What is TMS therapy? TMS stands for Transcranial Magnetic Stimulation. It is a noninvasive procedure that uses magnetic pulses to treat depression.

This procedure is not experimental. It was approved in the U.S. by the FDA for depression treatment in 2008. The treatment is done on an outpatient basis in a doctor’s office or clinic. Indication for this treatment is usually for adult patients who still struggle with depression despite trying several antidepressants and counseling.

Depression is the leading cause of disability in the U.S.  among people ages 15 to 44 years. There are many antidepressants available for the treatment of depression. Even though many of these medications are helpful for treatment, they, however, do not help everyone.

Some studies show that as much as two-thirds of people with depression do not get enough relief from the first antidepressant they try. Also, trying subsequent medications is less likely to help than the prior one.

Given this, it is essential to have other options outside of medications. Some other treatment modalities for depression include counseling, Electroconvulsive Therapy, Spravato, and of course, TMS.

Electroconvulsive therapy (“shock therapy” or ECT) has been used for many years for treatment-resistant depression. Despite the negative connotations to ECT, it remains an available treatment for depression. Indeed, it is still the most effective treatment for severe depression.

Unfortunately, ECT has many side effects, including memory problems. As a result of this, many people are reluctant to try ECT, even though it is effective. TMS, therefore, makes for an excellent alternative treatment for severe depression.

So, what is TMS?

 

Transcranial Magnetic Stimulation (TMS)

TMS is a noninvasive procedure that uses recurring magnetic pulses to stimulate specific regions of the brain to improve the symptoms of depression. The treatment involves using a TMS machine to generate magnetic pulses that stimulate the brain cells. In most cases, TMS is used when an individual has tried a few antidepressants. Because TMS involves using repetitive magnetic pulses, it is called repetitive TMS or rTMS.

TMS involves applying magnetic fields to specific parts of the brain that affect your mood. Unlike ECT, transcranial magnetic stimulation does not require anesthesia. Another considerable advantage is the tolerability of TMS. In addition, it has minimal side effects compared to medications and ECT.

 

How Does TMS Work?

It is unclear exactly how TMS works. For depression treatment, the magnetic pulses stimulate the left side of the brain. They pass through the skin and bone to stimulate the brain cells. This process helps the brain cells release brain chemicals that make depression better. The three main brain chemicals are dopamine, serotonin, and norepinephrine.

Unlike ECT, which uses electrical energy, TMS treatment involves magnetic pulses. Even though this may sound scary, it is generally not a painful process. Though some people describe pain during the process, tolerance is fairly good. Besides, adjustment of the machines is possible if there is some discomfort.

The TMS and MRI machines are similar in that they both use magnetic pulses. There are no major concerning short and long term side effects.

During a TMS session, an electromagnetic coil is placed on your head. For depression, this placement is on the left side, close to your forehead. Some treatment centers may provide off-label treatment for other disorders like anxiety and post-traumatic stress disorder. In this case, coil placement is different from depression treatment.

TMS does not require sedation or a recovery period. It also does not come with the memory problems seen with ECT. It is a reasonably safe treatment.

 

What is TMS Used For?

We know TMS helps with depression treatment, but what else is TMS used to treat? The answer to this question depends on the country. The use of this procedure varies somewhat depending on the location. In some European countries, there are several other uses for this treatment modality.

Uses in the United States

  • Major Depressive Disorder
  • Obsessive-Compulsive Disorder (Brainsway machine only)

In the U.S., there is ongoing research with transcranial magnetic stimulation and other medical disorders. There will likely be more indications soon. There are many current researches, as well as off-label treatments.

Off-Label Treatments

  • Past-Traumatic Stress Disorder (PTSD)
  • Anxiety
  • Pain management
  • Nicotine addiction
  • Parkinson’s disease
  • Stroke rehabilitation
  • Alzheimer’s dementia
  • Fibromyalgia
  • Tourette’s syndrome,
  • Multiple sclerosis
  • Autism
  • Tinnitus
  • Mal de Debarquement Syndrome

 

Does TMS Work?

The response rate for this procedure is about 60% to 70%. This value means that nearly two-thirds of people who did not benefit from medications feel better with transcranial magnetic stimulation. Out of this number, about one-third achieve full remission – meaning their depression goes away completely.

Note, however, that this improvement may not be permanent. Depression is a chronic illness; therefore, there will likely be ups and downs. Some people may feel well for many months before they relapse. Individuals can have another round of treatment if they develop symptoms of depression again.

 

Procedure

What does the TMS procedure involve? This process involves the following steps:

Before Treatment

  1. A healthcare provider does a consult. This consult aims to ensure that this treatment is a good fit for you. Also, to make sure you have no issues that can lead to complications.
  2. History of seizures and metal implants in your head, neck, or chest area will disqualify you for this therapy.
  3. The consultation involves a full psychiatric history and may last about an hour on average. During this session, you will also get some information on the specifics of TMS.
  4. Following this office visit, the healthcare provider sends your information to your insurance for a benefits investigation. Because this may take about 3-7 days for approval or denial, you may want to contact your insurance company prior. Paying cash avoids this step.
  5. The next step is scheduling your first treatment with the treatment office.

Treatment

  1. Your first treatment involves finding your Motor Threshold (MT). Also known as brain mapping, it refers to finding the right amount of magnetic pulses required to treat you. It involves stimulating your brain to make your finger twitch. This mapping is different for everybody. The MT can take anywhere from 10 mins to 30 mins on average. To start the MT, you sit on a reclining chair – somewhat like a dental chair. Earplugs are available to wear. Note though that the machine is not very loud and some people opt not to wear earplugs.
  2. After the MT, you receive your first treatment, which lasts about 20 mins on average. The older machines used to take longer – up to 40 mins. Given this, it means your first session will last approximately one hour and subsequent sessions for about 20 minutes. The machine produces a clicking sound that switches on an off. You also feel a tapping sensation on your forehead. Some people describe this as the feeling of a woodpecker on your head.
  3. This process is noninvasive. There is no sedation, surgery, or placement of electrodes. During treatment, you are awake and alert.
  4. A full course of treatment is 36 sessions. Subsequent sessions, after the MT, last about 20 mins. With theta-burst, however, treatment is much shorter – about 3-5 minutes.
  5. Usually, treatment is done Mondays to Fridays for six weeks, with a slow taper over the next three weeks. Thus, a total of 9 weeks. You can drive yourself back to work or home after each treatment.
  6. Continue to take your antidepressants during treatment.
  7. You may begin to see changes from even as early as the second week of treatment. For most people, though, it is usually between four to six weeks.

After Treatment

  1. Carry on with your normal daily activities. In between treatments, you can continue to work and drive.
  2. Continue taking your medications as usual if you are on any. Note that you also continue to take your medicines during treatment.
  3. Follow up regularly with your mental health provider.

There are two essential regions of the brain that come into play during transcranial magnetic stimulation. These are

  1. Motor Cortex: during the MT, this part of the brain helps with positioning the treatment coil correctly. It also helps determine the intensity of the magnetic pulses for the treatment.
  2. Left dorsolateral prefrontal cortex: after the MT, some calculations are done to locate this part of the brain. This region is responsible for depression. As a result, the placement of the treatment coil is over this site for all 36 treatments.

TMS is not a cure for depression. It is a treatment procedure that helps your depressive symptoms. What this means is that your symptoms may come back again. On average, some people feel well for about a year. It may be shorter or longer for others. Unfortunately, about 30-40% of people do not respond to treatment at all.

It is important to remember, however, that depression is due to many factors. These include chemical, biological, social, and psychological reasons. As a result, your lifestyle choices, relationships, and coping skills affect your depression, in addition to your genetics.

Thus, using the improvements in your mood, drive, and energy after transcranial magnetic stimulation is essential. You can apply these positive changes to start therapy and improve your lifestyle. Exercising, improving your diet, and more social connectedness will help keep you mentally stable.

 

Types of TMS Machines

There are different types of transcranial magnetic stimulation machines. Even though they look different with some variations in how they work, they are quite similar. These machines all produce magnetic pulses for treating depression. Some examples are:

  1. Neurostar TMS Therapy
  2. Magstim
  3. Magventure TMS Therapy
  4. BrainsWay Deep TMS (has approval for treating OCD)
  5. Nexstim
  6. CloudTMS
  7. Apollo TMS

There is no need to bother about what kind of machine your healthcare provider uses. All these machines produce focused magnetic pulses, and as such, improvements in symptoms of depression.

 

Side Effects of TMS

TMS has minimal side effects. It is a noninvasive procedure that does not require sedation, surgery, or placement of electrodes. Even though most people tolerate this procedure very well, some issues may occur.

Common Side Effects

Side effects are rare. When they do occur, however, they tend to be mild to moderate. Also, they usually go away quickly and decrease as you have more sessions.

  • Headaches
  • Dizziness
  • Scalp discomfort at the site of treatment
  • Spasms, twitching or tingling of the face during sessions

An advantage of TMS machines is that the settings can be adjusted to help with these side effects. In cases of a headache, over-the-counter pain medications usually help.

Uncommon Side Effects

It is rare to have any severe side effects with TMS. Some possible problems which may arise are:

  • Seizures: most reports indicate that when this happens, it is usually in people who already have a seizure disorder. Studies report the risk to be as small as 0.001%.
  • Mania: this condition occurs mostly in bipolar patients. Transcranial magnetic stimulation only has approval for major depressive disorder, not bipolar disorder.

Note that this treatment is not necessarily a replacement for medications. The advice is to continue to take your medications. However, some people who are not on medications still do quite well with this treatment.

 

Reasons to Avoid TMS Therapy

There are not many reasons to avoid Transcranial Magnetic Stimulation. The significant issues to look out for are:

  • History of seizures
  • Metal implant in your head, neck or chest area
  • Previous adverse reaction to TMS therapy
  • Caution in people with a history of severe head injury and serious neurological conditions

TMS treatment is usually not done if you have the following magnetic metal objects:

  1. Bullet fragments or shrapnel
  2. Pacemakers
  3. Deep brain stimulators
  4. Aneurysm clips
  5. Magnetic metallic ear or eye implants
  6. Stents

Most patients with braces or dental fillings can have this treatment as the materials are non-magnetic.

 

What is TMS?

Transcranial Magnetic Stimulation

Conclusion

Depression is the leading cause of disability in the U.S.  among people ages 15 to 44 years. Antidepressants and counseling are first-line treatments for depression. However, other types of treatment may be necessary. Inadequate response and side effects to primary modalities for depression are reasons to consider other therapies. ECT, Spravato, and TMS are some alternatives.

TMS is a noninvasive treatment that uses magnetic fields to treat depression. In the United States, there is approval for the treatment of major depressive disorder and obsessive-compulsive disorder. It is different from ECT (shock therapy), which uses electrical energy.

There is no sedation during treatment. Work and normal activities resume after each treatment. A full session consists of 36 treatments – done five days a week for six weeks, with a slow taper over another three weeks. The first session lasts about an hour, but subsequent treatments are about 20 mins long.

The primary reasons to avoid doing TMS are a history of seizures, and metal implants in the head, neck, or chest area. There are different types of TMS machines, but they mostly do the same thing. Headaches, dizziness, and scalp pain are the most common side effects, though uncommon.

It is an outpatient treatment in a doctor’s office. There are many TMS treatment centers, and there is likely one around you.

Though this procedure is a great treatment for depression, it is not a cure. Your depression may recur even after TMS therapy. On average, some people tend to be stable for about a year before they begin to go downhill again.