Transcranial Magnetic

Stimulation Therapy
The Future Direction of
Neuropsychiatry

Transcranial Magnetic Stimulation

Mechanism: To target and modulate neuroplasticity to influence

behavior consequences.

Neuroplasticity: the brains ability to reorganize itself by forming

new neural connections throughout life. It allows the neurons in the
brain to compensate for the injury and disease, and to adjust their
activities in response to new situations or to changes in their
environment.

Transcranial Magnetic Stimulation

Brain reorganization takes place by mechanisms
such as axonal sprouting in which undamaged
axons grow new nerve endings to reconnect
neurons whose links were injured or severed.
Undamaged axons can also sprout nerve
endings and connect with other undamaged
nerve cells, forming new neural pathways to
accomplish a needed function.
In order to reconnect, the neurons need to be
stimulated through activity.
Neuroplasticity allows us to compensate for
irreparably damaged or dysfunctional neural
pathways by strengthening or rerouting our
remaining ones.

Transcranial Magnetic Stimulation

Compensatory Masquerade

brain injury cases, cognitive disability. Allows already-constructed

pathways that neighbor a damaged area to respond to changes in
the bodys demands caused by lost function in some other area.

Homologous Region Adoption

allows one entire brain area to take over functions from distant brain
areas that has been damaged.

Cross model reassignment

allows the brain of a blind individual in learning to read Braille, to rewire

the sense of touch so it replaces the responsibilities of vision in the
brain areas linked with reading.
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Use it or Lose it!

Neuroplasticity throughout life span: use it or lose it

New research indicates that human brain cells are able to
regenerate new brain cells even into the golden years of age 70
and beyond if ones brain is constantly challenged by and
engaged with a variety of stimulations and new experiences.

Plasticity
The capacity of the brain to change with learning is
known as plasticity.
The brain may change in two aspects:
1. internal structure of the
Neurons; area of synapses.
2. increases in the number
of synapses between
neurons.
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Faradays Principle

It is the electric stimulation via magnetic induction, not the

magnetic field, that does the effect, thus passing current
through the coil of the wire and then inducing the magnetic
field. Induced currents are critical to the rate of change of the
current, known as Michael Faradays principle

I. The rate of change matters. The speed of the current affects the
depolarization of neurons.

II. Orientation of the coil-critical-neural elements perpendicular to

the plane of the coil, using bidirectional pulses.

TMS History

At first, TMS was developed by Barker et al. It was used as a

brain mapping tool, as a tool to measure cortical excitability, as
a probe of neuronal networks, and as a modulator of brain
function.

Low Frequency vs. High Frequency

TMS
Concept of Depolarization Function

Low Frequency Stimulation--inhibitory, more focal effect

High Frequency Stimulation--facilitatory, multiple, spread out, global
dendritic, axonal effect.
When higher frequency rTMS is applied, a longer lasting effect can be induced
which is thought to result from a long term potentiation (LTP), or depression
(LTD) at the neuronal level.

What Could TMS Treat?

I. Psychiatry: Depression (FDA approval, Oct 2008), treatment

refractory cases, co-morbid, Panic DO, OCD, PTSD, Addiction
(pathologic gambling), food, other substances cocaine,
opiates, nicotine, schizoaffective disorder.

II. Chronic neuropathic pains, phantom pain, fibromyalgia,

Migraine headaches, Tourette's, tinnitus, painful dystonia.

III. Neurology: Rehabilitation- after stroke , recovery-Aphasia,

Neglect, Brain Injury, Seizures

Transcranial Magnetic Stimulation

For MDD patients who have not adequately benefited from prior medication
treatment attempts

New treatment recently cleared by FDA

Has been studied by researchers for 20+ years

Works by using MRI-strength magnetic field pulses

Activates nerve cells in the brain, causing them to normalize neurotransmitter

function

Non-systemic and non-invasive

Does not circulate in the blood throughout the body
Does not involve surgery

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Transcranial Magnetic Stimulation

In an open-label trial (most like real world clinical practice),

1 in 2 had a significant improvement in symptoms
1 in 3 had complete symptom resolution

Patients also experienced significant improvement in anxiety,

appetite changes, aches and pains, and lack of energy
associated with depression

Over 10,000 procedures performed in clinical trials

No systemic side effects such as weight gain, sexual

dysfunction, nausea, dry mouth, and sedation

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NeuroStar TMS Therapy

Positive Value Proposition
Significant chance of improvement (1 in 2)
Despite not having adequately benefited from previous
treatment attempts

No systemic side effects, such as weight gain and

sexual dysfunction
Non-invasive, no anesthesia, no sedation
Favorable benefit/risk ratio compared to alternatives
Associated with less hospitalizations, doctor visits,
drugs, etc.

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FAQsClinical

What are the chances it will work?

In open-label trial (most like real-world), 1 in 2 patients had significant
improvement & 1 in 3 had complete symptom resolution

How long will it take to feel better?

May feel some improvement in 2 weeks, but most improvement will take 4-6
weeks

How long will the effect last?

In a 6-month follow-up study, patients received a single medication as
maintenance treatment
Approximately 1/2 had symptom recurrence and required TMS re-treatment
Through the maintenance medication and the TMS re-treatment, less than
10% of patients relapsed

What are the side effects?

Scalp pain or discomfort and headache
Decreased significantly after the 1st week of treatment
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FAQsFinancial (cont.)

How much does it cost?

Recommend speaking about cost for acute course, not per
treatment
Some will require more treatments, others less

Put it in context with the cost of other treatments

Acute course of ECT is ~$18,000
Acute course of a branded drug combination is ~$2,000

Provides good value for the money

Significant chance of improvement (1 in 2)
No systemic side effects
Non-invasive, no anesthesia, no sedation
Favorable benefit/risk ratio compared to alternatives
Associated with less hospitalizations, doctor visits, drugs, etc.

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Indication Statement

NeuroStar TMS Therapy is indicated for the treatment of Major

Depressive Disorder in adult patients who have failed to
achieve satisfactory improvement from one prior
antidepressant medication at or above the minimal effective
dose and duration in the current episode

54-00008-000 Revision A

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Fair Balance Statements

NeuroStar TMS Therapy is contraindicated in patients with

implanted metallic devices or non-removable metallic objects
in or around the head

As with any antidepressant treatment, patients should be

monitored for symptoms of worsening depression

NeuroStar TMS Therapy has not been studied in patients who

have not received prior antidepressant treatment

Efficacy has not been established in patients who have failed

to receive benefit from two or more prior antidepressant
treatments at minimal effective dose and duration in the current
episode

The most common adverse event related to treatment was

scalp pain or discomfort

54-00008-000 Revision A

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New APA Guidelines

and CPT Coding

APA GUIDELINES

Transcranial magnetic stimulation is now listed in the American Psychiatric

Associations 2010 Practice Guideline for the Treatment of Patients with Major
Depressive Disorder

It is listed as an acute phase treatment option for patients who do not respond
adequately to pharmacotherapy.

This recent guideline states; Acute phase treatment may include

pharmacotherapy, depression-focused psychotherapy, the combination of
medications and psychotherapy, or other somatic therapies such as
electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), or light
therapy. (APA Guidelines 2010; Pg 46).

CPT CODING

Effective January 01, 2011, the American Medical Association has elevated the
current codes to Category I CPT codes.

The new codes are published as 90867 for a treatment planning session, and
90868 for treatment delivery and management per session.

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