Transcranial Magnetic Stimulation for Depression

Transcranial Magnetic Stimulation (TMS) is a brain stimulation technique used to treat major depression. The technique has been researched over the past 25 years and received FDA approval for the treatment of major depression in 2008.  However, TMS  was not easily available to patients due to the fact that most insurance companies did not cover the treatment.  Only those patients with resources could afford the treatment, which typically costs $8000-$12,000 dollars without insurance coverage.  

Up to 30% of patients suffer from treatment resistant depression where patients fail to espond to multiple trials of medication and/or psychotherapy.  These patients often suffer unnecessarily and are often candidates for brain stimulation techniques, which work by a completely different mechanism of action than medications.  

Until the advent of TMS, electroconvulsive therapy (ECT) was a brain stimulation technique that was most frequently recommended for treatment resistant major depression.  However, this treatment is arduous to endure.  ECT, although the most effective treatment available for treatment resistant major depression, requires general anesthesia for each treatment and, for many patients, results in significant cognitive problems during the acute course of treatment.  Patients undergoing this treatment often need to take weeks or months to recover prior to going back to work and are unable to drive during the course of treatment.  There is also the infrequent risk of permanent memory or cognitive changes.  Despite these risks, ECT is an extremely effective treatment with robust response rates. 

TMS, on the other hand, is an easy treatment to tolerate.  A treatment course of TMS is typically 20 sessions, administered Monday through Friday.  Each treatment takes approximately 20-40 minutes depending on the type of coil that is used.  It is an extremely safe procedure.  Although there is some discomfort during the treatment itself (most patients describe the feeling as a persistent tapping on their scalp..almost as if a woodpecker was tapping on their head).  Side effects are rare and typically include headache, fatigue and the small risk of having a seizure.  

I recently reviewed a meta-analysis (a type of study where results of multiple studies are pooled together) looking at response and remission rates following a course of TMS.  Response rates (at least 50% improvement on the Hamilton  Depression Scale) were 51%, and remission rates (virtually no residual symptoms of depression) were 29%.  In addition, the treatment was also shown to improve cognitive function.  As in other studies reviewing the efficacy of TMS, less severe depression and fewer treatment failures from medication trials predict  higher response and remission rates. The authors of the article are Helena M. Gellersen1 and Karina Karolina Kedzior, Behavioural and Clinical Neuroscience Institute (BCNI), Department of Psychology, University of Cambridge, UK and Institute of Psychology and Transfer, University of Bremen, Germany.  The article is recent and was published in  Psychologie (2018), 226(1), 30–44.

These response and remission rates are impressive for patients who have failed multiple trials of medication and psychotherapy.  It is a safe treatment, patients are awake during the treatment and may return to their daily routine immediately following the treatment.  The treatment is now covered by several major insurance companies pending pre-authorization documenting several failed mediation trials.  

In summary, TMS is a safe treatment that should be considered as a treatment option for those patients who have failed multiple trials of medication or who are unable to tolerate taking anti-depressant medications.  

Attached are links to You Tube Videos reviewing some of the research and demonstrating the technique.

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