How MindSkiller enhanced a TMS mental health service for young adults

Why TMS? What is TMS?

It’s not just adults who might not recover in a timely way from clinical depression, young adults also sometimes don't respond fully to psychotherapy and medication treatment. A common cause of lack of response to usual treatments is that there are other comorbid conditions that are continuing to fuel the depressive symptoms, such as ADHD, substance use disorders, personality disorders and anxiety disorders - especially OCD and PTSD. MindSkiller® explains to patients suffering persistent depression that a way of thinking about the underlying mechanism is that their brain's ‘mood switch’ has become stuck in the ‘down’ position because their nervous system mistakenly believes that the world is too threatening a place to warrant it to reset.

Transcranial magnetic stimulation (TMS) is a non-invasive alternative or add-on treatment that has an ever higher response rate. TMS is essentially an electro-magnet positioned against a patient’s left frontotemporal forehead area, to stimulate specific brain circuitry underneath. This circuitry is the DLPC - which is what MindSkiller calls your ‘mood switch’. Stimulating your left ‘mood switch’ repeatedly coaxes it into eventually flicking into the ‘up’ position. This brings on recovery from the depressive episode. It opens up the flow of energy that had been dammed up, bringing up mood, returning motivation, normalising sleep-wake patterns and dissipating anxiety, frustration and negative thinking. 

It takes at least 4-6 weeks of TMS to get results based on the experience of clinicians at Uspace St Vincent's Private Hospital in Sydney. The TMS course MindSkiller designed for Uspace and Vision XRAY Group called VisionTMS runs 5 days per week for a month straight and then a weaning course over the next 2½ months to prevent relapse. A modified course has been designed for patients from interstate or regional areas, who come to Sydney where they can have an accelerated initial course with twice daily sessions for two weeks with the weaning course then broken up into weekly segments rather than flowing on immediately after the initial course. 

The clinicians at Uspace noticed not just improved mood and cognition, but an improved level of function. People find themselves able to engage in self care, studies, work and social life. Their quality of life markedly improves when people emerge from their state of hibernation. 

Why MindSkiller developed a radiology-based TMS service

TMS uses its magnet to focus magnetic pulses on the mood switch, repeatedly stimulating the brain circuits within it, which eventually coaxes it to flick into the up position and this re-opens the flow of energy that had been shut down during the episode of clinical depression. 

The dose of magnetic energy is determined by a psychiatrist in a procedure where the magnet is used to stimulate the motor cortex. The dose that causes a muscle flicker in the muscle between the thumb and index finger is used as a reference point to the dose used to stimulate the emotional circuitry where there’s no external indicator of success other than recovery from depression, which takes time.  

• All the technical procedures are done in the one location at VisionTMS - at a radiology practice where staff have been trained and equipment calibrated to maximise precision, consistency and efficiency. Because the patient is given a cap with the marking on it of where the magnet needs to be positioned, they only need to have the targeting and dosing procedures done once in most cases. Then the treatment sessions can be done at any of the radiology clinics that form part of the Vision XRAY Group throughout NSW. 
• This type of medical practice is designed to be super time efficient to take patients a minimum amount of time out of their day. Each treatment session is either 3 minutes or 18 minutes for the bulk-billed version. So most patients can continue to work or study during their courses. 
• Apart from increased choice of location where to have their treatment, patients are afforded maximum discretion and a procedural approach helps to ‘normalise’ the intervention.

Expanding the mental disorders that TMS can treat

Since MindSkiller  established this TMS service in 2022 for Uspace and Vision XRAY Group, both sets of clinicians have been astounded by the success of most of their patients for treatment resistant depression.

Shall we call it a 'game-changer'?At the beginning of 2024, MindSkiller  launched a TMS program for OCD as well for Uspace. Instead of the left DLPC, which is positioned on the frontotemporal area of the scalp (above the middle of the left eye and ear), the VisionTMS service targets the DMPC, which is closer to the midline (above the left eye socket). This brain circuitry can be thought of as a ‘panic button’.  The difference to using TMS for OCD compared to TMS for clinical depression is that, instead of trying to change the position of the mood switch by activating it, for OCD we are trying to disrupt the brain circuitry relating to the loop of intrusive thoughts and compulsive urges that occurs in an episode of OCD. To disrupt that circuitry, the ‘panic button’ is targeted by the magnetic pulses in TMS. 

Therefore, for OCD, that ‘panic button’ needs to be activated by the patient during their TMS session.  We do this by engaging in ‘exposure’ to the specific intrusive thoughts and compulsive urges that occur in their subtype of OCD for at least 5 minutes - whilst having their 18 minute TMS session.  

The MindSkiller® platform has been designed to provide 2D or even VR based visualisations of intrusive thoughts and compulsive urges for the patient during their TMS sessions. 

Where is this all leading? TMS may well develop into an intervention that can treat ‘low energy’ disorders like depression, chronic fatigue, the negative features of psychosis, autism spectrum disorder and dementia by targeting the brain’s ‘mood switch’.  

The challenge of providing psychiatric governance, person-centred care and team based care for a decentralised statewide TMS service

Because the NSW-wide TMS VisionTMS service is delivered from a network of radiology practices in partnership with a multidisciplinary team based in a psychiatric hospital based inpatient, day patient and outpatient mental health service, MindSkiller® needed to ensure that psychiatric governance incorporates all the separate facilities and scattered stakeholders. Are you wondering how MindSkiller® did that? 

An added challenge is that the TMS courses are delivered over an extended period of time (months) whilst the patients are concurrently receiving mental health care from their community psychiatrists, psychologists and GPs. So there are multiple intersecting but separate networks. 

How can person-centred care operate effectively and safely in such a potentially fragmented and chaotic system? 

Firstly, MindSkiller® developed care pathway forms that can be used by a team of clinicians to collaborate about a specific patient. This enables me to be able to monitor a patient’s TMS course off-site.  

Second, MindSkiller® ensured more than one team could be involved in the care of that patient by enabling external clinicians to monitor what was going on ‘real-time’ by giving them access to a care pathway form, with patient consent.  

Thirdly, MindSkiller® enabled  the patient to be able to have the power to link all help-providers and services, by being able to invite a multidisciplinary team or a clinician to be able to monitor the care that another team is providing. 

Voila! We have a person-centred shared care model allowing teams to work more effectively as a team, multiple teams to be aware of the work each is doing with the patient, and the specialist is able to oversee what is happening remotely no matter where their patient is receiving in-person or digital care. As the MindSkiller® platform that allows this to occur is a data-driven platform, it also opens the possibility for clinicians to have access to distributed information when guiding patients and for AI to have a role in providing guidance to the clinicians and their patient.