Well tolerated in medically complex patients Provides a treatment option for those resistant to medications or therapy Generally accepted by Veterans as a novel technology and has less stigma than ECT. TMS Advantages:
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Transportation: Requires daily treatment for 4-6 weeks. Time: Standard treatment session lasts 37 minutes. (clinicians may shorten this or provide multiple treatments in a day depending on their practice decisions.) Resource intensive: Limited clinic throughput per day. For safety patient needs to be on stable medications, stable medical condition, no active substance abuse especially Stimulants. May not be the best tool for crisis intervention although inpatient TMS is being considered. TMS Disadvantages:
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Side Effects Mild headache (1/3 of patients after first tx) Mild discomfort at site of stimulation Temporary increase in auditory threshold (without ear plugs) Induced mania (rare) Induced seizure (rare) TMS Safety:
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TMS Contraindications: Increased seizure risk Seizure disorders Brain tumor, major stroke, meningitis Severe head trauma Heavy alcohol use, stimulant use Use of medications that significantly lower seizure threshold Infection Lack of sleep Ferrous Metal & Implants (Similar to MRI) Metal in head – shrapnel, surgical clips, welding fragments Pacemaker Intracardiac lines Ocular or cochlear implant Implanted medication pump Rossi 2009
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National Clinical rTMS Team
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Chair’s office for CSP556 rTMS and MDD Research in the VA 7 year project. 9 VA sites, 164 Veterans Participated Sham controlled 50/50 study Pending publication Other TMS studies at PAD TMS and Gulf War Chronic Pain TMS and Cognition Neuroimaging and TMS TMS and TBI TMS and Addiction TMS and Schizophrenia Palo Alto TMS Background:
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TMS Need - Palo Alto Data: The Jan-March 2016 VAPA Mental Health clinic data showed 950 vets with MDD; 1,829 unique appointments in the mental health clinics. Suicide among veterans continues to be a problem. At Palo Alto there are about 12 completed suicides/year. Last year, approximately 180 pts on the "high risk for suicide" flagging list in CPRS.
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TMS Funding Source: Advocated with mental health leadership for funding Facility has past experience with successful EBP roll-outs Had support of national suicide prevention team Was able to demonstrate feasibility of national program through leadership on multi-site CSP556 research study Ability to show need in the VA system Growing evidence of efficacy and adoption of this technology as a treatment option for major depressive disorder. Inclusion in new VA/DoD guidelines
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National TMS Clinical Pilot Program: Contract with Magstim for 60 TMS machines. Purchased and delivered 30 TMS machines. Future purchases pending additional funding. Developed and Coordinated Training (4 national trainings, about 100 clinicians trained) Assist with clinic start-up and ongoing support Program Evaluation Quarterly CME case conferences Monthly National Calls
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VA TMS Clinics:
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Who to contact for more information: Megan Reif, RN National TMS Clinical Program Coordinator Megan.Reif@va.gov