Barriers to Brain Stimulation Therapies for Treatment-Resistant Depression: Beyond Cost Effectiveness

Perceived Barriers to Using Neurostimulation

“…In terms of differences by intervention, frequency of treatment was perceived as a key barrier by psychiatrists for rTMS. This is similar to previous findings highlighting the time it takes for the treatment itself and to transport to and from the treatment as being limiting 8,14,24 . Standard rTMS protocols require sessions 5 days a week for at least 6 weeks; however, newer, shorter courses of treatment such as the SAINT protocol, which require a 5-day consecutive treatment plan, may diminish the importance of this barrier 25 …”

“…Part of the difference might be due to privately insured patients being more likely to have the social support needed to undergo ECT on an outpatient basis than some publicly insured patients. In discussing rTMS, Goldbloom and Gratzer 14 point to access as a key barrier and the fact that rTMS remains largely unknown and underused. Connected to our findings, psychiatrists perceived lack of insurance coverage and out-of-pocket costs as top barriers for rTMS, highlighting that treatment availability in a geographic region does not necessarily translate to ability to access that treatment.…”

“…This is similar to previous findings highlighting the time it takes for the treatment itself and to transport to and from the treatment as being limiting. 8,14,24 Standard rTMS protocols require sessions 5 days a week for at least 6 weeks; however, newer, shorter courses of treatment such as the SAINT protocol, which require a 5-day consecutive treatment plan, may diminish the importance of this barrier. 25 Finally, it is important to emphasize that barriers to these types of treatment intersect in important ways and are not experienced equally by all patients.…”

“…[11][12][13] Furthermore, although contemporary ECT treatment is vastly safer now than previously due to changes in anesthetic practices and modifications in stimulus delivery, some psychiatrists hold negative perceptions of ECT. 7 Repetitive transcranial magnetic stimulation remains largely unknown to the general public, 14 although its use is expanding to a growing number of neuropsychiatric conditions, 15 with novel devices approved, new protocols (eg, different stimulation parameters) introduced, and combinations of TMS with brain imaging techniques.…”

Utilization and outcomes of transcranial magnetic stimulation and usual care for MDD in a large group psychiatric practice

“…However, despite a growing evidence base indicating that TMS should be introduced early in the care of patients with MDD, general psychiatrists in community practice have not yet adopted a consistent standard for when TMS should be introduced into the MDD treatment pathway, and it remains underutilized [ 11 ]. Several factors likely contribute to this inconsistent and low utilization, including limited TMS curriculum in psychiatry training programs, limited access to TMS devices, and inconsistent and restrictive payer coverage of TMS therapy [ 11 – 13 ]. Additionally, there are a number of siloed TMS-focused specialty clinics, which may create additional barriers for patients, the majority of whom are treated in general psychiatric practices that only offer medication management and psychotherapy [ 14 ].…”