Julie Plummer, CEO

October 17, 2011 2

PineWood TMS

Supporting Integrated Wellness

PineWood Transcranial Magnetic Stimulation

2

Julie Plummer, CEO

Why the Name Pinewood TMS?

Neuro-Modulation Programs

in the North East

LegendPineTree= PineWood TMS, Brattleboro, VT

Red Dots= TMS

Magenta= ECT + TMS

Blue 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 MillionAdequately

Treated

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

prefrontal

cortex

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

neurotransmitter

projections

concentration

pleasure/

interests

guilt

suicidality

worthlessness

mood

sleep

appetite

psychomotor fatigue (physical)

pleasure/interests

psychomotor

fatigue (mental)

guilt

suicidality

worthlessness

mood

Regions implicated in MDD are

connected to the brainstem via

monoaminergic circuits

Chemical Antidepressants

Antidepressant

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

worthlessnessweight 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.

SSRI

SNRINDRI

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

Num

ber

of

MD

D P

ati

ents

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

Dorsolateralprefrontal

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 regulation

Directly depolarizes cortical neurons and modulates neurotransmitter release in the brain

Effects involve both the local and deep neural circuits in the brain

Accomplishes 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 Street

Brattleboro, VT 05301

802-246-1304

WWW.PineWoodTMS.com

Julie@PineWoodTMS.com

PineWood TMS