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Our Experience Contemporary Care. 15 Valley Drive, Suite 304 Greenwich, CT 06831. 100+ Patients 19 Currently in TMS Treatment. 36 Old Kings Highway South Darien, CT 06820 (203) 321-5063. Patient Outcomes N=100. 10%. 51%. **Indicates 81% Response Rate. -60 Patients remitted

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Our experience contemporary care
Our Experience Contemporary Care

15 Valley Drive, Suite 304

Greenwich, CT 06831

  • 100+ Patients

  • 19 Currently in TMS Treatment

36 Old Kings Highway

South Darien, CT 06820

(203) 321-5063


Patient outcomes n 100
Patient Outcomes N=100

10%

51%

**Indicates 81% Response Rate

-60 Patients remitted

-30 Patients improved

-10 Patients had no response


Patient videos
Patient Videos

Patient is a 24 year old male student at Columbia University treated for severe medication resistant depression. After 6 weeks of high frequency rTMS, his Hamilton score improved from a 36 to a 3 indicating full remission.


Patient videos1
Patient Videos

Patient is a 25 year old female nursing student with medication resistant depression, anxiety, and suicidal ideation. Her Hamilton score improved from a 46 to a 0. The patient continues to be in remission 4 months after completion.


Partial response
Partial Response

  • Partial Responders

    • * One patient exhibited recurring GI cancer, however is now off medication and doing well

    • * 18 year old male was found to be abusing THC

    • * 50 year old female was remitted (HAMD-24 = 4) and then relapsed


Relapses
Relapses

  • Four patients out of 44 completers relapsed after 1-3 months following completion of treatment. (10% Relapse Rate)

  • Man in 50s bipolar depression relapsed but achieved remission again after one treatment of TMS.

  • Woman in 40s with MDD and GAD relapsed after losing her job and her depression responded to 5 TMS treatments over a week but she remains anxious.

  • Man in 50s with severe MDD and anxiety NOS relapsed with severe MDD and has just begun TMS again.

  • Man in 40s with severe MDD and GAD relapsed mildly and is beginning TMS this week.


Evidence based support for other applications
Evidence based support for other Applications

  • Psychiatric Disorders

  • Generalized Anxiety Disorder

  • Bipolar Depression

  • Post Traumatic Stress Disorder

  • Social Anxiety Disorder

  • Substance Abuse

  • Panic Disorder

  • Schizophrenia

  • Attention Deficit Disorder

  • Bulimia

  • Neurological Disorders

  • Asperger’s Disorder

  • Autism

  • Chronic Pain

  • Migraines

  • Tinnitus

  • Tourette’s

  • Alzheimer’s Disease

  • Parkinson’s Disease

  • Stroke


Bipolar disorder
Bipolar Disorder

  • Nahas Study

    • 23 patients with bipolar depression received rTMS or Placebo left prefrontal cortex low frequency, 10 treatments, ddays a week 2 weeks

    • No difference between groups

    • Active rTMS, compared with sham rTMS, produced a trend but not statistically significant greater improvement in daily subjective mood ratings post-treatment (t = 1.58, p = 0.13)

  • Dolberg Study

    • 20 patients received active or sham treatment

    • Difference seen at week 2; change not significant by end of treatment (week 4)

    • Brief report does not say low/high frequency or site of tms administration

  • Cohen Study

    • 22 patients received 3 weeks (15 sessions) of low frequency rTMS as an adjunctive therapy

    • 16 showed improvements

  • Tamas Study

    • 4 patients on active treatment plan compared to 1 patient on placebo treatment plan

    • Group difference seen at week 6

    • DLPFC , low frequency

  • Dell’Osso Study

    • 11 patients received low frequency rTMS in an open label study

    • All patients showed reductions on all rating scales

  • George study

  • 16 manic patients greater efficacy of right sided TMS not replicated I follow-up study

  • Conclusion: High frequency TMS maybe effective for Bipolar Depression while low frequency rTMS is somewhat effective as a mood stabilizer.

  • Our Experience: 8/10 patients with Bipolar II Depression responded rapidly to TMS.

  • Two pts had hypomanic episodes but responded to mood stabilizer, 1 relapsed (due to THC abuse).


General Anxiety Disorder (GAD)

  • Brystritsky et al. (2008): Found that fMRI-guided low-frequency rTMS (90% MT over frontal cortex) in 10 GAD patients produced significant decreases in anxiety measures. Methods:

  • Patients were between the ages of 18-56 years.

  • Measures used: Hamilton Rating Scale for Anxiety (HAM-A) & the Clinical Global Impressions-Improvement of Illness (CGI-I) scale.

  • Results:

  • rTMS was associated with significant decreases in HAM-A scores (t = 6.044, p = .001) indicative of clinical improvement in symptoms.

  • At endpoint, 60% of the participants who completed the study showed a reduction of 50% or more on the HAM-A and a CGI-I score of 1 or 2 ("very much improved" or "much improved," respectively).

  • This study suggests that fMRI-guided rTMS treatment may be a beneficial technique for the treatment of anxiety disorders.

  • Conclusion: Slow TMS to the right DLPFC has significant potential in treatment refractory patients

  • Our experience: 12/14 patients with MDD and comorbid GAD showed responded to slow right sided TMS (and fast left for MDD)

  • 3 patients relapsed but one improved after 4 follow up sessions.

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PTSD

  • In a study which consisted of presenting pictures of faces depicting various emotional states, patients with PTSD showed significant deficits in mPFC activity as compared to normal controls.

  • Neuroimaging studies have revealed abnormalities in the prefrontal cortex of patients with PTSD. Additionally, patients with PTSD showed significant deficits in mPFC activity as compared to normal controls.

  • Grisaru Pilot Study (1998)

    • 10 patients with PTSD received bilateral low-frequency (0.3Hz) rTMS therapy on the motor cortex.

    • Transient improvements were seen.

  • Rosenberg Study (2002)

    • Frontal cortical rTMS therapy was used as an adjunctive therapy in patients with PTSD and MDD.

    • Significant improvements in mood, anxiety and sleep symptoms but not in core PTSD symptoms

  • Cohen Study (2004)

    • 24 patients participated in a double-blind, placebo-controlled treatment study where they received low-frequency (1Hz), high-frequency (10Hz) or sham rTMS treatment over the right PFC for 2 weeks (10 sessions).

    • Core symptoms of PTSD significantly improved.

    • Most improvement was seen when rTMS was administered to the right prefrontal cortex at high frequency.

  • Osuch Study (2009)

    • Patients participated in a double-blind, sham-controlled cross over study where they received low frequency rTMS over the left prefrontal cortex in combination with exposure therapy.

    • Patients who received active rTMS treatment showed greater improvement.

  • Conclusion: rTMS both as monotherapy and as adjunctive therapy shows significant promise in the treatment of PTSD

  • Our experience: 4/6 patients with PTSD did better with our customized TMS protocol than any other treatment


Substance abuse
Substance Abuse

  • Increased dopamine levels as a result of TMS therapy would reduce nicotine/drug cravings and consumption

  • Seven studies (152 patients)

  • Treated for nicotine/cocaine/alcohol addiction

  • High Frequency rTMS to the left DLPFC

  • Reduced craving and consumption of addictive substance-potentially by increasing dopamine produced in mesolimbic dopaminergic system

  • Conclusion: TMS has shown efficacy for alcoholism, nicotine abuse, cocaine abuse.

  • Our experience: 5/5 responded well to our customized a TMS protocol in patients with refractory polysubstance abuse for several weeks

Hymen et al., 2006; Vandershuren and Kalivas et al., 2000; Wolf et al., 2004; Keck et al., 2002; Kano et al., 2004.


Schizophrenia

Slotema et al., 2010

12

Moderate effects (p<0.001) for hallucinations

Slotema et al., 2010)


Patient
Patient

This is a 52 year old women who was diagnosed with Schizoaffective Disorder.  She experienced daily auditory hallucinations (AH) telling her to kill herself and other people, which ended up in a number of hospitalizations. Just 6 weeks after bilateral rTMS the patient's Hamilton score improved from a 24 to a 0 and her AH completely disappeared.  Due to this result, and a re-analysis of the patient's symptoms, the patient was re-diagnosed with Severe Depression with psychotic features.  She continues to be in remission to date, five months after she has completed TMS.


Chronic pain fibromyalgia
Chronic Pain (Fibromyalgia)

  • Pridmore et al (2005): In studies of TMS treatments for chronic pain, there is some evidence that temporary relief can be achieved in a proportion of sufferers.

  • André-Obadia et al (2008): In a double-blind, randomized, cross-over study, evaluated the pain-relieving effects of high-rate, postero-anterio rTMS on neuropathic pain (n = 28).

  • TMS decreased pain scores significantly more than placebo.

  • TMS also outmatched placebo in a score combining:

    • Subjective criteria of treatment (pain relief, quality of life)

    • Objective criteria of treatment (rescue drug intake)

  • Analgesic effects of postero-anterior rTMS lasted for approximately 1 week.

  • Pain-relieving effects were observed exclusively on global scores reflecting the most distressing type of pain in each patient.

  • Conclusions: TMS has potential in treating chronic pain by activating descending pathways that bare effective in suppressing proximal pain i.e. back pain, fibromylagia etc.

  • Our experience: 4/4 patients responded rapidly to the same TMS protocol that is used for MDD.

14


Cost

Cost: $500 for treatment planning and

$300-$500 per treatment session

Course: Five sessions a week for 4-6 weeks for a total of 24-30 sessions

Total cost: $8,000 - $14,000

Insurance:

Only covers treatment refractory unipolar depression.

Almost never provides preapproval

Most commercial plans that are not self-pay reimburse 80-100% of costs after the 3rd appeal, which occurs 2-6 months after TMS completion

Medicare may cover about 50%^ of costs about 50% of the time.

Brunoni et al 2009


Conclusions

  • TMS is effective in treating:

    • Depression that is refractory to medications

    • Depression in patients intolerant to medications

  • Besides depression we have effectively treated:

    • Anxiety Disorders (PTSD, GAD, Panic)

    • Substance abuse

    • Chronic pain (fibromyalgia)

    • Eating disorders

    • Parkinson’s Disorder

  • TMS virtually no side effects and appears to be safe even in adolescents, pregnant women, and the elderly


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