Dr McClintock and Colleagues Reply to Roles and Qualifications of TMS Treatment Team Members

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See letter by Feifel et al and article by McClintock et al

Dr McClintock and Colleagues Reply

To the Editor: We appreciate the interest of Drs Feifel, Dunner, and Press in our consensus recommendations for the clinical use of repetitive transcranial magnetic stimulation (rTMS) in the treatment of depression.1 They raised 3 main points about our consensus recommendations, focused on physical examination, qualifications of the TMS clinician, and qualifications of the TMS operator.

Regarding physical examination, Drs Feifel, Dunner, and Press disagree with the recommendation for physical examination in assessing a patient’s suitability for rTMS. However, as we noted in our consensus recommendations1 and in our reply to Tendler and Gersner,2 physical examination3,4 provides useful evidence to inform medical decisions, medical safety, and necessity of rTMS. Also, the American Psychiatric Association Practice Guideline for the Treatment of Patients With Major Depressive Disorder5 noted that pretreatment evaluation should include physical examination and clinical care coordination between the psychiatrist and other health professional(s), such as a primary care provider, who may perform the physical examination. On the basis of this information, we recommend that a targeted physical examination (either newly conducted or previously conducted and documented in the medical record) be a component of the pre-rTMS treatment evaluation.

Regarding qualifications of the TMS clinician, we agree that the individual should have an extensive background in brain physiology, competency in the neurophysiological (and antidepressant) effects of rTMS, and certification and/or credentialing in rTMS administration. However, we disagree with Drs Feifel, Dunner, and Press that “the TMS physician should be a psychiatrist.” The TMS clinician needs to be a properly trained physician or clinician with prescriptive authority (eg, nurse practitioner or physician assistant with a cooperative agreement with a physician with expertise in TMS) who practices within his or her scope of practice as defined by the respective state licensing board. For example, if TMS is being used to treat depression, the clinician should have treatment of depression within his or her scope of practice. While the clinician may be a psychiatrist, it is possible that the clinician could be a primary care physician, neurologist, nurse practitioner, or physician assistant with expertise and scope of practice in treating depression and TMS training and credentialing. As the clinical practice of TMS continues to evolve, continued conversations among multiple stakeholders (eg, clinicians, policy makers) will be warranted regarding who can be a TMS clinician.

Regarding qualifications of the TMS operator, while the risk of seizure with rTMS has been found to be low,6 we nonetheless recommend that the TMS operator have basic life support training certification and be trained as a first responder to a seizure.7 As the TMS operator will already be in the room with the patient, he or she can take immediate action to minimize complications and ensure patient safety. We agree that it would be beneficial for the TMS operator to have a knowledge base of mental illness, particularly major depressive disorder given the current US Food and Drug Administration label for rTMS.

We appreciate the comments by Drs Feifel, Dunner, and Press as they highlight practical questions that clinicians may have regarding the clinical practice of rTMS for the treatment of depression. Continued discussions such as these are helpful to the clinical growth of TMS, and we hope our consensus recommendations will help to advance, inform, and strengthen such discussions.

References

1. McClintock SM, Reti IM, Carpenter LL, et al; American Psychiatric Association Council of Research Task Force on Novel Biomarkers and Treatments. Consensus recommendations for the clinical application of repetitive transcranial magnetic stimulation (rTMS) in the treatment of depression. J Clin Psychiatry. 2018;79(1):16cs10905. PubMed CrossRef

2. McClintock SM, Reti IM, Carpenter LL, et al. Dr McClintock and colleagues reply. J Clin Psychiatry. 2018;79(1):17lr11851a.

3. Azzam PN, Gopalan P, Brown JR, et al. Physical examination for the academic psychiatrist: primer and common clinical scenarios. Acad Psychiatry. 2016;40(2):321-327. PubMed CrossRef

4. Garden G. Physical examination in psychiatric practice. Adv Psychiatr Treat. 2005;11(2):142-149. CrossRef

5. Gelenberg AJ, Freeman MP, Markowitz JC, et al; Work Group on Major Depressive Disorder. Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. Arlington, VA: American Psychiatric Association; 2010.

6. Carpenter LL, Janicak PG, Aaronson ST, et al. Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depress Anxiety. 2012;29(7):587-596. PubMed CrossRef

7. Seraj MA, Naguib M. Cardiopulmonary resuscitation skills of medical professionals. Resuscitation. 1990;20(1):31-39. PubMed CrossRef

Shawn M. McClintock, PhD, MSCSa,b

shawn.mcclintock@utsouthwestern.edu

Irving M. Reti, MBBSc

Linda L. Carpenter, MDd

Marc Dubin, MD, PhDe

Stephan F. Taylor, MDf

Mustafa M. Husain, MDa,b

Christopher Wall, MDg

Shirlene Sampson, MDh

Mark S. George, MDi,j

Sarah H. Lisanby, MDb

aDepartment of Psychiatry, UT Southwestern Medical Center, Dallas, Texas

bDivision of Brain Stimulation and Neurophysiology, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina

cDepartment of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland

dButler Hospital, Brown Department of Psychiatry and Human Behavior, Providence, Rhode Island

eDepartment of Psychiatry, Weill Cornell Medical College, White Plains, New York

fDepartment of Psychiatry, University of Michigan, Ann Arbor, Michigan

gPrairieCare, Rochester, Minnesota

hDepartment of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota

iDepartment of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina

jRalph H. Johnson VA Medical Center, Charleston, Charleston, South Carolina

Potential conflicts of interest: The authors’ disclosures accompany the original article.

Funding/support: None.

J Clin Psychiatry 2018;79(1):17lr11887a

To cite: McClintock SM, Reti IM, Carpenter LL, et al. Dr McClintock and colleagues reply. J Clin Psychiatry. 2018;79(1):17lr11887a.

To share: https://doi.org/10.4088/JCP.17lr11887a

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