In the Wise Buy series of  MedPage Today 2.12.16 article written by contributing writer Paul Raeburn, he assesses therapies, both new and old, to determine if Transcranial Magnetic Stimulation (TMS) treatment is not only a "wise choice", but also a "wise buy".

In summarizing Raeburn's article, he states that "TMS is rated as a cheaper and safer alternative than ECT, the other proven therapy for "refractory depression", ie., cases of major depressive disorder (MDD) which don't respond adequately to at least two courses of antidepressants.

According to Raeburn, "determining whether rTMS is a wise buy requires juggling a number of factors. The treatment itself costs about $200-300 per daily session. That's 3,000-5,000 magnetic pulses over a period of about 20 minutes. Multiply the cost by five sessions a week (with weekends off) for 4 to 6 weeks, and the price tag ranges from about $5,000-$10,000. Patients who need adjunctive medication or psychotherapy will face additional charges. (on the other hand) Medication for 6 weeks might cost "a couple of hundred bucks," Mark S. George, MD says. George who is "a brain imager, psychiatrist, and neurologist at the Medical University of South Carolina, was the first to use rTMS for depression in the early 1990s."

While the commonly prescribed medications may be relatively inexpensive, they are not without side effects, such as:

  • nausea
  • increased appetite and weight gainTMS_AntiD_Image_500.png
  • loss of sexual desire and other sexual problems, such as erectile dysfunction and decreased orgasm
  • fatigue and drowsiness
  • insomnia
  • dry mouth
  • blurred vision
  • constipation

In many cases, patients routinely fail to either feel better, or due to the adverse side effects, are prescribed another antidepressant, or cocktail of antidepressants. Currently TMS Therapy is only indicated for adult patients who have failed at two courses of antidepressants as noted above. However, there the technology is also being successfully used to treat PTSD, Postpartum depression and Tinnitus. While only indicated for adults currently, a press release was released in November, 2015 regarding the upcoming "Clinical Trial that will examine acute and long-term benefits of TMS, including symptom reduction and remission rates in Adolescent Depression", according to Christopher Blackburn, Co-Founder of Colorado based TMS Solutions.  "TMS Solutions has been invited to participate in this Neuronetics, Inc. sponsored clinical trial, and we are, indeed, excited to be a part of it", Blackburn says. 

As far as treating depression when medications fail to help depression patients, the traditional "go to" is Electro Convulsive Therapy (ECT), which uses electric shock to create seizures that stimulate underactive areas of the profontal cortex. While it does ease the symptoms there are significant side effects.  "The reason is that there is no way to confine the current to the prefrontal cortex. The electricity, delivered to the skin, floods the entire brain, stimulating areas that trigger seizures and memory loss. And ECT has a long, dark history, from an era when voltages were much higher than now used, which still makes it intolerably scary for many patients."

When comparing TMS to ECT, "ECT costs about twice as much, Dr. George says. Patients are anesthetized, so they need an anesthesiologist. Many of these severely ill patients also require hospitalization. And the patients need to be driven home from the treatment. In contrast, patients who receive rTMS can jump in their cars afterwards and drive home themselves."

"ECT patients also need a physician's supervision. rTMS needs physician supervision initially, but once a psychiatrist has determined the dose, nurses, or technicians can do the follow-up treatments, George says." " It's also expensive, in part because it requires a physician's supervision. Psychiatrists have long sought something better."

Paul Raeburn notes that "Many now believe they have found it. The treatment is repetitive Transcranial Magnetic Stimulation,(TMS or rTMS), in which the prefrontal cortex is stimulated with a magnetic field -- rather than an electrical shock. The shape of the field can be controlled so it's confined to where it's needed, eliminating the side effects of ECT."

Because ECT patients must be anesthetized in a hospital or clinicm whereas rTMS can be done on an outpatient basis rTMS is much less expensive than ECT--between a third and half the cost, "is it cheap and effective enough to justify its use as routine treatment for depressed patients resistant to medication?"  Great question...but that is based on cost alone.

ECT patients must be driven home, and iin many cases require followup treatment. TMS patients can drive themselves to and from the 30 or so visits it takes for the 5-6 week course. In the article Dr. George was quoted as saying, "ECT patients also need a physician's supervision. rTMS needs physician supervision initially, but once a psychiatrist has determined the dose, nurses, or technicians can do the follow-up treatments,"

So is TMS a wise choice and a wise buy?  According to Raeburn, "Kit Simpson, a professor of public health at the Medical University of South Carolina, has analyzed the costs of rTMS in terms of QALYs, or quality adjusted life years. In the U.S., the benchmark for whether a treatment is cost effective is whether the cost of a QALY comes in at less than $50,000. For TMS, producing one QALY costs $36,000, according to Simpson's analysis.  "This is a good deal. This is a wise buy," she says. That's true for insurance companies and it's true for patients themselves. They have a good chance of not being depressed."

Hope is what TMS offers. Hope of a normal life again...

So a case has been made that TMS Therapy is a wise choice and a wise buy, but isTMS affordable? While it can be paid for out of pocket, Raeburn quotes Mark Demitrack, MD,a psychiatrist and the chief medical officer at Neuronetics, who said, "A substantial portion of consumers who have health insurance have access to a policy that covers at least a portion of rTMS treatment," says   "And Medicare covers it in most jurisdictions."

"Demitrack estimates that some 30,000 people have been treated with TMS and that about 4 million could benefit from it. "We're at exceedingly small clinical penetration," he says. In contrast, about 100,000 to 150,000 people are treated with ECT each year, he says."

 


 

 

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Topics: Transcranial Magnetic Stimulation, TMS Therapy