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TMS: It’s not just for TRD anymore by Earle Shugerman, MD

Check out this awesome video as Dr. Earle Shugerman talks about the significance and risks of TMS.

And then in off label applications of TMS. We’ll talk about several of these – depression during pregnancy, postpartum depression, maintenance treatment for chronic depressive disorders, which is a very important area. Bipolar depression, depressive disorders that are non-treatment resistant, most of the FDA approval has focused on patients who had failed to respond to an adequate course of antidepressant therapies. And that’s still mostly how TMS is used.

Risks for TMS
● Mild headache is most common
● Seizures
● Treatment emergent hypomania or mania
● Exposure risk for COVID 19

The risks of TMS are very low. Mild headache is the most common side effect. Usually, this is something that’s noted in the first week of treatment and tends to diminish over the course of the first couple of weeks. Some patients will take Tylenol or Ibuprofen before they’ll come in for treatment. But usually by the second or third week, they’re no longer needing to do that. TMS has to be done with hearing protection. The coil makes a fairly loud clicking noise during the treatment. So, patients are given ear protection to wear, ear plugs that they wear during their treatment.

Insurance requirements
Insurance still only covers treatment of major depressive disorder, even though OCD is a FDA approved indication. So far, insurance plans are not covering OCD. Insurance plans create a certain gauntlet that has to be cleared before they will approve TMS. They view it as a relatively expensive treatment and they try to encourage people to use less expensive treatments before they will want to underwrite it.

Commonly, they will require anywhere from one to four failed trials of antidepressant medications and generally also require the use of medication augmentation with lithium or atypicals, or a combination of SSRI and bupropion, and will also require some documentation of psychotherapy.

Contraindications for TMS
The only absolute contraindication is metal implanted in the head. That said, we have treated some patients with metal plates, who had had injuries to the cranium and had had replacements with titanium. But they were on the contralateral side and distant from our treatment site. But something like aneurysm clip or deep electrode is probably going to be an absolute contraindication.

How will TMS evolve and improve?
One thing that would be very valuable is if we could identify better likely non-responders. Even when TMS is well covered by insurance coverage, if somebody spent six weeks coming into our clinic daily for an hour, they’ve invested a lot of time, many times they’ve invested a lot of money in copays and if they’re in the one-third non-responder group, that’s painful. And so, if we could use some kind of functional imaging to better advise patients on their likelihood of response, and there’s some research going on on this with some promising early results, but nothing that has been useful outside of a research setting quite yet.