Trans Cranial Magnetic Stimulation r TMS setting up
![Trans Cranial Magnetic Stimulation (r. TMS) setting up a service in the Private sector Trans Cranial Magnetic Stimulation (r. TMS) setting up a service in the Private sector](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-1.jpg)
![What is TMS? • A relatively new treatment for depression • Relies on direct What is TMS? • A relatively new treatment for depression • Relies on direct](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-2.jpg)
![Role of r. TMS • r. TMS is used to treat depression. • Depression Role of r. TMS • r. TMS is used to treat depression. • Depression](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-3.jpg)
![How does TMS work? • A magnetic field created by a coil placed close How does TMS work? • A magnetic field created by a coil placed close](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-4.jpg)
![5 5](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-5.jpg)
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![Our Service – how we started • Psychiatrist proposal • Committee established • Strong Our Service – how we started • Psychiatrist proposal • Committee established • Strong](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-7.jpg)
![Costs A typical commercial TMS device and chair. The total cost of equipment, software Costs A typical commercial TMS device and chair. The total cost of equipment, software](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-8.jpg)
![Training • Professor Paul Fitzgerald (The Alfred Hospital in Melbourne) provided training for service Training • Professor Paul Fitzgerald (The Alfred Hospital in Melbourne) provided training for service](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-9.jpg)
![Training cont’d • Practical session and operation of the r. TMS device • Treatment Training cont’d • Practical session and operation of the r. TMS device • Treatment](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-10.jpg)
![Staffing and Administration • Two Clinical Directors (Psychiatrists) • Registered Nurses • Psychologist (Research Staffing and Administration • Two Clinical Directors (Psychiatrists) • Registered Nurses • Psychologist (Research](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-11.jpg)
![r. TMS Suite • • • An area of the hospital identified Treatment room r. TMS Suite • • • An area of the hospital identified Treatment room](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-12.jpg)
![Clinical interest • Psychiatrist “interest” evening with the machine • CME Clinical interest • Psychiatrist “interest” evening with the machine • CME](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-13.jpg)
![Referral • Credentialled Psychiatrists • Outpatient status but must have private health cover • Referral • Credentialled Psychiatrists • Outpatient status but must have private health cover •](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-14.jpg)
![Initial Assessment • • Locate motor cortex Determine intensity of motor threshold Measure 6 Initial Assessment • • Locate motor cortex Determine intensity of motor threshold Measure 6](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-15.jpg)
![Safety / side effects • The stimulation produces a loud audible ‘click. ’ Patients Safety / side effects • The stimulation produces a loud audible ‘click. ’ Patients](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-16.jpg)
![Ethics Approval • All patients treated participate in Research protocol • Approved by Ramsay Ethics Approval • All patients treated participate in Research protocol • Approved by Ramsay](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-17.jpg)
![t. TMS • 222 referrals received from 51 psychiatrists • 160 patients accepted for t. TMS • 222 referrals received from 51 psychiatrists • 160 patients accepted for](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-18.jpg)
![Funding • Currently no Medicare item number • Costs of treatment not reimbursed by Funding • Currently no Medicare item number • Costs of treatment not reimbursed by](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-19.jpg)
![Obstacles • Challenging financial aspect • Coils overheating • Mechanical issues – support arm Obstacles • Challenging financial aspect • Coils overheating • Mechanical issues – support arm](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-20.jpg)
![Measures • Primary outcome measure: 21 item Hamilton Rating Scale for Depression (HAMD; Hedlung Measures • Primary outcome measure: 21 item Hamilton Rating Scale for Depression (HAMD; Hedlung](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-21.jpg)
![Results – Overall Efficacy Significant improvement on all outcome measures at the p<. 001 Results – Overall Efficacy Significant improvement on all outcome measures at the p<. 001](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-22.jpg)
![Conclusion • Effective • Well tolerated • Advantages over alternate treatment methodologies i. e. Conclusion • Effective • Well tolerated • Advantages over alternate treatment methodologies i. e.](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-23.jpg)
![Enhanced r. TMS • Recently commenced stage 2 • r. TMS plus Mindfulness group Enhanced r. TMS • Recently commenced stage 2 • r. TMS plus Mindfulness group](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-24.jpg)
![Thank you Any questions? Thank you Any questions?](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-25.jpg)
- Slides: 25
![Trans Cranial Magnetic Stimulation r TMS setting up a service in the Private sector Trans Cranial Magnetic Stimulation (r. TMS) setting up a service in the Private sector](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-1.jpg)
Trans Cranial Magnetic Stimulation (r. TMS) setting up a service in the Private sector Carol Turnbull CEO, Ramsay Health Care SA Mental Health services APHA Congress October 2011
![What is TMS A relatively new treatment for depression Relies on direct What is TMS? • A relatively new treatment for depression • Relies on direct](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-2.jpg)
What is TMS? • A relatively new treatment for depression • Relies on direct stimulation of the brain using a magnetic pulse to generate brief electrical currents that stimulate nerve cells in the regions of the brain involved in depression. • No anaesthetic required • No cognitive side effects • Treatment can be administered by Nusing staff/trained technicians
![Role of r TMS r TMS is used to treat depression Depression Role of r. TMS • r. TMS is used to treat depression. • Depression](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-3.jpg)
Role of r. TMS • r. TMS is used to treat depression. • Depression is very common – approx 55% patients admitted to RHC private psychiatric hospitals in Adelaide had depression. • Not all patients respond to antidepressant medication and/or psychological therapies. • Antidepressant medications have many side effects so are not always well tolerated. • Sometimes trials of several different antidepressants are needed and are still unsuccessful. • Patients who do not respond to antidepressants are often treated with electroconvulsive therapy (ECT).
![How does TMS work A magnetic field created by a coil placed close How does TMS work? • A magnetic field created by a coil placed close](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-4.jpg)
How does TMS work? • A magnetic field created by a coil placed close to the scalp induces a current in the cortex • This current causes depolarization and stimulation of a local cortical region • Provided the stimulus is of sufficiently low current and frequency, a generalized seizure is not produced
![5 5](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-5.jpg)
5
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![Our Service how we started Psychiatrist proposal Committee established Strong Our Service – how we started • Psychiatrist proposal • Committee established • Strong](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-7.jpg)
Our Service – how we started • Psychiatrist proposal • Committee established • Strong Research and Evaluation component • Consistent with RANZCP position statement • Costings • Approvals under Research protocols
![Costs A typical commercial TMS device and chair The total cost of equipment software Costs A typical commercial TMS device and chair. The total cost of equipment, software](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-8.jpg)
Costs A typical commercial TMS device and chair. The total cost of equipment, software and training is over $100, 000.
![Training Professor Paul Fitzgerald The Alfred Hospital in Melbourne provided training for service Training • Professor Paul Fitzgerald (The Alfred Hospital in Melbourne) provided training for service](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-9.jpg)
Training • Professor Paul Fitzgerald (The Alfred Hospital in Melbourne) provided training for service directors and Nursing staff • Funded by Ramsay Health Care • Assessment and suitability criteria established • Practical training in mapping the position of the DLPFC (Dorsolateral prefrontal cortex) and the motor threshold
![Training contd Practical session and operation of the r TMS device Treatment Training cont’d • Practical session and operation of the r. TMS device • Treatment](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-10.jpg)
Training cont’d • Practical session and operation of the r. TMS device • Treatment and research protocols and policies
![Staffing and Administration Two Clinical Directors Psychiatrists Registered Nurses Psychologist Research Staffing and Administration • Two Clinical Directors (Psychiatrists) • Registered Nurses • Psychologist (Research](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-11.jpg)
Staffing and Administration • Two Clinical Directors (Psychiatrists) • Registered Nurses • Psychologist (Research Assistant) • Clinical Governance by the r. TMS Committee which meets every 3 months.
![r TMS Suite An area of the hospital identified Treatment room r. TMS Suite • • • An area of the hospital identified Treatment room](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-12.jpg)
r. TMS Suite • • • An area of the hospital identified Treatment room Waiting room Office Coil cooling room Mag. Pro R 30 r. TMS machine and two MCF coils purchased • Comfortable chair • Disposable earplugs
![Clinical interest Psychiatrist interest evening with the machine CME Clinical interest • Psychiatrist “interest” evening with the machine • CME](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-13.jpg)
Clinical interest • Psychiatrist “interest” evening with the machine • CME
![Referral Credentialled Psychiatrists Outpatient status but must have private health cover Referral • Credentialled Psychiatrists • Outpatient status but must have private health cover •](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-14.jpg)
Referral • Credentialled Psychiatrists • Outpatient status but must have private health cover • Inclusion criteria include MDD, over 18 yrs no history of seizures, no metal in head (eg surgical clips) not psychotic, willing to attend 3 -5 mornings/week for an hour (up to six weeks). • Must be able to speak and understand English
![Initial Assessment Locate motor cortex Determine intensity of motor threshold Measure 6 Initial Assessment • • Locate motor cortex Determine intensity of motor threshold Measure 6](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-15.jpg)
Initial Assessment • • Locate motor cortex Determine intensity of motor threshold Measure 6 cm forward to DLPFC Make individual patient template • These parameters determine the location and intensity of treatment 15
![Safety side effects The stimulation produces a loud audible click Patients Safety / side effects • The stimulation produces a loud audible ‘click. ’ Patients](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-16.jpg)
Safety / side effects • The stimulation produces a loud audible ‘click. ’ Patients wear earplugs to prevent acoustic trauma. • There is a very small risk of seizures – usually with higher stimulus intensities or patients with low seizure threshold (e. g. on tricyclics, or with a past history of epilepsy) • Small rates of induction of mania or hypomania are noted – smaller rates than with antidepressant medication • Some transient treatment related effects – Scalp pain or discomfort during stimulation (due to scalp nerve or muscle stimulation during treatment) – Headaches • No cognitive side effects noted in studies
![Ethics Approval All patients treated participate in Research protocol Approved by Ramsay Ethics Approval • All patients treated participate in Research protocol • Approved by Ramsay](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-17.jpg)
Ethics Approval • All patients treated participate in Research protocol • Approved by Ramsay Health Care SA Ethics Committee • All patients give written informed consent
![t TMS 222 referrals received from 51 psychiatrists 160 patients accepted for t. TMS • 222 referrals received from 51 psychiatrists • 160 patients accepted for](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-18.jpg)
t. TMS • 222 referrals received from 51 psychiatrists • 160 patients accepted for treatment • 92 completed first course, 18 completed 2 nd course, 9 maintenance, 1 auditory hallucinations patient • Only r. TMS service in SA
![Funding Currently no Medicare item number Costs of treatment not reimbursed by Funding • Currently no Medicare item number • Costs of treatment not reimbursed by](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-19.jpg)
Funding • Currently no Medicare item number • Costs of treatment not reimbursed by Private Health funds • 2005 application made to MSAC by RANZCP • More evidence now supporting efficacy of r. TMS with antidepressant medication as the preferable comparator • Application made to Medicare (MSAC)for item number
![Obstacles Challenging financial aspect Coils overheating Mechanical issues support arm Obstacles • Challenging financial aspect • Coils overheating • Mechanical issues – support arm](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-20.jpg)
Obstacles • Challenging financial aspect • Coils overheating • Mechanical issues – support arm • Software issues
![Measures Primary outcome measure 21 item Hamilton Rating Scale for Depression HAMD Hedlung Measures • Primary outcome measure: 21 item Hamilton Rating Scale for Depression (HAMD; Hedlung](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-21.jpg)
Measures • Primary outcome measure: 21 item Hamilton Rating Scale for Depression (HAMD; Hedlung and Vieweg, 1979) • Montgomery-Åsberg Depression Rating Scale (MADRS; Montgomery & Åsberg, 1979) • Zung self-rating depression scale (Zung, 1965) • 14 item Hamilton Anxiety Rating Scale (HAMA; Hamilton 1959) 21
![Results Overall Efficacy Significant improvement on all outcome measures at the p 001 Results – Overall Efficacy Significant improvement on all outcome measures at the p<. 001](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-22.jpg)
Results – Overall Efficacy Significant improvement on all outcome measures at the p<. 001 level (paired t-test results) 22
![Conclusion Effective Well tolerated Advantages over alternate treatment methodologies i e Conclusion • Effective • Well tolerated • Advantages over alternate treatment methodologies i. e.](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-23.jpg)
Conclusion • Effective • Well tolerated • Advantages over alternate treatment methodologies i. e. no sedation or agitation no weight gain no sexual dysfunction r. TMS provides another valuable treatment option
![Enhanced r TMS Recently commenced stage 2 r TMS plus Mindfulness group Enhanced r. TMS • Recently commenced stage 2 • r. TMS plus Mindfulness group](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-24.jpg)
Enhanced r. TMS • Recently commenced stage 2 • r. TMS plus Mindfulness group therapy, Internet CBT, Relaxation and Gym (Physical exercise)
![Thank you Any questions Thank you Any questions?](https://slidetodoc.com/presentation_image_h/9a7311d48861ffab9e5962e0d933ed2f/image-25.jpg)
Thank you Any questions?
Seioh
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