‘We Need This on the Front Line of Care’: TMS Rises as Vital Tool in Outpatient Mental Health

This is an exclusive BHB+ story

Outpatient mental health providers increasingly see transcranial magnetic stimulation (TMS) as a potential answer to helping patients with treatment-resistant depression find relief.

But the path to including this type of intervention in the context of existing therapy and psychiatry offerings is a winding and not-terribly-well-trodden path.

A growing body of research shows that TMS has some of the best response rates of any treatment for depression, offering the rare opportunity for patients and provider organizations to have something that looks like a genuine answer to a common but difficult-to-treat condition. One study finds that more than half of patients saw the severity of symptoms cut by more than half after a course of treatment.

While some meta-analyses highlight high variability in outcomes, leaders at provider organizations have seen enough evidence and anecdotes to think of TMS not as the late-stage treatment that the prevailing payer-provider apparatus makes it. Rather, many believe that it should be considered early on in treatment.

“If I were depressed or had a family member who was depressed, for me, [TMS] should be the first line of defense,” Meghan Herwehe, CEO of San Francisco-based outpatient mental health provider Mindful Health Solutions, told Behavioral Health Business.

What’s more, several behavioral health organizations that started out as therapy-focused outpatient mental health practices are adopting more and more interventional psychiatric services in the hope of giving providers and patients as many options as possible for treatment. This raises several strategic and operational challenges for those providers.

Previously, leaders in the behavioral health space told BHB that the addition of TMS is enough to fundamentally change the character of a practice office.

Mindful Health Solutions, however, started on the other end of TMS adoption: It was founded as a TMS company about 15 years ago, Herwehe said. Since then, the company has organically established a number of additional psychiatric and psychological services geared toward addressing treatment-resistant depression and other conditions.

Over the course of time, the company has evolved administrative processes that allow for the coordination of services. In that process, Mindful Health Solutions has found that a lot of “brass tacks” work has to be done to figure out the right way to address multiple services in one location.

The key element to that — and the addition of esketamine and IV ketamine therapy — has been time to layer services in over the course of years.

Transformations Care Network CEO Brian Wheelan told BHB a similar thing when speaking about de novo clinics. He would expect TMS to be a viable service at a very-well-performing clinic in at least 24 months.

“If it happens sooner, it’s because that clinic is really successful from a leadership, from a clinical training, from a hiring, from a demand-generation perspective,” Wheelan said.

Size and buy-in are key considerations

TMS makes the most sense at the local level when a practice or organization has a large enough patient base, administrative support and a vibrant patient pipeline. This doesn’t necessarily mean that TMS can only succeed in large metros. In many cases, provider organizations can establish a large enough patient base in communities where there has been historic underinvestment to support TMS services.

That said, larger metros simply have more people. And that might mean more people who could be clinical candidates for TMS and other supportive services.

At least for Transformations Care Network, TMS is most successful in large clinics that have very large patient bases, Wheelan said. Specifically, well-established clinics with TMS within Transformations Care Network have around 3,000 active patients, dozens of therapists and about five psychiatrists.

“In the case of TMS, you’re making a capital expenditure to buy a machine. That is expensive,” Wheelan said. “Plus, that machine has operating costs. So you need it to be in full use. And that’s different [for outpatient mental health] because so much of our other costs are variable. That’s the way we think about productivity pay for clinicians.

“TMS flips it on its head. All of a sudden, I’ve got this fixed cost to figure out.”

What’s more, TMS forces clinicians to make in-person services a more serious consideration for their work. TMS machines take up space in a clinic, require the service to be delivered in person and require a trained “treater” to deliver TMS. While Transformations Care Network does offer services by telehealth, the company leans into an in-person care delivery model.

This necessarily means that clinicians need to buy into the idea of giving access to TMS in-house and being ready to take on the clinical and administrative challenges to do so. Ensuring that patients also are brought into the service is vital as well.

“It starts with a passion for the work and the patient population and a willingness to maybe accept some risk to see the benefit in patients,” Dr. Rachel Dalthorp, an executive medical director of specialty services at LifeStance Health Group Inc. (Nasdaq: LFST), told BHB. “TMS isn’t the only evidence-based treatment for treatment-resistant depression. So of course, there’s partnership with the patient to make the decision.

“But I think what makes an organization or practice successful is, No. 1, a drive to make it happen and to overcome obstacles. It can be complicated.”

The most complicating factor is the hoops that payers often require patients and providers to jump through before approving prior authorizations for TMS. Typically, health plans will require patients to spend several months trying and failing multiple iterations of medication and therapy before clearing a TMS approval. That puts a lot on patients and providers. But just behind that is coordination within an approved patient population.

If I were depressed or had a family member who was depressed, for me, [TMS] should be the first line of defense.

— Meghan Herwehe, CEO, Mindful Health Solutions

Most TMS protocols require patients to come to the clinic for sessions that are about 30 minutes long for up to 30 days over the course of six weeks. Some TMS machines and intervention protocols may require more sessions, multiple sessions a day, or longer sessions. This presents several hurdles to patients, such as transportation and work accommodations.

With the right amount of buy-in, these challenges are surmountable.

“When you say treatment-resistant depression, the patient is not resistant,” Dalthorp said. “That patient has been engaging in mental health care for years, sometimes decades. They’ve tried everything. They are not resistant. We just need to match their depression up with something that treats it differently. … So I think if a clinician that’s passionate about the service and knowledgeable has an opportunity to talk to a patient, I think it’s an easy decision for the patient to think about moving forward.”

While buy-in and willingness to tackle challenges is key to operationalizing TMS, Herwehe said that it’s possible to establish successful clinics with TMS in smaller metros.

“I think what’s different about this is that depression is nondiscriminatory; it impacts everyone, irrespective of age, income or other demographics,” Herwehe said. “There are huge groups of treatment-resistant depression patients, no matter where you go. … The people we can treat are everywhere.”

Previous to working at Mindful Health Solutions, Herwehe worked at other health and wellness organizations where it only made sense to establish services in and around large metros. But Herwehe notes the company has established what it considered successful operations in places such as Wenatchee, Washington, or Stockton, California.

While administratively burdensome, operating on an in-network basis, as Mindful Health Solutions does, eliminates some willingness- and ability-to-pay concerns to a certain degree. This removes the need to operate in locations that have large populations of high-income earners willing to pay out of pocket for treatment.

Progress with payers

While still the biggest challenge at the macro level, several people BHB spoke to for this article noted that payers of late have made progress when it comes to covering and improving the administrative burden related to getting approval and payment for TMS.

This progress is highly varied.

Some said a certain payer’s progress with TMS includes simply providing service-specific forms to submit with prior authorizations. Others noted that payers are willing to engage in coverage for TMS protocols that are closer to the edge of the latest science.

“There’s no question the direction of travel here is irreversibly favorable,” Wheelan told BHB. “I think we only have one or two players out of 100 right now where you still have to do four drugs [before starting TMS]. … What we’re seeing is a very clear direction of travel here that is widening the aperture for the use of TMS — not as a first-line treatment, but not as a ‘there’s-no-hope’ treatment.”

Wheelan noted that some payers have engaged with TMS coverage for adolescents. This is a relatively recent development. The Food and Drug Administration approved TMS and technology provider Neuronetics Inc.’s (Nasdaq: STIM) application for approval to use TMS as an adjunctive treatment for young people ages 15 to 21 who have major depressive disorder (MDD) in March 2024.

Dalthorp said that it’s “rare” to demonstrate medical necessity in a prior authorization process and get denied. Wheelan described payers as being “restrictive” as more payers struggle to grapple with higher-than-anticipated costs in 2025.

When you say treatment-resistant depression, the patient is not resistant. … That patient has been engaging in mental health care for years, sometimes decades.

— Dr. Rachel Dalthorp, executive medical director of specialty services, LifeStance Health Group

As with inner-clinic dynamics, size matters with payer relations.

“To have those big payer contracts and to get good rates, you have to have some level of scale to do that,” Herwehe said.

At the end of the day, the establishment of TMS and other interventional psychiatry services centered on the fusion of operational savvy and clinical belief. Despite its growing accessibility and popularity among provider organizations, it is not the only intervention that shows promise. Before committing to TMS, some providers may want to consider other potential interventions that are on the horizon such as psychedelics to ensure patients and providers have access to the right treatment.

“Whatever the next greatest thing that is going to help people feel better, we will offer that too — we will figure it out,” Merwehe said. “Our ethos is: what’s going to serve the patient and help them feel better? How do we give our psychiatrists and psych NPs the biggest toolbox to operate with?”