Questions About TMS
All your Questions answered in one place
A noninvasive, nonmedication option that uses electromagnetism to effectively treat depression in patients who have failed prior antidepressant treatments.
Magnetic pulses are emitted by the TMS machine close to the patient’s head over a specific area of the brain, the prefrontal cortex. These magnetic pulses cause increased activity in the brain cells in this area of the brain which, with repeated treatments, results in a decrease in depressive symptoms for many patients.
TMS has been FDA approved for the treatment of Major Depressive Disorder in patients whose symptoms have not improved after one or more trials of antidepressants. Other studies have suggested benefit from TMS for a wide range of conditions such as OCD, anxiety, autism, tinnitus, Parkinson’s disease, PTSD and addictive disorders. However, TMS has not been FDA approved for any condition except Major Depressive Disorder after adequate antidepressant medication trials.
The most common side effect, reported in about 50% of patients, is headache which can usually be managed with over the counter pain medications like Advil (ibuprofen) or Tylenol (acetaminophen). The frequency and intensity of these headaches generally diminish as treatment proceeds. The next most common side effect is uncomfortable sensations on the scalp where the magnet is placed and/or facial twitching. These symptoms also tend to decrease as the treatment progresses and are usually limited to the duration of the treatment (about 20 minutes with our deep TMS machine). These side effects occur in about 25% of patients. Other common side effects include jaw pain which is also generally manageable with over the counter pain relievers. This side effect occurs in about 10% of patients. The most serious side effect that occurred in the study that led to FDA approval for the deep TMS device was one patient who had a seizure during treatment. While this seizure was attributed to the TMS treatment, it was noted in the FDA approval that this patient drank at least a half bottle of wine the night before the treatment where the seizure occurs. Alcohol withdrawal is a known risk factor for seizures so the alcohol could have increased the chances of a seizure occurring. For this reason, our TMS providers ensure that patients are not taking medications or other substances that may increase their chances of a seizure. The overall risk of seizures for TMS patients is estimated to be .1% (1 in 1000 patients). In most TMS studies, the dropout rate was no more than 10% because of side effects. This rate is much lower than most medication studies which range from 20-40%. TMS also does not induce the common side effects of antidepressant medications including nausea, dry mouth, sedation, weight gain and sexual dysfunction.
Patients with metal in their heads should not have TMS (dental fillings and braces are ok) because of the risk of the metal heating up or otherwise causing damage because of the effects of the magnetic pulses. The following are examples of metal objects that generally prohibit patients from receiving TMS treatment:
- Metallic implants in the ears or eyes
- Aneurysm clips/coils in the head/neck
- Deep Brain Stimulators or Vagus Nerve Stimulators
- Shrapnel/bullet fragments in or near the head
Many major insurance companies are covering TMS for patients who meet specific criteria for Major Depressive Disorder. Different insurance companies use different standards for when they will cover TMS. Our office can help you determine if your treatment is covered by your insurance carrier.
A treatment session with our dTMS machine lasts approximately 20 minutes. Standard procedure calls for 5 treatments per week for a minimum of four weeks. This is often extended to 6 or more weeks depending on the patient’s response to the treatment. Every patient is evaluated weekly by our TMS physicians to discuss changes in symptoms and consider adjustments that can be made to increase the likelihood of treatment success.
The first TMS session is used to determine the location on the scalp where the magnetic coils should be positioned. One of our TMS physicians will work with one of our TMS technicians during this session to ensure correct placement of the magnetic coils. Subsequent treatments are usually carried out by our trained TMS technicians. A TMS physician may also attend if there is a need for an adjustment of the treatment protocol during the treatment process.
TMS treatment is a relatively new form of antidepressant treatment so long-term studies have not been completed yet. However, the electromagnetic field used in TMS is similar to MRI machines which have been used for many years without evidence of significant long-term side effects. One full course of TMS (4-6 weeks) only exposes patients to a fraction of the magnetic field exposure of an MRI.
While it is not known whether taking antidepressants during or after TMS treatment increases the likelihood of treatment success, TMS trials have regularly included patients taking antidepressant medications. There is no indication that there is any safety risk to patients who take antidepressants before, during or after treatment with TMS.
Most other medications can also be taken before, during and after a course of TMS. There are some medications that can increase the seizure risk with TMS and these should be discussed with your TMS physician. However, it is rare that a medication would preclude a patient from getting treatment with TMS.
No, these treatments work on very different principles. The main difference is that ECT causes a generalized seizure and this is repeated usually on alternating days for several weeks. While ECT is overall more effective in treating depression, it is also associated with significant side effects including memory loss (which is usually sort-term but can be longer lasting). ECT also requires the patient to be under anesthesia which carries its own risks. Because of the confusion that usually occurs after ECT, patients undergoing ECT must have someone to care for them after their treatment. TMS patients can receive their treatment and return to their usual activities, including driving, immediately after their treatment.
While the overall efficacy of TMS is still being investigated, clinical studies seem to indicate that 40-60% of patients have a good response to TMS and that 75-90% of patients who do respond maintain their improvement after 6-12 months. Those who do have recurrence of their depressive symptoms often respond to repeat or "maintenance" sessions of TMS. This can be compared to recurrent of depressive symptoms successfully treated with antidepressants
Patients are seated comfortably in a chair and will feel a tapping sensation on their scalp during the treatment. Patients also hear a "clicking" noise. To prevent discomfort from the clicking noise, earplugs should be worn (and are provided). However, the risk of any permanent hearing loss is extremely low.
The TMS technician will note any side effects the patient experienced during the treatment. Because there is no sedation or anesthesia, patients can leave immediately after their treatment and resume normal activities including driving.
Most trials indicate that patients experience improvement by the 4th week of treatment. However, some patients may experience improvement before or after the 4th week.
No. Multiple clinical trials have not shown any increase in memory loss with TMS treatment. This is an important difference from ECT where there is a risk of memory loss.
TMS has been used since the mid 1980s in research settings to investigate the functioning of different parts of the brain. TMS began to be investigated for use as an antidepressant therapy in the 1990s. Neuronetics, the makers of the Neurostar TMS device, sponsored a study in 2007 (O’Reardon, et al 2007) that showed the efficacy of TMS in treating Major Depressive Disorder. Because the efficacy of TMS was only demonstrated in post-hoc analyses instead of the primary outcome, the FDA did not initially approve the device out of concern for bias. However, the device was eventually approved in 2008 in part based on post hoc analyses that suggested that TMS was particularly more effective for patients with treatment resistant depression. A subsequent NIH study (George, et al 2010) largely replicated the industry sponsored study (O’Reardon, et al 2007). Since then multiple studies including multiple metaanalyses, have shown TMS is effective in treating Major Depressive Disorder. Other studies have also shown promising results in other psychiatric and neurologic disorders. In 2013, Levkovitz, et al published a clinical trial that led to FDA approval of the deep TMS (dTMS) device made by Brainsway. Since then multiple studies have confirmed the efficacy of dTMS.
Most standard rTMS machines use a figure 8 magnetic coil to induce electrical charges within the cells of the brain. These electromagnetic pulses reach about 0.7cm below the scalp into the brain. The dTMS system stimulates the neurons about 1.7cm below the skull and over a wider area than the standard rTMS system. Patient sessions with dTMS machines are also shorter, approximately 20 minutes compared to 37 minutes on a standard rTMS system.