Transcranial Magnetic Stimulation

Unfortunately, many people either do not receive sufficient benefit from psychiatric medications, they cannot tolerate the side effects, or perhaps they prefer to adopt other treatments instead of psychiatric medications altogether. In this case, TMS is a unique and innovative, non-pharmacologic treatment approach that can provide relief from persisting symptoms. We have considerable expertise in the use of TMS for a range of clinical conditions.

What is TMS?

It uses a pulsed, rapidly changing magnetic field produced by electrical current running through a coil housed in a metal box. The magnetic field is applied to the head at roughly the same magnetic field strength as an MRI scanner. The magnetic field penetrates the brain and induces very small electric currents in the brain tissue, to safely and effectively modulate the function of brain circuits to remediate clinical symptoms. No electric current is directly administered to the patient, unlike electroconvulsive therapy (ECT).

What is TMS useful for?

The first TMS device was FDA-approved for treatment of MDD in the US in 2008. At present in mental health treatment, TMS devices are approved by the US FDA for treatment-resistant major depressive disorder (MDD), and in 2018, for obsessive-compulsive disorder (OCD) as well. TMS is currently reimbursed by most major private (employer-based) health plans such as PPOs and HMOs.

Why Is TMS Needed?

Major Depressive Disorder is very common worldwide. Estimates of the lifetime prevalence of MDD are as high as 20%, and the one-year prevalence 5-8%. 35-40% of these patients experience treatment-resistant depression (TRD), usually defined as having had inadequate clinical response to at least two adequate trials of antidepressant medications during a current depressive episode. In routine practice, large numbers of MDD patients do not respond clinically to many more treatments for depression, including 5-10 or more antidepressants, psychotherapy, and adjunct treatments which can be biomedical (e.g. lithium, atypical antipsychotics, light box therapy, etc.) or psychosocial in nature. TRD patients experience considerable suffering and functional impairment (inability to maintain a job or social relationships, live independently, etc.), including a significantly higher rate of suicide.

TMS for Other Clinical Conditions

There is also a substantial unmet need, together with preliminary evidence for efficacy of TMS, in other psychiatric conditions, including anxiety disorders, bipolar disorder, and schizophrenia. While TMS is not currently FDA-approved for these conditions, we will discuss with you the possibility of receiving this treatment on a fee-for-service basis.

Does TMS Really Work for TRD Patients?

Yes! There is considerable and consistent evidence for clinical efficacy and effectiveness in TRD. TMS is generally effective for patients whether they have experienced a clinical lack of response to a few, many, or no prior antidepressant trials; whether they are in concurrent treatment with medications, psychotherapy or neither; at ages ranging from adolescence to old age; whether or not they have co-occurring medical or psychiatric problems (excepting a few conditions such as severe substance use disorders, late-stage dementia). Most studies indicate that approximately 50-60% of patients undergoing a standard 6 to 7-week course of treatment with TMS will have a significant clinical response, with cumulative effects (for both individuals and groups) over the treatment course. Approximately half of this 50-60% will achieve full clinical remission (with very low or absent symptom severity) and the other half will be identified as “responders” by showing symptom reduction of at least 50% (using standardized symptom scales, such as those we employ in our program). These benefits are durable, as most of those who have a significant response will continue to be well at least one year later. It is always important to note that not everyone derives benefit. This is true for TMS just as it is for all treatments, whether biomedical or psychotherapeutic in nature.

What is Required of a Patient to Receive TMS?

Patients must typically be referred by their current psychiatrist, and undergo a routine clinical evaluation to ascertain their eligibility and appropriateness for TMS, to support informed consent. TMS is somewhat unusual among most biomedical treatments for mental health conditions in the intensity of visits, in that patients must typically come to the clinic 5 days each week, continuously for at least 6-7 weeks, in order to maximize their likelihood of benefit. Anecdotal experience suggests that reduced treatment adherence is associated with lesser benefit.

What does the patient experience with TMS?

In a TMS treatment session, the patient sits comfortably in their own clothes in a large reclining chair, in a quiet and private room, and the coil (in its housing) is placed in contact with the patient’s scalp at the predetermined treatment target site. The patient puts earplugs in place to attenuate the clicking sound of the coil. Then, the device initiates a series (a “train”) of pulses. These can be at relatively high-frequency (e.g. 10 times per second, or 10 Hertz), low-frequency (e.g. 1 Hz), or a more complex “patterned” types of stimulation (such as “theta-burst stimulation”, or TBS). Each of these stimulation protocols has roughly comparable efficacy for TRD. The treatment sessions typically last 40-60 minutes, though there are newer, effective stimulation protocols as brief as 3-4 minutes, and we will utilize these as clinically-appropriate. The patient hears a clicking sound and feels a tapping sensation at the point of contact, which is typically cyclic and repetitive in nature. Patients can rest, engage in conversation with companions in the room, view a TV or other screen during the treatment session, or other activities that are not excessively activating or requiring head movement.

Patients are instructed to not move their head, as head movement will change the point of contact with the coil, moving it off-target. On occasion, patients will have more than one treatment site on the head, and these treatments are given sequentially, immediately upon re-placing the coil to the next target. Patients are typically under continuous monitoring by clinical staff, and can be sent home immediately after the completion of the treatment session. Over time, sessions tend to be similar, though routine adjustments are made, especially relating to stimulation parameters. Patients generally do not experience benefits in the first week, and the onset of efficacy is variable; however, the longer patients persist, the more likely they are to experience benefit. Drop-out rates are generally low, well under 10%. Patients usually maintain all other concurrent treatment regimens (medications, psychotherapy) as a conservative measure.