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ADDITIONAL INFORMATION
10 Minutes
CONTENTS
Depression is one of the leading causes of disability worldwide, and millions of patients struggle to find lasting relief. While antidepressant medications and psychotherapy remain the first line of treatment, many people experience limited benefits or intolerable side effects.
For decades, electroconvulsive therapy (ECT) was considered the gold standard for treatment-resistant depression. However, its invasive nature and cognitive risks have made it a difficult choice for many patients.
Today, a safer and more effective alternative exists: Transcranial Magnetic Stimulation (TMS). This FDA-approved, non-invasive therapy uses magnetic pulses to stimulate brain regions involved in mood regulation. Backed by extensive clinical research, TMS is transforming how we treat depression, anxiety, PTSD, OCD, and other mental health conditions.
Transcranial magnetic stimulation (TMS) is a safe, effective, convenient, and noninvasive method of brain stimulation therapy. It is frequently advised for people with depressive disorders whose symptoms have not been sufficiently relieved by antidepressant medication and/or psychotherapy. TMS devices generate magnetic energy which is transformed into electrical current beneath the patient’s skull to help manage the patient’s emotional state. The device operates outside the body and uses powerful magnetic fields to stimulate neuron cell bodies in specific areas of the brain. The US Food and Drug Administration (FDA) approved TMS as a treatment modality in 2008.
TMS Treatment for Depression and Anxiety
It has research-proven benefits as in various clinical trials after six weeks of treatment, 1 in every 2 patients with depression showed significant improvement whereas 1 in 3 patients had complete relief of symptoms. TMS therapy is indicated in patients who are either unable to tolerate the side effects of antidepressant medications such as decreased libido, sexual dysfunction, weight gain or they are non-compliant with a daily dose of medicines in case of a comorbid condition.
The application of TMS is twofold; can be used alone effectively in selected patients while in others, a combination of TMS and medications has an agonist effect in increasing the efficacy of the oral medication. It is a highly convenient modern-day office treatment that does require anesthesia and the patients usually resume routine activities right after the treatment session.
Although the precise mechanism of how TMS works is not fully understood, the nerve fibers in the central nervous system are stimulated with each pulse of electromagnetic current that traverses through the skull to the brain. A transient activity of the brain cells under the treatment coil is prompted. It appears to generate changes in neurons in regions of the brain implicated in mood regulation such as the prefrontal cortex.
This alters the biological function of the brain by enhancing the release of specific neurotransmitters that are deficient in individuals with depression. This in turn seems to improve mood and alleviate the symptoms of depression. Depending on the frequency and amplitude of the magnetic pulse delivery, the biological activity of the brain can be influenced to varying levels with regard to the type and severity of symptoms. It has also been suggested by some of the recent studies that eliciting the right and left hemispheres of the brain to have variable effects on the mood of the patient.
In an outpatient setup or a medical center, during a TMS session, a trained technician or a physician places an electromagnetic coil against the scalp near the forehead. The electromagnet coil will deliver a magnetic pulse that elicits nerve cells in the region-specific to mood. As a painless, highly convenient procedure, general anesthesia is not required. The patient is awake throughout the procedure and barely feels anything over the scalp.
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There might be some clicking sounds when the device starts delivering the magnetic impulses. Each session can last for 20 to 40 minutes. There is no downtime and routine activities can be immediately resumed. Generally, a total of 5 sessions per week for about 6 weeks are required for significant results. There are various methods to perform the TMS procedure, and techniques may change slightly with different experts.
Mental health is still stigmatized in many parts of the world and only a fraction of patients suffering from depression would seek medical treatment. Among these, more than 30% fail to achieve reasonable improvement. Medications or psychotherapy are not suitable for all patients.
About 25% of individuals with depression will not respond to several trials of medication therapy either due to a lack of efficacy or compliance to medication. Similarly, a vast majority of patients have failed to respond to psychotherapy due to a lack of follow-up or a dearth of financial resources and/or time. Other treatment modalities are vital in addressing the unending needs of patients who suffer from the devastating effects of depression.
Some of the key benefits of TMS therapy over the more conventional ECT (electroconvulsive therapy) include:
The TMS therapy was approved by FDA after 13 years of clinical trials mostly in the United States. The company that created the first Transcranial Magnetic Stimulator machine was Neuronetics Inc. The machine is called NeuroStar. To date, it remains a state-of-the-art machine that has earned significant recognition among practitioners and patients. The FDA approved these magnetic stimulators to deliver electromagnetic pulse at a frequency of 10 Hz for 37.5 minutes including breaks.
FDA approved a second machine that was manufactured by a company called Brainsway. The claims for this pulse generator machine were slightly different. The manufacturers claimed that the pulse generated by this machine would reach much deeper brain structures than its counterpart NeuroStar. In strictly technical terms, these claims are only theoretical as it has not been scientifically proven that the Brainsway machines hit a deeper part of the brain.
That being said, the spherical models of Brainsway claim that in comparison with other machines, they have achieved a further deeper stimulation of brain structures (about 0.7 centimeters) with their deep TMS devices. One of the main advantages marketed for using Brainsway machines was the short treatment length as it is employed for 20 minutes compared to 37.5 minutes for conventional TMS machines. This allows the practitioners and physicians to decrease the interval time in between stimulations so the TMS sessions could practically be half as long.
Several studies do show a higher efficacy of Deep TMS. Apart from stimulation of deeper structures, stimulation of a much larger portion of the brain with each pulse is also predicted. On the contrary, a study published in 2017 found out that patients reported a greater decrease in depressive symptoms from Surface TMS compared to Deep TMS. Patients were also more confident in undergoing Surface TMS therapy. Likewise, practitioners who worked on both devices reported that Surface TMS therapies have fewer side effects compared to Deep TMS.
TMS therapy is generally well-tolerated. Over the last few years, it has been linked with fewer side effects and a bare minimum percentage of patients stop treatment because of the side effect. The most common side effect reported by almost half of individuals treated with TMS is a headache. This is usually mild and would generally diminish over the course of the treatment session. Over-the-counter oral analgesics can be advised by the practitioner for the subtle post-procedure symptoms. The most severe side effect of TMS therapy is generalized seizures, though the risk of getting a seizure is extremely low.
One of the downsides of TMS therapy is the longer period of treatment. The time required for a full course of TMS treatment is 5 days per week for 6 weeks. Also, procedural anxiety (before and during treatment) is an add-on side effect in comparison with medication therapy. As a costly procedure, sometimes the patients will complain about the issues with their insurance coverage of TMS therapy.
In comparison with the more invasive ECT which has well-documented side effects, there are no distinguished long-term side effects of TMS therapy. Generalized seizures are a potential long-term serious side effect but the chances of seizures with TMS therapy alone are extremely low. That being said, TMS therapy has not been linked with the most usual side effects of antidepressant medications including sexual dysfunction, sedation, GI upset, weight gain, and dry mouth.
Like with all other procedures involving magnetic currents (for instance, MRI), TMS therapy is not recommended for patients with any type of non-removable metal device in their head or facial skeleton. Some exceptions to these are dental fillings and braces. Likewise, TMS therapy is not advised to patients who have has a seizure in the past. In case such negligence is practiced, a serious injury or even death can occur with the object malfunctions and heats up inside the body. These metal implants/devices include but are not limited to:
TMS therapy is a fairly new treatment modality. Ongoing research data has shown amazing results regarding its efficacy. A recent systematic review showed that a total of 9 studies reported 63% of individuals noticed significant relief of depression symptoms who had undergone TMS treatment. In the same study, response rates post TMS therapy for 5 weeks were found to be 70.6% and the remission rates were 41.2%.
Some studies conducted on depression questionnaire scores showed that it reduces depression scores significantly by up to 40-50%. Numerous high sample studies on TMS therapy advocates that it is effective in improving symptoms of depression. In one study of relapse rates after six months conducted with 204 patients, the relapse rates of patients who had undergone TMS therapy were 22.6%. This means that about 80% of patients were symptom-free at six months period post TMS.
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In another observational study including 42 clinical settings where 307 patients identified with medication-resistant Major Depressive Disorder received up to 6 weeks of TMS therapy. Patient on three symptom assessment scales; the Patient Health Questionnaire, Inventory of Depressive Symptoms Self Report, and the Clinician Global Impressions Severity of Illness scale. The reported results showed statistically and clinically significant improvement in response as well as remission rates after TMS therapy.
Studies have also shown considerable response of patients with generalized anxiety disorder. In a study conducted by the neurosurgery department in University hospital Belgium, the scientists found out that anxiety scores decreased significantly by 33% along with a 40% reduction of depression scores, 45% decrease in tension levels, and 44% in fatigue. Similar studies could be found for other psychiatric illnesses, advocating the ‘off-label’ use of TMS therapy beyond Major Depressive Disease.
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