Assessment and Management of Concurrent Substance Use in Patients Receiving Repetitive Transcranial Magnetic Stimulation for Depressive, Obsessive-Compulsive, Psychotic, and Trauma-Related Disorders: A Delphi Consensus Study and Guideline

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. 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. 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. 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.