Transcript:
"I've been here since the mid 2000s, one of the things I do in my practice is I treat people with psychiatric illness in acute care settings-- usually in a hospital setting. I also see people in a home environment-- board and care or other types of outpatient settings. So as a psychiatrist I really have a wide variety of patients that I focus on. My career really is centered on people with chronic and severe psychiatric illnesses-- so primarily, Schizophrenia, Bipolar Disorder, people who have severe mood disorders and suffer with suicidal thinking or suicide attempts. In that practice, I really end up dealing with a population that's fairly disabled from their illness. One of the rewards is that when you can get some improvement in someone’s level of functioning, it may not seem like a lot to someone on the outside but to that individual it can really be the difference between being independent or being dependent. So typically, I’ll start a person’s care episode in the acute care psychiatric hospital. They’ve come in involuntarily, maybe on a hold or maybe their family member has brought them in. The goals of the treatment in that setting are to ensure safety and try to control someone’s symptoms and have them return to the community. If they’re not able to do that-- if they need a longer period of time before they are able to fully recover or function at a level where they can be back in the community-- they may come to a long term facility like Alpine. One of the struggles with psychiatric illnesses is they tend to be fairly chronic conditions. So [it’s] different than if someone has a sinus infection and takes a course of antibiotics for a week and recover, this may take weeks and weeks or months and months before the person really fully recovers from their illness, or at least as much as possible. For me, one of the most rewarding things working at Alpine is seeing people recover in their illness. For some people, it’s a very slow process, it’s very gradual, but if you do it in a controlled setting and do it over a long term, you really do see a recovery. You really do see a control of illness, you really do see people be able to flourish in life again. It’s not an unusual situation where my initial interaction with a person is centered around them wanting to leave, and me trying to explain the legal ramifications of why they are in the facility and the process that resulted in that happening. And not for everyone, but for a lot of people, that does change at some point and they do start to recognize that there has been a benefit here, and that things have improved, and that their life will be better because of it. Having a relationship over a period of time is sometimes the best thing I can do to convince the person that I really am on their side. I’m not the enemy, the enemy isn't the fact that they are in the facility, the enemy is the illness, and that we’re working together to try to control that illness as best as possible. One of the challenges in psychiatry and particularly dealing with some of the more severe psychiatric illnesses, is that the organ of decision is the organ of disease. So struggling with trying to help a person see when their brain isn't functioning as best as it should be, why are they having symptoms or why are they having difficulties in their life and recognizing that it is something medical and something we can treat."
TMS Therapeutics in San Diego: 3 min Express TMS is advantageous for social distancing
Dr. Brian Miller, MD and Medical Director of TMS Therapeutics in San Diego has, for the past close to 10 years, provided TMS therapy to many, many patients suffering from severe, treatment-resistant depression. With the results he has seen for his patients – he thus describes himself a “wholehearted believer in TMS therapy.”
Dr. Miller has also closely followed the development of every new TMS device as they came to market and has for several years used MagVenture TMS Therapy: “MagVenture has always appealed to me, given its presence in the research arena even before becoming commercially available. I prefer the versatility and flexibility of their figure of 8 coils as well as the stimulator’s ability to adapt to advances in TMS techniques.”
In recent years, Dr. Miller has increasingly used the Theta Burst (or Express TMS®) protocol for his depression patients, a protocol which cuts treatment time from the standard 37 or 19 minutes down to just 3 minutes per session. The safety and efficacy of TBS have been documented in the largest randomized controlled TMS trial to date, known as the THREE-D trial from 2018, which compared the standard 37 minute protocol with the 3 minute Theta Burst (TBS) protocol. The researchers found similar efficacy – and safety – between the two, with 27% and 32% achieving full remission, respectively. The results were published in The Lancet and led to an FDA clearance of the TBS protocol for MagVenture in 2018.
Increased need for mental health services
To Dr. Miller, the pandemic outbreak of Covid-19 “has clearly caused an exacerbation of ongoing illnesses as well as leading people to seek treatment for the first time. Given the variety of associated stressors it is reasonable to expect a greater demand for mental health services for the foreseeable future,” predicts Dr. Miller, while further mentioning that he, even before the pandemic, had already adopted TBS for the majority of his patients.
Theta Burst now standard of care treatment
As a direct result of the pandemic outbreak TBS is now offered to his patients as the standard TMS Therapy: “TBS is markedly advantageous for social distancing and the comfort of staff wearing PPE,” he says, and mentions that the longer protocols are still offered but as the second-line option. As far as reimbursement, Dr. Miller has not had any issues with TBS, reimbursement is granted in the same degree as standard TMS.
Pre-screenings, testing, social distance
Due to universal masking and availability of rapid testing, TMS Therapeutics in San Diego has managed to continue providing TMS throughout the pandemic. Several adjustments have, however, been applied, he says: “We reviewed all existing patients carefully to adjust the frequency of treatment based on risk of exposure to both our patients and staff. New consults are now done remotely. Patients entering the clinic are screened at each treatment, and – as mentioned – our staff uses PPE. The layout of the office and treatment schedules have also been changed to maximize social distancing.”
Convenient for the patient
According to Dr. Miller, his patients also like the shorter protocol: “The convenience of TBS has been a major advantage for many patients. It has become practical to have a treatment in the middle of the workday without too much disruption. Some patients really miss the extended treatments when they used to watch TV, movies, or just talk with the technician. I try to look at other ways to increase their socialization, and use it as an opportunity to remind people that it's OK to carve out some time for themselves every day.”