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Julie Plummer, CEO
October 17, 2011 2
PineWood TMS
Supporting Integrated Wellness
PineWood Transcranial Magnetic Stimulation
2
Julie Plummer, CEO
Why the Name Pinewood TMS?
Neuro-Modulation Programs
in the North East
LegendPineTree= PineWood TMS, Brattleboro, VT
Red Dots= TMS
Magenta= ECT + TMS
Blue Dots= ECT
Many Patients with Depression Remain Poorly Served:
Kessler RC et al. JAMA. 2003;289(23):3095-3105.
14 Million US Adults
7.2 MillionTreated
6.8 MillionUntreated
3.2 MillionAdequately
Treated
4 MillionPoorly Served
Inadequate response
Intolerant to side effects
6
Major Depressive Disorder
“Adequate” Treatment
Is Difficult to Achieve
Adequate Dosage Adequate Duration
Poor Tolerability
Nonadherence Safety Issues
Lack of Efficacy
Comorbidities
1. Nemeroff CB. Depress Anxiety. 1996/1997;4(4):169-181; 2. Oquendo MA et al. J Clin Psychiatry. 2003;64(7):825-833; 3. Oquendo MA et al. Am J Psychiatry. 1999;156(2):190-194.
Factors contributing to inadequate treatment include:
Neuro-anatomy and physiology
of Major depressive disorder
prefrontal
cortex
In MDD, some
areas of the
brain are
hypoactive and
others are
hyperactive.
amygdala
brainstem
neurotransmitter
centers
thalamus
striatum
anterior
cingulate
cortex
hippocampus
hypothalamus
LOW
HIGH
Neural
Activity
When there is an
appropriate
amount of
monoamine
neurotransmitter
activity, neuronal
activity
throughout the
brain functions
normally.
• Monoamine
dysfunction is
linked to MDD
• Malfunctioning
circuits lead to
specific
symptoms
Major Depressive Disorder:
Circuits and Neurotransmitters
Serotonin (5-HT) Dopamine (DA) Norepinephrine (NE)Monoamine
Neurotransmitters
monoamine
neurotransmitter
projections
concentration
pleasure/
interests
guilt
suicidality
worthlessness
mood
sleep
appetite
psychomotor fatigue (physical)
pleasure/interests
psychomotor
fatigue (mental)
guilt
suicidality
worthlessness
mood
Regions implicated in MDD are
connected to the brainstem via
monoaminergic circuits
Chemical Antidepressants
Antidepressant
weight gainsexual
dysfunction
insomnia
nausea
GI
distress
blood
pressure
changes
blurred vision
AntidepressantTherapeutic Effects such as:
improved
mood
increased
concentration
reduced feelings of
guilt, suicidality, and
worthlessnessweight gain
insomnia
agitation dry mouth fatigue
APA Accepted Treatment
Algorithm for MDD
Kessler RC et al. Arch Gen Psychiatry. 2005;62(6):617-627; Kessler RC et al. JAMA. 2003;289(23):3095-3105; Herrmann RC. Am J Psychiatry. 1995;152(6):869-875.
SSRI
SNRINDRI
TMS
Primary Care
• Initial Diagnosis
• Early Treatment Attempts
Psychiatry
• Improved Diagnosis
• Improved Dosing
• Psychotherapy
• New Treatment Options
Combination & Augmentation
– Atypical Antipsychotics
– Mood Stabilizers
MAOI & TCA
ECT
10M
8M
6M
4M
2M
0 1 2 3 4 5 6 7 8
Failed Treatment Attempts in Current Episode
Num
ber
of
MD
D P
ati
ents
VNS
Treatment-Resistance Continuum
ECT Video
13
Transcranial Magnetic Stimulation
Therapy System
Treatment coil
Head support unit
Treatment chair
Mobile console
Touchscreen
NeuroStar TMS Therapy System User Manual. Neuronetics, Inc: Malvern, PA; 2008.
TMS Video
Neuron
TMS Directly Depolarizes Cortical
Neurons
Pulsed magnetic fields
from TMS Coil:
• induce a local electric
current in the cortex
which depolarizes
neurons
• elicit action potentials
• cause the release of
chemical
neurotransmitters
Depolarization leads to action
potentials in local neurons and
thereby releases neurotransmitters
Neurons are
“electrochemical
cells” and respond to
either electrical or
chemical stimulation
TMS Releases Neurotransmitters
in the Brain
Depolarization of neurons
in the DLPFC causes local
neurotransmitter release
Depolarization of pyramidal
neurons in the DLPFC causes
neurotransmitter release in
deeper brain neurons
Activation of deeper brain
neurons then exerts secondary
effects on remaining portions of
targeted mood circuits
Dorsolateralprefrontal
cortex
Cingulate cortex
Kito (2008) J Neuropsychiatry Clin Neurosci
These effects are
associated with
improvements in
depressive symptoms
TMS Mechanism of Action Summary
TMS Therapy:
Specifically targets the underlying brain circuits involved in mood regulation
Directly depolarizes cortical neurons and modulates neurotransmitter release in the brain
Effects involve both the local and deep neural circuits in the brain
Accomplishes these effects without unwanted systemic adverse effects
Feature-Benefits Table
Features Benefits
No Anesthesia Physiological, psychological,
logistical
Non-Systemic Minimal side effects, no
memory loss or confusion
Non-Invasive TMS is not disfiguring
Concurrent use of
other therapies
Potentiate Positive Outcomes
PineWood TMS in
Brattleboro, VT
The Clinical Role of Psychiatric RNs in TMS
• Initial patient
assessment
• Education
• Establish therapeutic
treatment setting
• Observe therapy
• Assess patient
outcomes
Process for Patients Entering
PineWood TMS
1. Referral.
2. Education.
3. Evaluation.
4. Informed Consent.
Process TMS When Treatments are Ordered
1. Treatment Parameters Set.
2. Treatment Commences.
3. Weekly Assessment of Depression.
4. Psychiatrist is Updated Weekly.
Frequently Asked Questions
• What are the chances it will work?
• How long will it take to feel better?
• How long will the effect last?
• What are the side effects?
Contact Information
Supporting Integrated Wellness
167 Main Street
Brattleboro, VT 05301
802-246-1304
WWW.PineWoodTMS.com
PineWood TMS