TRANSCRANIAL MAGNETIC STIMULATION

Transcranial magnetic stimulation (TMS) is a FDA-approved, non-invasive method of treating depression using pulsed magnetic fields to stimulate parts of the brain.

Is TMS right for you?

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Who can benefit from TMS?

TMS procedure is typically used to treat individuals with depression who have not had adequate relief of symptoms from medication(s)and/or are experiencing significant side effects from anti-depressant medication(s). In studies, TMS has been shown to benefit individuals who have failed multiple courses of medication (and psychotherapy) as well as a trial of electroconvulsive therapy (ECT). TMS offers an alternative to medications for patients concerned about side effects of anti-depressants such as weight gain and sexual dysfunction.

Why TMS?

More than 300 million people of all ages suffer from depression worldwide. Americans spend billions of dollars on antidepressant medications every year, but the National Institute of Heath estimates that it only benefits 60 to 70% of people who take them. TMS therapy offers the possibility of long lasting symptom relief and freedom from side effects of antidepressants.

How does TMS work?

An electromagnetictreatment coil placed on the scalp above the left prefrontal cortexpainlessly delivers highly concentrated electromagnetic fields to stimulate the region of the brain involved in mood regulation and depression. The magnetic fields generated by TMS is comparable to that of a standard magnetic resonance imaging (MRI) device (approximately 1.5 to 3 Tesla), however, the TMS field is focal. These magnetic fields are generated by an alternating current passed through the metal coil andmove 2 to 3 centimeters into the brain directly beneath the treatment coil to produce very small electrical currents that activate the nerve cells in focal area of the brain cortex.

The mechanism of TMS therapy is not yet completely understood. The stimulation of focal region of the brain cortex is thought to alter the release of neurotransmitters or chemical messengers such as serotonin, norepinephrine and dopamine, and help restore their balance within the network of nerve cells involved in mood regulation. This is supported by the normalization of prefrontal serotonin deficiency observed on neuroimaging study of depressed patients after repetitive TMS therapy. Further, functional imaging studies have also shown that TMS can change activity in brain regions remote from the site of stimulation.

Repetitive TMS (rTMS) treatment for depression

In 2008, Food and Drug Administration (FDA) cleared the use of TMS treatment for medicationresistant depression. TMS therapy for depression involves a series of treatment sessions, hence it is also called repetitive TMS or rTMS.Patients receive TMS treatment 5 days a week and a typical course is 4 to 6 weeks. This can vary depending on individual's response to treatment.

Prior to initiating TMS treatment, the patient will need a thorough evaluation by his/her mental health provider to assess whether the intervention can be used safely. In addition to psychiatric history and mental status examination, treating psychiatrist will obtain a detailed general medical history, as well as laboratory tests and neuroimaging studies if indicated. A standardized questionnaire will be administered to screen patients for contraindications to TMS treatment. Click here for QUESTIONNAIRE

What to expect during TMS procedure?

TMS treatment is a short outpatient procedure performed in the office under the supervision of the treating psychiatrist.Patients are awake and seated in a reclining chair during treatment. The first session is typically 60-90 minutes, and the subsequent treatmentscan lastupto45 minutes. Before initiating treatment, provider will identify the best location to place electromagnetic coil on the head. To determine the amount of magnetic energy, the electromagnetic coil will be switched off and on repeatedly until the fingers/hands twitch. This "motor threshold" is different for each individual and is used to determine the right treatment dose. The patient will experience intermittent tapping sensation on the scalp during the delivery of magnetic pulses. Patients can return to normal daily activities including work and driving after the treatment sessions.

What are the risks and side effects?

TMS is a non-invasive form of brain stimulation and does not require surgery or sedation with anesthesia. rTMS is considered safe and is generally well-tolerated. Potential side effects include headache, scalp discomfort at the site of stimulation and/or tingling or twitching of facial muscles. These side effects are mild to moderate, improve after the treatment session and diminish over the course of rTMS therapy.

Some patients may experience transient hearing problems immediately following treatment. Patients are given ear plugs during the treatment session to prevent any adverse effect on hearing from the noise produced by the TMS machine.

The most serious risk of rTMS is seizures. However, the seizure risk is extremely low (0.1% to 0.5%) and comparable to that for anti-depressant medications. The seizure described were self-limited, required no medications and did not recur. Our treatment guidelines have incorporated safety precautions to minimize the seizure risk. Patients with underlying bipolar disorder may develop mania.

rTMS treatment does not cause typical side effects observed with anti-depressant medications such as dry mouth, weight gain, gastro-intestinal upset, sexual dysfunction or sedation.

How is TMS different from ECT?

TMS and ECT are both non-invasive neuromodulation procedures used to treat individuals with depression who do not respond to standard medication(s). However, ECT is associated with a number of safety risks, adverse effects and logistical constraints.

ECT (also referred to as "shock therapy") uses an electric current that passes between two electrodes placed on the scalp to induce a "generalized seizure" while the patient is under general anesthesia. A course of ECT involves a series of treatments delivered over several days to weeks. Unlike ECT, TMS induces electrical activity in specific regions of the brain using pulsed magnetic fields and does not require anesthesia. Patients are fully awake and alert during the TMS procedure, and able to converse.

ECT is generally administered in a hospital setting while TMS is an outpatient procedure done in an office setting. Patients do not need sedating or muscle relaxant medications for TMS procedure and are able to drive themselves home after the treatment session.

The immediate side effects of ECT can be headaches, muscle pain, nausea, and confusion requiring observation in the hospital. Patients may experience mild to moderate scalp discomfort after TMS procedure but this generally lasts for a short duration. Some patients receiving ECT may develop "short term" memory loss (inability to remember the new information) and/or "long term" memory loss(inability to recall events from the distant past). Rarely, impairment of long term memory can be permanent. Memory loss has never been reported in patients receiving TMS treatment.

How can I get started?

Patients can schedule an appointment with the Psychiatrist for TMS therapy evaluation by calling our office during normal business hours (8AM to 5PM, Mon-Fri) or by contacting us at appointment@texasholisticpsychiatry.com

References:

1. Perera T, George MS, Grammer G et al., The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy of Major Depressive Disorder. Brain Stimul 2016; 9:336

2. American Psychiatric Association. Practice guidelines for the Treatment of Patients with Major Depressive Disorder, third edition. Am. J Psychiatry 2010; 167 (supplement):1

3. Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 2006; 163:1905

4. George MS, Post RM. Daily left prefrontal repetitive transcranial magnetic stimulation for acute treatment of medication-resistant depression. Am J Psychiatry 2011; 168: 356

5. Mayberg, HS. Defining Neurocircuits in Depression: Insights from functional neuroimaging studies if diverse treatments. Psychiatric Annals 2006;36(4):258-266

6. Connolly KR, Helmer A, Cristancho MA et al. Effectiveness of transcranial magnetic stimulation in clinical practice post-FDA approval in the United States: results observed with the first 100 consecutive cases of depression at an academic medical center. J Clin Psychiatry 2012; 73: e567

7. UK ECT Review Group. Efficacy and safety of electrocolvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361:799.

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