Transcranial Magnetic Stimulation: Relief for Treatment-Resistant Depression?

One search on the internet for “transcranial magnetic stimulation reviews” and you’re sure to come across differing opinions regarding its effectiveness.

Since the FDA first approved transcranial magnetic stimulation (or TMS) in 2008 as a treatment intended to alleviate symptoms of “mildly treatment-resistant depression,” TMS therapy techniques and research have come a long way.

For people suffering from depression — which is now the leading cause of disability in the United States among people ages 15 to 44 — TMS offers a safe, non-invasive option for finding relief. Today, TMS is being used to help treat not only patients who haven’t found relief from antidepressant medications, but also those with schizophrenia, chronic pain, symptoms due to suffering a stroke, ALS and other ailments.

What Is Transcranial Magnetic Stimulation?

Transcranial magnetic stimulation (TMS) is a non-invasive form of brain stimulation that uses repetitive pulses of an MRI-strength magnetic field placed over the scalp. TMS is also sometimes called repetitive transcranial magnetic stimulation, or rTMS.

How does transcranial magnetic stimulation work?

Since it was first developed in the 1980s for the purpose of treating treatment-resistant depression, meaning the kind that doesn’t improve with medication and/or therapy, TMS has since become approved in Canada, Australia, New Zealand, the European Union, Israel and the United States. According to the Mayo Clinic, “the biology of why rTMS works isn’t completely understood … There are different ways to perform the procedure, and techniques may change as experts learn more about the most effective ways to perform treatments.”

TMS therapy is performed to stimulate and normalize nerve cells in regions of the brain that are known to be associated with depression and other mental health problems. The procedure works by placing coils over the scalp, which are powered by a rapidly pulsed current. The magnetic field passes through the skull and stimulates brain tissue beneath without producing pain or causing seizure-like effects. Newer “Deep Transcranial Magnetic Stimulation (dTMS)” devices are able to target deeper and larger brain volumes and extensive neuronal pathways, including deeper cortical regions and fibers.

Advantages that TMS has over other stimulation therapies is that it’s generally well-tolerated and does not require surgery, anesthesia or sedation, or implantation of electrodes. While electroconvulsive therapy (ECT or “shock therapy”) is still the “gold standard for treatment-resistant depression,” according to some experts TMS is another alternative when ECT causes too many unwanted side effects, like changes in memory and cognition.

The most common reason that TMS is performed is to help improve symptoms of depression. How successful is TMS?

Results from TMS seem to depend on a number of factors, such as: how severe someone’s depression symptoms are, the number of stimulations performed, the sites on the brain that are stimulated and how many sessions are performed in total. TMS for depression seems to be less effective among people who haven’t responded well to multiple types of antidepressants.

How long do the effects of TMS treatment last?

When TMS therapy does work, symptom relief usually takes a few weeks to kick in following treatments. Positive effects typically last six months, one year or sometimes even longer. Ongoing treatment is sometimes needed to manage depression symptoms (called re-induction) and to help prevent relapse.

Potential Benefits of Transcranial Magnetic Stimulation

Although there are ongoing trials and more research is still needed, TMS has been studied as a possible treatment for a wide range of psychiatric conditions, including:

• Unipolar major depressive disorder
• Bipolar disorders
• Anxiety disorders
• Pediatric depression
• Schizophrenia, including to manage symptoms like auditory hallucinations (hearing nonexistent voices) and apathy
• Parkinson’s disease
• Smoking cessation
• Post-traumatic stress disorder (PTSD)
• Dystonia
• Tinnitus
• Migraines and other types of recurrent headaches
• Eating disorders
• Stroke
• ALS

TMS is still not considered to be a first-line treatment for these conditions. As more findings from large clinical trials looking at the effectiveness of TMS in various conditions come out, we can expect to see TMS used in more settings.

How Transcranial Magnetic Stimulation May Help Treat Depression

Some research shows that TMS can activate regions of the brain that have decreased activity among people suffering from depression.

According to the International Neuromodulation Society, “In open-label clinical trials, after four to six weeks of treatment, one out of two patients treated with rTMS for depression experienced a reduction in symptoms of 50% or more, and one out of three experienced remission.” This means that half or more people who receive TMS therapy for depression will experience at least some benefits from treatment, and in some cases, depression will almost completely go away, at least for several months.

Some research shows that TMS can improve emotion regulation by stimulating the region of the brain called the left dorsolateral prefrontal cortex (DLPFC), which plays a central role in emotion-regulation processes. The DLPFC is a structure responsible for maintaining task goals and interacting with other brain regions to maximize goal attainment. TMS can also stimulate other cortical and subcortical regions that have important connections with the DLPFC.

Transcranial magnetic stimulation for depression is usually recommended when other treatments haven’t been successful, such as therapy, medication or electrostimulation (ECT). TMS is also a good option for patients who cannot tolerate antidepressant medications due to side effects, such as weight gain, sleep issues, etc. While TMS causes less side effects, it doesn’t seem to be as effective as ECT.

Is TMS effective for anxiety?

Because TMS focuses on targeting areas of the brain that are thought to play a role in mood regulation, it may also help reduce symptoms of anxiety or mood swings. Findings from some clinical trials suggest that anxiety symptoms in patients with depression improve after TMS. However, there has been far less research on using TMS to treat anxiety disorders compared to depression. At this time, TMS is only approved to treat depression, which means it’s used “off label” when given to treat anxiety or other conditions.

Transcranial Magnetic Stimulation Cost and Where to Receive

Since its approval more than 10 years ago, TMS has become widely available at clinics and hospitals across the U.S., Europe and elsewhere. In most cases, TMS is performed at a doctor’s office or a clinic that specializes in mental health conditions.

In order to see results, a series of TMS treatment sessions are needed, typically about five times a week for four to six weeks. Each session is about 20 to 60 minutes long. Your first treatment may be the longest as your doctor determines the best location to place the magnetic coils on your scalp.

What is a transcranial magnetic stimulation session like?

A patient typically sits in a reclining chair and wears earplugs. Electromagnetic coils are placed against the patient’s head and switched off and on repeatedly, with pauses between. This can feel like tapping sensations on the forehead and makes a sound similar to a “woodpecker tapping.”

Magnetic pulses generated by TS devices are described as being the same type and strength as those generated by magnetic resonance imaging (MRI) machines. The magnetic dosage can be adjusted as needed (known as the motor threshold). Because no sedation is used, the patient will remain awake and alert throughout the session.

Here’s what you need to know before beginning TMS treatments:

• Your doctor may want to do a physical exam or other tests to make sure TMS if safe for you.
• Always talk to your doctor about your history with any psychiatric/mood disorders, including depression, seizures or epilepsy, substance misuse, bipolar disorder or psychosis, brain damage from illness or injury, brain tumor, stroke or frequent headaches. Your doctor will want to know about your symptoms in order to make sure that TMS is a good option for you.
• You should also tell your doctor if you’re pregnant, have any metal or implanted medical devices/stimulators in your body (such as pacemakers, hearing implants or medication pumps) or if you’re taking any medications.
• Although TSM usually doesn’t cause pain or strong side effects, some doctors will recommend taking an over-the-counter pain medication before a TMS session if someone is susceptible to experiencing symptoms like headaches.
• After a treatment session, you shouldn’t feel sedated and won’t need someone else to drive you home.

How much does TMS cost?

Regarding transcranial magnetic stimulation costs, some research shows that TMS is more cost-effective than repeatedly trying medications that don’t work, especially if paired with psychotherapy sessions. According to Psychology Today, “TMS is typically in the range of  $400—500 per session for a total cost of about $15,000.”  While more insurance providers are starting to cover at least some of the cost of TMS, many patients will still need to pay out of pocket.

TMS therapy may be expensive, but it can offer hope when other options do not. It’s important to keep in mind that about 40 percent of patients with depression either do not respond to or tolerate pharmacotherapy, and that up to 85 percent of patients who do respond will relapse within 15 years.

Transcranial Magnetic Stimulation Side Effects

What are the side effects of TMS? In most cases, TMS doesn’t cause any side effects, or causes side effects that are mild and temporary. Most of the time side effects will improve shortly after the first session and decrease over time.

When they do occur, potential transcranial magnetic stimulation side effects can include:

• Headache, which is usually mild to moderate. About one-third of patients experience a mild headache following treatment.
• Scalp discomfort/irritation, due to repetitive, prickly, tingly sensations from the coils
• Tingling, spasms or twitching of facial muscles
• Lightheadedness

Rarely serious side effects can occur that include seizures, mania in people with bipolar disorder or hearing loss. About one in 1,000 patients experience a seizure following TMS. Hearing loss occurs if there is inadequate ear protection during treatment. TMS is generally not appropriate for people at high risk, such as those with epilepsy, a history of head injury or other serious neurologic issues

While transcranial magnetic stimulation is considered to be generally safe, remember that therapy and/or medications are still the first-line treatment options for depression — which means that TMS may not be necessary for most people.

Final Thoughts

• TMS or Transcranial Magnetic Stimulation is a safe and non-invasive therapy that is approved to treat treatment-resistant depression. TMS therapy uses repetitive pulses of an MRI-strength magnetic field placed over the scalp. TMS is also sometimes called repetitive transcranial magnetic stimulation, or rTMS.
• Due to its non-invasive nature and minimal side effects, TMS is a good alternative treatment option when medications, therapy or electrostimulation (ECT) have not brought about relief from depression symptoms.
• While it’s currently only approved to treat depression, there’s ongoing studies looking at the effectiveness of TMS in treating other conditions, including: anxiety, PTSD, stroke, schizophrenia, substance abuse, Parkinson’s and others.
• TMS is generally well-tolerated and safe but can cause side effects like headaches and scalp irritation. It can also be expensive, costing about $15,000 for a course of treatment.

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