Transcranial Magnetic Stimulation (TMS) compared to Electroconvulsive Therapy (ECT)
Transcranial Magnetic Stimulation (TMS) and Electroconvulsive Therapy (ECT) are two different types of brain stimulation therapies used for the treatment of depression, along with other disorders. They use similar methods to stimulate areas of the brain using electricity and magnetic stimulation. However, there are some significant differences.
Electroconvulsive Therapy, also called Electroshock Therapy
- Requires a hospital procedure and the use of general anesthesia
- Medications and general anesthesia are necessary
- An electrical current is sent into the brain
- A brain seizure is produced, including areas that control mood, sleep and appetite
- The patient remains in recovery for about 30 minutes afterward
- One treatment performed about 3 times a week, 6 to 20 treatments,
Transcranial Magnetic Stimulation
- Procedure is performed at the doctor’s office
- No general anesthesia or procedural medication required
- Magnetic pulses are sent into the brain
- There is no seizure, only pulses sent to areas of the brain controlling mood
- No need for recovery
- One treatment performed 5 days a week, for 4 to 6 weeks
ECT is a hospital procedure because it is intense, with electrodes that deliver electric shock. TMS treatment is much less involved. Although the action and effect are similar, the procedures are quite dissimilar.
- Care team includes a psychiatrist, resident, anesthesia team and two nurses
- Patient checks into the hospital and puts on a gown
- Cardiac monitoring pads placed on the chest, electrodes on the head
- IV fluids inserted for medication, then anesthesia
- Electrical currents sent for 15-20 minutes
- Patient is moved to the recovery room for monitoring
- Patient must be driven home and watched until bedtime
- Care team includes a psychiatrist (for initial mapping) and a technician
- Patient reports to the doctor’s office and remains in street clothes
- A TMS coil is positioned on the patient’s head
- No medication is required since there is little to no pain
- Magnetic pulses are delivered for 25-40 minutes
- The patient drives home afterward
The Side Effects of Treatment
People are naturally concerned about side effects, especially when it comes to brain stimulation therapy. Because ECT has had a history of being painful and invasive, many are fearful of it. However, many improvements have been made over the years. Now, because a patient is under anesthesia, there isn’t pain felt during the treatment although there can be afterward. One of the huge advantages of TMS over ECT is evident with regard to side effects.
ECT side effects
- Memory loss is often the greatest concern, and there are two different kinds:
- Short-term memory that includes the time during which when you’re treatments
- Longer-term memory loss of past events from 2 weeks up to 6 months before treatment
- Immediately after treatment, the patient may be confused for a few minutes to several hours
- Physical side effects such as nausea, headache, jaw pain or muscle ache often treated with as-needed analgesic medication
- Medical complications typically involved with the risk of anesthesia
- Heart rate and blood pressure increase, so occasionally heart problems result such as arrhythmias and/or ischemia
- Mild dental and oral difficulties especially with dental fractures and prosthetic damage
- Prolonged seizures are uncommon
- Rare risk of death, resulting from reactions to anesthesia, cardiovascular complications, pulmonary complications, or stroke
TMS side effects
- Mild eye pain or facial pain at treatment site
- Slight headache
- Rare risk of seizure equal to that of antidepressants
Efficacy and Use
Because ECT has been in use since the 1930s and TMS therapy was introduced in the 1980s, far more studies have been conducted surrounding ECT. Thanks to ever-improving techniques, both treatments continue to improve. Currently there are more ongoing studies surrounding TMS, not only with regard to depression but also several other maladies.
Uses and studies regarding ECT
ECT is often used as a last line of intervention for major depressive disorder, bipolar, mania, catatonia and schizophrenia. The effectiveness of ECT is most evident shortly after treatment.
A review was done in 2008 that analyzed data collected with regard to the efficacy of ECT. It stated that there was a “significant superiority” in comparison of ECT to placebos, antidepressants, TCAs and MAOIs.”
(Daniel Pagnin, M.D., M.Sc.; Valéria de Queiroz, M.D., M.Sc.; Stefano Pini, M.D.; Giovanni Battista Cassano, M.D. “Efficacy of ECT in Depression: A Meta-Analytic Review”. Focus.)
One study concluded, “ECT is still highly effective in severely treatment-resistant patients with major depressive disorder, with more than half of such patients achieving remission.”
(Khalid N1, Atkins M, Tredget J, Giles M, Champney-Smith K, Kirov G. The effectiveness of electroconvulsive therapy in treatment-resistant depression: a naturalistic study.)
ECT techniques can vary in three ways: electrode placement, frequency of treatments, and electric waveform of the stimulus. Not only do they differ in technique, they also have different results. The technique affects the rate of remission with ECT, which varies from 20 to 80 percent in research studies using different procedures. (Lisanby SH. Electroconvulsive therapy for depression. N Engl J Med 2007; 357:1939.)
Other major studies regarding ECT include the following:
Grunhaus L, et al, Response to ECT in major depression: are there diﬀerences between unipolar and bipolar depression? Bipolar Disord 2002; 4(Suppl. 1): 91–93. (http://www.ncbi.nlm.nih.gov/pubmed/12479688)
Sackeim, HA et al, Length of the ECT Course in Bipolar and Unipolar Depression. J ECT 2005; 21 (3): 195-197. (http://www.behaviorismandmentalhealth.com/wp-content/uploads/2013/11/Sackeim-et-al-J-ECT-2005.pdf)
Medda P, et al, Response to ECT in bipolar I, bipolar II and unipolar depression. J Aﬀect Disord 2009; 118: 55–59. (http://www.ncbi.nlm.nih.gov/pubmed/19223079)
Sienaert P, et al, Ultra-brief pulse ECT in bipolar and unipolar depressive disorder: diﬀerences in speed of response. Bipolar Disord 2009; 11: 418–424. (http://www.ncbi.nlm.nih.gov/pubmed/19500095)
Bailine S, et al, Electroconvulsive therapy is equally eﬀective in unipolar and bipolar depression. Acta Psychiatr Scand 2010; 121: 431–436. (http://www.ncbi.nlm.nih.gov/pubmed/19895623)
Daly JJ, et al, ECT in bipolar and unipolar depression: differences in speed of response. Bipolar Disorder 2001; 3: 95–104. (http://www.ncbi.nlm.nih.gov/pubmed/11333069)
Uses and studies regarding TMS
In 2008, TMS became FDA approved for the treatment of major depression. In 2015, it was approved for the treatment of migraines. In Europe, it has also been approved for OCD, PTSD, stroke after-effects, bipolar depression, schizophrenia, Parkinson’s disease, cigarette addiction, autism spectrum disorders, Asperger’s, multiple sclerosis and chronic pain.
Many of the studies performed with regard to TMS and the treatment of depression did not allow for antidepressant treatment to continue, nor for the parameters of the TMS treatment to be altered. Both of those factors can be important, however, in individualized TMS therapy.
Fortunately, in 2012, a TMS study was performed using typical clinical practice settings. It included outcomes from 307 patients with Major Depressive Disorder who had been unresponsive to treatment with antidepressants. Results included a 58% positive response rate and a 37% remission rate
Carpenter LL1, Janicak PG, Aaronson ST, Boyadjis T, Brock DG, Cook IA, Dunner DL, Lanocha K, Solvason HB, Demitrack MA. Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depress Anxiety. 2012 Jul; 29 (7):587-96. Epub 2012 Jun 11.) (http://www.ncbi.nlm.nih.gov/pubmed/22689344)
The NeuroStar TMS machine received FDA approval based on what was the largest multi center controlled study at the time.1 A second study conducted in 2010 provided additional evidence to support the efficacy of TMS.2
- O’Reardon, J. P., H. B. Solvason, et al. (2007). “Efficacy and Safety of Transcranial Magnetic Stimulation in the Acute Treatment of Major Depression: A Multisite Randomized Controlled Trial.” Biol Psychiatry 62(11): 1208-1216. (http://www.ncbi.nlm.nih.gov/pubmed/17573044)
- George, M. S., S. H. Lisanby, et al. (2010). “Daily Left Prefrontal Transcranial Magnetic Stimulation Therapy for Major Depressive Disorder A Sham-Controlled Randomized Trial.” Arch Gen Psychiatry. 67(5): 507 – 516. (http://www.ncbi.nlm.nih.gov/pubmed/20439832)
Background of ECT
Electroconvulsive therapy (ECT) was first used in 1938. Initial function producing seizures was rudimentary and this is where many of the negative images began. The shock treatments were rigorous and painful. Because of the severe memory loss that also occurred, patients could not recall the treatment nor the discomfort surrounding it. Of course, that still meant severe memory loss. Work was then performed to improve the process, including the addition of muscle relaxants in order to modify the convulsions. Anesthesia was also added to reduce pain. When antidepressants began to be administered during the 1960s, the use of ECT declined.
The single most negative portrayal of electroshock therapy took place in “One Flew Over the Cuckoo’s Nest.” That movie probably did more to sway public opinion against ECT that anything else. At about that same time, ECT delivery was changed to a constant current in brief pulses. Even though the treatment improved, there were still negative side effects and, at times, it was used as a form of abuse or punishment in some mental health facilities.
The method of ECT has continually been refined. Delivery has become more patient-friendly and less invasive. In 1990, the APA outlined details about its methods, usage, and patient education. In 2001, the APA emphasized the importance of informed consent so that potential patients would be made more aware of the risks involved.
Background of TMS
TMS was first introduced as therapy in 1985. Rather than using the invasive direct electric current as implemented through ECT, TMS uses electromagnets which reduce patient discomfort, avoid the side effects of memory loss, and enable doctors to map the cerebral cortex. In fact, its use and effects are comparable to that of an MRI rather than ECT.
With regard to a history of patient safety, TMS is far ahead of ECT. Although ECT has become milder and is performed while the patient is under general anesthesia, TMS does not use a shock at all. Instead, pulsating magnetic fields create electric currents in the neurons and change the firing potential, a mechanism of action much safer than that of ECT. So, with TMS, there is no history of severe pain or invasive treatment. Over the years, patients have reported little more than a mild headache, or minor pain at the treatment site during therapy.
Perhaps the most telling comparison between ECT and TMS can be found with regard to the informed consent required for patients to read before treatment. Such forms vary from state to state, even from office to office. Below you will find two such forms.
ECT informed consent
From the State of Vermont, Department of Health, Division of Mental Health
(retrieved at http://www.timesargus.com/assets/pdf/BT345781212.PDF)
Basic Background On ECT
What is ECT? How is it done? What are the risks and benefits? ECT is a medical treatment in which a small amount of electricity is applied to the scalp and this produces a seizure in the brain. The procedure is painless because the patient is under general anesthesia. ECT involves a series of treatments. Before patients begin to receive these treatments, they have various testing done in order to evaluate their overall physical health. Testing will also establish how they are doing in various psychological areas before ECT.
To receive each treatment, patients are brought to a specially equipped area in this hospital. Because the treatments involve general anesthesia, there can be nothing to eat or drink for at least eight hours before each treatment, apart from any medication ordered by the doctor. After being placed on a stretcher in the ECT area, the patient has a medical needle placed in the vein so that medication can be given through an intravenous (IV) catheter.
Then the patient is prepared for treatment. Monitoring sensors are placed on the head and other parts of the body, in order to keep track of brain waves, heart, and the oxygen being taken in. A blood pressure cuff is placed on an arm or leg to measure blood pressure. These monitors are not painful or uncomfortable. When the patient is ready, a medicine (anesthesia) is given intravenously that quickly puts him or her to sleep. A second drug is given to relax the patient’s muscles, including the muscles that help the patient breath. Throughout the procedure, the patient receives oxygen through a mask.
Breathing is assisted until breathing resumes on its own. Because the person is unconscious (under anesthesia), he or she does not feel pain and is not uncomfortable during the ECT. After the patient is under anesthesia, a small amount of electricity is passed between two electrodes that have been placed on the head. When the current is passed through the brain, a generalized seizure occurs. This is also called a convulsion. Because of the medication received to relax the muscles, the movements in the body that would ordinarily come with this reaction are very decreased.
The seizure lasts for about one minute. The amount of electricity used is adjusted to individual needs, based on the judgment of the ECT physician. In one method, during the first treatment, more than one electrical stimulation may be applied to establish the level needed to produce a seizure. After that usually only one stimulation will be applied in each treatment session. Within a few minutes, the anesthesia wears off and the patient wakes up. He or she is then brought to a recovery room, and is watched over for recovery from the anesthesia and any initial confusion.
The Benefits and Risks
The potential benefit of ECT is that it may lead to improvement in an individual’s condition. ECT has been shown to be a treatment that works well for a number of conditions. As with many kinds of medical treatment, some patients improve quickly, some improve only to relapse
again and need more treatments; while some are not helped at all. The chances of being helped vary. People less likely to be helped include those who have not been helped in the past by medications or ECT. Like other medical treatments, ECT has risks and side effects. To reduce the risk of problems, patients receive a full medical review before starting ECT. The medications a person has been taking may be changed. Even with precautions, it is possible that a medical problem will result from the ECT. As with any procedure, placing someone under anesthesia, there is a remote possibility of death. The risk of death from ECT is very low, about one in 10,000 patients. This rate may be higher in patients with serious medical problems.
ECT rarely results in serious medical problems, such as heart attack, stroke, breathing problems, or continuous seizures. More often, ECT results in heartbeat problems. These problems are usually mild and short lasting, but in some instances can be life threatening. With modern ECT methods, problems with teeth are not frequent. Bones being broken or moving out of joint are very rare. Uncommonly, as with other antidepressant treatments, ECT may bring on mania or hypomania in a person with bipolar disorder, which may or may not have been previously diagnosed. The minor side effects that are common include headache, muscle soreness and nausea. These side effects usually get better with simple treatment.
When the person wakes up after each treatment, he or she may be confused. This confusion usually goes away within an hour.
Common side effects of ECT are changes in memory. The memory problems with ECT have the following pattern: Shortly after a treatment, the problems with memory are the greatest. As time from treatment increases, these memory problems lessen. Shortly after the course of ECT, the person may have problems remembering events that happened before and while receiving ECT. This spottiness in memory for past events may go back to several months before ECT, and in some people, to one, two, or more years. Many of these memories should return during the first few months after the ECT course. However, individuals may be left with some permanent gaps in memory, particularly for events that happened close in time to the ECT.
Also, for a short time period following ECT, there may be difficulty in aspects of thinking such as learning and remembering new events. This problem with making new memories should be short term and will most likely be gone within several weeks following the ECT course. People vary greatly in their experience of the confusion and memory problems during and shortly following ECT. However, some mental conditions themselves cause problems in learning and memory. In part because of this, some patients report that their learning and memory is improved after ECT; testing shows that some people experience improvements to pre-illness levels. However, there are reports of some people who have memory loss that is much more serious, long lasting or permanent. In addition, some people report difficulties with thinking and problem solving. There is not enough research to predict which person will experience a return to improved thinking and memory, have temporary problems, or have more severe difficulties and/or memory loss for which there is no known treatment.
The memory problems that a person may have are partly related to the number and type of treatments the person gets. A smaller number of treatments are likely to cause fewer memory problems than a larger number. There are fewer memory problems with unilateral than bilateral (bitemporal) ECT. In unilateral ECT, electrodes are placed on only one side of the head. In bilateral (bitemporal) ECT, electrodes are placed on both sides of the head. In bifrontal ECT, electrodes are placed on both sides of the front of the head, and it is not yet as fully researched. Because electrode placements impact on how well ECT works and how significant the side effects may be, the decision about electrode placements should be discussed with the patient and treating doctor. There are other potential electrode placements and these should be discussed with your doctor.
Plans to Consider before Receiving ECT
ECT may cause you to forget information you learned before the treatment. While receiving ECT, you may wish to review some of this information again. Some patients take notes, tape or even videotape some of the information being discussed. You can also have a family member or a friend present. Additional educational materials are available. If you have questions about information you receive from any source, feel free to bring it in and ask your doctor about it. You may want to consider asking for the support of family or friends ahead of time to help in coping with the possible memory problems. They could help you prepare summaries of important events of the recent past, or develop lists of things you may need to remember. They could also help by coaching you after ECT to help remember events. Because of the possible problems with confusion and memory, you should not make any important personal or business decisions during or immediately after the ECT course. This may mean postponing decisions about financial or family matters. After ECT treatment you should not drive, do business or do other activities where having memory problems could interfere, until you have talked it over with your doctor.
Before your discharge from ECT treatment, you will be given the name and phone number in writing of a person you will be referred to work with for follow-up care, if it is different from your current doctor. You should inform this person promptly if there are any unexpected changes in your condition at any time, including whether you feel your memory problems are worse than you expected. ….
Review of Risks and Side Effects
Like other medical treatments, ECT has risks and side effects, as also discussed in Part A.
Serious risks include:
- Complications from anesthesia including death
- Heart attack
- Breathing problems
- Continuous seizures
- Life threatening heart beat irregularities
- Broken bones or bones out of joint
- Mania or hypo-mania in people with bipolar illness
- Permanent memory loss
Minor risks include:
- Muscle soreness
Shortly after a course of ECT, a person may have problems remembering events that happened before treatment, and which may go back several months before receiving ECT. Many of these memories return during the first few months after the ECT course. Permanent loss of memory may occur for some, especially events close in time to the ECT. There may also be difficulty in aspects of thinking such as learning and remembering new events and problem solving. There is not enough research to predict which person will experience a return to improved thinking and memory, have temporary problems or have more severe difficulties….
TMS informed consent
Consent for TMS
Taken from Northeast TMS
(retrieved from http://www.northeasttms.com/wp-content/uploads/2014/06/consent-form-northeast-tms.pdf )
Consent Form for Treatment with the Deep TMS System
On and Off-Label Consent
This consent form outlines the treatment that your doctor has prescribed for you, the risks, potential benefits, and any alternative treatments if you decide not to be treated with dTMS.
What is dTMS?
Deep Transcranial Magnetic Stimulation (dTMS) is a noninvasive technique used to apply brief magnetic pulses to the brain. The pulses are administered by passing high currents through an electromagnetic coil placed adjacent to a patient’s scalp. The pulses induce an electric field in the underlying brain tissue. When the induced field is above a certain threshold, and is directed in an appropriate orientation relative to the brains’ neuronal pathways, the neurons in the relevant brain structure are activated.
Is it approved?
The Brainsway Deep TMS System is cleared by the Food and Drug Administration (FDA) for the treatment of depressive episodes in adult patients suffering from Major Depressive Disorder.
How does it work?
dTMS will be administered by a trained Technician. During a dTMS treatment session, the technician will place the magnetic coil cover over your head. To calibrate the intensity of dTMS you need, we will stimulate the region of your brain that makes the thumb move. You will hear a click and sound and feel a tapping sensation on your scalp. The device will be adjusted to give just enough energy to send electromagnetic pulses into the brain so that your thumb twitches. The intensity of stimulation that barely produces a movement is called the motor threshold (MT). Once your MT is determined, the magnetic coil will be moved to the location of the brain that scientists think may be responsible for causing depression. The stimulation will be set to 120% of your MT. How often your MT will be re-evaluated will be determined by your doctor. The treatment session is delivered as a series of pulses that last 2 seconds, with a rest period of 20 seconds between each pulse sequence for a total of 1,980 pulses. Treatment is targeted to the region of your brain called the dorsolateral prefrontal cortex (DLPFC). Each treatment session lasts approximately 20 minutes.
This treatment does not involve any anesthesia or sedation and you will remain awake and alert during the treatment. You may be evaluated by a healthcare provider during this treatment course.
Is the treatment effective?
The effectiveness of the Brainsway Deep TMS System has only been tested in patients receiving 5 daily sessions over a four-week course, and optional maintenance treatments with bi-weekly sessions for an additional 12 weeks, with the stimulation parameters outlined above. Any change in this treatment course, intensity, or location has not been tested, and efficacy results are not available.
Brainsway Deep TMS System is not effective for all patients with depression. Any signs or symptoms of worsening depression or signs of suicidality should be reported immediately to your doctor. You may want to ask a family member or caregiver to monitor your symptoms to help you spot any signs of worsening depression.
Are there any risks?
The most common adverse events reported are application site pain or discomfort and headache. If you experience these, we may be able to modify the location or intensity of the treatment, or you can use over-the-counter analgesics for relief. Brainsway Deep TMS System is contraindicated for use in patients who have conductive, ferromagnetic or other magnetic-sensitive metals implanted in their head or are non-removable.
Failure to follow this restriction could result in serious injury or death. An object that may have this kind of metal includes, but is not necessarily limited to:
- Aneurysm clips or stents
- Implanted electrodes/stimulators
- Ferromagnetic implants in ears or eyes
- Cochlear implants
Brainsway Deep TMS System should be used with caution in patients who have pacemakers or implantable cardioverter defibrillators. If you have a removable device or object that may be affected by the magnetic field, the device should be removed from the patient area before treatment to prevent possible injury to the wearer or damage to the device. Examples include wearable monitors, bone growth stimulators, earrings, hearing aids, eyeglasses, jewelry, hair barrettes, cell phones, MP3 players, etc.
One seizure has been reported with the use of the dTMS device in the clinical study leading to Food and Drug Administration (FDA) approval. The seizure was reported in a patient who drank a significant amount of alcohol the day before treatment. Therefore, we advise that you refrain from alcohol consumption during the course of the treatment. Some patients may be at potential increased risk of seizure, including those with a history or family history of seizure or epilepsy, a history of stroke, head injury or trauma, presence of other neurological disease (CVA, cerebral aneurysm, dementia, increased ICP, or movement disorder), concurrent use of tricyclic antidepressants, neuroleptic medications, or other drugs known to lower the seizure threshold.
Long term effects of exposure to magnetic fields are not known. Due to the loud sound, earplugs or similar hearing protection devices with a rating of 30dB or higher of noise reduction must be used during treatment. Your hearing will be assessed before we begin treatments, and again once they are completed. Your insurance may be charged for this. Brainsway Deep TMS System has not been studied in patients who have had no prior antidepressant medication.
I understand that my treatment may be considered off-label for the following reasons:
(please initial where applicable):
_____ More or less than 5 treatments per week for 4 weeks
_____ More or less than 1,980 pulses per treatment session
_____ dTMS prescribed for a diagnosis other than Major Depressive Disorder
_____ Insufficient antidepressant medication trial
_____ I am younger than 22 years old
_____ I am older than 70 years old
I have read the information contained in this Consent Form about Brainsway Deep TMS System and its potential risks and possible benefits. I understand that my course of dTMS treatment may be considered off-label for the reasons stated above. I have discussed this treatment with Drs. Schmidt or Naimark and/or their designee, and all of my questions have been answered.
I understand that there are other treatment options that are considered safe and efficacious (medications, therapy, ECT, etc.). I further understand that no guarantee of any results has been made. I understand that if during the course of treatment, in the best judgment of the neuromodulation or medical staff, I require emergency treatment, I authorize and request that the said treatment be performed.
I understand that I can change my mind any time, and choose a different option. I voluntarily choose to receive dTMS Therapy with the Brainsway Deep TMS System and authorize Northeast TMS, Dr. Schmidt, Dr. Naimark, and his staff to administer dTMS treatments to me.
In comparing ECT and TMS overall, it is generally to be found that TMS is preferable because of fewer, less severe side effects and results that are similar in efficacy.