CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS 

Office of the Chief Medical Officer 
Clinical Operations 


Transcranial Magnetic Stimulation 

Medication Use - 11
Category: Medication Use
Published Date: August 2024
  1. PARAMETER GOAL
    1. To ensure standards for the use of Transcranial Magnetic Stimulation in Los Angeles County Department of Mental Health (DMH) programs while expanding treatment options for client's mental health recovery.
  2. TERMINOLOGY
    1. Referring Psychiatrist: Treating psychiatrist who has the responsibility for discussing the benefits and potential risks of the procedure with the client.
    2. Transcranial Magnetic Stimulation (TMS): A non-invasive treatment approved by the Food and Drug Administration (FDA) which utilizes magnetic pulses to stimulate key areas of the brain of a client in order to reduce symptoms of a mental health disorder. This treatment is administered while a client is awake and is not invasive. The client feels tapping sensations on the head and hears a clicking sound. Treatment sessions last between 10-45 minutes and are administered once per day for 5 consecutive days a week over 4 to 8 weeks.
    3. TMS Psychiatrist: The psychiatrist trained in TMS treatment who has the responsibility for the oversight of TMS program for DMH programs.
    4. Treatment refractory depression (TRD): Clinical depression that has not responded adequately to antidepressant medication.
    5. Treatment Resistant Obsessive Compulsive Disorder (OCD): OCD that has not responded adequately to medication and psychotherapy.
  3. MEASURES
    1. Referring Psychiatrists requesting TMS for clients shall establish medical necessity including diagnosing and/or confirming:
      1. TRD
      2. Treatment resistant OCD
      3. Psychiatric disorders for which evidence suggests that TMS is safe and effective
      4. Severity of presenting illness
      5. Client's treatment history
      6. Medical risks including screening for risk of seizure
    2. The TMS psychiatrist shall assess for the appropriateness of the referral in terms of overall safety and diagnosis. 
  4. TREATMENT STRATEGY
    1. TMS trained psychiatrist shall explain treatment and shall obtain informed consent from the client.
    2. The TMS trained psychiatrist is responsible for:
      1. Reviewing of referring diagnosis
      2. Confirming that:
        1. At least 1 trial of psychotropic medication at adequate dose and adequate duration has failed to relieve symptoms or
        2. Client could not tolerate psychotropic medications appropriate for diagnosis
      3. Confirming that the referring psychiatrist is in agreement with the procedure
      4. Ensuring that the client understands the nature, benefits, and potential risks of TMS.
  5. PROVISION OF SERVICE
    1. The TMS Psychiatrist shall document monitoring of mood and symptoms between treatments using clinical assessments and weekly symptom specific rating scales.
    2. Treatment shall be discontinued when:
      1. There is no benefit reported after an adequate number of treatment sessions
      2. Consent for treatment is withdrawn
      3. The client's condition necessitates discontinuation
    3. Requests for Transcranial Magnetic Stimulation shall:
      1. Be submitted to the TMS Psychiatrist
      2. Include up to date medical records and diagnosis
      3. Include the reason for referral
    4. If additional information is needed, TMS physician shall contact the treating psychiatrist for a consultation.
    5. Once a determination of authorization is made, a decision shall be provided to the treating psychiatrist by phone or secure email.
      1. Regardless of the method of delivery, the authorization will be documented in the medical record.
    6. If approved, the DMH specialty mental health service (SMHS) linkage staff shall assist with connecting the client to the TMS team.
    7. If in the judgment of the TMS psychiatrist more than the standard number of sessions (30 sessions) per client are indicated, TMS psychiatrist will document reasons for additional treatments.  This documentation must include:
      1. Documentation of the diagnosis
      2. Clinical findings leading to the recommendation for additional sessions
      3. The specified recommended number of additional sessions
  6. OUTCOMES AND MONITORING
    1. Absolute Contraindications:
      1. The presence of a medically implanted magnetic-sensitive device or other implanted metal items includes, but not limited to:
        1. Cochlear implant
        2. Implanted cardiac defibrillator
        3. Pacemaker
        4. Vagus nerve stimulator
        5. Metal aneurysm clips/coils, staples, or stents, that are located less than or equal to 30 cm from the TMS magnetic coil
    2. Relative Contraindications:
      1. The presence of a seizure disorder or any history of seizures except:
        1. Those induced by Electroconvulsive therapy (ECT);
        2. Febrile seizures in infancy without subsequent treatment or recurrence;
        3. An isolated “evoked” seizure; or,
        4. Active substance use disorders.
      2. The presence of acute or chronic psychotic symptoms or disorders in the current depressive episode.
      3. The presence of any neurological conditions including but not limited to epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, or primary or secondary tumors in the central nervous system.
  7. SUPERVISION AND CONSULTATION
    1. Supervision of TMS treatments from the TMS Psychiatrist should occur with each treatment.
    2. The TMS psychiatrist should consult with the referring provider as appropriate in order to obtain and share relevant clinical information.
  8. RESOURCES
    1. Neuromodec
    2. Medicare & Medicaid Services: Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder
    3. Sarah H. Lisanby: Introduction to Transcranial Magnetic Stimulation, April 28, 2020, National Institute of Mental Health