On May 1, 2012, Dr. Cady presented "Magnets, Not Drugs" to the medical staff at Deaconess Hospital, Evansville, IN, for their weekly Grand Rounds program. In this presentation, Dr. Cady reviews the "three things you could do in psychiatry before TMS," which he categorizes as "shrinking, shocking, and drugging." Using the Faraday principle of electromagnetic induction, and applying it to neurochemistry, this new development resulted in a breakthrough treatment for depression, FDA approved only three years ago. In this presentation Dr. Cady reviews TMS (transcranial magnetic stimulation) completely.
This document discusses pain management and opioid addiction. It begins with introductions and disclosures from the presenter, Dr. Mel Pohl. The objectives are then outlined as reviewing addiction as a brain disease, describing chronic pain, and discussing pain treatment in the context of opioid addiction. Key facts about chronic pain and definitions of pain and addiction are provided. The neurobiology of addiction and how it is similar to other diseases is examined through PET scan images. Issues with using opioids to treat chronic pain like side effects, tolerance, and hyperalgesia are covered. The emergence of the opioid epidemic in the US is shown through various graphs and charts. Non-opioid and non-medication treatment options at Las Vegas Recovery Center are
The document discusses depression in women and improving outcomes. Major depression has a significant public health impact and is the leading cause of disability among women worldwide. Women experience depression rates 1.5-2.5 times higher than men ages 15-54. Key ways to improve outcomes include considering differential diagnoses, treating to remission, measuring symptom improvement, using evidence-based interventions personalized to the individual woman, and providing self-help resources.
The document discusses migraine, including:
1) Migraine affects 10% of the population and is more prevalent than diabetes or asthma. It places a large burden on individuals and healthcare systems.
2) Migraine involves complex neurological changes including cortical spreading depression, activation of the trigeminovascular system, and abnormal brainstem activity.
3) Treatment involves lifestyle modifications to avoid triggers, pharmacological interventions like triptans, and behavioral/psychological therapies. Managing migraine requires an integrated approach.
1 adequate therapy for chronic non cancer painPuya Arash
This document discusses chronic non-cancer pain (CNCP) and barriers to its treatment. It reviews the prevalence of CNCP, affecting over 25% of the population. Current therapeutic approaches include non-pharmacological measures, analgesics like opioids and tramadol, and invasive interventions. However, barriers remain for physicians, patients, and the healthcare system. The document calls for a multidisciplinary approach and changes to improve CNCP management.
This document discusses chronic non-cancer pain. It begins by emphasizing the importance of considering pain as the 5th vital sign and properly assessing and treating patients' pain complaints. It then discusses types of pain including acute, cancer, and chronic non-cancer pain. It provides an overview of the chronic pain treatment continuum and targeting approaches based on pain type. Principles of chronic pain treatment include reducing pain, rehabilitation, and coping. Treatment objectives aim to decrease pain frequency/severity and increase activity and quality of life. The document then summarizes pharmacological and non-pharmacological options for chronic pain symptom control.
Efta Triastuti's document discusses competence targets and considerations for schizophrenia and bipolar disorder. It covers epidemiology, etiology, pathophysiology, clinical presentation, treatment algorithms, pharmacology, side effects, drug interactions, and monitoring protocols for both conditions. The document provides a comprehensive overview of schizophrenia and bipolar disorder for pharmacy students.
Three pronged approach to migraine epilepsy and neuropathic pain–role of oxca...webzforu
The document discusses the use of oxcarbazepine for the treatment of migraine, epilepsy, and neuropathic pain, noting that as an anti-epileptic drug it has better pharmacokinetic properties than carbamazepine with fewer drug interactions and side effects. It provides information on the prevalence, triggers, and classification of migraine as well as the relationship between migraine and epilepsy.
This document discusses the management of chronic (neurogenic) pain. It provides information on understanding pain, its pathophysiology, assessment, and treatment options. Chronic pain is a complex condition with physical and psychological components. Proper management requires a multidisciplinary approach including pharmacological, rehabilitative, and psychologic interventions to help improve patient function and quality of life.
This document discusses pain management and opioid addiction. It begins with introductions and disclosures from the presenter, Dr. Mel Pohl. The objectives are then outlined as reviewing addiction as a brain disease, describing chronic pain, and discussing pain treatment in the context of opioid addiction. Key facts about chronic pain and definitions of pain and addiction are provided. The neurobiology of addiction and how it is similar to other diseases is examined through PET scan images. Issues with using opioids to treat chronic pain like side effects, tolerance, and hyperalgesia are covered. The emergence of the opioid epidemic in the US is shown through various graphs and charts. Non-opioid and non-medication treatment options at Las Vegas Recovery Center are
The document discusses depression in women and improving outcomes. Major depression has a significant public health impact and is the leading cause of disability among women worldwide. Women experience depression rates 1.5-2.5 times higher than men ages 15-54. Key ways to improve outcomes include considering differential diagnoses, treating to remission, measuring symptom improvement, using evidence-based interventions personalized to the individual woman, and providing self-help resources.
The document discusses migraine, including:
1) Migraine affects 10% of the population and is more prevalent than diabetes or asthma. It places a large burden on individuals and healthcare systems.
2) Migraine involves complex neurological changes including cortical spreading depression, activation of the trigeminovascular system, and abnormal brainstem activity.
3) Treatment involves lifestyle modifications to avoid triggers, pharmacological interventions like triptans, and behavioral/psychological therapies. Managing migraine requires an integrated approach.
1 adequate therapy for chronic non cancer painPuya Arash
This document discusses chronic non-cancer pain (CNCP) and barriers to its treatment. It reviews the prevalence of CNCP, affecting over 25% of the population. Current therapeutic approaches include non-pharmacological measures, analgesics like opioids and tramadol, and invasive interventions. However, barriers remain for physicians, patients, and the healthcare system. The document calls for a multidisciplinary approach and changes to improve CNCP management.
This document discusses chronic non-cancer pain. It begins by emphasizing the importance of considering pain as the 5th vital sign and properly assessing and treating patients' pain complaints. It then discusses types of pain including acute, cancer, and chronic non-cancer pain. It provides an overview of the chronic pain treatment continuum and targeting approaches based on pain type. Principles of chronic pain treatment include reducing pain, rehabilitation, and coping. Treatment objectives aim to decrease pain frequency/severity and increase activity and quality of life. The document then summarizes pharmacological and non-pharmacological options for chronic pain symptom control.
Efta Triastuti's document discusses competence targets and considerations for schizophrenia and bipolar disorder. It covers epidemiology, etiology, pathophysiology, clinical presentation, treatment algorithms, pharmacology, side effects, drug interactions, and monitoring protocols for both conditions. The document provides a comprehensive overview of schizophrenia and bipolar disorder for pharmacy students.
Three pronged approach to migraine epilepsy and neuropathic pain–role of oxca...webzforu
The document discusses the use of oxcarbazepine for the treatment of migraine, epilepsy, and neuropathic pain, noting that as an anti-epileptic drug it has better pharmacokinetic properties than carbamazepine with fewer drug interactions and side effects. It provides information on the prevalence, triggers, and classification of migraine as well as the relationship between migraine and epilepsy.
This document discusses the management of chronic (neurogenic) pain. It provides information on understanding pain, its pathophysiology, assessment, and treatment options. Chronic pain is a complex condition with physical and psychological components. Proper management requires a multidisciplinary approach including pharmacological, rehabilitative, and psychologic interventions to help improve patient function and quality of life.
This document provides information about end-of-life care, including:
1. It describes the concept of "convergence of symptoms" where the failure of one organ system affects others in the final stage of life, leading to common symptoms like pain, shortness of breath, secretions, etc. regardless of the underlying illness.
2. It identifies strategies for managing common end-of-life symptoms like pain, shortness of breath, secretions, changes in consciousness, and delirium through the appropriate use of medications and other interventions.
3. It emphasizes the importance of expert symptom management, clear communication with families, and support from hospice professionals to help ensure a smooth passage for patients and loved
This document provides a guide for managing common symptoms in seriously ill pediatric patients, with a focus on end-of-life care. It outlines the social and medical aspects of accepting palliative care over curative treatment, maintaining comfort through active medical care, and managing a home or hospital death. The document also provides guidance on treating pain, nausea, anxiety, and other symptoms through pharmacological and non-pharmacological means.
The document discusses the medical model approach to treating mental disorders, which views symptoms as indicative of an underlying pathology that can be diagnosed and treated. It describes the classification system for mental disorders in the DSM-IV-TR manual and some major categories of disorders like anxiety disorders, psychosis, and mood disorders. The document then covers early treatment methods for mental disorders like malaria therapy and insulin shock therapy. It discusses the discovery of antipsychotic medications and their mechanisms and side effects. Finally, it outlines major types of antidepressant medications including MAO inhibitors, tricyclics, and SSRIs.
- Mr. P injures his finger with a hammer, resulting in acute pain that transitions to chronic neuropathic pain over months as central sensitization develops in his brain and spinal cord.
- His pain spreads from his finger to his whole hand and increases in intensity, severity, and frequency of flares.
- Despite seeking medical care, tests find no physiological cause and treatments provide no relief, leaving Mr. P increasingly disabled, depressed, and distrustful of doctors.
Chronic pain: Role of tricyclic antidepressants, dolsulepinSudhir Kumar
Chronic pain is common. Depression often co-exist with chronic pain. This article looks at the pathophysiology, prevalence of chronic pain and depression. The role of TCA, especially dosulepin and amitriptyline has been discussed.
Explores impact of disturbed sleep on symptom management in patients with concurrent serious illness and at the end of life. Presented during Hospice and Palliative Medicine Fellowship at the University of Kansas 2014
This document discusses the treatment of psychiatric disorders through pharmacotherapy, psychotherapy, and somatic treatments. It focuses on the role of medications in treating various conditions like mood disorders, schizophrenia, anxiety, sleep disorders, substance use disorders, and others. It provides details on specific drug classes and examples used to treat each condition. It also covers electroconvulsive therapy (ECT) and discusses what it is, how it works, when it may be used, potential side effects, and the ECT administration and recovery process. Psychotherapies are also mentioned as important treatment options.
Abnormal mental states and behaviours in MSMS Trust
Learning outcomes:
Recognition and treatment of depression and anxiety in MS
Recognise sudden changes in emotional state (laughter, crying, anger)
Recognition of mania and psychosis in MS
Cognitive impairment
The document provides an overview of depression, including:
1. Defining depression and outlining the diagnostic criteria according to the DSM-IV, including symptoms such as persistent sadness, loss of interest, changes in appetite and sleep.
2. Describing different types of depression such as major depression, bipolar disorder, seasonal affective disorder, and discussing their symptoms.
3. Explaining various factors that can contribute to the development of depression including genetics, life stressors, medical conditions, and changes in the brain.
4. Outlining treatment approaches including antidepressant medications, psychotherapy, electroconvulsive therapy, and the nursing care role in monitoring safety, providing support, and promoting wellness
This document summarizes the clinical uses of the antipsychotic drug quetiapine. It discusses quetiapine's approval for treating schizophrenia, bipolar disorder, depression, and other off-label uses. Key points include quetiapine being the first-line treatment for bipolar depression, its efficacy in reducing symptoms of schizophrenia and mania, and dosage guidelines for different conditions. Recent studies are cited showing quetiapine's benefits for outcomes in schizophrenia and improvements in working memory compared to other antipsychotics.
Schizophrenia and bipolar disorder are severe mental illnesses that affect millions of people in the US. Seroquel is an atypical antipsychotic approved to treat schizophrenia, acute manic episodes associated with bipolar disorder, and depressive episodes associated with bipolar disorder. It is available in different oral formulations and has the indication of being the first drug approved to treat both manic and depressive episodes of bipolar disorder. Common side effects include drowsiness, dry mouth, and weight gain. Major competitors of Seroquel include Risperdal, Zyprexa, Abilify, and Invega.
Hanipsych, antipsychotics and antidepressants actionHani Hamed
Antipsychotics have long been used as an adjunct treatment for depressive disorders. Only 60-70% of patients respond to antidepressants alone. Adding an antipsychotic can target multiple receptor systems and may improve outcomes. Second-generation antipsychotics are now preferred due to their safer side effect profiles. Several atypical antipsychotics have been approved to treat depressive disorders based on evidence they provide antidepressant effects. Their mechanisms of action are not fully understood but may involve influencing serotonin and dopamine pathways in areas involved in mood regulation.
This document provides an update on antipsychotic medications from Prof. Hani Hamed Dessoki. It discusses oral and long-acting injectable second-generation antipsychotics (SGAs) including two new products, Vraylar and Nuplazid. It also mentions guidelines for antipsychotic use in dementia and a new boxed warning for olanzapine regarding DRESS syndrome. Product and guideline updates are provided at the end.
The Shri Isari Velan Mission hospital provides comprehensive palliative care to patients with serious illnesses to help them live with comfort and dignity. Palliative care aims to enhance quality of life through effective symptom management and attention to patients' psychological, social, and spiritual needs. It can be delivered alongside life-prolonging care or as the main focus of care. The goal of palliative care is to improve quality of life for both patients and their families through a holistic, family-centered approach.
Antipsychotics are increasingly being used as antidepressants due to their ability to improve outcomes for patients with treatment-resistant depression. While antipsychotics can provide benefits when augmenting antidepressants, they also carry risks like weight gain, akathisia, and metabolic side effects. Future research should aim to better identify patient subgroups most likely to benefit from specific antipsychotic medications and combinations with antidepressants, as well as optimal dosages and durations of treatment to maximize effectiveness and minimize adverse reactions.
Hani hamed dessoki, alternative ttt of depressionHani Hamed
This document discusses complementary and alternative medicine (CAM) approaches for treating mental health conditions like depression. It begins with an introduction to CAM and discusses essential nutrients that can support optimal brain function, like omega-3 fatty acids, amino acids, vitamins, and minerals. It then covers herbal remedies commonly used for depression, such as St. John's Wort, and reviews the evidence for their effectiveness and safety. The document also discusses mind-body connections and how lifestyle factors like exercise, sleep, nutrition, and stress management can impact mental health.
Magnets - Not Drugs: TMS IMMH San Antonio 2014Louis Cady, MD
In this talk, Dr. Cady covers a remarkable new treatment for depression: transcranial magnetic stimulation. The historical roots of this treatment are traced, followed by a review of the literature in terms of the proven efficacy of this treatment. A comparison with ECT shows that TMS has a very favorable profile, with remarkably fewer side effects and incredibly better tolerated side effects compared to ECT. Given that this was a "CME" talk, off-label uses of TMS were reviewed, including stepping stones for future avenues to explore
rTMS therapy uses magnetic pulses to the brain to treat depression. It works by increasing or decreasing activity in targeted brain areas like the left prefrontal cortex. Studies show rTMS is effective for medication-resistant depression, with over 30% of patients experiencing remission of symptoms and over 50% experiencing an improvement. Brain imaging studies also show rTMS may normalize activity in limbic and cortical brain regions involved in mood regulation. Potential side effects include headache or discomfort at the site of stimulation, but rTMS is considered safe and better tolerated than antidepressant medications.
This document provides information about end-of-life care, including:
1. It describes the concept of "convergence of symptoms" where the failure of one organ system affects others in the final stage of life, leading to common symptoms like pain, shortness of breath, secretions, etc. regardless of the underlying illness.
2. It identifies strategies for managing common end-of-life symptoms like pain, shortness of breath, secretions, changes in consciousness, and delirium through the appropriate use of medications and other interventions.
3. It emphasizes the importance of expert symptom management, clear communication with families, and support from hospice professionals to help ensure a smooth passage for patients and loved
This document provides a guide for managing common symptoms in seriously ill pediatric patients, with a focus on end-of-life care. It outlines the social and medical aspects of accepting palliative care over curative treatment, maintaining comfort through active medical care, and managing a home or hospital death. The document also provides guidance on treating pain, nausea, anxiety, and other symptoms through pharmacological and non-pharmacological means.
The document discusses the medical model approach to treating mental disorders, which views symptoms as indicative of an underlying pathology that can be diagnosed and treated. It describes the classification system for mental disorders in the DSM-IV-TR manual and some major categories of disorders like anxiety disorders, psychosis, and mood disorders. The document then covers early treatment methods for mental disorders like malaria therapy and insulin shock therapy. It discusses the discovery of antipsychotic medications and their mechanisms and side effects. Finally, it outlines major types of antidepressant medications including MAO inhibitors, tricyclics, and SSRIs.
- Mr. P injures his finger with a hammer, resulting in acute pain that transitions to chronic neuropathic pain over months as central sensitization develops in his brain and spinal cord.
- His pain spreads from his finger to his whole hand and increases in intensity, severity, and frequency of flares.
- Despite seeking medical care, tests find no physiological cause and treatments provide no relief, leaving Mr. P increasingly disabled, depressed, and distrustful of doctors.
Chronic pain: Role of tricyclic antidepressants, dolsulepinSudhir Kumar
Chronic pain is common. Depression often co-exist with chronic pain. This article looks at the pathophysiology, prevalence of chronic pain and depression. The role of TCA, especially dosulepin and amitriptyline has been discussed.
Explores impact of disturbed sleep on symptom management in patients with concurrent serious illness and at the end of life. Presented during Hospice and Palliative Medicine Fellowship at the University of Kansas 2014
This document discusses the treatment of psychiatric disorders through pharmacotherapy, psychotherapy, and somatic treatments. It focuses on the role of medications in treating various conditions like mood disorders, schizophrenia, anxiety, sleep disorders, substance use disorders, and others. It provides details on specific drug classes and examples used to treat each condition. It also covers electroconvulsive therapy (ECT) and discusses what it is, how it works, when it may be used, potential side effects, and the ECT administration and recovery process. Psychotherapies are also mentioned as important treatment options.
Abnormal mental states and behaviours in MSMS Trust
Learning outcomes:
Recognition and treatment of depression and anxiety in MS
Recognise sudden changes in emotional state (laughter, crying, anger)
Recognition of mania and psychosis in MS
Cognitive impairment
The document provides an overview of depression, including:
1. Defining depression and outlining the diagnostic criteria according to the DSM-IV, including symptoms such as persistent sadness, loss of interest, changes in appetite and sleep.
2. Describing different types of depression such as major depression, bipolar disorder, seasonal affective disorder, and discussing their symptoms.
3. Explaining various factors that can contribute to the development of depression including genetics, life stressors, medical conditions, and changes in the brain.
4. Outlining treatment approaches including antidepressant medications, psychotherapy, electroconvulsive therapy, and the nursing care role in monitoring safety, providing support, and promoting wellness
This document summarizes the clinical uses of the antipsychotic drug quetiapine. It discusses quetiapine's approval for treating schizophrenia, bipolar disorder, depression, and other off-label uses. Key points include quetiapine being the first-line treatment for bipolar depression, its efficacy in reducing symptoms of schizophrenia and mania, and dosage guidelines for different conditions. Recent studies are cited showing quetiapine's benefits for outcomes in schizophrenia and improvements in working memory compared to other antipsychotics.
Schizophrenia and bipolar disorder are severe mental illnesses that affect millions of people in the US. Seroquel is an atypical antipsychotic approved to treat schizophrenia, acute manic episodes associated with bipolar disorder, and depressive episodes associated with bipolar disorder. It is available in different oral formulations and has the indication of being the first drug approved to treat both manic and depressive episodes of bipolar disorder. Common side effects include drowsiness, dry mouth, and weight gain. Major competitors of Seroquel include Risperdal, Zyprexa, Abilify, and Invega.
Hanipsych, antipsychotics and antidepressants actionHani Hamed
Antipsychotics have long been used as an adjunct treatment for depressive disorders. Only 60-70% of patients respond to antidepressants alone. Adding an antipsychotic can target multiple receptor systems and may improve outcomes. Second-generation antipsychotics are now preferred due to their safer side effect profiles. Several atypical antipsychotics have been approved to treat depressive disorders based on evidence they provide antidepressant effects. Their mechanisms of action are not fully understood but may involve influencing serotonin and dopamine pathways in areas involved in mood regulation.
This document provides an update on antipsychotic medications from Prof. Hani Hamed Dessoki. It discusses oral and long-acting injectable second-generation antipsychotics (SGAs) including two new products, Vraylar and Nuplazid. It also mentions guidelines for antipsychotic use in dementia and a new boxed warning for olanzapine regarding DRESS syndrome. Product and guideline updates are provided at the end.
The Shri Isari Velan Mission hospital provides comprehensive palliative care to patients with serious illnesses to help them live with comfort and dignity. Palliative care aims to enhance quality of life through effective symptom management and attention to patients' psychological, social, and spiritual needs. It can be delivered alongside life-prolonging care or as the main focus of care. The goal of palliative care is to improve quality of life for both patients and their families through a holistic, family-centered approach.
Antipsychotics are increasingly being used as antidepressants due to their ability to improve outcomes for patients with treatment-resistant depression. While antipsychotics can provide benefits when augmenting antidepressants, they also carry risks like weight gain, akathisia, and metabolic side effects. Future research should aim to better identify patient subgroups most likely to benefit from specific antipsychotic medications and combinations with antidepressants, as well as optimal dosages and durations of treatment to maximize effectiveness and minimize adverse reactions.
Hani hamed dessoki, alternative ttt of depressionHani Hamed
This document discusses complementary and alternative medicine (CAM) approaches for treating mental health conditions like depression. It begins with an introduction to CAM and discusses essential nutrients that can support optimal brain function, like omega-3 fatty acids, amino acids, vitamins, and minerals. It then covers herbal remedies commonly used for depression, such as St. John's Wort, and reviews the evidence for their effectiveness and safety. The document also discusses mind-body connections and how lifestyle factors like exercise, sleep, nutrition, and stress management can impact mental health.
Magnets - Not Drugs: TMS IMMH San Antonio 2014Louis Cady, MD
In this talk, Dr. Cady covers a remarkable new treatment for depression: transcranial magnetic stimulation. The historical roots of this treatment are traced, followed by a review of the literature in terms of the proven efficacy of this treatment. A comparison with ECT shows that TMS has a very favorable profile, with remarkably fewer side effects and incredibly better tolerated side effects compared to ECT. Given that this was a "CME" talk, off-label uses of TMS were reviewed, including stepping stones for future avenues to explore
rTMS therapy uses magnetic pulses to the brain to treat depression. It works by increasing or decreasing activity in targeted brain areas like the left prefrontal cortex. Studies show rTMS is effective for medication-resistant depression, with over 30% of patients experiencing remission of symptoms and over 50% experiencing an improvement. Brain imaging studies also show rTMS may normalize activity in limbic and cortical brain regions involved in mood regulation. Potential side effects include headache or discomfort at the site of stimulation, but rTMS is considered safe and better tolerated than antidepressant medications.
Transcranial Brain Stimulation: Science and EthicsJames David Saul
This document discusses the promise and potential risks of noninvasive brain stimulation techniques like transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS). It notes that these techniques have shown promise in transiently improving cognition in domains like language, learning, attention, and problem-solving. They have also shown potential for mood enhancement and manipulating social cognition. However, the document also discusses safety concerns, issues of character and justice, and questions around autonomy that arise from the ability to manipulate human cognition and behavior without consent through these techniques.
1) Repetitive Transcranial Magnetic Stimulation (rTMS) is a new tool that could provide a new therapy and hope for treating ADHD. It has been found effective in treating other neurological and psychiatric disorders.
2) rTMS may target the prefrontal-caudate-cerebellar pathways and dopamine abnormalities involved in ADHD by modulating neurotransmitters like dopamine through cortico-striatal projections.
3) Carefully conducted clinical trials are still needed, but initial evidence suggests rTMS may help treat ADHD symptoms and is a safe technique worth exploring further.
This chapter discusses somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) which are used to evaluate spinal cord tracts. SEPs are elicited by electrical stimulation of nerves and recorded from the spine and scalp. They provide information about lesions proximal to the dorsal root ganglion and are useful for diagnosing spinal disorders. MEPs involve transcranial stimulation of motor areas and recording from muscles. They are helpful for evaluating conditions like multiple sclerosis, ALS, spinal cord injury, and stroke. Both SEPs and MEPs have clinical applications in determining prognosis and evaluating treatment for various spinal conditions.
ECT was developed in the 1930s-1940s by Meduna, Cerletti, and Kalinowsky. It involves inducing seizures through electricity to treat psychiatric conditions. ECT is regulated by California law AB1032 and requires documentation by two psychiatrists or neurologists. Patients must receive a detailed explanation of ECT at least 24 hours before providing consent.
Repetitive transcanial magnetic stimulation(r tms) for depression treatmentGuru Prasath
Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive treatment used for depression when common treatments do not work. rTMS uses rapidly changing magnetic fields to induce weak electric currents in neurons, targeting areas of the limbic system associated with depression. This triggers neurotransmitter secretion and facilitates neural activity in the targeted area. rTMS has advantages over antidepressants as it does not cause side effects and its effects can last beyond the stimulation period.
transcranial magnetic stimulation , deep brain stimulation and vagal nerve st...أنس زيتون
This document discusses several neuromodulation techniques for treating neurological conditions like depression. It describes transcranial magnetic stimulation (TMS), which uses magnetic fields to stimulate brain regions involved in mood control. Deep brain stimulation involves implanting electrodes in the brain to regulate abnormal impulses through electrical stimulation. Vagus nerve stimulation stimulates the vagus nerve with electrical impulses to treat epilepsy and depression. All three methods aim to improve symptoms but have risks like infection, side effects from stimulation, and require follow up surgeries as batteries need replacement over time.
The document summarizes research on transcranial magnetic stimulation (TMS) and its ability to induce savant-like skills in normal individuals. The research involved using TMS to inhibit the left fronto-temporal lobe and test effects on drawing ability and proofreading skills. Some participants showed enhanced attention to detail, changing their drawing style and improving at detecting errors. This suggests suppressing certain brain regions can produce savant-like abilities temporarily. TMS provides a method to study brain-behavior relationships and further research may help understand cognition.
Brain Stimulation & Neuromodulation September 2016 - BH SummitJay Yeomans
Brain stimulation techniques like transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT) show promise for treating neuropsychiatric conditions like depression. TMS uses magnetic fields to noninvasively stimulate areas of the brain and has been FDA approved for treating depression, while ECT uses electric currents to induce controlled seizures and is very effective for severe depression. Newer non-invasive techniques like transcranial direct current stimulation (tDCS) are also being studied for modulating brain activity. These neuromodulation approaches aim to alter brain circuits and neurotransmitter activity to improve mood and other symptoms.
Via Christi Women's Connection presentation on advance in depression treatment by Matthew Macaluso, DO, medical director of Via Christi Psychiatric Clinic.
This document discusses depression in older adults, including barriers to treatment, treatment goals and modalities, and considerations for providers and patients. It describes common psychotherapies and pharmacotherapies used to treat depression at different phases. The goals are to resolve current episodes, prevent relapse and recurrence, and improve quality of life and functioning. Barriers include inadequate treatment, lack of accessible care, and limited specialty mental health use.
Transcranial magnetic stimulation (TMS) is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain.
This video explains the physics of this method and how it can be used in daily practice.
More about magnetic simulators: http://www.neurosoft.ru/eng/product/neuro-msd/index.aspx
Comparison Of Drug Tx & Psycotherapy in the treatment of DepressionDMFishman
This document discusses and compares pharmacotherapy (medication) and psychotherapy in the treatment of depression. It outlines the diagnostic criteria for major depressive disorder and dysthymia. It then discusses the epidemiology and clinical course of depression before comparing different treatment approaches. Pharmacotherapies discussed include SSRIs, TCAs, and MAOIs. Psychotherapies discussed include cognitive-behavioral therapy and interpersonal therapy.
Depression: What Is It and What Are My Treatment Options? (Community Lecture)Summit Health
This document discusses depression, including its definition, statistics, types, causes, consequences, role of neurotransmitters, treatment options like medication and cognitive behavioral therapy. It defines depression and differentiates it from normal sadness. It covers diagnostic criteria, risk factors, and treatments including antidepressant medications, electroconvulsive therapy, light therapy, and cognitive behavioral therapy. Relapse prevention and the importance of continued treatment are also discussed.
Antidepressants are the second most prescribed medication in the US, with 15 million Americans affected by depression each year. Depression is treated through medications and therapy. Antidepressants work by adjusting neurotransmitter levels in the brain like serotonin, dopamine, and norepinephrine. Common classes include SSRIs, SNRIs, TCAs, and MAOIs. While effective, antidepressants can cause side effects like nausea, insomnia, sexual dysfunction, and increased suicide risk initially. Doctors closely monitor patients to improve treatment outcomes and safety.
This document summarizes key facts about depression from the World Health Organization, including that over 350 million people worldwide suffer from depression, 80% of those affected do not receive treatment, and close to 1 million people take their own lives each year due to depression. It encourages early detection and effective treatment, noting that treatment is effective for 60-80% of those affected and will allow them to smile again. It also provides signs of depression and tips for how to help those suffering.
Headache School provides education to help patients better manage migraine. Migraine is a very common neurological disorder that affects over 30 million Americans. Formal educational programs have been shown to produce better outcomes for patients with headache. The classes cover topics like different medication options, how diet can impact headaches, and headaches in women. Understanding the science behind migraine can help patients identify triggers to prevent attacks and choose effective treatment options.
The document discusses medications for mental illness in adolescents. It covers topics like side effects, time to onset of effects, monitoring medication effectiveness and safety, and tools/resources for patients and providers. The presentation addresses prevailing attitudes toward psychotropic medications in youth and promotes education on proper medication use and monitoring to promote mental wellness. Resources for further information on mental health medications are also provided.
The document discusses mental illnesses such as depression, mania, and schizophrenia. It defines depression as a medical condition that affects mood and lists common signs like persistent sadness, sleep issues, appetite changes, fatigue, and thoughts of death. Depression is caused by biological, genetic, environmental, and psychological factors and impacts serotonin levels in the brain. Treatment includes medication like SSRIs that prolong serotonin activity, as well as teaching coping skills. Mania involves heightened energy and activity as part of bipolar disorder, alternating with depression. The causes of mania may involve neurotransmitter imbalances.
This document discusses various dissociative anesthetics including prescription drugs like ketamine, tiletamine, and amantadine as well as street drugs and over-the-counter drugs that can be abused for their dissociative effects. It provides information on drug names, forms, effects, uses, and risks. The document focuses on dissociative anesthetics that distort perceptions, produce feelings of detachment from self and environment, and alter glutamate distribution in the brain to impact pain, environmental responses, and memory.
The document discusses various sleep disorders including primary sleep disorders like insomnia, narcolepsy, breathing-related sleep disorders, and circadian rhythm sleep disorders. It also discusses parasomnias such as nightmares, night terrors, sleepwalking, sleep paralysis, and restless leg syndrome. Insomnia is characterized by difficulty falling or staying asleep and can be acute or chronic, treated with medication or behavior modification. Other disorders discussed include sleep apnea, circadian rhythm disorders, narcolepsy which involves daytime sleepiness and cataplexy, and various parasomnias. Maintaining good sleep hygiene through a regular schedule, light and temperature control can help address sleep problems.
Antianxiety drugs are used to treat anxiety disorders when anxiety levels are disproportionate to the situation or excessive. They include benzodiazepines like diazepam and alprazolam, azapirones like buspirone, and sedating antihistamines. These drugs enhance the effects of the neurotransmitter GABA in the central nervous system, producing a calming effect without interfering with normal mental or physical functions. While effective for treating anxiety, antianxiety drugs can cause side effects with long-term use like tolerance, dependence, and withdrawal symptoms.
This document provides an overview of depression, including its central features, classifications, causes, course, and management. Key points include:
- Central features are depressed mood, negative thinking, lack of enjoyment, reduced energy, and slowness.
- Depression can be classified as melancholic, psychotic, seasonal affective, or atypical based on symptoms.
- Causes involve biological, genetic, environmental, and psychosocial factors. Leading theories implicate neurotransmitter deficiencies.
- If left untreated, depressive episodes typically last 6-13 months and recur more frequently over time, with a 15% suicide risk.
- Management involves antidepressants, psychotherapy, and ECT or TMS.
1) The document discusses guidelines developed by Dr. Papadakos for sedation of critically ill patients, including the first use guidelines for propofol in neurosurgery patients and development of protocols for sedation in critically ill patients.
2) It describes goals of sedation in the ICU as well as characteristics of an ideal sedation agent. Common sedative drugs used in the ICU like benzodiazepines, propofol, and dexmedetomidine are discussed along with their mechanisms of action, pharmacodynamics, clinical effects, and limitations.
3) Sedation scales used to assess level of sedation like the Ramsay and SAS scales are also summarized.
This presentation gives an over view: of the depression, its symptoms, prevalence, and patho-physiology. It then reviews various treatment options for depression, first starting with medication, and then moving to neuro-modulation. Focus is then on the similarities and differences of ECT and TMS. And finally information is provided about PineWood TMS.
This presentation gives an over view: of the depression, its symptoms, prevalence, and patho-physiology. It then reviews various treatment options for depression, first starting with medication, and then moving to neuro-modulation. Focus is then on the similarities and differences of ECT and TMS. And finally information is provided about PineWood TMS.
03 13-12 neuro-modulation power point-2PineWood TMS
This presentation gives an over view: of the depression, its symptoms, prevalence, and patho-physiology. It then reviews various treatment options for depression, first starting with medication, and then moving to neuro-modulation. Focus is then on the similarities and differences of ECT and TMS. And finally information is provided about PineWood TMS.
03 13-12 neuro-modulation power point-2PineWood TMS
1) PineWood TMS is a transcranial magnetic stimulation clinic located in Brattleboro, Vermont. It was founded by Julie Plummer, a psychiatric nurse and CEO, to provide alternative treatment for depression.
2) TMS works by using magnetic pulses to directly stimulate neurons in the brain and release neurotransmitters, targeting the circuits involved in mood without systemic side effects.
3) At PineWood TMS, nurses play a key role in assessing and educating patients, overseeing their treatment, and monitoring outcomes under a psychiatrist's supervision.
lecture 28 from a college level introduction to psychology course taught Fall 2011 by Brian J. Piper, Ph.D. (psy391@gmail.com) at Willamette University, includes drugs, electroconvulsive therapy
The document discusses gender differences in depression across the female life cycle. It notes that depression is the leading cause of disease burden for women. Some key points made include that women have higher lifetime prevalence of depression compared to men, and are more likely to experience atypical symptoms. Depression risk for women varies at different life stages like puberty, reproductive years, menopause, and is also impacted by hormonal fluctuations, pregnancy, and hormone treatments. The document provides an overview of neurobiological factors like the role of estrogen and progesterone in mood, as well as sex differences in antidepressant response. It also discusses depressive disorders specific to women like premenstrual dysphoric disorder and postpartum depression.
Disorders of Mood include affective psychosis, bipolar disorder, and depression. They are fundamentally disorders of inappropriate depression or elation that causes distress or impairment. Depression has a lifetime prevalence of 5-20% and bipolar disorder has a prevalence of 1%. Females are diagnosed twice as often as males. Mood disorders have a significant economic impact due to direct healthcare costs and indirect costs from reduced productivity. They are classified as either unipolar or bipolar and have genetic, biochemical, and environmental contributors. Symptoms include changes in mood, sleep, appetite, and energy levels. Treatment involves medication, electroconvulsive therapy, cognitive behavioral therapy, and counseling. The course involves self-limiting episodes but
This document discusses the role of serotonin in depression. It states that approximately 2% of the population suffers from pure depression, while a further 8% have a mixture of anxiety and depression. Serotonin levels are associated with behaviors like aggression and depression. Selective serotonin reuptake inhibitors (SSRIs) are effective treatments for depression by blocking the reuptake of serotonin, though their mechanisms of action are more complex than just affecting serotonin. SSRIs are an advanced treatment over older antidepressants but still require careful use to balance serotonin levels in patients.
The document discusses psychotherapeutic agents used to treat mental disorders like depression and anxiety. It describes how these disorders are associated with imbalances in neurotransmitters in the brain like serotonin and dopamine. Several classes of psychotherapeutic drugs are outlined, including antidepressants like SSRIs, tricyclics, and MAOIs. Tricyclics work by blocking the reuptake of neurotransmitters to increase their levels in the brain. Side effects include sedation and hypotension. MAOIs are considered second line but can cause hypertensive crisis if taken with foods containing tyramine.
Depression is a common and serious medical illness that negatively impacts mood, thinking, and behavior. It causes feelings of sadness and loss of interest in activities. Depression has various types and can be caused by genetic and environmental factors. Symptoms include changes in sleep, appetite, energy, concentration, and thoughts of death. It is diagnosed when 5 or more symptoms are present for 2 weeks. Treatment involves antidepressant medication, cognitive behavioral therapy, or a combination which can help most people recover.
Mental health disorders that caregivers may assist with include anxiety disorders like panic disorder, phobias, obsessive-compulsive disorder, and post-traumatic stress disorder. Schizophrenia is a severe disorder characterized by delusions, hallucinations, and psychosis. Mood disorders caregivers encounter comprise bipolar disorder and depression, where individuals experience manic or depressive episodes.
Similar to MAGNETS NOT DRUGS - 5 1 2012 - Deaconess Hospital Grand Rounds (20)
SEND IN THE SHRINKS - 2009 Oliver CME seminarLouis Cady, MD
This one was fun.
I was invited by Dr. Randalll Oliver, MD, Founder of the Oliver Heachache and Pain Clinic in Evansville, to present to an audience of primary care practitioners about how to use pysychiatric mediations ("psychopharmacology") in clinical practice.
Along the way, I covered, ADHD and treatments, depression, anxiety, erectile dysfunction, hypoadrenia, and even touched on hypothyroidism. Although this presentation was in 2009, all of the drugs covered are stills in use, and, at times.... stupidly.
This presentation deconstructs the intricacies of selecting and antidepressant, particularly in the SSRI class.
What is the nature of QUALITY in medicine -for ASQ 11 14 2023.pptLouis Cady, MD
In this presentation, Dr. Cady deconstructs the tensions and stressors on both patients and health care providers in today's system.
This presentation reviews checklists foe liminating mistakes, the actual number of mistakes that are being made in medical practice, and what patients and their loved ones can do for self protection.
This isn't a "bash the doctor" presentation. It's a thoughtful, careful exploration of stresses and ramifications to the current US healthcare system.
This document provides information about a presentation given by Dr. Louis B. Cady on transcranial magnetic stimulation (TMS) as a treatment for depression. It begins with Dr. Cady's credentials and commercial disclosure stating he has received honoraria from several companies but that this presentation is not being underwritten by any company. The presentation then covers how TMS works, its safety and effectiveness compared to antidepressant medications and electroconvulsive therapy (ECT), and its inclusion in treatment guidelines for depression.
Hormones and Mental Health - Thyroid and Testosterone.pptxLouis Cady, MD
In this presentation for the Psychiatry Redefined program, Dr.
Cady breaks down and deconstructs the accepted, unthinking, "practice guideline based" notions of thyroid and tesotsterone, with there seemingly "normal" levels and dosing, versus what the actual peer reviewed medical literature says. In this presentation, do use of all forms of thyroid, and all forms of testosterone are reviewed. The idiocy of "T4 only treatment" is covered. The use of T4, T3, a combination of T4 and T3, and all of the porcine and compounded products is review.
In terms of testosterone, dr. Katie reviews the concept of "do you want to be optimal or do you want to be normal." He notes that it is "normal" for oil in cars to deteriorate and break down with age. It's also "normal" for men's and women's testosterone (as well as thyroid) to go down with age. The question is, "do we want to do anything about it?"
Logical ways of intervening in both the thyroid and female and male gonadal axes are covered. There is scrupulous attention paid to the thyroid hormone pathways, and the relevance of reverse T3 versus free T3. Similarly, in terms of women, the downstream effect of estradiol coming from testosterone is also reviewed.
The Moral Imperative of Integrative Medicine 2022.pptLouis Cady, MD
The document discusses the case of a 16-year-old teenager with a long history of treatment-resistant depression and anxiety. Previous medication trials with SSRIs, SNRIs, atypical antipsychotics, and lamotrigine had failed to provide sustained relief. Upon further evaluation, the doctor found potential contributing factors including an undiagnosed MTHFR gene mutation and hormonal imbalances. The doctor adjusted the teenager's supplements and medications, focusing on addressing the underlying functional issues. At follow-up several months later, the teenager reported significantly improved mood with only brief periods of low mood, though menstrual irregularities persisted.
CORONOFOBIA - Passos práticos para equilibrar as defesas do corpo e da menteLouis Cady, MD
Esta palestra, apresentada em 29 de maio de 2021 para o Congresso de Medicina Integrativa para a Saúde Mental 2020, promovido pelo Laboratório Great Plains no Brasil, enfocou coisas simples e de bom senso que os pacientes (e seus médicos) podem fazer para se manter seguros e viver durante o Pandemia do covid.
Os seguintes conceitos holísticos foram revisados:
- sono adequado e por que é tão importante;
- o uso de melatonina, cientificamente validada como tendo atividade antiviral (referências citadas);
- a importância de diminuir o estresse e técnicas para fazê-lo;
- a necessidade de "comer frutas e vegetais" como sua mãe e sua avó ensinaram devido à ingestão de carotenóides e antioxidantes ((referências citadas);
- o uso adequado de suplementos vitamínicos / nutricionais (referências citadas).
O foco desta apresentação não foram medidas heróicas para salvar vidas na unidade de terapia intensiva para pacientes gravemente enfermos com COVID, mas, sim, técnicas de bom senso, práticas, baratas e (em alguns casos) GRATUITAS para melhorar você e seus pacientes 'saúde e resistência às doenças.
THE MORAL IMPERATIVE OF INTEGRATIVE MEDICINE - O IMPERATIVO MORAL DA MEDICINA...Louis Cady, MD
Neste programa, o Dr. Cady baseia-se em uma série de casos clínicos para ilustrar a necessidade absoluta e moral do tratamento de precisão de nossos pacientes com todas as ferramentas disponíveis para uso por meio da medicina integrativa.
O uso de testes de polimorfismo MTHFR, testes convencionais e laboratoriais e testes farmacogenômicos foram revisados.
Os casos apresentados ilustram a trágica dificuldade de um menino com deficiência de MTHFR que estava prestes a desviar sua vida; um paciente esquizofrênico com vários problemas de medicina funcional que precisavam ser resolvidos (levedura, glúten, sensibilidade alimentar de IgG); uma estudante universitária a quem foi dito "não há nada de errado com você; seus laboratórios estão bem", embora ela tenha manifestado todos os sintomas relevantes de hipotireoidismo; e um CEO do sexo masculino de 42 anos que estava "tão cansado que parecia morrer" e que, na verdade, estava funcionalmente com pouco testosterona. O último caso revisado foi de um adorável garotinho que tinha autismo e foi recuperado por meio de uma abordagem focada e intensa de medicina integrativa.
Dr. Cady deconstructs some the medical literature about the use of nutrients - and the evidence of what happens in the presence of their insufficiency. Everything for decreased viral replication to decrease brain shrinkage is covered. The role of antioxidant and carotenoids, measured by the Pharmanex Biophotonic Scanner, is reviewed.
Please note - there is no representation that any nutrient or supplement can treat, prevent, mitigate, or cure any medical condition. It does seem, however, upon reflecting on the medical literature, that there seems to be a lot of evidence for therapeutic effect in the presence of good levels of nutrient, and harm to patients if they have insufficient levels.
Subtitle: The Moral Imperative of Integrative Medicine
This presentation, two hours in length, was delivered to the A4m MMI Audience in their Frontiers of Neurology - Module 3.
The following topics are reviewed:
- ADHD, Autism, Depression, Schizophrenia
- the impact of neuroinflammation on all of these.
- confounding factors and the ways to mitigate them: Omega6/Omega 3 imbalance in the Western diet, MTHFR polymorphism, the use of elemental lithium, the presence of intestinal dysbiosis and the role of gluten/dairy IgG Food allergies.
- pharmacogenomic testing
The Moral Imperative of Integrative Medicine - IMMH 2020Louis Cady, MD
IN this presentation, Dr. Cady reviews several of the handful of functional, integrative medicine techniques required for a holistic and comprehensive management of psychiatric issues. MTHFR, hormone balance, diagnosis and treating intestinal dysbiosis, need for trace elements, and hormones (including thyroid, testosterone and estradiol) are reviewed.
This brief webinar, a gift to the local Jewish community and Temple Adath B'Nai Israel here in Evansville, IN, reviews the tradition of mindfulness and the interdigitation of Buddhist practices with some Jewish traditions. Dr. Cady reviews the downstream effects of stress, how meditation and mindfulness are useful tools and techniques, and actually how to practice it. Multiple references without being complicated or overdone are provided.
Webinar 5: Designing Your Future: WHAT'S COMING NEXT?Louis Cady, MD
In this capstone webinar presentation, closing out Dr. Cady's series on dealing with COVID 19, he turns his attention to a nunmber of interesting thems:
- what's the REAL case fatality rate of COVID 19
- How is it likely that society will reopen?
- What's going to happen in education and medicine?
- What's going to happen when the robots and AI arrive?
- What's the future going to be out 500 years?
HOW TO SAVE MONEY ON YOUR HEALTHCARE: An Integrative Medicine ApproachLouis Cady, MD
In this webinar, the fourth in a series of five from Dr. Louis Cady and the Cady Wellness Institute, we focus on the actual dollars and cents of health care expenditures, and the societal and PERSONAL costs of poor health maintenance behavior. We examine the essentially passive US medical system, that would rather drug a symptom than fix the underlying problem.
Great attention is paid on not shaming the patient or the doctors as they exist in the current system. Both groups "do not know what they do not know." Confirmation bias is rampant.
This webinar points the way to living a more vital, energetic life, with a minimum of cost, grief, and misery.
The Do It To Yourself Treatment of Depression - Webinar #3Louis Cady, MD
This is the third in a series of five webinars. The first was on staying alive by boosting your immunity during COVID 19. The second was on not screwing yourself up inside your head. This third one encompasses a romp through the peer reviewed medical literature looking for supplements and nutrients that you could use to self treat depression at home, CAREFULLY. Numerous cautions and warnings are included.
The driving impetus to this program is that many people - due to social isolation and their mental health care, or medical practitioners' offices being closed down - have not been able to get help or succeed in optimizing their treatment for depression. There are multiple useful nutrients for both depression and anxiety in nature's abundant pharmacopeia, and this webinar touches on just a few of them.
I hope you enjoy it.
HOW TO COPE WITH THE PSYCHOLOGICAL IMPACT OF COVID 19 AND SOCIAL DISTANCINGis...Louis Cady, MD
In this presentation, Dr. Cady will review:
- What did Sparky learn about not being an emotional support animal?
- "Do it to yourself psychotherapy." Learn the following:
- What are the wrong - and the RIGHT ways of any sort of "behavioral therapy"?
- How to use a journal to think RATIONALLY and “get out of your head.”
- How to get out of your HEAD and into your LIFE.
- We'll cover all 10 of David Burns’ cognitive distortions, customized and gift-wrapped for dealing with COVID 19.
- We will cover actionable examples of how to reprogram yourself.
We will review What are the 3 P's of Positive Psychology and Learned Optimism?
The Cady 5 "5P’s” and “How to shrink yourself."
Can we find the GOOD in COVID?
This presentation is meant to be provocative and to challenge you mentally, intellectually, and emotionally. Some of the great thinkers and exemplars of human performance and possibility are featured.
BOOSTING YOUR IMMUNITY During the COVID 19 PandemicLouis Cady, MD
In this presentation, presented as a live webinar on Monday, April 27th, Dr. Louis Cady of the Cady Wellness Institute reviewed practical, common-sense things that can be done to boost your immunity, with documentation from the peer-reviewed medical literature. Dr. Cady also reviews supplements and nutrients that are established in the peer-reviewed medical literature as having antiviral capabilities. These include Vitamins C,D, and E, Zinc, carotenoids and antioxidants, probiotics, the reishi mushroom, elderberry, cannabidiol (CBD - not marijuana or weed!).
Points presented are scrupulously documented from the medical literature. This presentation does not guarantee or represent that using ANY of these nutrients will "keep you from getting infected or dying" from COVID 19. They are presented for your thoughtful consideration.
Tratamento holistica de ezschizophrenia - São Paulo, Brazil April 20, 2019Louis Cady, MD
Esta é a versão em inglês da apresentação do Dr. Cady feita na UNIP (Campus Paraiso - São Paulo, SP Brasil) para o Congresso de Saúde Mental de 2019 (Conferência sobre Saúde Mental). Foi entregue em 20 de abril de 2019.
Nesta apresentação, o Dr. Cady analisa brevemente a história da esquizofrenia, a falha do bloqueio do receptor de dopamina D2 como uma cura universal na esquizofrenia, e várias intervenções holísticas que podem impactar forte e positivamente os sintomas da esquizofrenia. Incluídos na pesquisa do Dr. Cady estavam o papel dos ácidos graxos essenciais, deficiências nutricionais (particularmente vitaminas do complexo B), o perigo de supercrescimento da cândida, testes farmacogenômicos, polimorfismos da MTHFR e muito mais.
Foi uma honra e um privilégio entregar esta apresentação em
São Paulo.
Para mais informações no Brasil sobre este tema, ou para solicitar uma gravação em vídeo / áudio da conferência, entre em contato com Luiz Dias do Laboratório Grandes Planícies no Brasil.
Slides, até o apêndice, são traduzidos por Luiz Dias.
The integrative treatment of schizophrenia brazil 2019Louis Cady, MD
This is the English language version of Dr. Cady's presentation given at UNIP (Campus Paraiso - Sao Paulo, SP Brazil) for the 2019 Congresso de Saude Mental (Conference on Mental Health). It was delivered April 20, 2019.
This presentation also includes extra slides in the appendix that were not presented, and, unfortunately, these slides of the appendix have not been translated in the Portuguse version of this presentation.
In this presentation (Portuguese presentation will also be posted next), Dr. Cady briefly reviews the history of schizophrenia, the failure of the dopamine D2 receptor blockage as a universal cure-all in schizophrenia, and various holistic interventions which can strongly and positively impact symptoms of schizophrenia. Included in Dr. Cady's survey were the role of essential fatty acids, nutrient deficiencies (particularly B vitamins), the danger of overgrowth of candida , pharmacogenomic testing, MTHFR polymorphisms, and more.
It was an honor and a privilege to deliver this presentation in
São Paulo,.
For further information in Brazil on this topic, or to order a video/audio recording of the conference (in Portuguese),contact Luiz Dias of Laboratorio Great Plains in Brazil.
Natural Treatments for ADHD (TADH) in Sao Paulo, Brazil, for Laboratorio Grea...Louis Cady, MD
In this presentation, given at UNIP (Campus Paraiso - Sao Paulo, SP Brazo) for the 2019 Congresso de Saude Mental (Conference on Mental Health), Dr. Cady reviewed the prevalence, inheritability, and social ramifications of ADHD (TADH in Brazil). He specifically reviewed multiple holistic interventions, including limiting "electric screen time,"good quality diet with adequate amounts of essential fatty acids and critically important trace elements, and the use of pharmacogenomic testing as well as functional, integrative medicine testing, all to better characterize logical and reeasonmable points for holistic intervention.
This presentation was simultaneously translated into Portugue for the attendees, but unfortunately the slides were not available in translated form.
For further information in Brazil on this topic, or to order a video/audio recording of the conference (in Portuguese),contact Luiz Dias of Laboratorio Great Plains in Brazil.
Thyroid, Adrenals, and Sex Steroids - A Balancing ActLouis Cady, MD
This was the second presentation gibven on MZarch 29, 2019 at the Manlove Psychiagtric Group and Brain Injury Institute spring conference in Rapid City, SD.
In this presentation, Dr. Cady carefully goes over the necessity of integrating and overview and awareness of hormones and their levels in the elucidation of what truly is going on with the patient.
This was an overview lecture only. Dr. Cady will be presenting a 16 hour CME program in Austin Texas on June 22 and 23 for the National Procedures Institute, and will explore all aspects of all relevant hormones and what can be done to manage and optimize them.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
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Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
MAGNETS NOT DRUGS - 5 1 2012 - Deaconess Hospital Grand Rounds
1. MAGNETS, NOT PILLS:
Transcranial Magnetic Stimulation - :
A New Depression Treatment
Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute
Adjunct Professor – University of Southern Indiana
Adjunct Professor – Indiana University School of Medicine
For Deaconess Hospital Grand Rounds
Evansville, IN May 1, 2012
2. “Slumber not in the
tents of your fathers.
The world is advancing.
Advance with it.”
- Giuseppe Mazzine
3. Topics we will cover in this talk
Major – Diagnosis
Depression – Unmet medical needs
TMS
– How it works
– Safety and tolerability
– Where it fits in the “Treatment
Algorithm” for Major Depression
7. Conceptual Evolution of
Depression/Anxiety Comorbidity
10.5% 67.8% 10.4%
of all
psychological
of all disorders
psychological
disorders
67.8% of patients diagnosed with depression also fulfill
the criteria for an anxiety disorder.
Boerner and Möller, 1999.
8. Depression—Impact on the
Healthcare System
• Compared with those without
depression, depressed individuals:
– Utilize all types of healthcare services more
often
– Incur 1½ to 2 times greater healthcare costs
– increased length of hospital stay
– significant worsening of physical, social, and
role functioning
Simon 1995; Luber 2000; Verbosky 1993; Wells 1989.
9. STAR*D Study demonstrates that current
treatments have limited effectiveness
Trivedi (2006) Am J Psychiatry; Rush (2006) Am J Psychiatry; Fava (2006) Am J Psychiatry; McGrath (2006) Am J Psychiatry
10. Likelihood of discontinuing treatment increases
with each new medication attempt
Systemic Drug Side Effects
Weight Gain Fatigue
Constipation Headache/
Migraine
Diarrhea
Abnormal
Nausea Ejaculation
Drowsiness Impotence
Insomnia Sweating
Decreased Tremor
Libido
Treatment
Nervous Discontinuation
Anxiety Side Effects
Increased Weakness
Appetite
Dry Mouth
Decreased
Appetite Dizziness
Trivedi (2006) Am J Psychiatry; Rush (2006) Am J Psychiatry; Fava (2006) Am J Psychiatry; McGrath (2006) Am
J Psychiatry; Neuronetics, Inc. (data on file)
11. Adequate Treatment Is Difficult to Achieve
• Adequacy of
Adequate Adequate treatment = C.
Dosage Duration
18%
Factors contributing to inadequate
• (regardless of
treatment include:
agent)
Lack of Poor
adherence to tolerability • The ratio of
recommended
treatment
Medical and
inadequate-to-
Lack of efficacy Psychiatric
Comorbiditie adequate
s
treatment
attempts is 4:1
…adequate treatment in depression
is the exception, not the norm
Nemeroff (1996/1997) Depress Anxiety; Oquendo (2003) J Clin Psychiatry; Oquendo (1999) Am J Psychiatry.
11
12. Best Practices Treatment Guideline for Depression
Based on 2010 APA guidelines and NeuroStar TMS Therapy® indication for use.
Unmet
Medical
Needs
Adapted from: Practice Guideline for the Treatment of Patients with Major Depressive Disorder, 3rd Edition, APA
(2010)
13. TMS is Included in Practice Guidelines
Following Failure of Initial Treatment
Guideline Sources
American Psychiatric Association (2010)
“…Acute phase treatment may include pharmacotherapy, depression-
focused psychotherapy, the combination of medications and psychotherapy,
or other somatic therapies such as electroconvulsive therapy (ECT),
transcranial magnetic stimulation (TMS), or light therapy…”
World Federation of Societies Canadian Network for Mood
for Biological Psychiatry and Anxiety Treatments
(2009) (2009)
Schlaepfer, et al. World J Biol Psychiatry (2009); Kennedy, et al J Aff Disorders (2009); American
Psychiatric Association (2010)
14. A quick look back in history
The Interpretation of Ugo Cerletti 1935
Prozac - 1987
Dreams – 1885 - 1890
15. The Therapeutic Trifecta of Psychiatry:
Shrinking
Shocking
or Drugging
[Supposedly] the only three
things you could do to a patient’s
brain…]
16. ECT – origins
• Origin in 1700’s – Middlesex Hospital
– machine with weak electrical current used for range of illnesses.
– John Birch, English neurosurgeon, used it to shock the brains of
depressed patients
– Benjamin Franklin, after shocked, recommended electric shock for
tx of mental illness
• Ugo Cerletti – 1935 – noted (incorrectly) that epilepsy and
schizophrenia didn’t occur in same patient
• Problems with ECT – memory loss, anesthesia risk
• Cost of $6400 for eight treatments
• 80% improvement
• 33,000 hospitalized Americans – ECT in 1980, last year for
NIMH figures
– http://www.faqs.org/health/topics/19/Electroconvulsive-therapy.html
17. "The Shock Shop,
Mr. McMurphy, might
be said to do the work of
the sleeping pill, the
electric chair and the
torture rack. It's a clever
little procedure, simple,
quick, nearly painless it
happens so fast, but no
one ever wants another
one. Ever.”
18. But even before these guys…
• Electromagneitc
induction – 1831
(Faraday & Joseph
Henry)
• 1st demonstrated by
Faraday August 29,
1831
19. Faraday’s law
• “The induced electromotive force (EMF) in
any closed circuit is equal to the time rate of
change of the magnetic flux through the
circuit.”
• Discovered by Michael Faraday and Joseph
Henry in 1831 – Faraday first to publish.
20. Faraday’s Law of Induction
TMS Induced neuronal
Magnetic current
field
21.
22. From electricity to
magnetism
• Bartholow, R (1874)
– Stimulation of human brain
(exposed cortex) of patient with
cranial defect.
• d’Arsonval – “Phosphenes
and vertigo” induced inside
powerful magnetic coil
• Silvanus P. Thomson, Ph.D.
– new type of magnetic Thompson, SP. “A Physiological
Effect of an Alternating Magnetic
stimulation (1910) Field.” Proceedings of the Royal
Society of London B82:396-399, 1910
23. First patent application for magnetic
therapy:
• 1902 Adrian Pollacsek
and Berthold Beer –
Vienna, Austria for a
“therapeutical apparatus”
• Electromagnetic coil,
placed over the skull was
noted to “pass vibrations
into the skull” and “treat
depression and
neuroses.”
24. First modern TMS:
• Barker AT, et al. “Non-
invasive magnetic
stimulation of the human
motor cortex. The
Lancet 1:1106-1107,
1985.
• 1st device – designed by
Barker – Univ. of
Sheffield, England.
– 100 microsecond, 2 T
pulse
25. Coil types and rationale
From Matt Edwardson, MD – Research Fellow and Acting
Instructor, Dept. of Neurology, Univ. of WA 10/16/2011
26. TMS Targeted Effects on Local and
Distant Regional Blood Flow
Nahas Z et al. Brain Effects of TMS Delivered Over Pefrontal Cortex in Depressed
Adults. Journal of Neuropsychiatry and Clinical Neurosciences 2001:13:459-460.
27. Nahas Z et al. Brain Effects of TMS Delivered Over Pefrontal Cortex in Depressed
Adults. Journal of Neuropsychiatry and Clinical Neurosciences 2001:13:459-460.
28. An unusual side effect
of imaging (2004)…
• CONCLUSIONS: “These preliminary data suggest
that the EP-MRSI scan induces electric field that
are associated with reported mood improvement in
subjects with bipolar disorder.”
29.
30. NeuroStar Directly Depolarizes Cortical
Neurons
Neuron Pulsed magnetic fields
from NeuroStar:
•induce a local electric
current in the cortex which
depolarizes neurons
Neurons are •eliciting action potentials
“electrochemical •causing the release of
cells” and respond to chemical
either electrical or neurotransmitters
chemical stimulation
31. NeuroStar Releases Neurotransmitters
in the Brain
Depolarization of neurons in
the DLPFC causes local
neurotransmitter release
These effects
Dorsolateral
are associated
prefrontal
cortex
with
improvements in
Anterior
cingulate depressive
cortex
symptoms
Kito (2008) J Neuropsychiatry Clin Neurosci
Depolarization of pyramidal
neurons in the DLPFC also Activation of deeper brain
causes neurotransmitter release neurons then exerts secondary
in deeper brain neurons effects on remaining portions of
targeted mood circuits
32. ECT TMS
Anesthesia, LOC ECT vs. TMS No
Yes
Induction of seizure Yes No
Systemic effects Anesthetic drugs, none
increase HR
Treatment schedule 3X/ week (8 -15 tx) Daily, M-F, six weeks (30
tx)
Rapidity of onset 2 – 3 treatments 2 – 3 weeks
Mechanism of action SEIZURE. Massive NT Reactivation of neural
release; rise in sz circuits. Precise, LOCAL
threshold release of NT’s.
Side effects Memory loss, confusion Essentially none (mild HA
1st week)
Psychosocial impact can’t work Drive to and from tx’s,
work improved
After-effects Mild (usually transient) None. Pro-cognitive
memory loss
Insurance coverage Almost always Rare. Improving
33. NeuroStar TMS in Clinical Practice at CWI
• Outpatient 37-minute daily
procedure (3000 pulses)
• 4-6 week treatment course
• “Antidepressant medication
monotherapy” may be used for
maintenance – we use multiple
both during and after.
• At CWI – multiple medications
thyroid balancing, NT
balancing,
and psychotherapy (during
treatment)
34.
35.
36. Does it work?
• Original registration trial
– 307 major depressed patients
• 67% women
• 93% recurrent depressives
• 43% had been hospitalized already
– 42 sites
– Treatment per label
• Results: ½ patients responded; 1/3 of
patients remitted.
• 80% patients completed the treatment.
37. Who Was Studied?
• Primary diagnosis: DSM-IV Major Depressive
Disorder
– Unipolar type, non-psychotic
– Moderate to severe symptoms at baseline
– Approximately one-third of patients had a co-morbid anxiety
disorder (OCD excluded)
• Antidepressant Treatment History:
– Average number of antidepressant medication trials in current
episode = 4 (range: 1 to 23 attempts)
• Majority of treatment attempts were unable to achieve adequate
dose and duration of treatment due to intolerance
– In the indicated patient population, all patients failed to
achieve satisfactory benefit from one antidepressant
medication at an adequate dose and duration in current
episode
37
Demitrack and Thase (2009) Psychopharm
Bulletin
38. O’Reardon, JP, et al. (2007) Efficacy and Safety of Transcranial Magnetic Stimulation in
the Acute Treatment of Major Depression: A Multi-Site Randomized Controlled Trial.
Biol Psychiatry 62:1208-1216.
39. Optimization of TMS (‘OPT-TMS’) Study
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 • MADRS total score decreased:16.6%
• N=190 patients, 4 premier academic sites (Active) vs 6.9% (Sham) p=0.01
• Primary outcome measure: (Effect size: 0.51)
% Remission - Active 15% vs Sham 4% (P = • 30% of patients achieved remission
0.015); Odds Ratio of achieving remission: in open-label extension phase
4.2 (95%CI, 1.3-13.2) • Excellent safety and adherence
Conclusion: “Daily left prefrontal rTMS as monotherapy produced statistically
significant and clinically meaningful antidepressant therapeutic effects greater than
sham.”
40. Recent TMS Literature Review
• Roughly 30 controlled clinical research studies to date
• 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….”
1.Slotema, CW, Blom, JD, Hoek, HW, Sommer, IEC. (2010) Should we expand the toolbox of psychiatric
treatment methods to include repetitive transcranial magnetic stimulation (rTMS)J Clin Psych 71(7):873-84.
2.Schutter, DJLG. (2009) Antidepressant Efficacy of High-Frequency Transcranial Magnetic Stimulation Over
the Left Dorsolateral Prefrontal Cortex in Double-Blind Sham-Controlled Designs: A Meta-Analysis. Psychol
Medicine, 39:65-75.
41. NeuroStar TMS
Therapy:
Acute Efficacy Outcomes
in Real-World Clinical
Practice
42. Treatment Utilization and Outcomes
Study ( Protocol No. 19-50001-000)
• Goal
– Define real world outcomes associated with NeuroStar TMS
Therapy across a broad spectrum of patients and practitioners
• Patient Population & Sites
– 307 evaluable unipolar, non-psychotic MDD patients in acute
phase
– 42 sites comprised of institutions and private practice
• Study Design Phases
– Acute phase (clinician determined care based on clinical
progress)
– Long-term outcomes at 12 months (study ongoing at present)
• Patient Treatment
– Clinical care initiated per current labeled guidelines
42
Neuronetics, Inc. (data on file) ; clinicaltrials.gov listing number NCT 01114477
43. Patient and Treatment Characteristics
(N=307)
N (%) Female 205 (66.8)
Age in years, mean (SD) 48.6 (14.2)
Disease and Treatment History N(%)
- Recurrent Major Depression 285 (92.8)
- Comorbid Anxiety Disorder 46 (15.0)
Psychiatric Treatment History N(%)
- History of Inpatient Hospitalization 133 (43.3)
- History of ECT Treatment 15 (4.9)
Prior Antidepressant Medication Treatment
mean(SD) 2.5 (2.3)
- Avg # of Adequate Treatments in Current
Episode
Mean (SD) Number of TMS Sessions During Acute
Treatment 43 28 (10.1)
Neuronetics, Inc. (data on file) ; clinicaltrials.gov listing number NCT 01114477
44. Comparison of End of Acute Treatment Clinical Status:
Clinician- and Patient-Assessed Outcomes
Clinician Rating Patient Rating
(CGI-Severity of Illness) (PHQ-9 Scale)
% of Patients (N=307)
Markedly ill or worse Moderately ill Mildly ill or better
OCF Analysis of intent-to-treat population
45. Comparison of End of Acute Treatment Clinical Status:
Clinician- and Patient-Assessed Outcomes
Clinician Rating Patient Rating
(CGI-Severity of Illness) (PHQ-9 Scale)
% of Patients (N=307)
Responders (CGI-S <3, PHQ-9 <10) Remitters (CGI-S <2, PHQ-9 <5)
LOCF Analysis of intent-to-treat population
46. Summary of Clinical Outcomes
• In research settings, two large, multisite,
randomized controlled trials demonstrated
clinically significant antidepressant effect of TMS
• Prospective, naturalistic study confirms these
results in real-world practice settings
• Overall, 1 in 2 patients respond and 1 in 3
patients achieve remission
• High level of treatment adherence , >80% of
patients completed acute treatment in both
research setting and in clinical practice
46
49. NeuroStar TMS Therapy: Safety
Overview
• 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 NeuroStar device during clinical
studies (over 10,000 treatments)
• Rare risk of seizure with NeuroStar TMS in post-market
use (0.003% per treatment, <0.1% per acute treatment
course) (>150,000 treatments in post-marketing experience to
date)
• Long term safety demonstrated in 6 months follow-up
Janicak, et al. J Clin Psychiatry, 2008; Janicak, et al. Brain Stimulation, 2010.
50. No Evidence of Emergent Suicidal Ideation
4.0
NeuroStar TMS Therapy (n=155)
HAMD Item 3 Suicidal Ideation
3.5
Sham TMS (n=146)
3.0
Shift Score (%)*
2.5
2.0
1.5
1.0
0.5
0.0
Baseline Week 2 Week 4 Week 6
* Shift Score indicates the percent of subjects who experienced a change in HAMD Item 3 score from 0 or 1 at baseline
to 3 or 4 at later point in time.
Janicak (2008) J Clinical Psychiatry.
51. Long Term Follow Up After Acute
Treatment
RCT or Open-Label Extension Study Long-Term Follow-Up Study
ACUTE TAPER LONG TERM OUTCOME
BENEFIT (3 Weeks) ASSESSMENT
(6 Weeks) (6 Months)
Transition from Antidepressant medication
TMS to monotherapy w/TMS rescue as
pharmacotherapy add-on if needed through 6 Months
Janicak, et al. Brain Stimulation, 2010.
52. Long Term Follow Up After Acute Treatment
• 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.
53.
54. “But my patients don’t know about
this and aren’t asking for it….”
“It’s not the
consumers’
job to know
what they
want.”
- Steve Jobs
55. “For me, the practice of medicine has
opened the door to the greatest adventure in
life. Medicine is like a hallway lined with
doors, each door opening into a different
room, and each room opening
into another hallway,
again lined with doors.
Medicine is always
wonderful and never will
be finished.”
- Charles H. Mayo, M.D.
Editor's Notes
Giuseppe Mazzini (22 June 1805 – 10 March 1872), nicknamed &quot;Soul of Italy,&quot;[1] was an Italian politician, journalist and activist for the unification of Italy. His efforts helped bring about the independent and unified Italy[2] in place of the several separate states, many dominated by foreign powers, that existed until the 19th century. He also helped define the modern European movement for popular democracy in a republican state. [ citation needed ] – Source - Wikipedia
Hello. My name is Dr._____________, and I am pleased to have the opportunity to speak with you today about the role of TMS Therapy in the treatment of patients in with major depression. In this presentation, I will cover three major areas: First, I will describe the current landscape of treatment options for major depression, with a particular focus on the concept of treatment resistance. I will also review the most recent Practice Guidelines for the Treatment of Patients with Major Depressive Disorder that have been promulgated by the American Psychiatric Association, highlighting their conclusions regarding the role of TMS in clinical practice. Second, I will describe the science behind TMS, explaining what it is and how it is thought to exert its effects as an antidepressant. I will also review the most recent clinical trial evidence for its efficacy and safety. Third and finally, I will conclude by placing this data in context by specifically describing the role of TMS in the treatment of patients with major depression who have not benefited from initial treatment with antidepressant medications. At the end of this presentation, we will have time for any questions that you may have.
First, let ’s talk about the current landscape of treatment options for major depression.
As demonstrated by this chart, psychiatric disorders are prevalent. 1-3 These data are from the National Comorbidity Survey (NCS) and the DSM-IV-TR ™ . The NCS is a collaborative epidemiologic investigation based on household survey data of over 8000 respondents from 1990 to 1992. 4
This slide depicts the changing conception of depression and anxiety, and their drug treatments, over the last 40 years. In the 1960s, there was a clear diagnostic distinction between major depressive disorder and GAD, paralleling the drug classification distinction between the antidepressants (eg, TCAs) and the anxiolytics (eg, benzodiazepines). During the 1970s and 1980s, some antidepressants were found to be effective in treating comorbid anxiety and depression, while some TCAs were found to be effective in treating some anxiety disorder subtypes. By the 1990s, SSRIs were the first line treatment for some anxiety disorder subtypes as well as effective antidepressants, while benzodiazepines became second-line or augmentation treatments for anxiety disorder subtypes. As illustrated above, a significant degree of diagnostic and therapeutic overlap is now recognized among depression, GAD, and anxiety disorder subtypes. Recently, venlafaxine XR became the first agent to be approved to treat both depression and GAD; positive nefazadone, mirtazapine, and paroxetine results will be discussed in upcoming slides. Boerner RJ, Moller HJ. The importance of new antidepressants in the treatment of anxiety/depressive disorders. Pharmacopsychiat . 1999; 31: 119-126.
In addition to utilizing services related to their depression, patients also tend to be high utilizers of general medical care services. It has been shown that depressed patients utilize all types of healthcare services more often than nondepressed patients and incur overall healthcare costs 1 ½ to 2 times higher than the average nondepressed patient. 27,28 It has also been demonstrated that depressed individuals were hospitalized longer and had significant worsening of physical, social, and role functioning, compared with nondepressed individuals. 28-30
Let’s take a closer look at the evidence generated in the STAR*D Study. The design of this study involved four treatment Levels. These Levels were pre-specified by expert consensus, and were intended to reflect the general approach taken in clinical practice at the time STAR*D was constructed, which was about 10 years ago. Patients treated in STAR*D were either first episode patients, or treatment-responsive patients. To get into the study, the patient could not have previously been treated with and failed to benefit from any of the options offered in either Level 1 or 2. Patients were recruited from both primary care and specialty psychiatric treatment settings in the United States. About 4,000 patients entered into this study. The first Level results showed that in response to an adequate course of treatment with an SSRI (in this study, citalopram was the option used) only about 28% of patients were able to achieve remission as measured using the 17 Item Hamilton Depression Rating Scale. At Level 2, the results are shown for those patients who were offered a switch to another antidepressant of the same or a different class (these options included sertraline, bupropion SR, or venlafaxine SR). You can already observe the drop in likelihood of remission, here at about 21% after failure of only one prior adequate antidepressant treatment. At Level 3, the switch options offered were either mirtazapine or Nortriptyline, and again the remission likelihood degrades further. Finally, at Level 4, the switch option offered was the MAOI tranylcypromine. Here the likelihood of remission after failure of three prior adequate treatments was 6.9%. References : Fava, M., A. J. Rush, et al. (2006). &quot;A Comparison of Mirtazapine and Nortriptyline Following Two Consecutive Failed Medication Treatments for Depressed Outpatients: A Star*D Report.&quot; Am J Psychiatry 163 (7): 1161-1172. McGrath, P. J., J. W. Stewart, et al. (2006). &quot;Tranylcypromine Versus Venlafaxine Plus Mirtazapine Following Three Failed Antidepressant Medication Trials for Depression: A STAR*D Report.&quot; Am J Psychiatry 163 (9): 1531-1541. Nierenberg, A. A., M. Fava, et al. (2006). &quot;A Comparison of Lithium and T 3 Augmentation Following Two Failed Medication Treatments for Depression: A STAR*D Report.&quot; Am J Psychiatry 163 (9): 1519-1530. Rush, A. J. (2007). &quot;STAR*D: What have we learned?&quot; Am J Psychiatry 164 (2): 201-204. Rush, A. J., M. H. Trivedi, et al. (2006). &quot;Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report.&quot; Am J Psychiatry 163 (11): 1905-1917. Trivedi, M. H., M. Fava, et al. (2006). &quot;Medication Augmentation after the Failure of SSRIs for Depression.&quot; New England Journal of Medicine 354 (12): 1243-1252. Trivedi, M. H., A. J. Rush, et al. (2006). &quot;Evaluation of Outcomes with Citalopram for Depression Using Measurement-Based Care in STAR*D Implications for Clinical Practice.&quot; Am J Psychiatry 163 (1): 28-40.
What about antidepressant tolerability and treatment adherence? A close look at the reported results of STAR*D reveals some important findings. We have learned from the STAR*D Study, that the likelihood of a patient dropping out of treatment because of side effects rises dramatically, nearly tripling in the transition from Level 1 ( about 9% ) to Level 2 ( about 23% ). By the time a patient had failed to benefit from three prior treatment attempts, the likelihood of their discontinuing due to adverse events from the next offered antidepressant monotherapy (in this case the MAOI tranylcypromine), was quite notable: slightly greater than 41% . There are many reasons why the intolerance to treatment rises with progressive levels of treatment resistance, and a full consideration of this is beyond the scope of this presentation. In general, this finding is both a reflection of how physically uncomfortable depression is as a disease, as well as the fact that each next treatment offering in this study brought the potential for an even greater degree of uncomfortable adverse events. Shown on the right side of this diagram is a list of those adverse events reported in product labels for all contemporary antidepressant medications, including the augmentation agents such as the atypical antipsychotics. The list specifically shows those adverse events that in each product’s labeling were observed to occur at an incidence of at least 5% in the antidepressant-treated group, and occurred at a rate at least twice as high as the incidence of that event reported in the placebo group. References : Fava, M., A. J. Rush, et al. (2006). &quot;A Comparison of Mirtazapine and Nortriptyline Following Two Consecutive Failed Medication Treatments for Depressed Outpatients: A Star*D Report.&quot; Am J Psychiatry 163 (7): 1161-1172. McGrath, P. J., J. W. Stewart, et al. (2006). &quot;Tranylcypromine Versus Venlafaxine Plus Mirtazapine Following Three Failed Antidepressant Medication Trials for Depression: A STAR*D Report.&quot; Am J Psychiatry 163 (9): 1531-1541. Nierenberg, A. A., M. Fava, et al. (2006). &quot;A Comparison of Lithium and T 3 Augmentation Following Two Failed Medication Treatments for Depression: A STAR*D Report.&quot; Am J Psychiatry 163 (9): 1519-1530. Rush, A. J. (2007). &quot;STAR*D: What have we learned?&quot; Am J Psychiatry 164 (2): 201-204. Rush, A. J., M. H. Trivedi, et al. (2006). &quot;Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report.&quot; Am J Psychiatry 163 (11): 1905-1917. Trivedi, M. H., M. Fava, et al. (2006). &quot;Medication Augmentation after the Failure of SSRIs for Depression.&quot; New England Journal of Medicine 354 (12): 1243-1252. Trivedi, M. H., A. J. Rush, et al. (2006). &quot;Evaluation of Outcomes with Citalopram for Depression Using Measurement-Based Care in STAR*D Implications for Clinical Practice.&quot; Am J Psychiatry 163 (1): 28-40. Product Labeling for currently marketed antidepressants (Neuronetics, Inc., data on file)
I ’ d like to expand a bit on the problem of antidepressant treatment adherence. As indicated on the previous slide, as a patient shows increasing levels of treatment resistance, the likelihood that they will keep taking the prescribed treatment also begins to decline. In fact, the occurrence of intolerable adverse events, and discontinuation of patient adherence to the treatment regimen, can become a major challenge in clinical management when treatment resistance worsens. The iceberg image on this slide portrays the nature of the problem. Clearly, getting to a defined and effective acute treatment (the tip of the iceberg) is the goal: effective treatment with the prescribed antidepressant at an adequate dose for an adequate length of time. Unfortunately, for the majority of patients, this does not occur, and is an especially significant challenge for the patient with a treatment resistant form of depression. Below the water line, are shown some of the potential factors that can confound achieving the goal of treatment adequacy. When looked at in rigorous research studies, adequate antidepressant treatment occurs in the minority of patients. Typically, only one in every four antidepressant treatments is able to achieve the ‘’ tip of the iceberg ’’ due to lack of efficacy, intolerance and other factors as shown here An effective and, most important, a tolerable treatment option is a critical goal in the setting of treatment resistance . References : Nemeroff CB. Depress Anxiety . 1996/1997;4(4):169-181 Oquendo MA, A, et al. J Clin Psychiatry . 2003;64(7):825-833 Oquendo MA, et. al. Am J Psychiatry . 1999;156(2):190-194 Prudic J, et. al. Psychol Med . 2001;31(5):929-934. Osterberg, L, et. al., NEJM , 2009 ; 353 5): 487-497
In 2010, the American Psychiatric Association updated their Practice Guidelines for the Treatment of Patients with Major Depressive Disorder, now in its 3 rd Edition. This slide depicts the general conclusions in that document for the next treatment steps in patients who have failed initial acute phase antidepressant medication. There are several points that I would like to comment on: As I mentioned above, the APA notes the progressive sequence of steps along the bottom as the next choice for antidepressant medications. As you can see, these options include both medication switches within and across pharmacologic classes, as well as augmentation options. While these options have some scientific evidence base for their support, very few have actually withstood FDA scrutiny in large, multisite, randomized controlled trials. The few that have been studied in this manner and are approved for use in treatment resistant depression are the atypical antipsychotic medications, as augmentation agents. As is also noted in this diagram and as you are well aware, each medication trial can take up to 2 months to clearly understand its potential benefits. Finally, in many instances, ongoing treatment may involve continuation of multiple antidepressant medications. TMS is now included as an accepted treatment option for patients who have failed to benefit from first line treatment attempts. As we will discuss later in this presentation, placing TMS at this earlier stage in treatment planning is consistent with the strength of the clinical trial evidence that led to the FDA clearance of the NeuroStar TMS Therapy system device. The NeuroStar TMS system is current the only TMS device in the US which has been cleared by the FDA for use in the treatment of major depression. A treatment course of TMS, as recommended in product labeling, is usually 4 to 6 weeks in duration, and when effective, has been safely followed by a course of a single antidepressant medication. References : American Psychiatric Association (2010) (eds: Gelenberg, AJ, Freeman, MP, Markowitz, JC, Rosenbaum, JF, Thase, ME, Trivedi, MH, Van Rhoads, RS). Practice Guidelines for the Treatment of Patients with Major Depressive Disorder, 3 rd Edition.
As I noted previously, TMS is now incorporated as an accepted treatment option for patients who have failed to benefit from initial antidepressant medication treatment for their illness. This is reflected in a growing body of published consensus. I mentioned earlier the recent publication of the APA Practice Guidelines, and you can read the quote from the Executive Summary of that document on this slide. Several other organizations have also acknowledged the scientific evidence for the safety and efficacy of TMS, including the World Federation of Societies for Biological Psychiatry (2009), and the Canadian Network for Mood and Anxiety Treatments (CANMAT, 2009). References : American Psychiatric Association (2010) (eds: Gelenberg, AJ, Freeman, MP, Markowitz, JC, Rosenbaum, JF, Thase, ME, Trivedi, MH, Van Rhoads, RS). Practice Guidelines for the Treatment of Patients with Major Depressive Disorder, 3 rd Edition. Kennedy, SH, Milev, R, Giacobbe, P, Ramasubbu, R, Lam, RW, Parikh, SV, Patten, SB, Ravindran, AV. (2009) Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. IV. Neurostimulation therapies. J Aff Disorders 117:S44-S53. Schlaepfer, TE, George, MS, Mayberg, H. (2009) WFSBP Guidelines on Brain Stimulation Treatments in Psychiatry. World J Biol Psychiatry Aug 26:1-7.
In the following section of my talk, I ’d like to discuss TMS in more detail. I will review its mechanism of action, and then discuss some of the most recent randomized clinical trial evidence supporting its efficacy and safety. I will also discuss recent outcomes in real-world practice settings obtained from an ongoing large, prospective outcomes study.
Capacitors of the day did not permit high intensity or rapid frequency use. The “ phosphenes ” were either generate from effects on the occipital cortex or directly on the retina of the eye. 1959 – Kolin et al – first to demonstrate magnetic field could stimulation a peripheral frog muscle preparation.
The underlying rationale for the use of TMS exploits the fact that neurons are electrochemical cells. This means that neuronal activity can be affected either chemically, via the use of drugs, or electrically, via interventions like TMS. Unlike drug action, whose effects tend to be anatomically diffuse, the effects of TMS are anatomically focused, and by design are non-invasive and non-systemic in action. Under normal conditions of use, TMS therefore incurs far fewer adverse events, and is devoid of undesired systemic adverse events commonly observed with antidepressant medications. The TMS device is a powerful electromagnet, which is turned on and off in a rapid fashion, producing a pattern of “pulsed” magnetic fields. When pulsed magnetic fields are positioned close to an electrical conductor, like neurons, a local electrical current is produced in that conductor. This electric current is powerful enough right under the magnetic coil to elicit action potentials, which then travel down the neuron, ultimately causing the release of neurotransmitters at the synapse (Post 2001, p. 193A) . References : Post A, Keck ME. Transcranial magnetic stimulation as a therapeutic tool in psychiatry: what do we know about the neurobiological mechanisms? J Psychiatric Research. 2001;35: 193-215.
When the pulsed magnetic fields from the TMS coil are applied to the left dorsolateral prefrontal cortex, there are a series of events that are thought to underlie the therapeutic effects of TMS in the treatment of major depression: First, direct neuronal depolarization under the coil leads to local action potentials in neurons and the local release of neurotransmitters in the cortex. In addition to these local effects, neuronal depolarization of cortical pyramidal neurons is thought to occur (as represented by the blue neural pathway), reaching to deeper brain regions that lie outside the direct action of the pulsed magnetic fields. Activation of these deeper brain regions is then presumed to lead to secondary activation of brainstem neurotransmitter centers, which are then presumed to result in upward influences on the remaining brain regions involved in mood regulation (represented by the purple neural pathway). As a result, dopamine (Kanno 2004, pp. 75A, 76A, 77A) and serotonin (Juckel 1999, pp. 393A, 394A) activity are increased in areas of the brain whose low neurotransmitter activity have been linked to depression. The activity may be increased both in the short term by increasing release of neurotransmitters and in the long term by modulating expression of proteins involved in neurotransmitters signaling (Post 2001, p. 200A,B). Presumably, as a result of these changes, depression lifts (Slotema 2010, p. 876A). The net action of TMS is therefore targeted on the specific brain areas known to be involved in the regulation of mood, and is comprehensive in that its action has both direct effects on local neurons in the cerebral cortex, and then results in deeper actions on brain regions that are distant from the site of stimulation, but neurally connected to these cortical areas. These effects can be demonstrated in human neuroimaging studies of patients who have undergone treatment with TMS for their depression, as shown in the SPECT (single photon emission computed tomography) scan on the right (Kito, et al, 2008). In this image, the TMS coil has been positioned over the dorsolateral prefrontal cortex on the left side of the head. The area just underneath the coil is showing increased metabolic activity as a direct result of the magnetic stimulation. You can also see that the increase in metabolism reaches secondarily the deeper brain regions, in this case the regions of the cingulate cortex also show increased activation. References : Kanno M, Matsumoto M, et al. Effects of acute repetitive transcranial magnetic stimulation on dopamine release in rat dorsolateral striatum. J Neurological Sciences. 2004;217:73-81. Juckel G, Mendlin MA, et al. Electrical Stimulation of Rat Medial Prefrontal Cortex Enhances Forebrain Serotonin Output: Implications for Electroconvulsive Therapy and Transcranial Magnetic Stimulation in Depression. Neuropsychopharmacology. 1999;21(3):391-398. Slotema CW, Blom JD, et al. Should we expand the toolbox of psychiatric treatment methods to include repetitive transcranial magnetic stimulation (rTMS)? A meta-analysis of the efficacy of rTMS in psychiatric disorders. J Clin Psychiatry. 2010;71(7):873-884. Kito, S, Fujita, K, Koga, Y. Changes in Regional Cerebral Blood Flow After Repetitive Transcranial Magnetic Stimulation of the Left Dorsolateral Prefrontal Cortex in Treatment-Resistant Depression . J Neuropsychiatry Clin Neurosci. 2008; 20(1):74-80.
The NeuroStar TMS Therapy system is the only FDA-cleared TMS device for the treatment of adult patients with major depression who have failed to benefit from initial treatment. In clinical practice, TMS Therapy is: An outpatient procedure, It is non-invasive and non-systemic in action, Shows a safety profile of few side effects, Is typically performed in an outpatient setting, without need for sedation or anesthesia, A standard treatment session is 37 minutes long, and a treatment course consists of daily (5 days per week) treatments for 4 to 6 weeks, A physician or other clinical professional is in attendance during the treatment session, which facilitates adherence with the prescribed treatment References : NeuroStar TMS Therapy System User Manual. Neuronetics, Inc: Malvern, PA; 2008.
This slide describes some of the major demographic and clinical characteristics of the patients studied in the registration clinical trials that led to FDA clearance for the NeuroStar TMS Therapy system. All patients had a diagnosis of unipolar, non-psychotic major depression, with moderate to severe symptoms at entry to the study. About a third of all patients had a concurrent secondary diagnosis of an anxiety disorder. All patients received a rigorous characterization of their antidepressant medication treatment history in the current illness episode. Most patients had received numerous medication treatment attempts, with one of these treatment attempts being administered at an adequate daily dose and for at least four weeks without clinical benefit. The average number of overall treatment attempts (which includes all antidepressant medications administered in the current episode, regardless of whether they reached an adequate dose and duration) was 4, with a range across the study population from 1 to as many as 23 treatment attempts. Consistent with the data that I reviewed earlier in this presentation, about 75% of the time, these antidepressant treatment attempts were unable to achieve this minimum level of exposure adequacy (usually because of treatment intolerance, or failure to adhere to the recommended treatment regimen). References : Demitrack, MA , Thase, ME,. (2009) Clinical significance of transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistant depression: synthesis of recent data. Psychopharm Bulletin 42(2) :5-38
Subsequent to the FDA clearance of the NeuroStar TMS system, the second-largest, randomized, sham-controlled clinical trial examining the safety and efficacy of TMS in major depression has now been reported. This study has been referred to as the Optimization of TMS Study, or ‘OPT-TMS’ by its investigators. It is a very important study for several reasons: It was conducted independent of industry, and was funded and sponsored by the NIMH, It studied patients similar in inclusion and exclusion criteria to those studied in the Neuronetics trial, It used the same device as was used in the Neuronetics trial, the NeuroStar TMS Therapy System, It incorporated several additional innovations, including the use of an active sham condition to address questions of adequacy of the study blind in TMS trials, and The results were published in the Archives of General Psychiatry. The main results of this study confirmed the observations of the earlier Neuronetics trial, and showed a statistically and clinically significant outcome on the primary efficacy measure of remission. For those patients on sham treatment who did not improve, an open-label extension study was also offered. In that open-label extension, about 30% of patients were able to achieve remission after treatment with TMS. This study also confirmed the safety and tolerability of TMS Therapy observed in prior studies, with a similar adverse event profile and with nearly 90% of patients fully adherent to the prescribed acute phase treatment course. References : George, MS, Lisanby, SH, Avery, D, McDonald, WM, Durkalski, V, Pavlicova, M, Anderson, B, Nahas, Z, Bulow, P, Zarkowski, P, Holtzheimer, P, Schwartz, T, Sackeim, HA. (2010) Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: A sham-controlled randomized trial. Archives of General Psychiatry 67(5) :507-516
The published scientific evidence supporting the antidepressant effect of TMS is substantial, and now spans nearly twenty years of scientific research, involving more than 30 published studies, and over 2000 patients. There are twelve published meta-analyses or qualitative reviews of this research. The most recent and comprehensive of these was reported by Slotema and colleagues last year. They analyzed the results of 34 studies involving 1,383 patients. They computed an effect size of 0.55 (P < 0.001), which represents a moderate to large clinical effect of TMS in the treatment of depression. In their conclusion, they noted that “…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…”. References: Slotema, CW, Blom, JD, Hoek, HW, Sommer, IEC. (2010) Should we expand the toolbox of psychiatric treatment methods to include repetitive transcranial magnetic stimulation (rTMS)? A Meta-analysis of the efficacy of rTMS in psychiatric disorders. Journal of Clinical Psychiatry 71(7) :873-84. Schutter, DJLG. (2009) Antidepressant Efficacy of High-Frequency Transcranial Magnetic Stimulation Over the Left Dorsolateral Prefrontal Cortex in Double-Blind Sham-Controlled Designs: A Meta-Analysis. Psychol Medicine , 39 :65-75.
All of the research I have reviewed to this point was obtained prior to the introduction of NeuroStar TMS Therapy into routine clinical practice. In the following slides, I would like to describe the results of an ongoing research study that is designed to characterize the outcomes of TMS in real world clinical practice settings.
The goal of this study was to define real-world outcomes associated with NeuroStar TMS Therapy across a broad spectrum of patients and practitioners as well as to follow patient outcomes for one-year after TMS treatment. This study involves 307 unipolar non-psychotic major depressive disorder patients enrolled within the acute phase. The study enrolled patients at 42 sites, comprised of both institutions and private practices with the vast majority being private practices. The study is currently on-going with the duration ultimately lasting two years. We recently closed the acute phase of the study during which enrolled patients received a full course of acute treatment of NeuroStar TMS Therapy as determined by their treating psychiatrist. Following the acute TMS treatment course, patient outcomes are being measured and followed for twelve months. The patient treatments during the follow-up period consisted of clinical care as usual with six clinical assessments made at seven time points. References : Neuronetics, Inc., data on file.
Among the 307 patients, About two thirds were women, The average age was about 49 years old, Most patients (over 90%) had a recurrent course of illness prior to this episode, Almost half of all patients had been hospitalized at some point for their depression, On average, patients had received 2.5 antidepressant treatments of adequate dose and duration in the current episode without receiving clinical benefit from these treatments On average, the course of TMS treatment spanned about 5 to 6 weeks, and reflected an average of 28 TMS sessions. References : Neuronetics, Inc. data on file.
This slide shows the outcome from baseline to end of acute treatment on the major clinician and patient rated scales. On the left hand side are the results of the CGI-Severity of Illness scale, a global illness outcome scale of disease severity rated by the psychiatrist. On the right hand side are the results of the PHQ-9 scale, a nine-item depression scale rated by the patient. The distribution of scores on these scales are shown at baseline, prior to NeuroStar TMS treatment, and then at the conclusion of the acute treatment course. The distribution of scores in terms of illness severity is shown in a three-tiered grouping for each scale. For the CGI-Severity of Illness scale, the category of Markedly Ill or worse reflects either a score of 5 (markedly ill), 6 (severely ill) or 7 (among the most extremely ill patients). The category of Moderately ill reflects those patients rated as 4 (moderately ill), and the Mildly ill or better category reflects those patients rated as either a score of 3 (mildly ill), 2 (borderline mentally ill), or 1 (normal, not at all ill). For the PHQ-9, the category of Markedly Ill or worse reflects a total score of 15 or more (moderately severe or severe depression). The category of Moderately ill reflects those patients rated as a total score between 10 and 15 (moderate depression), and the Mildly ill or better category reflects those patients rated as a score of less than 10 (mild depression or no depression). With these illness severity groupings, it can be seen that from both the clinician’s and the patient’s perspective, the majority of patients at baseline were seen as markedly ill or worse (nearly three quarters of the patients were rated at this severity level), while by the end of about 5-6 weeks of acute treatment with the NeuroStar device, more than half of patients had reached a substantial improvement at a level rated as only mildly ill or no symptoms. On the CGI-Severity of Illness scale, 58% of patients were rated by the clinicians in this category, while on the PHQ-9 scale, 56.4% of patient rated themselves at this level of improvement. References : Neuronetics, Inc. data on file.
The end of treatment categories for the CGI-Severity of Illness and PHQ-9 scales shown on the preceding slide demonstrate a substantial response among patients. However, the goal of depression treatment is remission of symptoms. This slide shows how many patients achieve this definitive level of wellness at the end of acute treatment with the NeuroStar TMS system. On the left, it can be seen that 37.1% of patients are rated by the clinician as having remitted on CGI-S (an endpoint score of 1 or 2 on this scale), which represents more than half of the 58% of responding patients. Similarly, on the PHQ-9 scale, 28.7% of patient self-report a score of less than 5 (remission), representing about half of the total group of responding patients. References : Neuronetics, Inc. data on file.
In summary, the data demonstrating the efficacy of NeuroStar TMS Therapy has been established in two, large, multisite randomized, sham-controlled clinical trials, both of which have shown clinically significant antidepressant effects of TMS. The research studies have been confirmed in the clinical outcomes in a multisite, real world clinical practice setting observational study. In real world clinical practice settings, the results of the outcomes study show that over 1 in 2 patients achieve clinical response to treatment, and 1 in 3 reach full remission. This data is consistent with open-label clinical trial data that was collected in the Neuronetics and OPT-TMS clinical trials. Adherence to treatment in a real world setting is also good, with over 80% of patients completing their prescribed course of TMS. References : Neuronetics, Inc. data on file.
In the following slides, we will review some important aspects of the safety data of the NeuroStar TMS system obtained in the registration clinical trials.
An overall summary of the main safety findings are shown on this slide: As I discussed earlier in reviewing its mechanism of action, TMS showed no systemic side effects, There were no adverse effects on cognition as measured by formal cognitive testing using the Mini Mental Status Examination (a measure of global cognitive function), the Buschke Selective Reminding Test (a measure of short-term memory), and the Autobiographical Memory Interview Short Form (a measure of long-term memory), The most commonly reported device-related adverse event was scalp pain or discomfort in about a third of all patients, Only about 5% of patients discontinued due to adverse events, and for the majority of patients, the device-related adverse events subsided substantially after the first week of treatment Long term safety was confirmed in a six month period of follow up after benefit from acute treatment Seizure is the major, medically significant potential safety risk of TMS. During clinical trials, no seizures were observed with the NeuroStar TMS system. In post-market use, the risk of seizure is rare. Since market introduction and based on current usage, an estimated risk of seizure is approximately 0.003% per treatment exposure, and <0.1% per acute treatment course. To date, over 150,000 treatments and more than 5,000 patients have been treated with the NeuroStar TMS Therapy system which confirms its safe use in the treatment of depression. References : Janicak, PG, O’Reardon, JP, Sampson, SM, Husain, MM, Lisanby, SH, Rado, JT, Demitrack, MA. (2008) Transcranial Magnetic Stimulation (TMS) in the Treatment of Major Depression: A Comprehensive Summary of Safety Experience from Acute and Extended Exposure and During Reintroduction Treatment. J Clin Psychiatry 69(2) :222-232. Janicak, PG, Nahas, Z, Lisanby, SH, Sovason, HB, Sampson, SM, McDonald, WM, Marangell, LB, Rosenquist, PB, McCall, WV, Kimball, J, O’Reardon, J, Loo, C, Husain, MH, Krystal, A, Gilmer, W, Dowd, SM, Demitrack, MA, Schatzberg, AF: (2010) Long-Term Durability of Acute Response to Transcranial Magnetic Stimulation (TMS) in the Treatment of Pharmacoresistant Major Depression. Brain Stimulation 3 :187-199.
This slide shows another important safety observation. The risk of emergent suicidal ideation is a concern with any antidepressant treatment. In the analysis shown on this slide, Item 3 of the Hamilton Depression Rating Scale (the Suicidal Ideation item), which ranges from 0 to 4, was used. The slide depicts the proportion of patients in either the active TMS or sham TMS treatment group in the randomized controlled trial who came in with no suicidal ideation (an Item 3 score of 0 or 1) at baseline, and who later experienced an abrupt emergence of suicidal ideation (a score of 3 or 4) at any later time point. It can be seen that virtually all of these instances occurred only in the sham treatment condition. This indicates that TMS is not associated with provoking emergent suicidal ideation during acute treatment in the indicated patient population. References : Neuronetics, Inc., data on file. Janicak, PG, O’Reardon, JP, Sampson, SM, Husain, MM, Lisanby, SH, Rado, JT, Demitrack, MA. (2008) Transcranial Magnetic Stimulation (TMS) in the Treatment of Major Depression: A Comprehensive Summary of Safety Experience from Acute and Extended Exposure and During Reintroduction Treatment. J Clin Psychiatry 69(2) :222-232.
TMS employs the same type of pulsed magnetic field technology used in modern MR imaging equipment. While the safety of this medical technology in short and long term exposure is well established, Neuronetics also characterized the long-term safety outcomes of patients treated with TMS during six months of follow up after cessation of acute treatment. The design of this open-label follow up study is shown in this diagram. Following completion of acute treatment with TMS alone, all patients were transitioned during a 3 week Taper Phase off of TMS and onto single antidepressant medication maintenance. The choice of medication was based on clinician and patient preference, but could not include use of a medication to which the patient had previously been non-responsive. The most commonly used medications in this study in long-term follow up were duloxetine and bupropion. During the 6 months of follow up, patients were not permitted to modify or add to the single medication regimen in any way. TMS treatment was permitted if the patient experienced symptom recurrence, as measured by the protocol rating scales. References : Janicak, PG, Nahas, Z, Lisanby, SH, Sovason, HB, Sampson, SM, McDonald, WM, Marangell, LB, Rosenquist, PB, McCall, WV, Kimball, J, O’Reardon, J, Loo, C, Husain, MH, Krystal, A, Gilmer, W, Dowd, SM, Demitrack, MA, Schatzberg, AF: (2010) Long-Term Durability of Acute Response to Transcranial Magnetic Stimulation (TMS) in the Treatment of Pharmacoresistant Major Depression. Brain Stimulation 3 :187-199.
The major results of this long-term, open-label safety follow up are shown here. No new safety observations related to TMS were reported. Approximately 37% of patients experienced symptom recurrence requiring reintroduction of TMS. For those patients, about 85% benefited from reintroduction of TMS given in addition to their ongoing antidepressant medication. Over 6 months of follow up, the net incidence of illness relapse (ie, those patients who deteriorated without receiving TMS and exited the study, or those patients for whom TMS reintroduction was not effective) was about 11%. This compares favorably to the long-term relapse reported in open-label naturalistic follow up in the STAR*D study, where 6 month relapse rates in Level 2 or 3 patients ranged as high as 35-50% despite continued best efforts at treatment as usual. References : Janicak, PG, Nahas, Z, Lisanby, SH, Sovason, HB, Sampson, SM, McDonald, WM, Marangell, LB, Rosenquist, PB, McCall, WV, Kimball, J, O’Reardon, J, Loo, C, Husain, MH, Krystal, A, Gilmer, W, Dowd, SM, Demitrack, MA, Schatzberg, AF: (2010) Long-Term Durability of Acute Response to Transcranial Magnetic Stimulation (TMS) in the Treatment of Pharmacoresistant Major Depression. Brain Stimulation 3 :187-199. Rush, A. J., M. H. Trivedi, et al. (2006). &quot;Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report.&quot; Am J Psychiatry 163 (11): 1905-1917.