If you suffer from treatment-resistant depression, TMS therapy could be the answer to your prayers.
Transcranial magnetic stimulation (TMS) has been gaining ground as a therapy for a treatment-resistant depression (TRD) ever since 2007. Treatment-resistant depression, turns out, is less responsive to medication than what was observed in the late 90’s. In 2008, TMS therapy was approved by the Food and Drug Administration for the treatment of major depression in the 30% to 50% of patients who had at least one unsuccessful antidepressant treatment course. FDA initially approved just one TMS device, the NeuroStar, manufactured by Neuronetics. A second device, manufactured by Brainsway, gained FDA approval in 2013. TMS treatment centers have been established across the country ever since, and insurance companies followed suit by covering the non-invasive yet expensive treatment.
Richard Bermudes, M.D., is the founder and chief medical officer of TMS Health Solutions, a team of clinicians and staff who have dedicated their lives to research, education, and treating those with mental health conditions. Relying on the most advanced therapies that are continually incorporating new and groundbreaking treatment methods, TMS Health Solutions offers a unique, patient-centered experience as it aims to help those with mental health conditions. In particular, the company specializes helping individuals with TRD, and one of the advanced therapies they offer is TMS.
So, what exactly is TMS, and why should psychiatrists, as well as the general public, be aware of it?
During a TMS therapy procedure, a physician or a nurse places a non-invasive TMS coil against the scalp, more specifically, over the left prefrontal cortex area which is the region of the brain that emits abnormal electrical activity in depressed patients. The non-invasive device then sends electromagnetic energy to the brain of the patient by sending short magnetic signals. This is different from electroconvulsive therapy (ECT), which has been an available procedure in the United States for more than 70 years. ECT is effective at alleviating major depressive disorder, albeit having some drawbacks. It must be administered under anesthesia, thereby prolonging preparation as well as recovery, and its side effects include confusion and memory loss. During TMS treatments, patients remain awake during the course of the treatment, while simply seated in a chair.
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Briefly, the device itself is a high powered magnetic coil that works to stimulate neurons in the brain. Essentially, the machine entails a stimulator with a bank of capacitors that allow energy to be stored and released in milliseconds. This movement of energy, or current, goes through a coil. Perpendicular to that coil a high powered magnetic field turns on and then off, and this fluctuation affects neuronal functioning at the molecular level.
“You sit in a chair, it takes about 30 minutes, and then you can get up and drive yourself home,” says William McDonald, M.D., a psychiatrist at Emory University School of Medicine who was involved in the clinical depression trials that led to the approval of the NeuroStar device, one of the first to be FDA approved for TMS purposes. Treatment side effects are minimal, with headache and muscle soreness being the most common complaints. Although there is a small risk of seizure associated with it, it is reportedly comparable to the seizure risk associated with antidepressant medications. Compared to ECT TMS is a walk in the park.
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A total of 20 to 30 sessions that are administered at a frequency of three to five treatments per week over the course of four to six weeks is a typical course of TMS therapy. Given that the TMS machines are expensive, the treatment is not cheap either: it can cost anywhere between $6,000 to $12,000.
According to Dr. Bermudes, TMS is a non-invasive therapy and it does not generate a seizure. It has a sub-seizure threshold. TMS therapy actually introduced the idea that it is possible to do neuro-modulation without generating a seizure and improve moods.
Dr. Bermudes highlights that TMS treatments are different from antidepressants. “It kind of works in the opposite. Anti-depressants seem to, what they say, work from the bottom up. Where cognitive therapy and TMS seem to work from the top down. Where anti-depressants would sort of down regulate limbic systems, and then you’d get more cortical control that way. That’s kind of how I try to keep it, sort of at these upper circuits and lower circuits,” he states.
Despite the several lingering questions surrounding TMS, including how best to deliver it, which patients make the best candidates, and what exactly the device is doing the brain, physicians are optimistic, and the therapy is supported by both the health care providers as well as patients. “I think it’s a promising treatment,” says William McDonald, M.D., a psychiatrist at Emory University School of Medicine who was involved in the clinical depression trials that led to the approval of the NeuroStar device. “I’m a skeptic. But if I had significant depression and I had failed one or two antidepressants, I’d have to consider TMS.”
Dr. Bermudes has received several TMS treatments himself. When asked about what it felt like, he compared it to the sensations he feels following a several-mile run, “I’ve sat through a treatment, sort of randomly. They’re not in a row, I have a similar sensation actually. Like I just went out for a nice four to five mile run, and sort of have this level of optimism about the day and clarity of thinking. That’s been my experience.”
After earning his medical degree from the University of California San Diego in 1997, Dr. Bermudes served as chief resident for the family medicine and psychiatry program at the University of Cincinnati. He then completed a fellowship at the Beck Institute for Cognitive Therapy and Research in Philadelphia. He is also the founding member of a clinical TMS society, and he chaired the first annual meeting in 2013. In 2015, he was elected president of the society.