Transcranial Magnetic Stimulation (TMS) is a non-invasive procedure for treatment resistant depression. It was approved by the FDA in 2008 and the techniques and devices used for the treatment have been steadily improving since. Treatment resistant depression has different definitions as experts have not fully agreed on the parameters. Basically, however, it is defined as major depression that does not respond to anywhere from two to four adequate medication trials.
Over the years, the volume of research on TMS has increased steadily with steadily increasing optimistic outcomes. A well-known study called the STAR*D study reported that the likelihood of major depression being successfully treated with medication goes down with each failed medication trial. In contrast, it was reported in 2012 that one out of two patients with treatment resistant depression experienced significant improvement in depression symptoms with TMS.
This is exciting for many reasons. First of all, there are less side effects associated with TMS than with medications. This is especially true when augmenting treatment with more than one medication. Additionally, over time, TMS is more cost effective as many patients continue to enjoy remission from depression months after treatment. They are more productive and generally are on less medication. Response can start in as little as three weeks.
At this point you may be wondering what TMS is. It is a treatment that utilizes intense, localized magnetic fields to stimulate neural circuits that are implicated in depression. The patient sits in a chair that looks a lot like a dentist’s chair. Good news; there are no drills, no bibs, no tooth-picking and scraping, no spitting. Once you are measured for where the magnetic coil is placed, your job is to sit and relax for each 37 minute treatment. The treatment is delivered five days per week, usually for six weeks.
Each session delivers a total of 3,000 magnetic pulses. The magnetic pulses induce small electric currents that depolarize neurons and release neurotransmitters. The stimulation is like dominos falling, it reaches more distant areas in the brain, especially related to emotion, that result in increased blood flow and glucose metabolism. This is the effect that is thought to result in treating depression.
By week three so many patients are feeling so much better they look forward to subsequent visits. The main side effect is scalp pain or discomfort. Generally people get used to the sensation of the coil very quickly. Patients are awake and alert throughout the treatment; there is no special shielding or medication required. After each treatment, patients go back to normal activities immediately. There is no recovery period.
This is now a modality that is offered in this practice. Before medical school, I worked as an Emergency Room Technician. In that field, we had lots of procedures to offer. We had X-Rays, blood tests, CT scans, etc. These were all proven procedures that aided greatly in diagnosis and treatment. When I decided to become a psychiatrist, I did so knowing that I would not have access to that side of medicine. I sacrificed the satisfaction of those for the more important satisfaction of connecting with people. The satisfaction of solving problems through connection and communication.
With TMS, there is a way to merge making connections with the ability to offer a procedure. I will always believe in a person’s ability to get better. I believe in self-directed wellness. This is a model that focuses on regular sleep behaviors, good attention to nutrition, work on using social supports, and regular exercise that involves either/or elevated heart rate and time outside. Finally, a cornerstone to self-directed wellness is using skills to tolerate feeling bad. These include deep breathing, meditation, mindfulness, reframing negative thinking. Those should always be incorporated in the care of a patient suffering from depression. The problem is, when a person is depressed enough, they cannot learn or access any of those skills.
At birth, we are wired to feel good, optimistic, to pursue success and productivity. We are not wired to be depressed, we are not wired to think in negative and depressive ways. These are intrusive thoughts that depression brings. These are indications that the nervous system, in charge of thinking, acting and behaving is not working right. You can get better; you have to be willing to work at recovery but it is worth it. I guarantee you the support will be there if you make the commitment.
It is very exciting to take a step in a new direction that can lead to growth and satisfaction as a provider in helping patients with depression. For more information on TMS, there is a website, www.tmssolutions.com. It is a terrific source of information. There are other disorders being researched for TMS and it looks like there will be even further application for this technology in psychiatry. Stay tuned.
After this last Independence Day, I ask, isn’t it time to find a new way to liberate yourself from the horrible oppression of depression? Yes it is! Explore your avenues to liberation. There is always a way. Happy Independence Day!
- Janicak PG et al. “Advances in Transcranial Magnetic Stimulation for Managing Major Depressive Disorders”, Current Psychiatry. 2016 15(6), pp 49-56.
- George MS, et al. “Daily Left Prefrontal Transcranial Magnetic Stimulation Therapy for Major Depressive Disorder”, Arch Gen Psychiatry, 2010, 67(5): 507-516.
- Carpenter LL et al. “Transcranial Magnetic Stimulation for Major Depression: a Multisite, Naturalistic, Observational Study of Acute Outcomes in Clinical Practice”, 2012 Jul; 29(7):587-96. Epub 2012 Jun 11.
- Rush AJ, et al. “Acute and Longer-term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: a STAR*D Report”, Am J Psychiatry, 2006, 163: 1905-1917.