Brain Stimulation American Psychiatric Nurses Association 24th Annual Conference October 16, 2010 Kentucky International Convention Center Louisville, Kentucky 1 Berry S. Anderson, PhD, RN Mary Rosedale, PhD, PMHNP-BC, NEA-BC Theresa Kormos, PMHCNS-BC Cindy Brown, BSN, RN
Brain Stimulation Techniques Electroconvulsive Therapy (ECT) Repetitive Transcranial Magnetic Stimulation (rtms) Vagus Nerve Stimulation (VNS) Magnetic Seizure Therapy (MST) Deep Brain Stimulation (DBS) Epidural Cortical Stimulation (EpCS) Transcranial Direct Current Stimulation (tdcs) 2
Electroconvulsive Therapy (ECT) 3 Evidence-based treatment Advances changing the role of ECT Nurse: Electrode placement Stimulus dosing Seizure threshold titration Changes in wave form and pulse width Use of physiological monitoring Choice of anesthetic agents Use of time outs
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Magnetic Seizure Therapy: Decreased Depression Severity on Clinician Rated Measure 5 Lisanby et al. (In submission)
VNS 6 Cyberonics, Inc., Houston, TX
FDA Approved Indications for VNS Therapy 7 On July 16, 1997, the FDA approved the NCP System (the predecessor to the VNS Therapy System) for use as an adjunctive therapy in reducing the frequency of seizures in adults and adolescents over twelve (12) years of age with partial onset seizures that are refractory to antiepileptic medications. On July 15, 2005, the FDA approved the VNS Therapy System for the adjunctive long-term treatment of chronic or recurrent depression for patients eighteen (18) years of age or older who are experiencing a major depressive episode and have not had an adequate response to four or more adequate antidepressant treatments.
Deep & Cortical Brain Stimulation Medtronic NeuroPace 8
What is TMS? (Transcranial Magnetic Stimulation) 1 Electric energy within insulated coil induces MRI-strength magnetic fields Magnetic fields pass unimpeded through the cranium for 2-3 cm In turn inducing an electric current in the brain This stimulates the firing of nerve cells and the release of neurotransmitters 1 Richelson, E. Mechanisms of Action of Repetitive Transcranial Magnetic Stimulation (rtms) and Vagus Nerve Stimulation (VNS). Psychiatric Annals, 2007; Vol 37-No. 3, 181-187. 9
Transcranial Magnetic Stimulation 1903- First Patent of TMS Pollacsek and Beer, Vienna, Austria 10
TMS Manufactures 11 Brainsway (Israel), www.brainsway.com CR Tech (Seoul, South Korea) Magstim Company, Ltd. (Whitland, UK) www.magstim.com MAG&MORE GmbH, (Munich, Germany) Mcube Technology Co., Ltd. (Seoul, South Korea) Medtronic Dantec NeuroMuscular (Skovlunde, Denmark) www.medtronic.com Neuralieve (California, USA) www.neuralieve.com Neuronetics Inc. www.neuronetics.com Nexstim (Finland) www.nexstim.com Schwarzer (München, Germany) www.schwarzer.net
NeuroStar TMS Therapy System Treatment Coil Display Senstar Treatment Link Mobile Console 12
TMS Remission Rates: Neuronetics Trial and NIMH OPT-TMS Study 14% 14.2 14.1 5% 5.2 5.1 Active Neuronetics Sham Active OPT-TMS Sham 13
FDA Labeling NeuroStar TMS System as a prescription device under 21 CFR Part 801.109 that is indicated for the treatment of Major Depressive Disorder in adult patients who have failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode. 14
Safety of TMS Side Effects Mild Headache Mild Discomfort at sight of stimulation Temporary increase in auditory threshold (without ear plugs) Induce Mania (rare) Induce Seizure (rare) 15 Contraindications - cochlear implant - aneurysm clips - brain electrodes - ferromagnetic material in their head or neck - stroke - head trauma
MT Site and Treatment Site Vertex Treatment Site Starting Point MUSC, Anderson, BS 16
Transcranial Direct Current Stimulation (tdcs) for Depression: 30 Bulow et al. (In submission) Non-responder Partial Responders 25 20 Responders 15 10 5 Baseline Week 2 Week 4 Week 6 Week 12 17
Psychiatric Nursing and Brain Stimulation Focus Issue: Transcranial Magnetic Stimulation (TMS) and Nursing: Science and Practice at the Cutting Edge, Journal of the American Psychiatric Nurses Association, 15 (5), 2009. http://www.tmsnurses.org/blog A place for dialogue about psychiatric nursing and brain stimulation methodologies 18