Transcranial Magnetic

Stimulation
Neurostar Treatment Device
Patient Introduction

Tariq J. Faridi, B. Sc, M. Ed.

Director of Education and Research, Visual Odyssey
Temple Georgia
Trivedi (2006) Am J Psychiatry; Rush (2006) Am J Psychiatry; Fava (2006)
2 Am J Psychiatry; McGrath (2006) Am J Psychiatry
 Systemic Drug Side Effects
Weight Gain Fatigue

Constipation Headache/
Migraine
Diarrhea
Abnormal
Nausea Ejaculation

Drowsiness Impotence

Insomnia Sweating

Decreased Tremor
Libido
Treatment
Nervous Anxiety Discontinuation
Side Effects
Increased
Appetite Weakness

Decreased Dry Mouth

Appetite
Dizziness

Trivedi (2006) Am J Psychiatry; Rush (2006) Am J Psychiatry; Fava (2006) Am J Psychiatry; McGrath (2006) Am 3
J Psychiatry; Neuronetics, Inc. (data on file)
 The NeuroStar TMS System is indicated for
the treatment of adult patients with Major
Depressive Disorder (MDD) who have failed to
receive satisfactory improvement from one
prior antidepressant medication at or above
the minimal effective dose and duration in the
current episode
Nearly all patients received multiple ineffective
treatment attempts in current episode (range: 1 to
23 attempts, avg: 4)
Demitrack & Thase. (2009) Psychopharm Bull
Adapted from: Practice Guideline for the Treatment of Patients with Major
5 Depressive Disorder, 3rd Edition, APA (2010)
6
 anterior
prefrontal cingulate
cortex cortex
striatu
m
HIGH hypothalamus
In MDD, some
thalamus
areas of the
brain are
Neural
Activity hypoactive and
others are
brainstem
neurotransmitter
hyperactive.
amygdala centers
LOW
hippocampus
 concentration
pleasure/ psychomotor fatigue
interests (physical)
pleasure/interests
psychomotor When there is
fatigue
monoamine an appropriate
Monoamine
(mental) sleep are
Regions implicated in MDD
neurotransmitter amount ofis
dysfunction
guilt appetite
connected to the brainstem via
projections monoamine
linked to MDD
suicidality monoaminergic circuits
worthlessness neurotransmitter
Malfunctioning
activity,
mood
circuits lead
neuronal to
activity
specific
throughout the
guilt symptoms
brain functions
suicidality normally.
worthlessness
mood

Monoamine Serotonin (5-HT) Dopamine (DA) Norepinephrine (NE)

Neurotransmitters
 The treatment coil
produces MRI-
strength magnetic
field pulses.

Magnetic field pulses

pass unimpeded
through the cranium
for 2-3 cm. and
induce a small
electric current.

Induced electric
currents stimulate
the firing of nearby
neurons, causing the
release of
neurotransmitters
and clinical effects.
Faraday (1839) Experimental Research in Electricity. Vol 1; Barker 9(1991) J Clin Neurophysiol; Barker (1985) Lancet
 Depolarization of neurons in
the DLPFC causes local
neurotransmitter release

These effects
Dorsolateral
are associated
prefrontal
cortex with
Anterior
improvements
cingulate
cortexin depressive
Kito (2008) J Neuropsychiatry Clin Neurosci
symptoms

Depolarization of pyramidal
neurons in the DLPFC also
causes neurotransmitter release
in deeper brain neurons
Activation of deeper brain
neurons then exerts secondary
effects on remaining portions of
targeted mood circuits
 L R

TMS Coil
L R

Activation of fronto-cingulate brain circuit following a

course of TMS applied to the left dorsolateral
prefrontal cortex in patients with Major Depression
Kito (2008) J Neuropsychiatry Clin Neurosci
 Only TMS device FDA-cleared for the treatment of depression
Non-invasive and non-systemic
The most common side effect associated with
treatment is scalp pain or discomfort
generally mild to moderate
Outpatient procedure, can be performed in a
psychiatrists office; no anesthesia or sedation
37 minute treatment, administered daily
for 4-6 weeks
Observed therapy facilitates
adherence with treatment
Available by prescription only

13
 No systemic side effects
No adverse effect on cognition
Most common adverse event associated with
treatment was scalp pain or discomfort
< 5% of patients discontinued due to adverse events
No seizures with TMS during clinical studies
(over 10,000 treatments)
Six seizures reported with TMS in post-marketing period
(estimated risk of seizure < 0.1% per acute treatment course)
Long term safety demonstrated in 6 months
follow-up

Janicak, et al. J Clin Psychiatry, 2008; Janicak, et al. Brain

Stimulation, 2010.
 John P. OReardon, H. Brent Sovason, Philip G. Janicak, Shirlene Sampson, Keith E. Isenberg, Ziad Nahas, William M. McDonald,
David Avery, Paul B. Fitzgerald, Colleen Loo, Mark A. Demitrack, Mark S. George, and Harold A. Sackeim
BIOL PSYCHIATRY 2007;62:1208-1216 2007 Society of Biological Psychiatry

Major Findings:
N=301 patients (ATHF 1 thru 4), Clinically meaningful effect size = 0.52
23 sites (in ATHF = 1 population)
22.1% reduction in MADRS total In open label extension study, 1 in 2
score with active NeuroStar TMS patients responded, 1 in 3 patients
vs 9.1% on sham at 4 weeks (in achieved remission at 6 weeks
ATHF = 1 population) Safety confirmed in 6 month follow-up

Conclusion: Transcranial Magnetic Stimulation was effective in treating

major depression with minimal side effects reported. It offers clinicians a
novel alternative for the treatment of this disorder.
Demitrack & Thase (2009) Psychopharm Bulletin
 Mark S. George, MD; Sarah H. Lisanby, MD; David Avery, MD; William M. McDonald, MD; Valerie Durkalski, PhD;
Martina Pavlicova, Phd; Berry Anderson, Phd, RN; Ziad Nahas, MD; Peter Bulow, MD; Paul Zarkowski, MD;
Paul E. Holtzheimer III, MD; Theresa Schwartz, MS; Harold A. Sackeim, PHD

Major Findings:
NIMH-funded, independent of industry 30% of patients achieved
N=190 patients, 4 premier academic sites remission in open-label
Primary outcome measure: extension phase
% Remission - Active 15% vs Sham 4% (P = Excellent safety, nearly 90% of
0.015); Odds Ratio of achieving remission:
patients adherent to acute
4.2 (95%CI, 1.3-13.2)
phase treatment course

Conclusion: Daily left prefrontal rTMS as monotherapy produced statistically

significant and clinically meaningful antidepressant therapeutic effects greater than
sham.
 The evidence for the clinical efficacy of
TMS in the treatment of depression is
considerable, spanning more than 30
controlled clinical research studies

Most recent meta-analysis (Slotema, et al, 2010):

Included analysis of 34 studies involving 1,383 patients
Estimated standardized effect size = 0.55 (P < 0.001)
Conclusion: rTMS deserves a place in the standard toolbox of
psychiatric treatment methods, as it is effective for depression
and has a mild side effect profile.

Slotema, et al. J Clin Psych (2010)

 Safety confirmed during long term, open-label 6 month
follow up period
During open-label follow up on antidepressant
medication monotherapy, ~37% of patients required
TMS reintroduction
~85% of patients who received TMS reintroduction
benefited
Net incidence of illness relapse under these open-label
follow up conditions: 11%
Six-month relapse with antidepressant treatment
alone in STAR*D study was 35-50% (Level 2 and 3
range)
Janicak, et al. Brain Stimulation, 2010.