Geoffrey Grammer

The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder

BACKGROUND Prefrontal Transcranial Magnetic Stimulation (TMS) therapy repeated daily over 4-6 weeks (20-30 sessions) is US Food and Drug Administration (FDA) approved for treating Major Depressive Disorder in adults who have not responded to prior antidepressant medications. In 2011, leading TMS clinical providers and researchers created the Clinical TMS Society (cTMSs) (www.clinicaltmssociety.org, Greenwich, CT, USA), incorporated in 2013. METHODS This consensus review was written by cTMSs leaders, informed by membership polls, and approved by the governing board. It summarizes current evidence for the safety and efficacy of the use of TMS therapy for treating depression in routine clinical practice. Authors systematically reviewed the published TMS antidepressant therapy clinical trials. Studies were then assessed and graded on their strength of evidence using the Levels of Evidence framework published by the University of Oxford Centre for Evidence Based Medicine. The authors then summarize essentials for using TMS therapy in routine clinical practice settings derived from discussions and polls of cTMSs members. Finally, each summary clinical recommendation is presented with the substantiating peer-reviewed, published evidence supporting that recommendation. When the current published clinical trial evidence was insufficient or incomplete, expert opinion was included when sufficient consensus was available from experienced clinician users among the membership of the cTMSs, who were polled at the Annual Meetings in 2014 and 2015. CONCLUSIONS Daily left prefrontal TMS has substantial evidence of efficacy and safety for treating the acute phase of depression in patients who are treatment resistant or intolerant. Following the clinical recommendations in this document should result in continued safe and effective use of this exciting new treatment modality.

A Review of Transcranial Magnetic Stimulation as a Treatment for Post-Traumatic Stress Disorder

Patients with post-traumatic stress disorder (PTSD) may fail to achieve adequate relief despite treatment with psychotherapy, pharmacotherapy, or complementary medicine treatments. Transcranial magnetic stimulation (TMS) is a non-invasive brain stimulation procedure that can alter neuronal activity through administration of various pulse sequences and frequencies. TMS may theoretically have promise in correcting alterations observed in patients with PTSD. While the precise treatment location and pulse sequences remain undefined, current evidence suggests two promising targets, the right dorsolateral prefrontal cortex and the medial prefrontal cortex. The beneficial effects may be due to the secondary or indirect regulation of other brain structures that may be involved in the mood regulatory network. TMS may be an effective part of a comprehensive treatment program for PTSD, although significant work remains to define optimal treatment parameters and clarify how it fits within a broader traditional treatment program.

Gender Differences on Documented Trauma Histories: Inpatients Admitted to a Military Psychiatric Unit for Suicide-related Thoughts or Behaviors

Suicide is a leading cause of death among men and women in the United States Military. Using a retrospective chart review design, the current study investigated gender differences on documented traumas for people admitted to a military inpatient psychiatric unit for suicide-related thoughts or behaviors (N = 656). Men more often had no documented lifetime traumas and women more often had 2 or more trauma types. Women had significantly more documented incidences of childhood sexual abuse, adulthood sexual assault, adulthood physical assault, and pregnancy loss. The gender gap in documented trauma types for childhood and adulthood traumas persisted even after adjusting for demographic variables, psychiatric diagnoses, and comorbid trauma types (i.e., trauma types other than the one being used as the dependent variable). Given the observed gender differences in documented traumas, professionals working with military women admitted for suicide-related thoughts or behaviors need to consider trauma in the context of treatment.

Three Scoring Approaches to the Neurobehavioral Symptom Inventory for Measuring Clinical Change in Service Members Receiving Intensive Treatment for Combat-Related mTBI.

Objective:To examine the use of the Neurobehavioral Symptom Inventory to measure clinical changes over time in a population of US service members undergoing treatment of mild traumatic brain injury and comorbid psychological health conditions. Setting:A 4-week, 8-hour per day, intensive, outpatient, interdisciplinary, comprehensive treatment program at the National Intrepid Center of Excellence in Bethesda, Maryland. Participants:Three hundred fourteen active-duty service members being treated for combat-related comorbid mild traumatic brain injury and psychological health conditions. Design:Repeated-measures, retrospective analysis of a single-group using a pretest-posttest treatment design. Main Measures:Three Neurobehavioral Symptom Inventory scoring methods: (1) a total summated score, (2) the 3-factor method, and (3) the 4-factor method (with and without orphan items). Results:All 3 scoring methods yielded statistically significant within-subject changes between admission and discharge. The evaluation of effect sizes indicated that the 3 different Neurobehavioral Symptom Inventory scoring methods were comparable. Conclusion:Findings indicate that the different scoring methods all have potential for assessing clinical changes in symptoms for groups of patients undergoing treatment, with no clear advantage with any one method.

Significant Reduction in Phantom Limb Pain After Low-Frequency Repetitive Transcranial Magnetic Stimulation to the Primary Sensory Cortex

OBJECTIVE Phantom limb pain (PLP) is believed to be linked to the reorganization of the deafferented sensory cortex. We present a case of a patient with upper extremity PLP who was successfully treated with repetitive transcranial magnetic stimulation (rTMS). METHODS We treated an active duty service member who suffered an amputation of his right upper extremity after sustaining a blast injury in Afghanistan. He had 28 sessions of alternating sequences of rTMS to the left dorsolateral prefrontal cortex and primary sensory cortex of the left cerebral hemisphere. Pain intensity was assessed with the Visual Analogue Scale. RESULTS We delivered 1 Hz stimulation to the sensory cortex corresponding to the area of amputation five times a week. After 4 sessions, the patients pain decreased from a Visual Analogue Scale of 5 to 2. Left 10 Hz stimulation was added and after 28 sessions, the pain decreased from 2 to 1. CONCLUSIONS Our findings support that rTMS was an effective modality for this patient in treating his PLP. The significance of 10 Hz stimulation is unknown because of the lack of an effect size and is possibly associated with a floor effect.

Severity of Depression Predicts Remission Rates Using Transcranial Magnetic Stimulation

Background Multiple factors likely impact response and remission rates in the treatment of depression with repetitive transcranial magnetic stimulation (rTMS). Notably, the role of symptom severity in outcomes with rTMS is poorly understood. Objective/hypothesis This study investigated the predictors of achieving remission in patients suffering from depression who receive ≥3 rTMS treatments per week. Methods Available data on 41 patients treated at Walter Reed National Military Medical Center from 2009 to 2014 were included for analysis. Patients received a range of pulse sequences from 3,000 to 5,000 with left-sided or bilateral coil placement. Primary outcome measures were total score on the Patient Health Questionnaire-9 or the Quick Inventory of Depressive Symptomatology-Self Rated. Remission was defined as a total score less than five, and response was defined as a 50% decrease in the total score on both outcome metrics. Outcomes in patients diagnosed as suffering from mild or moderate depression were compared to those suffering from severe depression. Results Of the 41 patients receiving treatment, 16 reached remission and 18 reached response by the end of treatment. Remission rate was associated with the initial severity of depression, with patients with mild or moderate depression reaching remission at a significantly higher rate than those with severe depression. Total number of rTMS sessions or length of treatment was not predictors of remission. Conclusion Patients with a baseline level of depression characterized as mild or moderate had significantly better outcomes following rTMS compared to patients with severe depression.

Evaluating the clinical utility of the Validity-10 for detecting amplified symptom reporting for patients with mild traumatic brain injury and comorbid psychological health conditions

ABSTRACT The objective of this study was to compare the Validity-10 scale with the PAI Negative Impression Management Scale (PAI-NIM) for detecting exaggerated symptom reporting in active-duty military service members (SMs) admitted with unremitting mild TBI symptoms and comorbid psychological health conditions (mTBI/PH). Data were analyzed from 254 SMs who completed the Neurobehavioral Symptom Inventory (NSI) and Personality Assessment Inventory (PAI) as a part of a larger battery of self-report symptom scales upon admission to the intensive-outpatient TBI treatment program at a military medical center. Symptom exaggeration was operationalized using the PAI Negative Impression Management Scale (PAI-NIM). A PAI-NIM score of ≥73 was categorized as positive for symptom exaggeration (SVTpos), while a lower score was categorized as negative for symptom exaggeration (SVTneg). SMs in the SVTpos group (n = 34) had significantly higher scores (p ≤ .004) on the PAI clinical scales as well as on the NSI total score (range: d = 0.59–1.91) compared to those who were SVTneg (n = 220). The optimal cut-score for the NSI Val-10 scale to identify possible symptom exaggeration was ≥26 (sensitivity = .29, specificity = .95, PPP = .74, NPP = .71). In patients suffering from mTBI/PH, the Validity-10 requires a higher cut-score than previously reported to be useful as a metric of exaggerated symptom reporting.

Post-Admission Cognitive Therapy (PACT) for the Prevention of Suicide in Military Personnel With Histories of Trauma: Treatment Development and Case Example

To date, no inpatient evidence-based psychotherapeutic interventions have been developed for suicidal individuals with psychological trauma. Therefore, we have adapted, refined, implemented, and pilot-tested an inpatient-based cognitive behavioral therapy protocol, named Post-Admission Cognitive Therapy (PACT), for the prevention of suicide. This article briefly describes the theoretical and research underpinnings for PACT, components of the treatment protocol, and clinical challenges. A case study of a traumatized military service member hospitalized following a suicide attempt is presented. Baseline and follow-up assessment data show general improvements in suicide ideation, depression, hopelessness, and Post Traumatic Stress Disorder symptomatology over time. While the data for the presented case appears promising, the efficacy of PACT remains unknown and is currently under investigation in a randomized controlled trial. Recommendations for clinicians and students who deliver care to suicidal psychiatric inpatients are provided.

Motor impulsivity differentiates between psychiatric inpatients with multiple versus single lifetime suicide attempts

A history of multiple suicide attempts conveys greater risk for suicide than a single attempt. Impulsivity may partially explain the association between multiple attempts and increased risk. We examined trait impulsivity, ability to engage in goal-directed behaviors, and impulse control among psychiatrically hospitalized United States military personnel and their dependents. Individuals with a history of multiple versus single attempts had significantly higher motor impulsivity, indicating spur of the moment action. Providers are encouraged to directly assess and treat motor impulsivity among suicidal individuals. Further research should explore whether motor impulsivity is a mechanism of change in psychosocial suicide prevention interventions.

Use of Transcranial Magnetic Stimulation for the Treatment of PTSD

Symptoms of posttraumatic stress disorder (PTSD) and depression often fail to resolve with traditional interventions using psychotherapy and/or pharmacotherapy. Transcranial magnetic stimulation (TMS) is a noninvasive brain stimulation treatment that may offer efficacy for those patients who have not obtained adequate relief from their symptoms.