Whitney Carrico is a Fellow in the Veterans Affairs (VA) War Related Injury and Illness Study Center; Gerald Georgette is a Clinical Research Nurse Coordinator; Michelle Madore is Director of the VA National Clinical Repetitive Transcranial Magnetic Stimulation (TMS) Pilot Program; Jong Yoon is an Attending Psychiatrist and Director of the Neuromodulation Clinic; Steven Lindley is Director, Outpatient Mental Health; Steven Lovett is Chief, Psychology Service; and Jerome Yesavage is an Associate Chief of Staff for Mental Health and Director of the Mental Illness Education, Research and Clinical Centers; all at VA Palo Alto Health Care System in California. Andrew Kozel is Director of the TMS Clinic and a Staff Psychiatrist at James A. Haley Veterans Hospital; and a Professor, University of South Florida in Tampa. Mark George is a Distinguished University Professor of Psychiatry, Neurology and Radiology and Director of the Brain Stimulation Division, Medical University of South Carolina, and a Staff Psychiatrist and Director of the TMS Clinic at Ralph H. Johnson VA Medical Center in Charleston. Steven Lindley and Jong Yoon are Associate Professors of Psychiatry; and Jerome Yesavage is an Associate Chair of Psychiatry and Behavioral Sciences and Professor of Neurology and Neurological Sciences (by courtesy); all at Stanford University School of Medicine in Palo Alto. Correspondence: Jerome Yesavage (yesavage@stanford.edu)
Author Disclosures The authors report no actual or potential conflicts of interest with regard to this article.
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A major challenge for the VHA with rTMS will be to maintain a consistent level of competence and training. There is a need for continued maintenance of staff competence with ongoing training and training for new staff. Novel ways of training operators have been developed including ERIK.
Determining treatment interaction with other psychotherapies and pharmacotherapies is another challenge. Currently, rTMS is considered an adjunctive treatment added to the current patient treatment plan. We do not know yet how best to incorporate this somatic treatment with other approaches, and further research is necessary. A key issue is to determine which approach provides the best long-term results for a patient at risk for recurrence of depression. In addition, more research into maintaining healthy relationships for veterans with both MDD and PTSD is needed.
Many misconceptions exist about rTMS and HCPs need to be educated about the benefits of this modality. In addition, patients should understand the differences between rTMS and ECT. Even with newer approaches that streamline rTMS, the therapy remains costly in terms of direct costs as well as patient and HCP time.
Streamlining rTMS treatment remains an important concern. Compressing treatment schedules (ie, many treatments delivered to a patient in a single day) would allow the entire process to be delivered in days, not weeks. This would be especially advantageous to patients who live far from a treatment site. Performing multiple rTMS daily treatments is especially feasible with iTBS with its short treatment time.
Conclusions
rTMS is an emerging modality with both established and novel applications. The best studied application is treatment resistant MDD. Currently, rTMS has only been approved by the FDA for treatment of MDD. A pilot program was established by the VHA to distribute 30 rTMS machines sites nationwide. Results from data collected by these sites have shown patients improving on standard psychometric scales. Future changes include upgrading the machines to provide θ bursts, which has been shown to be faster and noninferior. Integrating rTMS with other pharmacotherapies and psychotherapies remains poorly understood and needs more research.
