1. Helping Our MDD Patients Get Back To Well…
TMSS: I’d like to welcome everyone and thank you for taking time from your day to learn about NeuroStar TMS Therapy. My name is [TMSS Variable Field] and I am a TMS Specialist with Neuronetics. The focus of today’s presentation is for [Variable Field – Practice MD] to provide important information about NeuroStar TMS Therapy and I will provide each of you with a foundation and program toward integrating this exciting technology into your practice.
I will now turn the presentation over to [Variable Field – Practice MD] who will introduce NeuroStar TMS Therapy.
©2012 Neuronetics, Inc. All rights reserved.
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2. MDD: A Large Patient Population That Is Currently Being Underserved
14 Million US Adults with MDD
Inadequate response
Intolerant to side effects
7.2 Million Treated
4 Million Poorly Served
Practice Physician:
Major depression is an enormous problem. Each year, 14 million adults in the US experience this disease. Only about half make it into treatment and of the seven plus million who do get treated, four million are being poorly served, typically due to either inadequate response or intolerance to the numerous side-effects that are associated with drug therapy.
Reference:
Kessler, RC, et al. The epidemiology of major depressive disorder; results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003; 289(23):
Kessler RC et al. JAMA. 2003;289(23):

3. How Depression Is Treated
Drug therapy has been the standard of care
But drug therapy...
…doesn’t work for many people …may produce unwanted side effects in other parts of the body
Depression is typically treated using drug therapy. However, drug therapy doesn’t work for many people and may produce unwanted side effects in other parts of the body.
The graph on this slide summarizes results from a recently completed, National Institute of Health-funded STAR*D Study. STAR*D stands for: Sequenced Treatment Alternatives to Relieve Depression. This is the largest and most definitive research available on the use of antidepressant medication to treat depression.
This graph shows remission rates broken down by each level of treatment, starting on the left with the first-line treatment attempt, which was citalopram, and then moving to the right with subsequent treatments. Using the Hamilton Depression Rating Scale, you can see that the likelihood of achieving remission is limited and declines with each successive treatment attempt.
References:
Trivedi, M. H., A. J. Rush, et al. (2006). "Evaluation of Outcomes with Citalopram for Depression Using Measurement-Based Care in STAR*D Implications for Clinical Practice." Am J Psychiatry 163(1):
Rush, A. J., M. H. Trivedi, et al. (2006). "Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report." Am J Psychiatry 163(11):
Fava, M., A. J. Rush, et al. (2006). "A Comparison of Mirtazapine and Nortriptyline Following Two Consecutive Failed Medication Treatments for Depressed Outpatients: A Star*D Report." Am J Psychiatry 163(7):
McGrath, P. J., J. W. Stewart, et al. (2006). "Tranylcypromine Versus Venlafaxine Plus Mirtazapine Following Three Failed Antidepressant Medication Trials for Depression: A STAR*D Report." Am J Psychiatry 163(9):
Trivedi (2006) Am J Psychiatry; Rush (2006) Am J Psychiatry; Fava (2006) Am J Psychiatry; McGrath (2006) Am J Psychiatry

4. Likelihood of Discontinuing Treatment Increases with Each New Medication Attempt
What the STAR*D study demonstrated, as shown here, is that while study discontinuation rates due to side effects is relatively low initially (about 9%), it rises very rapidly - nearly tripling as patients moved from Level 1 to Level 2 (about 9% to about 23%). So by the time patients had failed to benefit from three prior antidepressant treatments, nearly half of the patients discontinued further treatment due to adverse events.
References:
Trivedi, M. H., A. J. Rush, et al. (2006). "Evaluation of Outcomes with Citalopram for Depression Using Measurement-Based Care in STAR*D Implications for Clinical Practice." Am J Psychiatry 163(1):
Rush, A. J., M. H. Trivedi, et al. (2006). "Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report." Am J Psychiatry 163(11):
Fava, M., A. J. Rush, et al. (2006). "A Comparison of Mirtazapine and Nortriptyline Following Two Consecutive Failed Medication Treatments for Depressed Outpatients: A Star*D Report." Am J Psychiatry 163(7):
McGrath, P. J., J. W. Stewart, et al. (2006). "Tranylcypromine Versus Venlafaxine Plus Mirtazapine Following Three Failed Antidepressant Medication Trials for Depression: A STAR*D Report." Am J Psychiatry 163(9):
Trivedi (2006) Am J Psychiatry; Rush (2006) Am J Psychiatry; Fava (2006) Am J Psychiatry; McGrath (2006) Am J Psychiatry

5. There Is A New Treatment Option
FDA-cleared for the treatment of depression
Used at over 365 centers including leading teaching institutions
Specifically for patients with depression who have not benefited from their initial antidepressant medication
There is a new treatment option – NeuroStar TMS Therapy. NeuroStar Transcranial Magnetic Stimulation Therapy is a new option that is FDA-cleared for the treatment of depression. It is used at over 365 centers across the US including leading teaching institutions.
NeuroStar TMS Therapy is a non-drug treatment for patients with depression who have not benefited from their initial antidepressant medication

6. NeuroStar TMS Therapy® System
Treatment Coil
User
Interface
Mobile Console
This is the NeuroStar TMS Therapy system. The NeuroStar system consists of:
A Mobile Console – which houses the power electronics
A Graphical Touch Screen User Interface – which allows users to easily operate the system
An Integrated Treatment Coil – this is the high-powered magnetic treatment coil which, when placed on the patient’s head, delivers TMS Therapy to a specific brain region.
A SenStar Treatment Link –an essential component which monitors and provides quality control for each treatment

7. NeuroStar TMS Therapy is Precisely Targeted
…at a key area of the brain known to be underactive in depression sufferers (called the prefrontal cortex)
NeuroStar stimulates that area to restore it to normal function and lift depression
NeuroStar TMS Therapy is precisely targeted at a key area of the brain known to be underactive in depression sufferers (called the prefrontal cortex. NeuroStar stimulates that area to restore it to normal function and lift depression. Because it is targeted specifically to the area of the brain associated with depression, TMS Therapy avoids the unwanted side effects of drug therapy.

8. How TMS Works
NeuroStar TMS Therapy works by activating neurons to normalize brain function. TMS directly stimulates neurons within the prefrontal cortex, the area of the brain thought to control mood. Neurons within the prefrontal cortex then communicate to deeper brain neurons. Stimulation of these deeper brain neurons causes a secondary effect on remaining portions of the brain involved in mood.

9. NeuroStar TMS Therapy Avoids Drug Side Effects
There are a wide range of unwanted side effects that can be caused by antidepressant medication because the effects of these powerful drugs can occur throughout the body – not just the brain. Because NeuroStar TMS Therapy is a targeted treatment, it avoids many of the side effects commonly seen with antidepressant medication.
The most commons side effect of NeuroStar TMS Therapy is scalp pain or discomfort at or near the treatment area. This pain or discomfort is typically mild to moderate and typically diminishes after the first week of treatment.
Adverse events are transient, occur during TMS treatment and do not occur for most patients after the first week of treatment.
In clinical trials, fewer than 5% of patients discontinued treatment with NeuroStar TMS Therapy due to adverse events.

10. NeuroStar TMS Therapy A Safe Treatment
Safety verified in multiple clinical trials
Patients are awake and alert throughout treatment - no need for anesthesia or sedation
Thinking and memory are not affected
Technology similar to MRI which has a long-term safety record
There is a rare risk of seizure associated with TMS (1 in 30,000 treatments)
Over 200,000 treatments demonstrate safety
The safety of NeuroStar TMS Therapy has been verified in multiple clinical trials. Patients receiving TMS treatment are awake and alert and do not requires anesthesia or sedation. Thinking and memory are not affected by treatment. TMS Therapy uses a similar technology to MRI (Magnetic Resonance Imaging) which has a long-term safety record. There is a rare risk of seizure associated with NeuroStar TMS Therapy (1 in 30,000 treatments). Over 200,000 TMS treatments have been performed to date, demonstrating its safety.

11. NeuroStar is Proven Effective
Many people treated with NeuroStar experience significant benefits
In clinical trials, after 4 to 6 weeks of treatment:
1 in 2 improved significantly
1 in 3 were free of symptoms
NeuroStar TMS Therapy is a proven depression treatment. Many people treated with NeuroStar have experienced significant benefit. In clinical trials, after 4 to 6 weeks of treatment:
1 in 2 patients improved significantly
1 in 3 patients were free of depressive symptoms
Efficacy for NeuroStar TMS Therapy was established in a controlled clinical trial comparing active
treatment with the NeuroStar TMS Therapy system to an inactive device. Patients treated with
active NeuroStar TMS Therapy received an average reduction in their depression symptom score
of 22.1% compared to a 9% average reduction in patients receiving inactive.
1. Demitrack MA, Thase, ME. Clinical significance of transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistantdepression: synthesis of recent data. Psychopharm Bull. 2009, 42(2): 5-38.

12. TMS Is Not Electroconvulsive Therapy (ECT)
NeuroStar TMS Therapy
Uses similar technology to Magnetic Resonance Imaging (MRI) with established safety
Performed in-office
No anesthesia or sedation
For patients who have not benefited from initial drug therapy
Most common side effect is localized pain or discomfort during treatment
ECT Treatments
Uses direct electric current to induce seizure
Typically performed in a hospital setting
Requires anesthesia
Indicated for severe depression
Common side effect – loss of memory
Before we speak further about the NeuroStar TMS Therapy system, there are important distinctions to make about TMS Therapy as compared to Electroconvulsive Therapy or ECT. TMS Therapy is NOT ECT. TMS is very different from ECT, both in terms of the technology itself and when it is appropriate for use.
TMS Therapy uses a focused electromagnetic field to stimulate a specific, targeted region of the brain. It does not require any sedation or anesthesia and has a mild adverse event profile. TMS Therapy is an office based procedure and is utilized after initial antidepressant medications have failed. In contrast, ECT uses direct electrical stimulation of the whole brain, requires anesthesia for delivery and is associated with cognitive side effects, some of which may be long term. Because of the invasive nature of ECT and its side effects, ECT is usually reserved for patients who have exhausted most treatment options.

13. NeuroStar TMS Therapy A Defined Treatment Course
Daily care performed in our office:
5 days a week
For 4 to 6 weeks
Less than an hour per session
NeuroStar TMS Therapy is performed right in our office. Treatment is administered 5 days a week, for 4-6 weeks with each session lasting than an hour.

14. NeuroStar TMS Therapy Patient Advantage
Let’s talk about the NeuroStar TMS Therapy patient advantage

15. What NeuroStar Patients Are Saying…
Lets hear from some actual patients as they talk about their experience with NeuroStar TMS Therapy
Efficacy for NeuroStar TMS Therapy was established in a controlled clinical trial comparing active treatment with the NeuroStar TMS Therapy system to an inactive device. Patients treated with active NeuroStar TMS Therapy received an average reduction in their depression symptom score of 22.1% compared to a 9% average reduction in patients receiving inactive treatment.

16. What NeuroStar Patients Are Saying…
Here are some actual quotes provided by NeuroStar patients.
Efficacy for NeuroStar TMS Therapy was established in a controlled clinical trial comparing active treatment with the NeuroStar TMS Therapy system to an inactive device. Patients treated with active NeuroStar TMS Therapy received an average reduction in their depression symptom score of 22.1% compared to a 9% average reduction in patients receiving inactive treatment.

17. NeuroStar TMS Therapy is:
NeuroStar TMS Summary
NeuroStar TMS Therapy is:
An effective, proven non-drug treatment for major depression when initial drugs fail
Included in APA Practice Guidelines
A valuable treatment for patients who want to reduce medications and the side effect burden they produce
In summary,
NeuroStar TMS Therapy is an effective, proven approach for patients with major depression when initial treatments have failed,
As a reflection of its clinical significance as an antidepressant, TMS is now incorporated into expert consensus treatment guidelines,
NeuroStar TMS Therapy is a valuable option for use in those patients who have failed initial treatment and would like to reduce their use of antidepressant medications and the side effect burden that goes along with them.

18. NeuroStar TMS Therapy In Our Practice
Who Will We Offer TMS?
Patients who are not benefiting from their current antidepressant medication
Patients whose next treatment option is second-line antidepressant medication
Patients who are suffering from antidepressant medication side effects
Who Will We Offer TMS?
Patients who are not benefiting from their current antidepressant medication
Patients whose next treatment option is second-line antidepressants
Patients who are suffering from medication side effects
I will now turn the presentation over to [Variable Field – TMSS] who will provide some information on how we will implement NeuroStar TMS Therapy into our practice.

19. Guiding Your Implementation of NeuroStar TMS Therapy
[Variable Field – TMSS]
Thank you – as mentioned, my name is [Variable Field – TMSS] and I’m going to talk about how I’ll help to guide your implementation of NeuroStar TMS Therapy
©2011 Neuronetics, Inc. All rights reserved.
Confidential PN XXXXXX

20. Congratulations On Becoming a NeuroStar TMS Therapy Provider!
Over 385 NeuroStar Providers Throughout the U.S.
Over 6,000 patients have been treated with TMS Therapy
Congratulations on becoming a NeuroStar TMS Therapy Provider!
There are over [Variable Field – NeuroStar Providers] NeuroStar Providers
Over [Variable Field – Patients Treated] patients have been treated with TMS Therapy
Over [Variable Field – Treatments delivered] treatments delivered demonstrate its safety
Over 200,000 treatments demonstrate safety

21. Online & Staff Training
NeuroStar Practice Success Program 6 SIMPLE STAGES TOWARD Successful TMS Implementation
Review Practice Assessment with TTC & TMS Specialist
Stage 1
Planning
Complete online clinical training modules 1 – 3
Complete staff training & integration visit with TMS Specialist
Stage 2
Online & Staff Training
Complete online clinical training modules 4 – 8
Complete patient consultation training with TMS Specialist
Stage 3
Consult Training
Schedule treatment of 3 – 5 patients for clinical training
Complete Hands-On Clinical Training
Stage 4
Clinical Training
Review each stage of the of the NeuroStar Practice Success Program along with key initiatives outlined
Treat, collect & submit data to Neuronetics on 10 TMS patients
Participate in 60-Day clinical evaluation call with TMS team
Stage 5
Outcome Analysis
Implement advanced marketing tactics
Stage 6
Increasing Awareness

22. Identifying NeuroStar Candidates
Ask all patients to complete patient survey to determine
How the patient is feeling
If patient is experiencing drug related side effects
Print schedule weekly and ask MD to highlight patients who are potential TMS candidates
Discuss the staff’s role in identifying Neurostar candidates. This includes identifying patients through either implementing the survey strategy or reviewing patient charts.
Discuss the process of flagging potential NeuroStar candidates to allow for the physician to try and set up an hour long TMS consultation.

23. Identifying NeuroStar Candidates TMS Patient Survey
The TMS Patient survey is a great starting point toward identifying patients. We’ve provided this survey to you in a generic template so it can be customized to fit your practice. This survey is also located on the back of your patient education brochure.

24. Identifying NeuroStar Candidates
Neurostar TMS Therapy is indicated for the treatment of Major Depressive Disorder in adult patients who have failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode.
NeuroStar TMS Therapy should not be used in patients with implanted metallic devices or non-removable metallic objects in or around the head
Neurostar TMS Therapy is indicated for the treatment of Major Depressive Disorder in adult patients who have failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode.
NeuroStar TMS Therapy should not be used in patients with implanted metallic devices or non-removable metallic objects in or around the head

25. Educating Patients TMS: Helping Patients Get Back to Life
So what do we do once we’ve identified a patient? We are introducing them to a completely new non-drug treatment. In order to help them make an informed decision about the future of their depression treatment, we have to educate them aboutTMS Therapy.
The following slides will introduce some new tools to help educate you and your patients on NeuroStar TMS Therapy

26. Tools For Your Success Simple NeuroStar TMS Therapy Key Messages
Here is an example of a “key messaging” cue card that can easily be placed by the telephone, in a waiting room or carried in the pocket of the staff member. It provides you with key phrases and talking points to assist you in talking with your patients. Practices continue to tell us how helpful the “key messages” have been for them.

27. Tools For Your Success Patient Education Flipchart
Comprehensive presentation to be used by physicians when introducing NeuroStar TMS Therapy
How TMS Therapy works
Why TMS Therapy works differently then medication
What to expect with treatment
This patient flipchart contains a complete education presentation to use in presenting NeuroStar TMS Therapy to a prospective patient.

28. Other NeuroStar TMS Therapy Tools For Success…
Other TMS Therapy tools for success…

29. Maximize Your Practice With Neuronetics FastLane
Access to Fastlane
Invitation will be provided – password needed
Comprehensive practice development web site designed to:
Develop your NeuroStar practice
Create awareness for NeuroStar TMS Therapy
Strengthen your reputation within your referring physician community
Access to Fastlane will be provided via an invitation. All staff members are invited to join the site. Fastlane is a comprehensive practice development web site designed to:
Develop your NeuroStar practice
Create awareness for NeuroStar TMS Therapy
Strengthen your reputation within your referring physician community

30. 24/7 Access to Practice Marketing
And here is what the home page of this site looks like.

31. Expand Your Knowledge With NeuroStar University Clinical Training Program
NeuroStar University Online Clinical Training
Invitation will be provided – password needed
Comprehensive didactic clinical training program designed to:
Teach set up, care and handling of the NeuroStar TMS Therapy System
Explain the principles of the TMS Therapy
Maximize your clinical experience
As you recall, your next step is to expand your clinical knowledge by visiting this web site and completing your clinical training.

32. NeuroStar University Clinical Training
And here is what the home page of this site looks like.

33. Our Commitment Your NeuroStar TMS Therapy Implementation Team:
Neuronetics Sales Representative (TTC):
Variable Field Name and Number: (###) ### - ####
Neuronetics TMS Specialist (TMSS):
Neuronetics Clinical Training Specialist (CTS):
Here is your NeuroStar TMS Therapy implementation team.

34. Next Steps One-On-One Training
Explain next steps with regard to one-on-on training

35. Thank You For Your Attention
We hope that you have found the information in this presentation helpful. Thank you for your continued dedication and support.