The Business of Selling TMS

Direct-to-consumer advertising of psychiatric drugs has become a staple of TV, magazines, medical websites, and social media feeds. Today, with the arrival of a relatively new technology called transcranial magnetic stimulation (TMS), equipment makers and medical practices alike are taking to Facebook, websites, highway billboards, and beyond to line up customers for a procedure they claim is a “safe, non-invasive, and side-effect-free” treatment for unremitting depression.

During TMS, electromagnetic coils are positioned on a person’s scalp to deliver a powerful electromagnetic pulse that stimulates nerve cells within the brain. At face value, one might interpret these marketing efforts as simply a way to make people aware of this less-familiar treatment—part of the larger “mental health awareness” campaign.  But based on my own painful experience with TMS and further research into its potential harms, I’ve observed these efforts with a critical eye.

There are two distinct types of TMS marketing materials: Those targeting potential patients and those aimed at doctors. What they have in common is framing TMS as a wonder technology that fits right in with the consumer wellness lifestyle. Here is what I found in my online searches for TMS clinic websites and other forms of advertising and why I believe they are misleading and unethical.

Patient Marketing: Promises, Promises
THE Answer to Your Problem

For those struggling with their mental health, TMS marketing materials make big promises. For example, the homepage for the Success TMS website declares, “Your depression ends here. Med-free!”

The website of the NeuroSpa practice in Florida tantalizes with copy such as “Your journey to happiness begins with us today” and “Visit us and watch your new life unfold.” The website of Genesis Behavioral Health, a mental health practice in Texas, has a webpage headlined, “Are You Ready to Get Your Life Back?” It also offers a downloadable booklet titled “The Benefits of TMS Therapy: Your Complete Guide” whose cover features a family dancing in a sunlit field. It opens, “It sounds like something out of a science fiction movie, but luckily for people with depression everywhere, it’s true.”

The Redemption Psychiatry practice in Arizona has a poster that makes TMS sound like everything you ever wanted in a treatment: “Extremely Effective,” “Very Safe,” “FDA Approved,” “Covered by Insurance,” and “Real Results.” It boasts that remission is eight times as likely with TMS as with medication and therapy and that treatment will not only make your depressed brain “normal” again, but also improve your “mood, anxiety, energy, sleep, concentration, motivation, and more.” Wow!

Testimonials are fairly common on TMS clinic websites.  Greenbrook TMS Neurohealth Centers (nationwide), for example, markets its services in Facebook feeds. One ad features a smiling young woman and a quote from patient “Christine” about her cure: “My depression, stress, and anxiety got in the way of work. After TMS therapy, I finally don’t deal with those symptoms anymore.”  Success TMS even features excerpts from the company’s Google Reviews on its website, as if it were a restaurant, and also includes a video of testimonials. One woman declares, “I started noticing a difference within the first week. It changes your life because you go from just existing in the world to actually living.” The TMS equipment manufacturer NeuroStar’s website (“People Just Like You are Feeling Better Every Day”) is centered on video testimonials for their product. None of them specify whether or not these people were paid to participate.

Needless to say, there are no negative reviews to be found on any of these sites.

It’s No Biggie

Despite that TMS can supposedly resolve your depression and transform your life, it’s really no big deal, according to the marketing. One element seen throughout these ads, websites, and brochures are descriptions of TMS as simple, virtually pain-free, and extremely low risk. The copy touts its “non-invasiveness” and lack of side effects compared with medication.

An image on Success TMS‘s Palm Beach, FL website is typical, showing a single side effect for TMS, “temporary discomfort,” while listing 20 different unpleasant symptoms for antidepressants. Similarly, a chain called NeuroMed Centers markets its services through an animated cartoon on its website and YoutTube that seems designed to calm a nervous child rather than educate an adult deciding about medical treatment. Here TMS’s main side effect is said to be “mild headache” which “disappears” after a few sessions.

Some sites make a course of TMS treatments sound downright pleasant. While they acknowledge that the treatment requires a commitment of at least 20 minutes a day every day for many weeks, practices like Greenbrook TMS reassure you that you can listen to music, surf the net, text with friends, or chat with the provider during sessions.

NeuroSpa takes this marketing to another level, portraying TMS as a spa-like environment where, according to the website’s tagline, you can “rediscover the best version of yourself with a safe solution you can trust.” In an uncritical segment on the practice featured on NeuroSpa’s website, a Tampa TV station repeated the medical director’s promise that TMS has NO side effects. He tells the reporter, “You can think of it like a rejuvenation treatment…your brain is being optimized.”

However it works, TMS providers assure us, the treatment will change your brain from a sick state to a normal, healthy one. To illustrate this, they often use dramatic, “high tech” images like the one at left.  This image was captured from SuccessTMS’s Facebook feed. Both Success and Redemption Psychiatry, among others, feature it on their websites and other sites use similar ones. The message: TMS if effective, and here’s physical proof.

 Image Vs. Reality

Based on all these exciting and reassuring messages, who wouldn’t want to try TMS?  But these claims are deceptive.

Let’s take another look at that “before and after” image of two brains. The image above has nothing to do with TMS. It actually depicts PET scans of two different individuals’ brains, used to show the difference between the scans of someone reporting depression and that of someone who is not depressed. The image comes courtesy of a Mayo Clinic web page on PET scans for depression–as I quickly learned from an internet search with the terms “depressed brain scan.”

Yet the ad copy clearly stated “before TMS” and “after TMS.” It is being circulated on social media and other platforms as a marketing tool to convince people to try the procedure.

And while medical pros serve as authority figures in these marketing materials, in reality TMS is commonly performed by technicians–the doctor might not even be on site during your appointment. The extent and type of hands-on staff training varies from clinic to clinic, and certification can be achieved in a few weeks (even online). Employment ads suggest some practices are willing to hire people with only a high school diploma and some medical office experience–all to treat someone’s delicate brain. Compare this with the greater degree of education and training required to become a hairstylist.

Because of this and individual patient differences, the possibility of TMS being performed incorrectly is ever-present. Although the patient’s brain is “mapped” before treatment, how can you be certain the technician treating you possesses the medical background to recognize a neurological problem if it occurred during treatment?

More important, as I wrote in my MIA essay “Can TMS Hurt You?,” TMS is neither non-invasive nor free of side effects. And far from inducing remission of depression symptoms in from 30% to 80% of patients (depending on whose marketing materials you read), for thousands of people like me, it wasn’t effective. Instead, it produced a host of unlisted side effects and debilitating new symptoms, bringing lasting damage to our health and lives.

Common side effects reported among the 1,800 members of the “Victims of TMS Action Group” I started on Facebook include: long-lasting or permanent cognitive impairment and memory recall, extreme irritability, intense and long-lasting anxiety and depression, panic attacks, new suicidal ideation, chronic headaches and migraines, dizziness, nausea, fatigue, tinnitus, depersonalization and derealization, and environmental sensitivities. People also report a host of less-common problems that are no less distressing and significant.

It’s not that this information isn’t available: Reports have been made to and are maintained in MAUDE, the FDA’s adverse events database for devices. Members of my Facebook group have regularly reported their post-TMS problems to the clinics that administered it to them. I have reported my own horrific experience to the FDA as well as to the clinic that treated me; all of us have been brushed off or ignored.

Additionally, many TMS  side effects are described in case reports and other recent research published in peer-reviewed journals. While preliminary, they include troubling findings well beyond “temporary discomfort”:

In addition, a 2014 analysis of TMS studies by retired psychologist Phil Hickey found incidents of seizures as well as high dropout rates, which he believes may indicate injury or other forms of harm among participants.

Marketing to Doctors
TMS as a Cash Cow

What makes healthcare providers engage in the questionable practice of hard-sell marketing? As the saying goes, follow the money. Psychiatrists and neurologists in private practice are running a business, and TMS equipment manufacturers and marketing companies are selling TMS to doctors as a win-win proposition: a supposedly life-saving treatment that’s also a potentially huge market.

The website of MarketTMS estimates that a TMS practice can build gross revenue of $3.1 million USD per year if it can manage to get 50 patients a day through their offices.

If we believe the statistic that 1 in 4 people in the US are afflicted with mental health issues and convince ourselves and others that TMS has virtually no side effects, that also theoretically means there is virtually no liability for the clinic. An earnings potential of over two hundred thousand dollars a month with a (supposedly) small risk profile sounds like a dream come true for entrepreneurial-minded medical practices.

According to materials from the iterate marketing group, they were able to help TMS providers in the Pacific Northwest “dominate the marketplace.” By the look of their website, the name of the game for TMS clinics is not helping patients by effectively treating illness but “getting market share” and “growing their business.”

On its site, MarketTMS states:

According to a leading research firm, the global TMS market size is anticipated to grow nearly 10% per year. US and Canada are expected to dominate the TMS market as a result of attractive insurance reimbursement policies, increased awareness, a large number of skilled physicians, and the proliferation of healthcare facilities.”

Notice there is no mention here of whether TMS is even effective.

Manipulating Patients

Marketers’ naked appeal to a practice’s bottom line includes encouraging doctors and staff to directly manipulate potential patients in both the recruitment and treatment phases of TMS. The website of the Beyond Marketing group, which advertises on LinkedIn and Facebook, overtly states that the goal is to compel patients to use TMS:

“On the marketing end, we use video to tell the story. Remember people don’t understand what TMS and ketamine is for the most part. So we need video to tell an effective story and give them a compelling reason to get started with you…. So when a clinic gets started with us, they get access to the Art of Converting New Patient training program. This gives you the frameworks, the scripts, the knowhow, the mindset, and everything you need to schedule and enroll new patients.”

Beyond Marketing even has a downloadable PowerPoint that includes a slide on the basics of patient manipulation—including “tactical empathy”—to sell people on the treatment:

The website also points out a new offering: Training in “how to hire a lead handler, who’s going to be able to follow up with your new patient opportunities and enroll them into care.” According to Beyond Marketing, in order to make the most money and be really effective with your TMS practice, you need to “handle” prospective patients in a particular way to get them enrolled and into the TMS chair. The name of this marketing program? “Seven Figure Psych.”

Beyond Marketing is only one small part of a larger enterprise marketing TMS to doctors or helping doctors to market TMS to patients. For example, the branding company Agency Creative proudly describes on its website how it helped Salience TMS Neuro Solutions in Texas overcome challenges like low public awareness and doctors’ reluctance to prescribe new treatments through a re-branding campaign called Reconnect to Life. The goal: to “make this complicated technology approachable and memorable for both patients and physicians.”

Image Versus Reality

No doubt TMS clinics and mental health practices are seeking to attract new patients and increase their revenue—that’s why they participate in marketing campaigns. It’s more direct than waiting for PCP or psychiatrist referrals, and the more these practices promote the treatment and unverified testimonials on various media platforms, the less the clinics need to rely on word of mouth and real-world outcomes to fill their chairs.

But because TMS equipment manufacturers and marketing companies can appeal to both greed and idealism by emphasizing how safe and effective TMS supposedly is, they are incentivizing practitioners to take an assembly-line approach to patient “recruitment” and care. This pays little regard to the real-world risks of serious harm—or even whether TMS is truly an appropriate treatment for a given individual. For example, many clinics use the PHQ-9 depression test or similar psychiatric screening to determine if patients are the right fit for TMS. It’s a short, subjective tool that’s been found to overestimate the prevalence of depression and generate many false positives. When I took the PHQ-9 at the TMS clinic I went to, the staff told me my score wasn’t high enough so I should change my answers if I wanted the treatment.

It is very unwise to tie financial incentives to medical treatment. If your professional success is tied not to patient outcomes but to how many people you treat, patients are bound to be harmed as treatment standards drop and/or the treatment protocols were ineffective or dangerous in the first place. Financial incentives also discourage much-needed accountability among TMS providers. If I’m a medical director and have been convinced that TMS is completely safe and saves lives, I’m unlikely to believe that a patient’s complaints of pain, anxiety, or cognitive issues during or after treatment is due to TMS. (So many former patients I’ve encountered tell of being reassured that their suffering is temporary, urged to stick with it, and/or that their new physical and psychological problems couldn’t possibly be due to TMS.)

So what happens when you aggressively market a new, expensive medical treatment where those who administer it have virtually no accountability? Patients who experience horrible neurological side effects, which are difficult to substantiate using standard or even advanced medical diagnostics, are forced into an almost impossible situation. They are unable to build a legal claim against the clinic or manufacturer that harmed them (it is incredibly difficult to find a lawyer to take your case without legal precedent) and discover that physicians don’t believe their TMS horror stories when they seek medical care for their injuries.

End High-Pressure Health Care

Widespread marketing media promoting TMS to the public and doctors is a morally bankrupt enterprise. People struggling with depression should not be enticed to try TMS based on pretty pictures and ad copy about miracle cures. It is a very complex and potentially dangerous medical treatment that involves applying electromagnetic energy to the brain. I believe people need to consider that fact very seriously before trying it, and make sure it is appropriate to their situation. This requires fully informed consent. Instead, as we scroll through social media or drive to the office, ads pitch us with a solution to our problem before anyone knows what our problem is, encouraging us to seek out TMS before we even know what it is or if it can help us.  Then, when we go to a clinic, the staff tell us that TMS is virtually harmless and helps almost all of the people who come through their doors.

How do you substantiate those claims? Most people don’t have the scientific background to evaluate clinical studies, additional marketing, and manufacturer claims. The office might point you to testimonials, but not to former patients who had a bad experience. And they probably won’t show you their records for outcomes, much less data on how treatment results look across large populations. On top of this, what if the staff at the office have been trained by a group like Beyond Marketing and give you the hard sell, offering a reassuring answer for every question while oozing “tactical empathy?”

Prospective patients should never be manipulated or “handled” into any kind of decision about their healthcare. They should be told the facts about what TMS is and what could happen during treatment by an experienced and honest doctor in order to make their decision on whether or not to pursue it. Instead, we see deception, manipulation, and profiteering in the TMS industry, which end up costing some people their quality of life and even their livelihoods.

Recently a friend of mine passed away of complications from medical issues that she believed were a result of her TMS treatment. She was 28 years old.  She was told TMS is harmless and that there would be no lasting side effects. I wonder which marketing campaigns she saw before and after she did her treatments. I wonder how hard the TMS clinic she went to for help relied on sales techniques instead of honesty about possible risks and benefits to get her into treatment. I wonder how many other people end up in a clinic for the same reasons—and how many will lose their own lives.

TMS marketing is a very dangerous proposition given its ability to exert a high level of influence over the public, doctors, and clinic staffs for a treatment that is potentially damaging and even lethal. In particular, when there is a very high earning potential tied to a treatment and also very little accountability and disclosure of harms, the least we can do is limit or restrict marketing so we can eliminate the potential for medical malfeasance and widespread harm.

 

Additional research by Miranda Spencer

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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