Julie Plummer, CEO

2October 17, 2011

PineWood TMS Supporting Integrated Wellness

PineWood Transcranial Magnetic Stimulation

2Julie Plummer, CEO

Why the Name Pinewood TMS?

Neuro-Modulation Programs in the North East

LegendPineTree= PineWood TMS, Brattleboro, VTRed Dots= TMSMagenta= ECT + TMSBlue Dots= ECT

Many Patients with Depression Remain Poorly Served:

Kessler RC et al. JAMA. 2003;289(23):3095-3105.

14 Million US Adults

7.2 MillionTreated

6.8 MillionUntreated

3.2 MillionAdequatel

yTreated

4 MillionPoorly Served

Inadequate response

Intolerant to side effects

6

Major Depressive Disorder“Adequate” Treatment Is Difficult to Achieve

Adequate Dosage

Adequate Duration

Poor Tolerability

Nonadherence

Safety Issues

Lack of Efficacy

Comorbidities

1. Nemeroff CB. Depress Anxiety. 1996/1997;4(4):169-181; 2. Oquendo MA et al. J Clin Psychiatry. 2003;64(7):825-833; 3. Oquendo MA et al. Am J Psychiatry. 1999;156(2):190-194.

Factors contributing to inadequate treatment include:

Neuro-anatomy and physiology of Major depressive disorder

prefrontalcortex

In MDD, some areas of the

brain are hypoactive

and others are hyperactive.

amygdala

brainstem neurotransmitter centers

thalamus

striatum

anterior cingulate

cortex

hippocampus

hypothalamus

LOW

HIGH

Neural Activity

When there is an appropriate

amount of monoamine

neurotransmitter activity, neuronal activity

throughout the brain functions

normally.

• Monoamine dysfunction is linked to MDD

• Malfunctioning circuits lead to specific symptoms

Major Depressive Disorder: Circuits and Neurotransmitters

Serotonin (5-HT) Dopamine (DA) Norepinephrine (NE)Monoamine Neurotransmitters

monoamine neurotransmitte

r projections

concentrationpleasure/interests

guiltsuicidalityworthlessnessmood

sleepappetite

psychomotor fatigue (physical)pleasure/interests

psychomotor fatigue (mental)

guiltsuicidalityworthlessness

mood

Regions implicated in MDD are connected to the

brainstem via monoaminergic circuits

Chemical AntidepressantsAntidepressant

weight gainsexual

dysfunction

insomnia

nausea

GI distress

blood pressure changes

blurred vision

AntidepressantTherapeutic Effects such

as:

improved mood

increased concentration

reduced feelings of guilt, suicidality, and worthlessness

weight gain

insomnia

agitation dry mouth fatigue

APA Accepted Treatment Algorithm for MDD

Kessler RC et al. Arch Gen Psychiatry. 2005;62(6):617-627; Kessler RC et al. JAMA. 2003;289(23):3095-3105; Herrmann RC. Am J Psychiatry. 1995;152(6):869-875.

SSRISNRINDRI

TMS

Primary Care• Initial Diagnosis• Early Treatment

Attempts

Psychiatry• Improved

Diagnosis• Improved Dosing• Psychotherapy• New Treatment

Options

Combination & Augmentation

– Atypical Antipsychotics– Mood Stabilizers

MAOI & TCA

ECT

10M

8M

6M

4M

2M

0 1 2 3 4 5 6 7 8

Failed Treatment Attempts in Current Episode

Nu

mb

er

of

MD

D P

ati

en

ts

VNS

Treatment-Resistance Continuum

ECT Video

13

Transcranial Magnetic Stimulation Therapy System

Treatment coil

Head support unit

Treatment chair

Mobile console

Touchscreen

NeuroStar TMS Therapy System User Manual. Neuronetics, Inc: Malvern, PA; 2008.

TMS Video

Neuron

TMS Directly Depolarizes Cortical Neurons

Pulsed magnetic fields from TMS Coil: • induce a local

electric current in the cortex which depolarizes neurons

• elicit action potentials

• cause the release of chemical neurotransmitters

Depolarization leads to action potentials in local neurons and

thereby releases neurotransmitters

Neurons are “electrochemical

cells” and respond to either electrical

or chemical stimulation

TMS Releases Neurotransmitters in the Brain

Depolarization of neurons in the DLPFC

causes local neurotransmitter release

Depolarization of pyramidal neurons in the DLPFC causes neurotransmitter release in

deeper brain neurons

Activation of deeper brain neurons then exerts secondary effects on remaining portions of targeted mood circuits

Dorsolateral prefrontal

cortex

Cingulate cortex

Kito (2008) J Neuropsychiatry Clin Neurosci

These effects are associated with

improvements in depressive symptoms

TMS Mechanism of Action Summary

TMS Therapy:Specifically targets the underlying brain circuits

involved in mood regulationDirectly depolarizes cortical neurons and

modulates neurotransmitter release in the brainEffects involve both the local and deep neural

circuits in the brainAccomplishes these effects without unwanted

systemic adverse effects

Feature-Benefits Table

Features Benefits

No Anesthesia Physiological, psychological, logistical

Non-Systemic Minimal side effects, no memory loss or confusion

Non-Invasive TMS is not disfiguring

Concurrent use of other therapies

Potentiate Positive Outcomes

PineWood TMS in Brattleboro, VT

The Clinical Role of Psychiatric RNs in TMS

• Initial patient assessment

• Education• Establish

therapeutic

treatment setting

• Observe therapy• Assess patient

outcomes

Process for Patients Entering PineWood TMS

1. Referral.2. Education.3. Evaluation.4. Informed Consent.

Process TMS When Treatments are Ordered

1. Treatment Parameters Set.2. Treatment Commences.3. Weekly Assessment of Depression.4. Psychiatrist is Updated Weekly.

Frequently Asked Questions

• What are the chances it will work?

• How long will it take to feel better?

• How long will the effect last?

• What are the side effects?

Contact Information

Supporting Integrated Wellness

167 Main StreetBrattleboro, VT 05301

802-246-1304WWW.PineWoodTMS.comJulie@PineWoodTMS.com

PineWood TMS