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TRANSCRANIAL MAGNETIC STIMULATION (TMS)

Intro

There is new hope for people who suffer with depression—Transcranial Magnetic Stimulation (TMS). It is especially helpful with treatment-resistant depression, for those who do not respond to antidepressants, as well as people who wish to avoid the side effects frequently caused by medication. TMS treatment usually includes four to six weeks of non-invasive, in-office treatments that take less than an hour each day, five days each week.

 

What is TMS? 

TMS is a treatment that safely delivers magnetic pulses to areas of the brain that are responsible for mood. Instead of using invasive electrical currents like in electroconvulsive therapy (ECT), the magnetic pulses from TMS are similar in strength to those emitted during a typical MRI. The pulses are directed toward the prefrontal cortex of the brain to change the magnetic field and stimulate neurons within the mood center. This not only mitigates depression for a short time but can also result in long lasting relief.

 

Benefits of TMS

  • Non-invasive—no anesthesia, electrodes or electrical current used  
  • Simple, in-office—administered by a technician and the patient can drive home afterward
  • For treatment-resistant depression—those not helped by antidepressants can benefit
  • No drug side effects—no reported nausea, weight gain, dry mouth or decreased sex drive
  • Long-lasting—after initial 4-6 weeks, maintenance may or may not be needed later

 

How does TMS work?

TMS treatment is performed in a doctor’s office, while the patient is fully awake and seated in a comfortable chair. Because the magnetic pulses make a sound similar to that of a woodpecker, earplugs are provided. The TMS device is then placed in the proper position on the head and the magnetic pulses are delivered. The process usually takes between 20 and 40 minutes. 

It is relatively simple.

  • Patient takes a seat
  • Device is placed on the head
  • Pulses are delivered for a short time
  • Patient returns to daily activities

 

Conditions treated by TMS

In the United States, the FDA approved TMS in 2008 as a treatment to alleviate the symptoms of treatment-resistant depression. It has also been approved for depression in Canada, Australia, New Zealand, Europe, and Israel. In addition, it has been CE approved in Europe for the treatment of bipolar disorder, PTSD, chronic pain, OCD, and adult AD/HD.

 

Advantages over other treatments.

In the past, the most common treatments for depression have been medication and/or psychotherapy. With TMS, psychotherapy is still encouraged because it can help people maintain mental health. However, unlike antidepressants, TMS has few if any side effects. 

 

Reported side effects of antidepressants include:

  • Nausea
  • Weight gain
  • Fatigue or drowsiness
  • Insomnia
  • Dry mouth
  • Decreased sexual desire or function
  • Anxiety
  • Irritability
  • Dizziness 

 

Side effects of TMS

Some patients report slight headaches or some discomfort at the treatment site just during the actual treatment. About a third of patients notice a prickly, tingly sensation on their scalp while the stimulating pulses are being administered. One in 1,000 patients experience a mild seizure; however, it should be noted that this risk is approximately the same as that cause by some antidepressants. In addition, the seizures related to TMS typically end when the magnetic stimulation is stopped.

 

Exceptions to TMS treatment

People who have metal implanted in or near their head should not have TMS. Exceptions include those with dental fillings, crowns and/or braces. Metals that prevent TMS treatment include:

  • Pacemakers or implanted defibrillators
  • Any stents from the neck up
  • Aneurysm clips
  • Metallic implants in ears or eyes
  • Ammo fragments near the head
  • Facial tattoos with metallic ink
  • Any metal near the head that cannot be removed

 

TMS and insurance

As TMS is being used by more physicians and patients with notable positive results, more and more insurance companies now cover or partially cover the treatment. Major insurance companies in the United States that now cover TMS include Anthem Blue Cross Blue Shield and MHN (HealthNet). There are several other state and national companies that provide reimbursement when TMS is deemed appropriate. Your local TMS treatment provider can help you determine eligibility and many will submit the paperwork for you.

 

The history of TMS

The idea of bioelectricity dates back to the late 1700s when Luigi Galvani and Alessandro Volta made differing yet similar discoveries regarding electricity and muscle contraction. Another important contribution came in 1831 when Michael Faraday discovered electromagnetic induction. The first study with TMS was performed by Anthony Barker and his colleagues who used electromagnets for the conduction (transmission of excitation) of nerve impulses. Direct electric current had been used previously, such as with ECT, but the magnetic stimulation greatly reduced the discomfort involved.

 

In 2008, TMS was approved by the FDA for use with treatment-resistant depression. It is currently being researched and used to help with a range of disorders and diseases such as anxiety, OCD, ADHD, schizophrenia, PTSD, substance abuse, addiction, tinnitus, multiple sclerosis, ALS, motor disability after stroke, Alzheimer’s and Parkinson’s.

 

The science behind TMS

 

The process of TMS treatment involves taking an enclosed coil that produces a magnetic field and placing it against the scalp. Capacitors from the TMS machine pass electrical currents through the coils that create brief, pulsating magnetic fields that pass through the skull and create electric currents in the neurons or nerve cells of the brain. The electric field changes the current of the neurons and the firing potential. This has a sort of ripple effect, as the firing of certain neurons then triggers the firing of adjacent neurons. In this way, TMS treatment accesses the area of the brain implicated in mood regulation, specifically the prefrontal cortex.

 

Research supporting TMS

In a study of 301 participants who had treatment-resistant depression, nearly half of them showed complete or partial improvement in symptoms. In addition, only 13% of those who had improvement noticed relapse of depression after six months. Also, when people started to show early signs of recurrence in depression over time, TMS was reintroduced and relapse was prevented in 85% of the cases.  (Biol Psychiatry. 2007 Dec 1;62(11):1208-16. Epub 2007 Jun 14.)

 

Types of TMS Machines

Currently there are two different types of TMS machines made by two different companies. One is called NeuroStar and the other is Brainsway. Both have proven to be effective in the treatment of depression. To date, there have been no direct comparisons that show which machine might be more effective. 

 

NeuroStar

  • Plastic covered coiled placed on skull
  • No cooling system required
  • Provides more focal or localized pulses
  • Pulses delivered 1.5 cm below the skull
  • Treatment time: 37 minutes
  • Total treatment time: 4-6 weeks 

 

Brainsway

  • Helmet with coils placed over skull cap
  • An in-helmet cooling system used for coils
  • Deeper, wider dispersion of pulses
  • Pulses delivered up to 8 cm in depth 
  • Treatment time: 20 minutes
  • Total treatment time: 4-6 weeks 

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Transcranial Magnetic Stimulation Q & A

Answers to your most commonly asked questions about TMS Therapy.

What is TMS?

Transcranial magnetic stimulation, also known as TMS, is a treatment that’s been effective for depression when psychotherapy and medications have not been beneficial. TMS therapy involves the delivery of short, magnetic pulses targeted at areas of the brain that are underactive in patients suffering from depression. Treatment plans typically involve five sessions per week over a four to six week period, with each session generally lasting fewer than 40 minutes.

What can patients expect from a typical session?

Sessions are performed right in the doctor’s office, with no need for anesthesia or any special preparation. Patients remain alert and awake as they sit or recline on the treatment chair while a device is either placed on or over the top of their head. The device remains in place throughout the 37-minute session, sending short, magnetic pulses that produce an electric current in the brain to help activate abnormally inactive brain cells, or neurons. One the session is complete, patients can immediately resume their normal activities.

How many sessions are required?

The typical course of treatment usually consists of five treatments per week over a four to six week period. This would calculate to anywhere from 20 to 30 treatment sessions, with each session lasting about 37 minutes. Specific treatment plans may vary based on individual needs.

How long do the effects last?

Most patients maintain the antidepressant effect of TMS therapy for at least six months, as evidenced by follow-up study. Those who require a long-term treatment plan can always discuss the options with their doctors.

Does TMS hurt?

Pain is not a common side effect, although some patients have experienced scalp discomfort during their treatment sessions. The discomfort was not severe, and it began to wane after the first week of therapy. Over-the-counter pain relief medications can help if necessary. If discomfort persists, the strength of the magnetic field stimulation can be reduced.

Are there other side effects?

One of the greatest benefits of TMS therapy is its lack of side effects typically associated with antidepressant medications. Because the treatment does not involve any medication or outside substance circulating throughout the blood, patients are not at risk for weight gain, nausea, sedation, dry mouth, sexual dysfunction or other uncomfortable conditions linked to certain medications. Scalp discomfort is the most common side effect, and some patients have experienced headaches during clinical trials.

Is TMS safe?

TMS is generally considered safe, although it does come with some risks. NeuroStar TMS therapy has been cleared by the FDA and Brainsway Deep TMS therapy is a CE-cleared treatment. Both types of TMS therapy are non-invasive, don’t involve the use of anesthesia and are performed while the patient is fully alert and awake. Patients can stop the treatment at any time if they feel discomfort.

What are the risks of TMS?

While seizures are rare, there is a small risk that they can occur. The risk of seizure from TMS, however, is no greater than the risk of seizure from oral antidepressant medications. Other side effects may include mild to moderate scalp discomfort, which typically wanes after the first week of treatment. Headaches have occasionally been reported.

Are there patients who should avoid TMS?

Patients who have certain implanted or non-removable metallic objects in or around the head area should not undergo TMS therapy. Physicians should be informed of such devices at the initial consultation.

Is TMS therapy similar to alternative therapies that use magnets?

No. TMS uses intense, targeted, pulsating magnetic fields similar to those used in MRI. Alternative magnetic therapies generally use a low intensity, static magnetic field that doesn’t have the power to activate brain cells. The static magnets are notoriously weak and untargeted.

Is TMS similar to shock therapy?

No. TMS is vastly different than electroconvulsive therapy, or ECT, sometimes referred to as shock therapy. TMS allows patients to stay awake throughout the entire procedure, drive themselves to and from the session, and resume normally activities directly following the sessions. Unlike shock therapy, TMS has had no reports of seizures in clinical trials more than 10,000 NeuroStar TMS treatments and no memory loss. It also eliminates the need for sedation and the extended recovery period and care giving generally required with ECT.

Does TMS cause memory loss?

No. No risk of memory loss is one of the major differentiating factors between TMS and ECT, or electroconvulsive therapy. Clinical trials showed that TMS has no ill effects on memory or concentration.

Does TMS cause brain tumors?

No. The magnetic fields used in TMS therapy are comparable to those used in MRIs. And millions of worldwide patients have undergone MRIs with no report of tumors. A single brain scan with an MRI uses a much higher dose of magnetic energy than is used with the entire course of TMS treatment.

Can TMS be combined with antidepressants?

Yes. Clinical trials have shown TMS therapy can be safe when used both with and without antidepressant medications.

Is TMS covered by health insurance?

Many companies have extended their coverage to include TMS therapy, generally for the treatment of depression when psychotherapy and medications have not been effective. Some of the larger companies that currently cover TMS include Blue Cross/Blue Shield, Anthem, MHN, or HealthNet. Many others are also on the list.

Is a brain imaging scan required before TMS treatment?

No. Brain imaging through the use of MRI, CT or similar procedures is not necessary to pinpoint specific areas of the brain for treatment. TMS therapy targets the region of the brain known as the Dorsal Lateral Pre-Frontal Cortex, and it can be located without the use of brain imaging scans. No research currently support the theory that treatment in other areas of the brain or using scans to locate other areas results in superior outcomes than the current method of treatment approved by the FDA.