Ns assessment tool r3:layout 1.qxd

Antidepressant Treatment Record (ATR)
An eligible patient for NeuroStar TMS Therapy has shown resistance, during the current episode of
Major Depressive Disorder, to one treatment. The treatment must have been administered for at least
four weeks, at or above the minimum effective dose as defined by the attached Approved Treatment
List. The ATR will clarify and capture for your records a patient’s eligibility for NeuroStar TMS Therapy.
Does the patient meet the criteria for MDD as defined in the DSM-IV? Create a treatment record chart on the next page to use in answering Questions 2 - 3 below. List all treatments administered in the current episode. For NeuroStar eligibility decisions, a treatment is:
1. An antidepressant medication . NOTE: Write each medication, whether administered alone or in combination, on a separate line. For your own records, indicate combinations by circling medications administered together.
2. A medication plus an augmenting agent. NOTE: If, after starting a medication, an augmenting agent was added, count that date as ending one treatment and starting another. Re-write the name of the medication and the agent on the next line.
Answer all questions for each line independently. Refer to the Approved Treatment List on the back of this page for treatment names and minimum dose. When you have completed the treatment record chart, return to this page to answer Questions 2-3. Is there at least one treatment on the chart for which all the answers are YES?
2 If not, please create a treatment record chart for the most recent episode in which treatment
occurred. Return to this question when the chart is complete.
Is there only one treatment on the chart for which all the answers are YES?
If the answer to all three questionson this page is YES, the patient iseligible for NeuroStar TMS Therapy. reatment List
etracyclic
Other Antidepressants
AUGMENTING AGENT
Approved T
All trademarks are the property of their respective manufacturers Antidepressant Treatment Record(ATR), CONTINUED
unsatisfactory?
Use both sides of the page when needed. For additional space, copy the chart. Antidepressant Treatment Record(ATR), CONTINUED
unsatisfactory?
Use both sides of the page when needed. For additional space, copy the chart.

Source: http://www.suffolktmsandbehavioraltreatmentcenter.com/pdf/ATR-%20Antidepressant%20Record%20Form.PDF