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Assessment and Management of Concurrent Substance Use in Patients Receiving Repetitive Transcranial Magnetic
Victor M Tang1, Scott Aaronson1, Mohamed Abdelghani1
1Temerty Faculty of Medicine, University of Toronto, Toronto (Tang, Le Foll, Voineskos, Blumberger), and the Centre for Addiction and Mental Health, Toronto (Tang, Le Foll, Voineskos, Blumberger); Institute for Advanced Diagnostics and Therapeutics, Sheppard Pratt, Baltimore, and Department of Psychiatry, University of Maryland School of Medicine, Baltimore (Aaronson); Camden and Islington NHS Foundation Trust, London (Abdelghani); Faculty of Medicine and Health Sciences, Department of Head and Skin, Ghent Experimental Psychiatry Lab, Ghent University, Ghent, Belgium (Baeken); Department of Psychiatry, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels (Baeken); Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands (Baeken); Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston (Barbour); Departamento de Clínica Médica, Faculdade de Medicina da Universidade de São Paulo; Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (Brunoni); CHU Nantes Department of Addictology and Psychiatry, U1246 SPHERE INSERM, Nantes University, Nantes, France (Bulteau); Butler Hospital, Department of Psychiatry and Human Behavior, Alpert Medical School at Brown University, Providence, RI (Carpenter); Mayo Clinic College of Medicine and Science, Rochester, MN (Croarkin); Department of Psychiatry, UC San Diego Health, La Jolla (Daskalakis); School of Medicine and Psychology, Australian National University, Canberra (Fitzgerald); FSU Neuromodulation, Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, Tallahassee (Kozel); Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario (Le Foll); Department of Psychiatry, National Institute of Mental Health and Neurosciences, and National Institute of Advanced Studies, Bangalore, India (Mehta); Department of Neuropsychiatry, Keio University School of Medicine, Tokyo (Noda); Department of Psychiatry and Psychotherapy, LMU University Hospital, Munich (Padberg); German Center for Mental Health, Tübingen (Padberg, Plewnia); Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany (Plewnia); Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai (Su); Department of Psychiatry, Radboud University Medical Center, Donders Institute for Brain, Cognition, and Behavior, Nijmegen, the Netherlands (van Eijndhoven); Department of Psychiatry, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam (van Exel); Old Age Psychiatry, GGZinGeest, Amsterdam (van Exel); Amsterdam Neuroscience, Amsterdam (van Exel); Neurocare Clinics, Nijmegen, the Netherlands (van Oostrom); Spanish Consortium of Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, and Health Technology Assessment in Primary Care and Mental Health Research Group (PRISMA), Barcelona (Vila-Rodriguez); School of Biomedical Engineering, University of British Columbia, Vancouver (Vila-Rodriguez); Poul Hansen Family Centre for Depression, Toronto Western Hospital, UHN and Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto (Voineskos); Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Voineskos, Blumberger); Department of Psychiatry and Behavioral Sciences, University of Minnesota-Twin Cities, Minneapolis (Wilson).
Objective:
Limited data are available to inform clinicians on how to manage concurrent substance use in the context of repetitive transcranial magnetic stimulation (rTMS) for the treatment of depressive, obsessive-compulsive, psychotic, or trauma-related disorders. The authors convened an international panel of 24 rTMS experts, representative of different geographic regions and subspecialities, and created a consensus guideline for clinicians and researchers on approaches to concurrent substance use in patients receiving rTMS as treatment for primary psychiatric disorders.
Methods:
A Delphi method survey and expert opinion elicited over consecutive rounds of surveys were used, with feedback and discussion after each round. Recommendation statements were established upon very high (≥80%) agreement.
Results:
Three rounds of surveys and feedback were sufficient to reach a consensus for most topics; where consensus could not be reached, the panel discussed limitations in the current evidence base. Informed by a synthesis of the literature and practice-based evidence, the expert panel provides several consensus recommendations on the topics of screening, monitoring, risk assessment, and mitigation associated with various degrees of substance use, and specific considerations for alcohol, cannabis, stimulants, and opioids. Instead of excluding all people who use substances, a nuanced approach should be taken based on an assessment of risk factors for clinical instability and severity of use. The most important safety risk with substance use is the presence of intoxication or withdrawal states, with the most data supporting seizure risk in unstable alcohol or nonmedical stimulant use. Although there is no evidence of reduced rTMS efficacy for a psychiatric disorder in the presence of concurrent substance use, the lack of data in this area warrants caution.
Conclusions:
These recommendations can be readily implemented clinically and provide a framework for future research. In patients receiving rTMS for a primary psychiatric disorder, assessment and management of co-occurring substance use is complex, requiring greater attention, standardization, and further study.
