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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).
slide9

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.

9

slide10
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.

slide12

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

slide15
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

slide16

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
ad