TMS & Ketamine FAQs

 

What is TMS?


TMS is non-invasive, meaning that it does not involve surgery and does not require any anesthesia orsedation. Patients remain fully awake and alert during TMS therapy sessions. TMS is non-systemic, meaning that it does not enter the bloodstream nor affect other areas of the body likemedications can.To add a new question go to app settings and press "Manage Questions" button.




How Does TMS Work?


TMS refers to a medical treatment which is delivered by a device that generates changing magnetic fields. TTMS Therapy system generates highly concentrated magnetic fields which are rapidly switched on and off. These magnetic fields do not directly affect the whole brain; they only reach about 2-3 centimeters into the brain. The device is positioned over the prefrontal cortex - the area of the brain which is being targeted when treating depression. These magnetic fields can create electrical activity in the nerve cells. It is well accepted by researchers and clinicians that the magnetic stimulation affects not only the targeted area (e.g. the prefrontal cortex), but also other areas of the brain connected to the prefrontal cortex, including the cingulate, hypothalamus, and thalamus. There are many devices which can be used by clinicians. In this office, we utilize several different devices, including the Neurostar Advanced Therapy System, the Magstim Rapid2 Therapy System, and the MagVenture Express TMS System.




Does TMS have side effects?


The most common side effects of TMS include dizziness, headache, and minor scalp pain. There is a risk of seizure with the use of Transcranial Magnetic Stimulation. Patients who have had a seizure or who have a medical condition which could increase the risk of having a seizure should share that information with Dr. St. John at their initial consultation. TMS treatment systems create a magnetic field that could cause metal objects near the stimulation area to move or heat up. Patients with non-removable magnetic-sensitive metals or metallic devices implanted in their head or in body parts during stimulation could experience adverse effects from the treatment and should not receive TMS therapy.




How well does TMS work?


Current literature indicates that approximately 50% of all treated patients who meet criteria for TMS (i.e. are considered treatment-resistant) respond to the treatment by bettering their score on a standardized rating scale by 50% or more. Approximately one-third of treated patients are so-called remitters, bettering their scores so much that they are considered depression-free. To put these statistics in perspective, it is important to note that the patient population undergoing treatment with TMS Therapy is often excluded from new antidepressant development research studies. In addition, the STAR*D study demonstrated that patients are likely to experience a poorer response to each new medication tried following successive treatment failures. For example, after the first medication attempt, about 30% of patients achieve remission. By the time the patient has attempted 3 different medications without improvement, the likelihood of the 4th medication leading to remission falls below 10%.




Will ketamine therapy help my treatment-resistant depression?


Based on published research data, and in our experience, up to 70% of all patients can expect to have responded by the time they have received 6 infusions.




Do I need to be referred by a psychiatrist for ketamine therapy?


If you are not currently a patient of Dr. St. John’s, she will meet with you for a consultation to discuss your psychiatric condition and history. She may want to obtain medical records and/or discuss your diagnosis and treatment history with other doctors whom you have been receiving treatment from. Patients who are currently receiving psychiatric treatment from Dr. St. John will work with her to determine appropriateness for ketamine infusion therapy during a routinely scheduled appointment or may schedule an additional office visit to discuss the treatment option.




Where is the ketamine treatment performed?


All treatments are performed within our existing outpatient offices.




How many ketamine infusions will I receive?


Most responsive patients receive an initial series of 6 (six) infusions. This is generally referred to as acute phase treatment or induction treatment. Some patients will choose to stop receiving IV ketamine therapy after 6 infusions and rely on another form of treatment instead to maintain or sustain improvement in their mood. These patients view ketamine infusions as a “stop-gap” treatment to bring about a rapid improvement in mood while they are also planning a change in medication or planning to start another treatment like TMS therapy or ECT – all treatments which take more time for patients to experience results. Other patients choose to obtain IV ketamine therapy on a longer-term basis. These patients may instead return to the office at various intervals for booster or maintenance infusions - generally when they begin to feel the initial series wearing off. Patients who do not experience an improvement in mood by the 3rd or 4th ketamine infusion during the acute phase may opt to discontinue IV ketamine therapy and try a different treatment instead.




If ketamine therapy works for me how soon will I begin to feel better?


Some patients will begin to feel better within several hours of the first infusion. Patients with thoughts of self-harm often notice those thoughts dissipating first. Other patients may not notice any mood improvement until the next day. Some patients will require a second (or even a third) infusion before feeling better.




Are there any long-term side effects with ketamine therapy?


Ketamine therapy results in no clear long-term side effects, though irritative and inflammatory urinary tract and bladder symptoms including cystitis have been reported in individuals with a history of chronic ketamine use or abuse.




I have bipolar disorder. Will ketamine make me hypomanic?


Hypomania has not been reported following ketamine therapy.




What medical conditions could keep me from receiving ketamine?


There are very few psychiatric contraindications. Dr. St John will discuss contraindications with you before you receive your first infusion. Patients with significant elevations of blood pressure may require treatment of their hypertension prior to beginning ketamine infusion therapy.




Are ketamine infusions addictive?


Ketamine has been reported being used as a drug of abuse. All patients are screened for substance use disorders. A thorough discussion including the risks and benefits of trying Ketamine Infusion therapy will take place between all patients and Dr. St. John, especially those with a history of a substance use disorder. Patients are required to follow clinic policies and will be dismissed if any evidence arises indicating that the patient has obtained oral, IV, or nasally inhaled ketamine from another source or provider. Ketamine dependence and tolerance are possible following prolonged administration.




Will my current psychiatric medications interfere with ketamine therapy?


Anti-depressant medications (SSRIs, SNRIs, TCAs, etc.) do not interfere with ketamine, and there is no need to stop them. Ketamine infusions can provide relief during the time it takes antidepressant medications to begin working. Important: You should not decrease or stop taking any prescribed medication without first consulting with your prescribing physician.




What should I expect during ketamine therapy?


Ketamine is administered over a period of 40 or more minutes. The dose is determined by your weight. The amount of ketamine administered is not enough to cause a loss of consciousness, so you will remain awake. During the infusion, some patients experience odd perceptions—like seeing bright colors. Some report what is referred to as a “dissociative” or “out of body” experience. Most commonly, patients describe experiencing a pleasant dream-like state. Once the infusion is complete, the dissociative effects of the drug rapidly dissipate. There are no delayed “flashbacks,” and patients generally leave the office within 30 minutes of the infusion feeling quite normal.




Are there other side effects that I would experience during or after my ketamine therapy?


Occasionally patients experience some nausea or dizziness during an infusion. More rarely, a patient may experience a transient headache. Patients can expect to be tired following the infusion. Increases in blood pressure and heart rate are also not uncommon. Your vital signs will be measured at intervals to ensure your safety. Rarely, patients have exhibited movements resembling a seizure. If you have a seizure disorder, please be sure to share that information with Dr. St John prior to receiving ketamine therapy.




Do I need to bring someone with me during my ketamine therapy?


You do not need to have someone bring you or accompany you during the infusion, but we request that you have someone drive you home. We advise you not to drive a car until the morning following your infusion.




Can I eat or drink before my ketamine appointment?


You cannot eat for the 4 hours prior to your scheduled appointment. You may have clear liquids up until 2 hours before your appointment.




What happens after my series of ketamine infusions?


Following the initial series of infusions, most patients will work with Dr. St John to begin a maintenance program, returning for a single infusion intermittently. The interval between maintenance infusions varies from patient to patient.




Will my insurance company pay for ketamine therapy?


Yes and no. We are “in network” with many insurance plans and can bill any required psychiatric evaluations and assessments directly to the insurance companies. However, because ketamine infusion therapy for mood and anxiety disorders are non-FDA approved indications, insurance companies view it as experimental and/or investigational and DO NOT provide reimbursement for the infusions.





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