Expert Witness Journal Issue 64 December 2025 - Flipbook - Page 68
directly targeting neural circuits, it can initiate
recovery at a biological level, providing the
patient with the 昀椀rst experience of improvement
in a long time.
Implications for Medicolegal Practice and
Reporting
For the expert witness, the existence and proven
e昀케cacy of Deep TMS have several critical, nonnegotiable implications:
2. Subsequent Pharmacological Optimisation:
Once symptoms begin to lift, pharmacotherapy
can be rationalised and optimised. This may
involve simplifying complex regimens or
reducing doses to levels that are better tolerated,
thereby mitigating side-e昀昀ect burdens while
maintaining e昀케cacy.
1.
3. Concurrent or Subsequent Psychotherapy:
The patient’s improved cognitive state –
better concentration, reduced emotional
overwhelm – allows for more e昀昀ective and
profound engagement with trauma-focused
psychotherapy (e.g., EMDR, CBT for PTSD),
which is often crucial for addressing the root
cause of the injury in medicolegal contexts.
2. Prognosis and Future Care Costs: The potential
for Deep TMS to induce remission or signi昀椀cant
functional improvement can fundamentally alter
the long-term prognosis. This must be accurately
re昀氀ected in any assessment of future care needs,
loss of earnings, and general damages for loss
of amenity. A care plan that includes a course
of Deep TMS, while a signi昀椀cant upfront cost,
may be profoundly more cost-e昀昀ective than a
lifetime of supportive care, repeated medication
reviews, and lost productivity. The expert’s role
is to quantify this potential paradigm shift.
This multi-modal approach o昀昀ers the best chance
for a holistic recovery, targeting the biological,
psychological, and social dimensions of the illness.
It moves beyond sequential monotherapies to a truly
integrated model of care.
Speci昀椀c Medicolegal Applications and
Case Conceptualisation
3. Quantifying ‘Maximum Medical Improvement’:
In cases where a claimant with a treatmentresistant condition has not undergone a trial
of neuromodulation, it is arguably premature
to conclude that they have reached Maximum
Medical Improvement (MMI). A robust
medicolegal opinion should state that MMI can
only be con昀椀dently assessed after all appropriate
interventions, including Deep TMS, have been
trialled or formally considered and ruled out for
speci昀椀c, documented clinical reasons.
The implications of Deep TMS extend across various
medicolegal scenarios:
•
Personal Injury and PTSD: Claimants with PTSD
often exhibit hyperactivity in the amygdala and
hypoactivity in the prefrontal cortex. Deep
TMS protocols can be tailored to modulate
this speci昀椀c circuit, potentially reducing
hyperarousal and re-experiencing symptoms,
thereby making them more amenable to traumafocused therapy.
•
Clinical Negligence: In cases where psychological
injury stems from medical negligence, and where
standard treatments have failed, the failure to
consider or refer for neuromodulation could
itself become a subject of scrutiny in subsequent
litigation, pertaining to the standard of ongoing
care.
•
Occupational Stress: Chronic work-related stress
can manifest as severe MDD. Deep TMS o昀昀ers a
tangible, advanced treatment option that can be
factored into assessments of 昀椀tness to work and
future earning capacity, potentially supporting
a return to productive employment rather than
a lifetime of incapacity.
EXPERT WITNESS JOURNAL
Assessment of ‘Reasonable Treatment’: A
claimant with a well-documented diagnosis of
TRD, PTSD, or OCD who has not been considered
for or o昀昀ered a trial of Deep TMS may not have
exhausted all reasonable treatment options.
This should be explicitly factored into opinions
on prognosis, future care, and loss of earnings.
An opinion on chronicity is incomplete without
a consideration of neuromodulation.
Conclusion
Deep TMS represents a paradigm shift in the
management of treatment-resistant psychiatric
disorders. Its non-invasive nature, targeted
mechanism, excellent safety pro昀椀le, and proven
e昀케cacy make it an indispensable tool in the modern
psychiatric arsenal. For medicolegal experts,
familiarity with this technology is no longer an
optional niche interest but an essential component
of contemporary practice. By incorporating a
thorough consideration of neuromodulation
into their assessments, experts can provide more
accurate, evidence-based, and equitable opinions
on prognosis and future care. This ensures that
claimants have access to the most advanced
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DECEMBER/JANUARY 2025-2026
