TMS: New Hope for Depression Sufferers

non-invasive and non-systemicuses

technology that is similar to MRI

awake, alert and

comfortable throughout the session

Sessions last a little less

than an hour

no anesthetics or systemic drugs used

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TMS: New Hope for Depression Sufferers

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

Dr. Matthew Stanley is Vice

President for Avera’s behavioral

health clinical service line. He is

also Medical Director of Avera

Behavioral Health Services in both

Sioux Falls, S.D., and Marshall,

Minn., and is a board-certified

psychiatrist with Avera Medical

Group University Psychiatry

Associates.

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.

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.

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

“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.

Long-Term Results for TMS Therapy

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

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.

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.

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.

TMS study:

achieved symptomatic improvement one year after treatment

reported complete remission one year after treatment

257 patients went through acute TMS

therapy

68%

45%Source: TMS for Resistant Depression: Long-Term Results Are In (Caroline Cassels; May 24, 2013)

Medication and ECT studies:

remained in remission one year after treatment13%

After achieving remission through medications or electroconvulsive therapy

A national study reported that 68

percent of TMS patients achieved

symptomatic improvement one

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.

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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.

“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.

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.”

One Avera Patient’s Story With TMS Therapy

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.

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

18 months pre-TMS

18 months post-TMS

3

8

3

2

3

BHS inpatient hospitalizations

Electroconvulsive therapy treatments

Emergency room visits

Careflight

Suicide attempts

Zero

Zero

Zero

Zero

Zero

Billed to patient 18 months pre-TMS

Billed to patient 18 months post-TMS

$32,000

$13,100

$35,500

$0

$80,600

ECT

Careflight

Emergency room/BHS inpatient hospitalizations

TMS

Total

$0

$0

$0

$8,000

$8,000

Total score Depression severity

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

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

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PHQ-9 at Six Weeks

Total score Depression severity

1-4 Minimal depression5-9 Mild depression10-14 Moderate depression15-19 Moderately severe depression 20-27 Severe depression

Average initial score: 17.15Average six-week score: 6.26Average reduction in score: 10.89IDS-SR at Six Weeks

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.

Total score Anxiety level

20 - 44 Normal levels 45 - 59 Mild to moderate anxiety 60 - 74 Moderate to severe anxiety 75 - 80 Extreme anxiety

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

Zung at Six Weeks

Comparative PHQ-9 StudyTotal score Depression severity

1-4 Minimal depression5-9 Mild depression10-14 Moderate depression15-19 Moderately severe depression20-27 Severe depression

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

(Caroline Cassels; May 24, 2013)

First Visit ScoreSix-Week Visit Sore

Another TMS study

Avera TMS study

Pre-TMS: 18.3

Post-TMS: 9.6

Pre-TMS: 17.15

Post-TMS: 6.26

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.

First Visit ScoreSix-Week Visit Sore

First Visit ScoreSix-Week Visit Sore

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

30

25

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

30

25

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

80

70

60

50

40

30

20

10

0

SC

OR

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PATIENTS

SC

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PATIENTS

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PATIENTS

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Facts about TMS

How TMS works:•TMSisnon-invasiveand non-systemic. It uses technology that is similar to MRI.

•Duringtreatment,amagnetic coil is placed against the head.

•Thecoilstimulatesneurons in the pre-frontal cortex.

•Theseneuronscommunicate to deeper brain neurons.

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

•Themostcommonsideeffect is mild to moderate discomfort at or near the treatment area, and this symptom lessens as treatment continues.

•Thereisarareriskofseizure (one in 30,000 treatments).

•Theonlyexclusionsfor treatment are implanted or non-removable metallic objects in or around the head.

01Patients come to

the TMS clinic at the Avera Behavioral

Health Center five days a week –

Monday through Friday for six weeks.

02 Sessions last a little less than an hour.

03Patients are seated

in a specialized chair.

05Patients are awake, alert and

comfortable throughout the session, and in fact engage with behavioral

health technicians for cognitive behavioral teaching and life coaching.

06Patients can return to their regular activities immediately following

the session. There are no restrictions on driving, work

or other activities.

07 There are no anesthetics or systemic drugs used.

What TMS treatment

is like:

04Patients hear a clicking sound and feel a tapping sensation on the head

BHCS-48070-REVAU2514

Avera Medical Group TMS Therapy4400 W. 69th St., Suite 200Sioux Falls, SD 57108605-322-4363

Avera.org/tms