Transcranial Magnetic Stimulation (TMS)?

Question by freebird: Transcranial magnetic stimulation (TMS)?
bipolar disorder, depression, seasonal depression

Best answer:

Answer by Kira Stein MD
TMS, or transcranial magnetic stimulation is a noninvasive and office-based treatment for clinical depression that has not responded to antidepressant medication. TMS uses MRI-strength magnetic fields to activate or inhibit neurons (cells) in very specific parts of the brain. This happens without TMS coming into direct physical contact with the brain or circulatory system. TMS has been shown to be safe and does not emit ionizing (x-ray) or radio-frequency (cell phone) radiation.

TMS is a treatment option for patients unresponsive to medication, because research shows that TMS is considerably more effective than trying a second medication – with less risk of side effects. Further, TMS is FDA-approved for the treatment of a major depressive episode that has failed to adequately respond to a first medication. TMS is not yet approved for the treatment of bipolar depression, though this is being done off-label, as well as studied in various parts of the United States (if you want to participate in a study on TMS and bipolar depression, on which I am working at UCLA, take a look at this one, which is currently recruiting:

Standard TMS depression therapy involves resting a small MRI-strength magnet on the area of scalp overlying a part of the brain called the left dorsolateral prefrontal cortex, which is known to be under-active in depression. To receive a full treatment course of TMS for depression, patients usually need 4 to 6 weeks of 40 minute TMS sessions, 5 days per week. While some patients may start to respond after only 2 weeks, others (usually those with severe, long-standing depression) may need longer than 6 weeks.

The magnetic pulses feel like a repetitive tapping sensation and sound very much like a loud old typewriter. Brain cells themselves have no ability to feel sensation, so activating them is essentially a painless process.

The tapping sensation is not caused by anything knocking on your head, but rather is produced by the magnetic field’s stimulation of a thin layer of superficial muscle underneath the skin of your scalp. This rather strange experience takes getting used to; after a few treatments, patients usually accommodate. In fact, they tend to acclimate so rapidly that they can often comfortably watch television or read a book during TMS. Very rarely, patients experience TMS as painful, but discomfort can be alleviated by using over-the-counter analgesics or by slight protocol changes. There is a very small risk of seizure, as low as 1/30,000 per TMS session, when using the NeuroStar TMS system.

Magnetic pulses emanating from the TMS machine induce tiny electrical changes in brain cells (neurons) that, when effective, normalize neurotransmitter and receptor levels, as well as connections between the frontal lobe and other brain areas.

Research shows that, when stimulated, frontal lobe neurons release the neurochemicals glutamate and dopamine into frontal lobe synapses that connect to other brain cells in other parts of the brain. TMS also appears to affect serotonin receptors in the frontal lobe and deeper brain structures. These and other changes in the brain are associated with improved mood.

When TMS is used alone without medications, research has shown that 1 in 2 patients who were unresponsive to one prior medication, experience a significant improvement in their depressive symptoms, while 1 in 3 completely remit – a rate of success comparable to a first trial of antidepressant medication. Keep in mind that second, third and fourth antidepressant medication trials each have significantly lower chances of achieving remission (21%, 16%, and 7% respectively) than TMS monotherapy.

When TMS is used as an add-on to medications that patients have partially responded to, this seems to further increase the response rate. Since a patient has a better chance of completely responding to TMS than to a second trial of medication, it makes sense to provide TMS as a treatment option early on in a patient’s struggle with depression.

Interestingly, at our center in the Los Angeles area, we are achieving a much higher response rate than the studies of TMS monotherapy. This could be in part due to our willingness to use TMS with medication. Patients also likely benefit from our holistic treatment approach. We recognize that seeing a patient five times weekly is an opportunity to help them develop hope and skills to achieve remission and maintain recovery.

My staff and I at the West Coast TMS Institute actively encourage a more comprehensive program beyond TMS that integrates dietary changes, exercise, meditation, psychotherapy and even bright light therapy. Furthermore, optimization and individualizing the TMS treatment protocol is based on the latest research, clinical experience, and a careful risk-benefit analysis.

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