As the efficacy of TMS for Obsessive-Compulsive Disorder (OCD) becomes increasingly evident, many psychiatric practitioners are considering integrating this innovative treatment into their practice. This comprehensive guide will walk you through the key steps of implementing TMS, from patient selection to follow-up care.
Patient Selection
Identifying suitable candidates for TMS is crucial for treatment success. Consider the following criteria:
❒ Diagnosis: Confirmed OCD diagnosis with moderate to severe symptoms (Y-BOCS score > 20).
❒ Treatment history: Inadequate response to at least one serotonin reuptake inhibitor (SRI) and/or cognitive-behavioral therapy (CBT).
❒ Age: Adults between 22-68 years old, as per FDA clearance.
❒ Exclusions: Patients with metal implants, seizure disorders, or certain neurological conditions may not be suitable candidates.
Assessment Protocol
Before initiating TMS, a thorough assessment is essential:
❒ Comprehensive psychiatric evaluation: Review the patient's OCD symptoms, treatment history, and comorbidities.
❒ Baseline measurements: Administer the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to quantify symptom severity.
❒ Medical clearance: Ensure there are no contraindications for TMS treatment.
❒ Informed consent: Discuss the procedure, potential benefits, and risks with the patient.
Treatment Protocol
The standard TMS protocol for OCD typically involves:
❒ Frequency: 20 Hz stimulation
❒ Intensity: 100% of resting motor threshold
❒ Session duration: 18-19 minutes (2-second trains, 20-second intervals, 50 trains)
❒ Course length: 29 sessions over 6 weeks (5 sessions per week for 5 weeks, followed by 4 sessions in week 6)
Key steps in each session:
❒ Coil positioning: Place the H7 coil 4 cm anterior to the motor hot spot.
❒ Symptom provocation: Conduct a 3-5 minute individualized symptom provocation before each treatment to activate relevant neural circuits.
❒ Stimulation: Deliver the TMS protocol as described above.
❒ Monitoring: Observe the patient for any adverse effects during and immediately after treatment.
Managing the Treatment Course
❒ Weekly assessments: Conduct Y-BOCS assessments to track progress.
❒ Adjustments: Modify symptom provocation techniques as needed based on patient response.
❒ Side effect management: Address any reported side effects, typically headache or scalp discomfort.
❒ Concurrent treatments: Maintain stable medication regimens and encourage continuation of CBT if applicable.
Follow-up Care
❒ Post-treatment assessment: Conduct a comprehensive evaluation, including Y-BOCS, at the end of the treatment course.
❒ Maintenance plan: Develop a strategy for maintaining improvements, which may include booster TMS sessions.
❒ Ongoing monitoring: Schedule regular follow-ups to assess symptom status and determine if additional TMS courses are needed.
❒ Integrate with other therapies: Encourage continued engagement with CBT and medication management as appropriate.
Implementing TMS for OCD in your practice can significantly expand your treatment options for patients with treatment-resistant OCD. Start with these guideline to ensure a smooth integration of this innovative therapy into your clinical workflow, potentially transforming outcomes for your OCD patients.
Ready to take the next step in optimizing your TMS protocols? Our next post will delve into advanced techniques for personalizing TMS treatments to maximize efficacy for individual patients.
References:
Carmi, L., Tendler, A., Bystritsky, A., Hollander, E., Blumberger, D. M., Daskalakis, J., ... & Roth, Y. (2019). Efficacy and safety of deep transcranial magnetic stimulation for obsessive-compulsive disorder: A prospective multicenter randomized double-blind placebo-controlled trial. American Journal of Psychiatry, 176(11), 931-938.
Roth, Y., Tendler, A., Arikan, M. K., Vidrine, R., Kent, D., Muir, O., ... & Zangen, A. (2021). Real-world efficacy of deep TMS for obsessive-compulsive disorder: Post-marketing data collected from twenty-two clinical sites. Journal of Psychiatric Research, 137, 667-672.
Shephard, E., Stern, E. R., van den Heuvel, O. A., Costa, D. L., Batistuzzo, M. C., Godoy, P. B., ... & Miguel, E. C. (2021). Toward a neurocircuit-based taxonomy to guide treatment of obsessive-compulsive disorder. Molecular Psychiatry, 26(9), 4583-4604.
Tendler, A., Barnea Ygael, N., Roth, Y., & Zangen, A. (2016). Deep transcranial magnetic stimulation (dTMS) - beyond depression. Expert Review of Medical Devices, 13(10), 987-1000.
U.S. Food and Drug Administration. (2018). De Novo Classification Request for Brainsway Deep Transcranial Magnetic Stimulation System. Retrieved from https://www.accessdata.fda.gov/cdrh_docs/reviews/DEN170078.pdf