Welcome to Inside the Mind, an insightful series focusing on the power of interventional psychiatry. Here, we’ll learn valuable tips, research, news, and more on treatments like TMS, SPRAVATO, and IV ketamine therapy from Dr. Omar Elhaj, Regional Medical Director of Mindful Health Solutions. 

 

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When Mindful Health Solutions led the way in offering in-network TMS in 2011, we quickly saw the power of brain stimulation to bring relief to depressed patients who had often failed four or more antidepressant medications. Over the ensuing 15 years of practice, we have treated thousands of treatment-resistant patients with TMS, often time bringing complete remission to people who struggled with this debilitating disease for years.

While this is a story we are all proud of at MHS, it’s also true that things haven’t changed much over the last decade regarding how we deliver TMS. Patients can expect to come to an MHS clinic daily for up to 6 weeks to receive treatment and can look forward to a promising 50-60% response rate and a 30-40% remission rate. While we believe that the current “Standard” in-network TMS protocols will continue to be a critical step in our depression care pathway, we are always looking for ways to push things forward, and for TMS that means getting more patients even better and faster. The field of TMS is moving rapidly to innovate in these two areas and we are excited to expand our TMS repertoire based on the latest published evidence with “Accelerated Deep TMS (dTMS)”. Let’s break this down:

Deep TMS (dTMS) – Does focality matter?

The most exciting advance in the TMS field occurred last year when Dr. Nolan Williams and colleagues at Stanford received FDA approval for a novel TMS protocol called SNT or “SAINT” (Stanford Neuromodulation Treatment)¹. This new approach combined a longer stimulation train with multiple treatments per day and (likely critically) personalized brain targeting based on the patient’s specific functional Magnetic Resonance Imaging (fMRI). With these 3 changes, the SNT protocol boasted an 85% remission rate, all in only 5 treatment days. While the future of TMS almost certainly will incorporate precision medicine via fMRI or other physiological measures, the SNT protocol at present is limited by payor restrictions as well as the cost and complexity currently associated with brain imaging and analysis to determine the personalized treatment location.

Until fMRI becomes more easily available, are there other strategies that may yield improved outcomes with TMS? One possible strategy currently available at MHS is “deep” TMS (dTMS). These TMS systems take a less focal (or precise) targeting approach in the brain, instead utilizing a broader and deeper stimulation pattern. Personalized targeting may be less critical in hitting the right area if more of the brain is being stimulated. The results from a recent large real-world study of daily dTMS for depression reported an impressive 80% response and 65% remission rate². dTMS also has shown impressive efficacy in treatment-resistant OCD, and there is ongoing research into using this TMS technology for other psychiatric diseases.

At MHS we are excited to provide dTMS therapy across most of most our geography including Seattle, San Francisco, San Rafael, Burlingame, Sacramento, Los Angeles, Mission Viejo, Tacoma and soon in Houston.

Accelerated TMS: More treatments per day = faster responses

The “standard” TMS that our clinics have delivered for the past decade requires one TMS treatment 5x per week for over 6 weeks (for a total of 30 to 36 treatments). While the treatments themselves are brief (as short as 3 minutes), extremely safe, well tolerated and with no recovery time, the visit frequency, distance to clinic and time to treatment response (usually several weeks) have all been significant barriers for some patients who might otherwise have benefited from treatment. There has been growing interest in recent years in “accelerating” the TMS course; providing multiple treatment sessions in a single day to compress the total time for a treatment course down to 1 to 2 weeks.

A recent exciting real-world study conducted by Brainsway compared providing dTMS treatments 2x, 3x, 5x or 10x per day for a total of 30 treatments³. Treatment course durations varied from 3 to 10 days. All accelerated protocols showed statistically similar benefits: 80% response and 50% remission rates with clinically significant benefits notable by day 3 of treatment in all cohorts. These findings show that patients can start to feel relief from their depressive symptoms within days of treatment initiation. This timeframe is a significant improvement over the time course of standard, daily treatment which generally takes 2-3 weeks to see similar effects.

Accelerated dTMS at MHS: Who’s a good candidate?

We are thrilled to launch Accelerated Deep TMS at MHS! We have crafted a protocol based closely on the most recent published evidence while being flexible for the needs of our patients for whom daily TMS is not logistically feasible or for patients just looking for a more rapid response. Our protocol will deliver dTMS 3 to 6 times per day ranging from daily to several days per week depending on the patient’s preferences. Our goal is to complete a course of 30 treatments in as short as 5 days. The brain requires at least 45 minutes of recovery between TMS treatments to work so patients can expect to spend several hours in our clinic on treatment days.

Good candidates for Accelerated Deep TMS include patients who live a longer distance from the clinic and wish to make fewer trips or patients who require (or prefer) a more rapid treatment response. Otherwise, there are no known additional safety or other considerations in receiving accelerated versus daily TMS. Accelerated dTMS is currently off-label and not covered by most insurance plans. We are currently offering this treatment at a competitive cash rate and our team can work with patients based on their individual financial situation. Contact us directly by calling (844) 867-8444 for more information and to set up a consult with one of our expert psychiatrists!

References:

1. Cole EJ, Phillips AL, Bentzley BS, Stimpson KH, Nejad R, Barmak F, Veerapal C, Khan N, Cherian K, Felber E, Brown R, Choi E, King S, Pankow H, Bishop JH, Azeez A, Coetzee J, Rapier R, Odenwald N, Carreon D, Hawkins J, Chang M, Keller J, Raj K, DeBattista C, Jo B, Espil FM, Schatzberg AF, Sudheimer KD, Williams NR. Stanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial. Am J Psychiatry. 2022 Feb;179(2):132-14. Epub 2021 Oct 29. PMID: 34711062
2. Tendler A, Goerigk S, Zibman S, Ouaknine S, Harmelech T, Pell GS, Zangen A, Harvey SA, Grammer G, Stehberg J, Adefolarin O, Muir O, MacMillan C, Ghelber D, Duffy W, Mania I, Faruqui Z, Munasifi F, Antin T, Padberg F, Roth Y. Deep TMS H1 Coil treatment for depression: Results from a large post marketing data analysis. Psychiatry Research. 2023 Jun;324:115179. Epub 2023 Mar 24. PMID: 37030054
3. Roth Y, Hanlon CA, Pell G, Zibman S, Harmelech T, Muir OS, MacMillan C, Prestley T, Purselle DC, Knightly T, Tendler A. Real world efficacy and safety of various accelerated deep TMS protocols for major depression. Psychiatry Research. 2023 Oct;328:115482. Epub 2023 Sep 14. PMID: 37738684

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The Challenge of Clinical Inertia in Psychiatry

“Clinical inertia is defined as the failure to initiate or intensify therapy when treatment goals are not met and is a well-recognized barrier to improving patient care and clinical outcomes.” – Dixon et al., J Am College of Cardiology, 2019

Contemporary psychiatry faces the difficult reality of a history marked by a certain level of complacency with mediocre outcomes. Despite the progress that began in the 1980s with the advent of the DSM system and the antidepressant revolution, the mental health field has not achieved the transformative clinical outcomes that parallel advances in other medical disciplines rooted in biological sciences. This shortfall has resulted in a concerning level of acceptance among both providers and patients for less-than-ideal response rates to psychiatric treatment. Remission, for many, has become a vague aspiration or a serendipitous outcome. Amidst this climate, both therapeutic inertia and its counterpoint—over-treatment—have come to characterize the landscape of psychiatric practice in the United States.

The New Horizon: Advanced Therapeutic Approaches

Despite these setbacks, there’s genuine cause for optimism. Groundbreaking therapeutic approaches like transcranial magnetic stimulation (TMS), esketamine, ketamine, and potentially psychedelics in the near future, bring the promise of a new age of psychiatry. In this evolving landscape, remission of mental health symptoms is becoming the expectation, not the exception. At Mindful Health Solutions, we believe that the most effective way to deliver these next-generation treatments requires both integration and measurement.

Embracing Integrative Care

As the number of new treatment modalities grows, we face the challenge of knowing how to match the right patients to the right treatments and in the right order. But how are interventional treatments currently delivered in the community? Unfortunately, most TMS and ketamine treatments are siloed in specialized clinics focused on only one specific modality (such as a “TMS clinic”). As a result, patients have to navigate a web of private specialty clinics each promoting their favored treatment as the (only) “answer”. And, perhaps more concerning, few mental health clinicians have the training and expertise in multiple treatment modalities to be able to guide their patients through the treatment selection process.

At Mindful Health Solutions, we’ve made it a priority to integrate cutting-edge treatments—like TMS, esketamine, Ketamine Infusion Therapy, and electroconvulsive therapy (ECT)—into our general psychiatry practice. This integration includes both medication management and psychotherapy services. Our clinician-prescribers, who are adept in these advanced treatment options, provide patients with a seamless, comprehensive treatment pathway under one roof, thereby maximizing continuity of care and the probability of full remission.

The Importance of Measurement-Based Care

Access to a wide range of evidence-based treatments is only part of the equation for achieving remission. To truly guide our patients toward optimal mental health, we need a robust, evidence-based treatment pathway built on rigorous measurement. At Mindful Health Solutions, we employ validated scales like the PHQ-9 for depression and the GAD-7 for anxiety at every patient encounter. This data informs our clinicians’ decisions, enabling timely adjustments to treatment plans as needed. Through this meticulous approach, we sidestep the pitfalls of therapeutic inertia, setting our patients on a course for rapid and lasting recovery.

Putting the Pieces Together for a New Era in Psychiatry

With an expanding array of effective treatment options, we now possess many of the puzzle pieces needed to break free from the inertia and nihilism that have long plagued the field of psychiatry. At Mindful Health Solutions, we are committed to assembling these pieces to create a comprehensive, evidence-based approach for our patients and their families. The picture coming into view is very encouraging: Remission is the mission.

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