Accelerated TMS Program for Depression

A new, accelerated, and more effective TMS treatment at NeuroSpa:

For many patients especially those who travel from a long distance or our international patients, a 30-day treatment duration is not feasible. Now, with the help of researchers at Stanford University,<u>a 3-to-5-day treatment delivers the same level of treatment efficacy</u>as the standard 30-to-40-day treatment.

A six-week protocol for TMS is already approved by the FDA for the treatment of depression. However, a recent study at Stanford University, entitledStanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression (SAINT-TRD) showed that when TMS was delivered in a more intensive schedule and accelerated pace, it provided remission (i.e. ‘cure’) from depression in greater than 90% of patients in as little as 3 to 5 days. These results were published online April 7, 2020 in theAmerican Journal of Psychiatry. A follow-up study published on October 29, 2021 in theAmerican Journal of PsychiatryentitledStanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial confirmed these results and renamed the procedure from SAINT to SNT.

NeuroSpa now offers an Accelerated Brain Stimulation Treatment for depression.

Remission of Depression in less than 1 week.

TMS Therapy at NeuroSpa

In the Stanford study, patients underwent 10 sessions per day of 10-minute treatments, with 50-minute breaks between treatments. Each treatment was a modified version of “Theta Burst” TMS, which requires specialized equipment to deliver. On average, three days of the therapy were enough for participants to experience relief from depression. The follow-up study showed virtually identical results to the original study.

How Safe is Accelerated TMS Therapy?

The only side effects of this new, rapid TMS approach were fatigue and some discomfort during treatment such as mild headache.

Of particular note: In order to assess safety, the researchers evaluated the participants’ cognitive function before and after treatment. They found no negative side effects. Instead, they discovered that the participants’ ability to switch between mental tasks and to solve problems had improved — a typical outcome for people who are no longer depressed.

Our Approach to Accelerated TMS

At NeuroSpa we are able to treat patients using precisely the same parameters used in the Stanford study including advanced targeting with MR-navigated TMS technology. The only difference in our approach is that we use an effective office-based method of finding the treatment location, called swLORETA (standardized-weighted low resolution electro tomography) QEEG (quantitative electroencephalogram) imaging or ‘brain mapping’, rather than a combination of MRI and computer modeling, as was used in the original studies. This type of imaging is very quick (less than 15-20 minute), does not expose patients to any radioactive agents or x-ray, helpful in guiding and evaluating treatment efficacy, and a fraction of the cost of fMRI. However, in select patients, we also have the capability to send patients for fMRI studies at our partner radiology center located in Westwood, Los Angeles.

What is MR Navigation

When stimulating critical brain regions, it is particularly important to be accurate and precise. MR-navigation refers to directing the TM S stimulation beam to very precise locations on the brain under direct view of each patient’s actual brain images. Our office has chosen to eliminate targeting errors by incorporating every one’s unique brain anatomical landmarks as captured by MRI imaging. We use same MR-navigation technology neurosurgeon’s use in the operating room when operating on the brain where precision counts. Our MR-navigation provides real-time tracking, meaning our staff is alerted if patient’s head moves even the slightest which allows us to continuously monitor and adjust the stimulation coil to stay on target.

Robust research trials (Fitzgerald et al. Neuropsychopharmacology, 2009) have clearly shown the benefits of MR-navigation with higher rates of efficacy in less time. Currently, there are less than a handful of centers that use the type of system used at NeuroSpa including several academic centers. The accelerated program developed at Stanford also used MR-navigation to ensure the highest level of precision and treatment efficacy.

Mapping and SNT (SAINT) TMS

The area of the brain that we target with TMS to treat depression is called the left dorsolateral prefrontal cortex (LDLPFC). This area is relatively underactive in patients with depression, and when we re-activate this region using TMS, the symptoms of depression often remit.

There are several methods to find the location of the L DLPFC. We use MRI neuronavigation or the ‘BEAM F3’ method.

The ‘BEAM F3 Method’

The BEAM F3 method is based on the international EEG convention termed the ‘10-20 system’, which is a system used to find spots for the placement of EEG (electroencephalography) leads. In the 10-20 system, the location referred to as F3 in correlates to the LDLPFC. Using the F3 method, three measurements of the patient’s head are taken, and then a computer program is used to calculate corresponding measurements that allow the clinician to locate F3.

SNT or SAINT TMS

Each participant in the SNT studies underwent two forms of MRI prior to treatment: structural MRI, which produces a static image of the brain, and resting-state fMRI, which measures the slight changes in blood flow that occur with brain activity. The precise region within the LDLPFC that is most functionally correlated with depression was located for each individual patient using these MRI images in combination with computer modeling, and treatment was directed to this area.

TMS Therapy at NeuroSpa

On close examination of the SNT research, it becomes clear that the treatment areas located using MRI and computer modeling were, on average, approximately 1 cm lateral to the F3 location. By locating the spot 1 cm lateral to F3 and using a coil that stimulates a large enough area we can therefore target the location that correlates to the average location of all patients in the SNT studies whose treatment target areas were located using the combination of MRI and computer modeling.

Given that SNT (or SAINT) relies in part on Stanford’s proprietary computer modeling and in part on MRI, we have named what we offer at NeuroSpa “Accelerated TMS” rather than SNT. However, given that (1) our targeting method closely replicates the SNT method, and (2) we are able to deliver the exact same high-dose iTBS (intermittent theta burst) protocol that was used in the SNT studies, we have found that Accelerated TMS can offer results similar, if not identical to, SNT.

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