Depression affects at least 21 million people in the United States. Feeling sad or down can affect how you handle life problems. (1) Because of this difficulty, handling simple tasks can seem monumental due to lack of energy and motivation to eat, sleep, and perform at school or work. Due to the symptoms of depression, many will also have difficulty with making decisions or concentrating. Sometimes the depression does not improve with common treatments such as antidepressants, mood stabilizers, and therapy. Fortunately, there are now more FDA-approved options if you are facing this kind of treatment resistant depression. Around since 1985, transcranial magnetic stimulation (TMS) is one modality that can help treat resistant depression.
How Transcranial Magnetic Stimulation (TMS) Works
Treatment for depression symptoms typically involves medications, education, and development of skills to help with symptoms of feeling sad, down, or depressed. When medications and improved skills still don't improve your depression symptoms, your provider may recommend a treatment such as TMS. The biggest difference between TMS and typical oral medications is that TMS is an external, focused treatment whereas medications are an internal, whole-body treatment (the medication can affect the whole body). Because of its more targeted approach, TMS can have fewer side-effects than oral medications. This targeted approach also means that those utilizing TMS will typically see results within 4-6 weeks whereas medications can sometimes take up to 12 weeks to reach full benefits.
TMS improves depression by utilizing a magnetic field to stimulate your brain's natural electrical activity. This magnetic field is similar to how an MRI machine operates (but without the body tube!). The magnetic field created by the TMS machine will create tiny electrical impulses in the treated area of the brain to stimulate those brain cells (neurons). These stimulated cells can then produce more of our 'feel-good' hormones (neurotransmitters): serotonin, dopamine, and norepinephrine. With more of these 'feel-good' hormones present for your brain cells to use, you can feel better.
Benefits and Risks of Transcranial Magnetic Stimulation (TMS) Treatment
In 2008, the FDA approved transcranial magnetic stimulation (TMS) for treatment of major depressive disorder. One of transcranial magnetic stimulation's many benefits is that its effects can be seen as early as 1 week from starting treatment, whereas most pills can take from 2-4 weeks before effects can start to be seen. Even with this wait time for oral medications, many people do not see significant positive effects. This is because 30-50% of patients taking a typical oral antidepressants will fail to respond within 4-6 weeks of first-line treatment with an oral antidepressant. Because TMS targets the brain cells directly, the effects are fast and notable. By 4 weeks, the response rate is 45-60% and the depression remission rate is 30-40%. (2) It is also safe and effective for pregnant and lactating women. (5, 6) Because there is no associated sedation, you can go directly back to work after treatment. Another positive aspect of TMS treatment is that it typically lasts 4-6 weeks, unlike pills that are taken for several months or years. FDA approval for TMS treatment of major depression has several advantages over oral medication.
Although safe and effective, transcranial magnetic stimulation (TMS) does have potential side effects and adverse reactions associated with it. One of the most common clinical side effects of TMS is mild headache or scalp discomfort. Up to half of TMS patients experienced some level of headache, but this side effects tends to diminish with treatment and can be relieved with over-the-counter pain relievers. In addition, about one-third of patients will experience scalp discomfort or facial twitching with the transcranial magnetic stimulation (TMS) pulses. These also tend to decrease over time of treatment and can usually be lessened with positional adjustments to the magnet. Finally, some patients may find the noise emitted by the TMS machine to be bothersome. This can be helped with earplugs during treatment. The potentially most serious risk of using TMS therapy is that of having a seizure. In studies, the rate of seizure with TMS therapy was <1% and is comparable to the risk with typical oral antidepressant medications. TMS has been used successfully in those with epilepsy, traumatic brain injury, and even those with a prior TMS-related seizure. (3, 4)
As with most treatments, not everyone can do transcranial magnetic stimulation (TMS) due to absolute contraindications to treatment. The following list overviews who cannot use TMS therapies. TMS cannot be used in these patients due to concerns about the metal heating up, malfunctioning, or moving during treatment. (3)
Non-removable metal in their heads
Aneurysm clips or coils
Stents in the neck or brain
Deep brain stimulators
Electrodes to monitor brain activity
Metallic implants in your ears and eyes
Shrapnel or bullet fragments in or near the head
Facial tattoos with metallic or magnetic-sensitive ink
Other metal devices or object implanted in or near the head
Transcranial magnetic stimulation (TMS) is not FDA-indicated for treatment in those under the age of 18 or those over age 68.
What a Typical Transcranial Magnetic Stimulation (TMS) Treatment Looks Like
Treatment with transcranial magnetic stimulation (TMS) usually begins in an outpatient medical office setting. During the first treatment session, your provider will work to identify the best position of the magnets on your head. Your provider will also work with you to decide which dose of the TMS magnet is best for you. This initial treatment session typically lasts about 1 hour. Treatment sessions are then generally completed five (5) days per week, last 20-40 minutes, and treatment is complete in about 4-6 weeks.
After checking in at the front desk, a healthcare provider will take you to the treatment room, have you sit in the TMS chair, and provide you with earplugs. The provider will then place the electromagnetic coil against your head. This coil then cycles on and off to produce electrical stimulation of your brain cells. This will sometimes create a clicking noise and a tapping sensation on your forehead. This important part of the process is necessary in order to map treatment areas for future sessions.
Your treating provider will then work with you to decide the best amount of magnetic energy necessary. Your treating provider will increase the magnetic dose until your fingers/hands twitch. This is an important step in the mapping process so that your treating provider knows what your motor threshold is. This is used as a reference to decide the correct magnetic energy level that is right for you during treatment. The dose can also be further tuned or adjusted during treatment depending how how you respond to TMS treatment or any unpleasant symptoms you may experience.
Other Treatment Resistant Approaches
The good news is that most people will respond positively with inhaled Spravato and can return to a better level of life-functioning. However, there are other approaches for treatment resistant depression as well. If you go through treatment with Spravato and decide its not right for you, your provider may suggest other treatments reserved for people who don’t respond to traditional approaches. These other treatments for depression in people that don’t respond to traditional approaches include the following:
Electroconvulsive therapy (ECT)
Vagus Nerve Stimulation (VNS)
Integrated Treatment with Spravato (esketamine) and Transcranial Magnetic Stimulation (TMS)
Treatment of individuals with treatment resistant depression and suicidal thoughts can vary. There have been no studies on combined treatments of Spravato (esketamine) and transcranial magnetic stimulation (TMS) to date. Their has been one small retrospective study on combination TMS and IV-infused ketamine. The good news is that there was a significant decrease in depression symptoms maintained over two years, but more research is needed with randomized studies prior to recommendation of combined treatment with any of these modalities.(3)
Treatment For Long-Term Success
At Pine Ridge Mental Healthcare, we’ve found success using a variety of approaches to major depressive disorder. Discussing these approaches with a trusted provider is the first and most important step. Getting your depression under control is a key to improving how you feel.
Our mental health team works to reduce your reliance on medications by educating you about the different tools available and how life situations can affect your mood. In addition, we help keep you on track with regular check-ins to monitor how you are doing.
For more information about if you may have depression, take our simple online depression quiz, or for help managing your health, schedule an appointment online or over the phone at Pine Ridge Mental Healthcare in Owasso, Oklahoma. If you are interested in other services we provide, check out our services page.