TMS Can Help Patients With Depression

Unlike electroconvulsive therapy, which applies electricity directly to the brain to induce seizures, TMS is a non-drug, non-invasive treatment that uses magnetic pulses to stimulate areas of the brain that are underactive in depression such as the prefrontal cortex. Patients are awake during the treatment and can get back to daily activities, including driving, immediately following the session.

During the first treatment session, doctors identify a patient’s motor threshold, which is the amount of magnetic field strength that will be administered throughout the course of treatment. This field strength is customized for each patient to deliver the correct treatment dose.

Individual TMS sessions do not take that long. The most recently approved device from NeuroStar can deliver the right dose in as little as 19 minutes. Therapy is usually administered five days a week for four to six weeks. At the end of the treatment, there may be a taper period where the number of treatments is gradually reduced.

TMS is indicated for the treatment of adult patients with major depression who have not responded to at least one antidepressant. TMS may not be right for everyone and patients are encouraged to talk with their doctors about the treatment. NeuroStar should not be used with patients who have non-removable conductive metal or stimulator implants in or near the head or patients who have active or inactive implants such as deep brain stimulators, cochlear implants, or vagus nerve stimulators.

For those who do not respond to medication, or who cannot tolerate the negative side effects from medication and want to explore other treatments, TMS may be a viable option. The most common side effect from TMS is mild to moderate pain or discomfort at or near the treatment site, which is a temporary side effect that typically only occurs during the first week of treatment (5).

TMS is covered by many commercial and government health plans, such as Medicare and Tricare, making the treatment a reality for many who need it.

Multiple studies support the efficacy of TMS for depression. A randomized control trial of 199 patients found that TMS quadrupled the odds of remission after six weeks when compared with a sham procedure (6). An open-label study performed with NeuroStar found that 58 percent of patients significantly responded to treatment, and 37 percent achieved complete remission of their depression symptoms (7).

Patient response to treatment varies, with some reporting positive effects within the first couple of weeks. In my practice, the effectiveness of TMS mirrors results from the clinical trials. About 65 percent of patients respond to the treatment and 35 percent go to remission of their symptoms. On average, these patients have not seen success with upwards of nine antidepressants, and the average length of their current depressive episode is three to five years. We have seen a good treatment response in people who have tried fewer antidepressant medications and those who have tried more.

I work with patients over the course of their TMS treatment and assess for tolerability as well as benefit early on. Around the three-to-four-week mark, I reassess the motor threshold to ensure we are giving optimal treatment. For patients who are not responding, changing the treatment protocol may help (8). Staying on top of patient progress and monitoring for external stressors that may impact their response is crucial to a successful outcome.

It has been my experience that patients who are asking for and being prescribed TMS have already discontinued medications because of their ineffectiveness.

When that is not the situation, my approach is to initiate TMS and leave the patient’s medication treatment in place. In certain cases, patients seem to do best with a combination of medications and augmentative TMS (9). Ultimately, I assess the patient after treatment and determine what, if any, changes need to be made. ■