Dr. Itteera on the Benefits of TMS Therapy 

We are honored to speak with Dr. Annupriya Itteera, a distinguished psychiatrist with an impressive career spanning over two decades. Dr. Itteera is double board certified by the American Board of Psychiatry and Neurology in General Psychiatry and Geriatric Psychiatry. She earned her medical degree from the Kempegowda Institute of Medical Sciences in India and completed her General Psychiatry residency at Creedmoor Psychiatric Center, affiliated with Columbia University Medical Center/New York Presbyterian Hospital. 

Following her residency, Dr. Itteera pursued a fellowship in Geriatric Psychiatry at Zucker Hillside Hospital/Northwell Health System. Her extensive training and experience are complemented by her active involvement with the American Psychiatric Association and the Clinical TMS Society. 

Dr. Itteera currently serves as the Medical Director of Hillside TMS, where she leads a team in providing innovative treatment options for patients. In addition, she maintains a thriving private practice, where she has been serving patients for eighteen years. Her approach to treatment is both comprehensive and integrative, combining medication management, psychotherapy, and cutting-edge neuromodulation techniques, including Transcranial Magnetic Stimulation (TMS). 

Today, we will delve into Dr. Itteera’s insights on TMS therapy, its application in treating various psychiatric conditions, and her perspectives on the evolving landscape of mental health treatment. 

What inspired you to incorporate TMS into your practice? 

After practicing psychiatry for over two decades, I have worked with many patients suffering from treatment-resistant depression (TRD). These individuals have often undergone numerous rounds of different antidepressants, each time hoping for improvement, but without success. As a clinician, it is difficult to see patients endure this cycle of trial and error, especially when their quality of life continues to be compromised. It led me to explore alternatives beyond medication. 

TMS caught my attention as a non-invasive, scientifically backed option that targets the brain differently than pharmacological treatments. Its ability to offer relief to patients who have not responded to conventional methods ultimately inspired me to integrate it into my practice. It provides a sense of hope and an additional path for those who feel they have exhausted all other options. In a field where personalized care is key, TMS offers another valuable tool for addressing the complex nature of depression and other mood disorders. 

For which mental health conditions is TMS most commonly used, and why? 

Repetitive Transcranial Magnetic Stimulation was first approved by the FDA in 2008 for TRD treatment. It is currently the most common condition for which TMS is utilized. The reason TMS is so effective in treating TRD lies in its mechanism of action. By applying electromagnetic pulses, TMS directly stimulates nerve tissue beneath the stimulation coil and indirectly affects other areas of the brain through their anatomical and functional connections. 

The pulses generate a transient electromagnetic field, which induces electrical fields in neurons in the brain’s superficial cortical layers. This process alters neuronal excitability—either increasing or decreasing activity in specific brain regions—and repeated sessions have been shown to enhance neuroplasticity, which contributes to long-term improvement in mood and cognitive function. 

In addition to TRD, TMS is being explored for use in other psychiatric and neurological conditions, such as anxiety disorders, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). Research in these areas is ongoing, but the ability of TMS to modulate brain circuits involved in mood, anxiety, and executive function makes it a promising treatment for a variety of mental health conditions. 

What about generalized anxiety disorder (GAD)? Are there any specific TMS protocols that are particularly effective for anxiety disorders? 

While TMS is not yet FDA-approved for the treatment of GAD, ongoing studies suggest it may offer significant benefits for individuals whose anxiety is not adequately managed with medication or therapy alone. In the case of OCD, a version of TMS known as deep brain TMS, which targets deeper brain structures using a specialized coil, has recently been FDA-approved as an adjunct treatment. This approval marks an important step forward in expanding the use of TMS for anxiety-related conditions. 

In my practice, I offer TMS to patients with treatment-resistant anxiety disorders, including those who struggle with GAD. We follow a specific anxiety protocol that targets the right dorsolateral prefrontal cortex, a region of the brain linked to emotional regulation and stress response. It is distinct from the protocol used for depression, which focuses on the left dorsolateral prefrontal cortex. 

Although TMS for anxiety is still an evolving area of research, many of my patients have experienced marked improvements in their symptoms following treatment. For some, this has led to a significant reduction in their reliance on anxiety medications. The neuroplastic effects of TMS seem to help recalibrate brain circuits involved in anxiety, offering a potential alternative for those who have not responded to traditional therapies. 

In which cases do you believe TMS is not the appropriate treatment option, and why? 

TMS is a safe and non-invasive treatment option for many individuals. However, there are specific cases where it may not be appropriate due to safety concerns related to certain medical conditions or implanted devices. In our practice, we carefully screen patients for contraindications before starting TMS therapy to ensure the treatment is safe and suitable. 

Patients who have metal or electronic implants, especially in or around the head, are typically not eligible for TMS. These contraindications include devices like cochlear implants, implanted electrodes or simulators, aneurysm clips, deep brain stimulators, pacemakers, cardioverter defibrillators (ICD), infusion pumps, and magnetically programmable shunt valves, among others. The electromagnetic pulses used during TMS could interfere with these devices, potentially causing malfunction or other adverse effects. 

We also screen for conditions such as ferromagnetic materials in the body (e.g., bullets or shrapnel within 30 cm of the coil), as well as metallic devices implanted in the head or neck, including ocular implants, dental implants activated by magnets, and cervical fixation devices. Patients with facial tattoos containing metallic ink or those who have had certain surgeries involving metallic staples or sutures are also carefully evaluated. 

There are also temporary precautions. Patients need to remove portable electronic devices, hearing aids, eyeglasses, and other metal-containing items, such as portable glucose monitors or headphones, before treatment. These steps ensure that the electromagnetic pulses delivered during TMS do not interfere with external electronics or cause unintended effects. 

While TMS is a powerful and effective therapy, it is crucial to exclude patients for whom it might pose risks to ensure safety and efficacy. 

How do you see TMS evolving in the future? 

I believe the future of TMS is incredibly promising, and we are only scratching the surface of its potential. As technology advances, I foresee TMS becoming more precise and personalized, allowing us to deliver even more targeted and effective treatments based on an individual’s specific brain activity and condition. This could lead to better outcomes and reduced side effects, making it an even more viable option for a broader range of patients. 

In terms of clinical applications, while TMS is currently most commonly used for treatment-resistant depression, ongoing research is exploring its potential for a wide array of mental health conditions. We’re seeing promising results in trials for conditions like bipolar disorder, post-traumatic stress disorder (PTSD), chronic pain syndromes, and even movement disorders such as Tourette syndrome. As the evidence base grows, I believe we’ll see expanded FDA approvals and increased adoption of TMS as a standard treatment across different specialties. 

Furthermore, there’s exciting research into combining TMS with other therapies, such as cognitive behavioral therapy (CBT), to enhance its effectiveness. This multimodal approach could become a standard part of treatment protocols, particularly for complex conditions like PTSD or anxiety disorders, where multiple treatment angles are often necessary. 

In essence, TMS is at the forefront of a revolution in neuropsychiatric treatments, and I expect its evolution to open up new frontiers in mental health care. 

Are there any ethical or social considerations when prescribing TMS, especially for elderly patients? 

While there are no unique ethical or social considerations specifically for elderly patients compared to the adult population, there are still some important factors to keep in mind, such as the potential for age-related medical conditions that could increase the risks associated with TMS. For example, elderly patients may have more comorbidities or be on multiple medications, which could interact with TMS or affect the outcome of the treatment. In such cases, it is essential to carefully screen and monitor these patients to ensure TMS is appropriate and safe for their particular health status. 

Socially, there may be challenges related to accessibility for elderly patients, such as mobility issues or lack of transportation to regular TMS sessions. We need to assess these logistical barriers and work with the patient and their support system to ensure they can complete the recommended treatment protocol. 

Ultimately, while there are no specific ethical guidelines that differ for elderly patients, careful attention to individual circumstances, informed consent, and the potential for medical complexities is essential for this population. 

What are the most common questions that patients ask you about TMS? 

Patients frequently have several important concerns when considering TMS treatment. Some of the most common questions include: 

• Effectiveness: Patients often want to know how effective TMS is, particularly if they’ve struggled with treatment-resistant depression or other mental health conditions. They ask if TMS can help where medications or traditional therapies have failed and what kind of improvement they can expect. 

• Number of Sessions: Many patients inquire about the duration of the treatment protocol—how many sessions they will need and how long each session will take. They also ask how quickly they might notice improvements. 

• Potential Side Effects: A key concern for many patients is whether TMS has any side effects. They want to know if the treatment is painful, if there are any long-term effects, and how it compares to the side effects of medications they may have taken in the past. 

• Cost of TMS: Cost is a significant factor, and patients often ask how much the treatment will cost them, especially if they need multiple sessions. This leads to questions about the overall affordability of the treatment. 

• Insurance Coverage: Insurance is another common topic, as patients want to know if TMS is covered by their health insurance plan. They inquire whether their specific insurance policy will cover the treatment, and if not, what other payment options might be available. 

How does billing work for TMS? Are there challenges with insurance coverage? 

Billing for TMS services requires proper alignment with insurance companies, which involves having the correct procedure codes included in the provider’s fee schedule. Some insurance providers also require prior authorization before TMS services can be administered. The key CPT procedure codes for TMS include: 

• 90867: This code is used for the initial mapping of the treatment target site and the first treatment session. 

• 90868: This code covers each of the subsequent daily treatment sessions. 

• 90869: This is used for remapping when adjustments are needed to improve the target site due to discomfort, such as excessive twitching or pain, or if sufficient improvement has not yet been achieved. 

Each insurance company may allocate a different number of authorized sessions for each of these codes, typically ranging from 36 to 39 daily treatments. These sessions usually occur over the course of several weeks, with an initial 6-week period where treatments happen 5 days a week, followed by a tapering phase of 3-4 treatments per week. 

Navigating insurance coverage can sometimes be challenging due to variations in the number of approved sessions and differences in how insurance companies handle reimbursement for TMS. Ensuring that billing practices are compliant and using appropriate codes is crucial for smooth reimbursement. I’ve found that working with a specialized billing service like WCH has been invaluable in overcoming these challenges. They’ve helped streamline the process, making it easier to manage the financial side of offering TMS treatments. 

What is involved in the credentialing process for healthcare providers who want to offer TMS? What are the key regulatory and licensing requirements for offering TMS in a clinical setting? 

To offer TMS (Transcranial Magnetic Stimulation) in a clinical setting, healthcare providers must navigate a detailed credentialing and regulatory process. First and foremost, the provider needs to be a certified psychiatrist. This certification often involves specialized training, typically conducted by the manufacturer of the TMS machine. Additional training opportunities may be available through universities or specialized institutions, which offer further education on the use of various TMS machines and protocols. 

The TMS equipment used must be FDA-cleared for the treatment of TRD. Compliance with FDA regulations is crucial for ensuring the machine meets safety and efficacy standards. 

If the psychiatrist plans to employ additional staff to assist with administering TMS treatments, those staff members must also receive TMS certification. It ensures they are properly trained to conduct daily sessions under the psychiatrist’s supervision, maintaining the quality and safety of the treatments provided.