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This presentation gives an over view: of the depression, its symptoms, prevalence, and patho-physiology. It then reviews various treatment options for depression, first starting with medication, and then moving to neuro-modulation. Focus is then on the similarities and differences of ECT and TMS. And finally information is provided about PineWood TMS.
Citation preview
Julie Plummer, RN, CEO
2October 17, 2011
PineWood TMS Supporting Integrated Wellness
PineWood Transcranial Magnetic Stimulation
2Julie Plummer, RN, CEO
3
Why the Name Pinewood TMS?
4
Neuro-Modulation Programs in the North East
LegendPineTree= PineWood TMS, Brattleboro, VTRed Dots= TMSMagenta= ECT + TMSBlue Dots= ECT
Many Patients with Depression Remain Poorly Served:
Kessler RC et al. JAMA. 2003;289(23):3095-3105.
14 Million US Adults
7.2 MillionTreated
6.8 MillionUntreated
3.2 MillionAdequatel
yTreated
4 MillionPoorly Served
Inadequate response
Intolerant to side effects
October 17, 2011 6
Major Depressive Disorder“Adequate” Treatment Is Difficult to Achieve
Adequate Dosage
Adequate Duration
Poor Tolerability
Nonadherence
Safety Issues
Lack of Efficacy
Comorbidities
1. Nemeroff CB. Depress Anxiety. 1996/1997;4(4):169-181; 2. Oquendo MA et al. J Clin Psychiatry. 2003;64(7):825-833; 3. Oquendo MA et al. Am J Psychiatry. 1999;156(2):190-194.
Factors contributing to inadequate treatment include:
Neuro-anatomy and physiology of Major depressive disorder
October 17, 2011
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prefrontalcortex
In MDD, some areas of the
brain are hypoactive
and others are hyperactive.
amygdala
brainstem neurotransmitter centers
thalamus
striatum
anterior cingulate
cortex
hippocampus
hypothalamus
LOW
HIGH
Neural Activity
When there is an appropriate
amount of monoamine
neurotransmitter activity, neuronal activity
throughout the brain functions
normally.
• Monoamine dysfunction is linked to MDD
• Malfunctioning circuits lead to specific symptoms
Major Depressive Disorder: Circuits and Neurotransmitters
8Serotonin (5-HT) Dopamine (DA) Norepinephrine (NE)Monoamine
Neurotransmitters
monoamine neurotransmitte
r projections
concentrationpleasure/interests
guiltsuicidalityworthlessnessmood
sleepappetite
psychomotor fatigue (physical)pleasure/interests
psychomotor fatigue (mental)
guiltsuicidalityworthlessness
mood
Regions implicated in MDD are connected to the
brainstem via monoaminergic circuits
Chemical Antidepressants
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Antidepressant
weight gainsexual
dysfunction
insomnia
nausea
GI distress
blood pressure changes
blurred vision
AntidepressantTherapeutic Effects such
as:
improved mood
increased concentration
reduced feelings of guilt, suicidality, and worthlessness
weight gain
insomnia
agitation dry mouth fatigue
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APA Accepted Treatment Algorithm for MDD
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.
SSRISNRINDRI
TMS
Primary Care• Initial Diagnosis• Early Treatment
Attempts
Psychiatry• Improved
Diagnosis• Improved Dosing• Psychotherapy• New Treatment
Options
Combination & Augmentation
– Atypical Antipsychotics– Mood Stabilizers
MAOI & TCA
ECT
10M
8M
6M
4M
2M
0 1 2 3 4 5 6 7 8
Failed Treatment Attempts in Current Episode
Nu
mb
er
of
MD
D P
ati
en
ts
VNS
Treatment-Resistance Continuum
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ECT Video
October 17, 2011 12
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Transcranial Magnetic Stimulation Therapy System
Treatment coil
Head support unit
Treatment chair
Mobile console
Touchscreen
NeuroStar TMS Therapy System User Manual. Neuronetics, Inc: Malvern, PA; 2008.
TMS Video
October 17, 2011 14
Neuron
TMS Directly Depolarizes Cortical Neurons
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Pulsed magnetic fields from TMS Coil: • induce a local
electric current in the cortex which depolarizes neurons
• elicit action potentials
• cause the release of chemical neurotransmitters
Depolarization leads to action potentials in local neurons and
thereby releases neurotransmitters
Neurons are “electrochemical
cells” and respond to either electrical
or chemical stimulation
TMS Releases Neurotransmitters in the Brain
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Depolarization of neurons in the DLPFC
causes local neurotransmitter release
Depolarization of pyramidal neurons in the DLPFC causes neurotransmitter release in
deeper brain neurons
Activation of deeper brain neurons then exerts secondary effects on remaining portions of targeted mood circuits
Dorsolateral prefrontal
cortex
Cingulate cortex
Kito (2008) J Neuropsychiatry Clin Neurosci
These effects are associated with
improvements in depressive symptoms
TMS Mechanism of Action Summary
TMS Therapy:Specifically targets the underlying brain circuits
involved in mood regulationDirectly depolarizes cortical neurons and
modulates neurotransmitter release in the brainEffects involve both the local and deep neural
circuits in the brainAccomplishes these effects without unwanted
systemic adverse effects
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Feature-Benefits Table
Features Benefits
No Anesthesia Physiological, psychological, logistical
Non-Systemic Minimal side effects, no memory loss or confusion
Non-Invasive TMS is not disfiguring
Concurrent use of other therapies
Potentiate Positive Outcomes
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PineWood TMS in Brattleboro, VT
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The Clinical Role of Psychiatric RNs in TMS
• Initial patient assessment
• Education• Establish
therapeutic
treatment setting
• Observe therapy• Assess patient
outcomes
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Process for Patients Entering PineWood TMS
1. Referral.2. Education.3. Evaluation.4. Informed Consent.
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Process TMS When Treatments are Ordered
1. Treatment Parameters Set.2. Treatment Commences.3. Weekly Assessment of Depression.4. Psychiatrist is Updated Weekly.
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Frequently Asked Questions
• What are the chances it will work?
• How long will it take to feel better?
• How long will the effect last?
• What are the side effects?
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Contact Information
Supporting Integrated Wellness
167 Main StreetBrattleboro, VT 05301
PineWood TMS