Summary
Dr. Owen Muir and Dr. Will Sauve discuss an emerging application of TMS: treating auditory hallucinations in psychosis and schizophrenia. They review a sham-controlled, triple-blind phase 3 trial from Germany using continuous theta burst stimulation of the temporoparietal junction to reduce auditory hallucinations. Dr. Sauve, a Navy-trained psychiatrist who has been doing TMS for over 15 years, shares a compelling case where D-cycloserine-augmented one-day TMS produced complete remission of auditory hallucinations lasting over six weeks. The episode highlights how TMS is expanding beyond depression into psychosis treatment, representing a potential paradigm shift for early psychosis intervention where the current treatment bar remains very low.
Key Points
- A German phase 3 trial used continuous theta burst stimulation of both auditory cortices to reduce hallucinations
- D-cycloserine-augmented one-day TMS achieved complete remission of auditory hallucinations lasting 6+ weeks
- Continuous theta burst stimulation reduces firing in targeted brain regions, unlike intermittent theta burst used for depression
- TMS for psychosis targets the temporoparietal junction rather than the DLPFC used for depression
- The treatment bar for early psychosis is extremely low, making even modest TMS results clinically meaningful
- Navy psychiatrist Dr. Sauve has 15+ years of TMS experience starting at Naval Medical Center San Diego
- The SAINT protocol was available only through Dr. Muir's practice in the Northeast at the time of recording
- TMS could potentially be delivered in brief 30-second sessions five days a week for psychosis treatment
Key Moments
Phase 3 trial of TMS for auditory hallucinations
The hosts discuss a sham-controlled, triple-blind phase 3 trial from Germany showing TMS of the auditory cortex can shut down auditory hallucinations using continuous theta burst stimulation on both sides of the head.
"The wonderful homework that you gave me showed a larger study, sham-controlled, by which stimulation using TMS of the auditory cortex really could shut down the experience of the auditory hallucination. The pattern of stimulation we used was called continuous theta burst stimulation."
One-day TMS eliminates auditory hallucinations for weeks
Dr. Muir shares a case where D-cycloserine-augmented one-day TMS achieved complete remission of auditory hallucinations lasting over six weeks before requiring retreatment.
"What we did is we used the D-cycloserine augmentation for one day of treatment. And the patient got about six or eight weeks of complete relief and then had to get retreated thereafter."
TMS as a paradigm shift for early psychosis treatment
The discussion highlights how TMS for psychosis could be transformative given the extremely low bar of current treatment options for people with chronic auditory hallucinations.
"For me, the bar is so low here. We've been struggling for so much with early psychosis and for people who have chronic psychosis."
