Abhijit Ramanujam, MD

Developed in 1985 and approved by the US Food and Drug Administration in 2008, transcranial magnetic stimulation (TMS) technology has been gaining clinical interest as an effective treatment option for patients with treatment-resistant depression. Two-thirds of TMS patients experienced either full remission of their depression symptoms or noticeable improvements.

 TMS is a noninvasive outpatient procedure without serious adverse effects, making it an attractive option for patients who have not found relief from other treatments, including psychopharmacology and psychotherapy.

TMS uses an alternating current passed through a metal coil placed against the scalp to generate rapidly alternating magnetic fields. These pass through the skull nearly unimpeded and induce electric currents that depolarize neurons in a focal area of the surface cortex.

The magnetic field generated by TMS is comparable to that of a standard magnetic resonance imaging device (MRI), measured at approximately 1.5 to 3 Teslas. However, the TMS field is focal (beneath the coil), whereas the MRI field is large and fills the room housing the MRI device.

One hypothesis on how TMS works is that the stimulation of discrete cortical regions alters pathologic activity within a network of gray matter brain regions, specifically those involved in mood regulation and connected to the targeted cortical sites.

 Functional imaging studies support this hypothesis by showing TMS can change activity in brain regions remote from the site of stimulation.

TMS has many molecular effects comparable to electroconvulsive therapy (ECT), including increased monoamine turnover and normalization of the hypothalamic pituitary axis.

 However, unlike ECT, TMS does not require general anesthesia and is not associated with impaired cognition. Additionally, in one neuroimaging study of depressed patients, a prefrontal serotonin deficiency at baseline normalized after treatment with TMS.

High-frequency stimulation is thought to excite the targeted neurons and is typically used to activate the left prefrontal cortex. Low-frequency stimulation appears to inhibit cortical activity and is usually directed at the right prefrontal cortex.

Consistent with this hypothesis, a review examined 66 studies in patients with depression who were treated with TMS targeting the dorsolateral prefrontal cortex. It found that high-frequency TMS generally increased regional cerebral blood flow, whereas low-frequency TMS generally decreased regional cerebral blood flow, which is reduced in a depressed brain.

TMS is indicated for patients with unipolar major depression who have failed at least 1 antidepressant medication. In addition, TMS is indicated for patients who responded to a prior course of TMS.

 Its use for these patients is consistent with treatment guidelines from the American Psychiatric Association, Canadian Network for Mood and Anxiety Treatments, and the Royal Australian and New Zealand College of Psychiatrists.

The patient evaluation should confirm the primary diagnosis of treatment-resistant depression and determine whether the TMS intervention can be used safely. The assessment includes examinations of psychiatric history, general medical history, physical health, and mental status with emphasis upon depressive symptoms. This should emphasize risk factors for seizures and preexisting neurologic disease, such as epilepsy, intracranial masses, and vascular abnormalities.

TMS is contraindicated in patients with: increased risks for seizures, implanted metallic hardware (aneurysm clips, bullet fragments, etc), cochlear implants, implanted electrical devices (pacemakers, intracardiac lines, medication pumps, etc), and unstable general medical disorders. The 

 shares a 12-item questionnaire to determine if a patient is a good TMS candidate.

Multiple reviews have found consistent evidence that TMS provides a clinically relevant benefit to patients with treatment-resistant depression. In patients with acute major depression who have not responded to at least 1 antidepressant medication, numerous meta-analyses of randomized trials have found TMS superior to placebo treatment.

 It is not known if maintenance treatment with TMS for unipolar major depression is beneficial.

A meta-analysis of 34 randomized trials compared TMS with placebo treatment in 1383 patients with treatment-resistant major depression. It found that improvement was greater with active treatment.

 Add-on treatment with TMS was efficacious in patients who had not responded to an adequate antidepressant therapy. Response (for example, the reduction of baseline symptoms ≥ 50%) occurred in more patients who received active (47%) versus placebo (22%) TMS.

There have been no consistent predictors of response according to a meta-analysis. A 1-year, prospective observational study of 120 patients who responded or remitted with acute TMS found that the durability of response to TMS was not associated with age, sex, severity of depressive symptoms prior to TMS, nor the number of failed antidepressant trials prior to TMS.

For treatment of major depression, TMS is less efficacious than ECT. Follow-up studies of patients with major depression who were treated acutely with TMS in randomized trials indicate that the short-term benefits of TMS are stable.

 With regard to longer-term benefits of TMS, prospective, observational studies lasting at least 6 months suggest that in patients with major depression who improve with acute TMS, relapse occurs in about 35%.

For patients with unipolar major depression who improve with a course of TMS and subsequently deteriorate or relapse, reintroduction of TMS using the same stimulation parameters may be helpful.

 It is not known if maintenance treatment with TMS for unipolar major depression is beneficial, as few randomized trials using standard protocols have been conducted. However, in several small, observational studies of patients, the results suggest that maintenance TMS may, perhaps, be beneficial.

TMS is generally safe and well-tolerated. For example, in a randomized trial of 301 patients, investigators found that study discontinuation due to adverse effects was comparable for active and placebo TMS (5% and 3%, respectively).

The most serious adverse effect of TMS is a generalized tonic-clonic seizure. However, the risk of seizure appears to be comparable to that for anti-depressant medications. Seizures probably occur in less than 0.1 to 0.5% of patients when safety guidelines are followed regarding patient selection and stimulation parameters. Seizures that have occurred were self-limited, required no medications, and did not recur.

 Factors that increase the risk of seizures can be found in the 

Other effects include hypomania and mania, described in randomized trials

 and reports of patients with major depression (both unipolar and bipolar) who were treated with TMS.

However, the clinical significance is not known, because patients with bipolar major depression can switch to mood-elevated states in the absence of an antidepressant treatment. Treatment of unipolar major depression with TMS does not appear to increase suicidal ideation or behavior.

 A review of randomized trials in patients with major depression found that the incidence of headache with active treatment and placebo treatment was 28% and 16%, respectively. The incidence of scalp pain with active and placebo treatment was 39% and 15%, respectively. No migraine headaches have been reported. Headache and scalp pain may be more pronounced when higher stimulation frequencies and intensities are used. Topical lidocaine may reduce scalp pain. Reducing stimulation intensity can decrease scalp discomfort, but this can also reduce efficacy of treatment. For sensitive patients, the dose of TMS can be titrated up during the first week. Headache and scalp pain generally resolve over the first 2 weeks, although some patients may require an analgesic, such as acetaminophen or ibuprofen.

Transient (< 4 hours) increase in auditory threshold.

 This is caused by repeated clicks that are produced as current passes through the stimulating magnetic coil and mechanically deforms the coil. Hearing loss is prevented with foam earplugs or noise protection ear coverings.

 Management generally consists of reassurance.

For older patients with major depression, TMS can be beneficial if the stimulation intensity is sufficient.

 Prefrontal atrophy in older patients can increase the distance between the coil and cortex to the point that lower-intensity stimulation, which typically penetrates to a depth of 2 to 3 cm, does not affect cortical activity. Increasing the intensity above the motor threshold can overcome the added distance.

Depression frequently occurs after stroke, and TMS may help these patients.

 For these patients with major depression, observational studies suggest that TMS may possibly be safe and effective. It appears unlikely that the fetus is directly affected by TMS because magnetic fields rapidly attenuate with distance.

TMS is an exciting and promising therapy that can provide real and lasting relief for patients with treatment-resistant depression. Conducted in an outpatient setting, TMS is a noninvasive procedure that is generally safe and well-tolerated. This provides patients with the flexibility to seek treatment in a way that does not disrupt their daily lives. TMS has an equally promising future, with studies exploring its expanded applications, as well as its use as an ongoing maintenance treatment.

is a psychiatrist and regional medical director at

1. Carpenter LL, Janicak PG, Aaronson ST, et al. 

Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice

Neurobiological mechanisms of repetitive transcranial magnetic stimulation on the underlying neurocircuitry in unipolar depression

Regional cerebral blood flow changes after low-frequency transcranial magnetic stimulation of the right dorsolateral prefrontal cortex in treatment-resistant depression

4. Fitzgerald PB, Sritharan A, Daskalakis ZJ, et al. 

A functional magnetic resonance imaging study of the effects of low frequency right prefrontal transcranial magnetic stimulation in depression

Daily left prefrontal repetitive transcranial magnetic stimulation for acute treatment of medication-resistant depression

6. Noda Y, Silverstein WK, Barr MS, et al. 

Neurobiological mechanisms of repetitive transcranial magnetic stimulation of the dorsolateral prefrontal cortex in depression: a systematic review

7. Perera T, George MS, Grammer G, et al.

 The Clinical TMS Society consensus review and treatment recommendations for TMS therapy for major depressive disorder

Quantitative review of the efficacy of slow-frequency magnetic brain stimulation in major depressive disorder

9. Berlim MT, Van den Eynde F, Jeff Daskalakis Z. 

Clinically meaningful efficacy and acceptability of low-frequency repetitive transcranial magnetic stimulation (rTMS) for treating primary major depression: a meta-analysis of randomized, double-blind and sham-controlled trials

10. Berlim MT, Van den Eynde F, Daskalakis ZJ. 

A systematic review and meta-analysis on the efficacy and acceptability of bilateral repetitive transcranial magnetic stimulation (rTMS) for treating major depression

Transcranial magnetic stimulation in the management of mood disorders

Transcranial magnetic stimulation for the treatment of major depression

Antidepressant efficacy of high-frequency transcranial magnetic stimulation over the left dorsolateral prefrontal cortex in double-blind sham-controlled designs: a meta-analysis

14. Kedzior KK, Reitz SK, Azorina V, Loo C. 

Durability of the antidepressant effect of the high-frequency repetitive transcranial magnetic stimulation (rTMS) in the absence of maintenance treatment in major depression: a systematic review and meta-analysis of 16 double-blind, randomized, sham-controlled trials

15. Avery DH, Holtzheimer PE, Fawaz W, et al. 

A controlled study of repetitive transcranial magnetic stimulation in medication-resistant major depression

Repetitive transcranial magnetic stimulation as an augmentative strategy for treatment-resistant depression, a meta-analysis of randomized, double-blind and sham-controlled study

Treatment-emergent mania in unipolar and bipolar depression: focus on repetitive transcranial magnetic stimulation

18. Stultz DJ, Osburn S, Burns T, et al. 

Transcranial Magnetic Stimulation (TMS) safety with respect to seizures: a literature review

19. Dolberg OT, Schreiber S, Grunhaus L. 

Transcranial magnetic stimulation-induced switch into mania: a report of two cases

Acute manic symptomatology during repetitive transcranial magnetic stimulation in a patient with bipolar depression

21. Abdelnaim MA, Langguth B, Deppe M, et al. 

Anti-suicidal efficacy of repetitive transcranial magnetic stimulation in depressive patients: a retrospective analysis of a large sample

22. O’Reardon JP, Solvason HB, Janicak PG, et al. 

Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial

23. Rossi S, Hallett M, Rossini PM, et al. 

Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research

Pascual-Leone A. Screening questionnaire TMS: an update

Articles

How can transcranial magnetic stimulation help patients with treatment-resistant depression?

TMS: A Useful Clinical Tool for Treatment-Resistant Depression

Repetitive transcranial magnetic stimulation (TMS) is a useful clinical tool that is effective in patients with treatment-resistant depression. This noninvasive treatment is an option for patients with depression who have not found relief from other treatments, such as psychotherapy and antidepressants.

TMS technology was developed in 1985 and has been gaining clinical interest since then. Two-thirds of TMS patients experienced either 

full remission of their depression symptoms or noticeable improvements

 An out-patient procedure, TMS does not have serious side effects.

Approved by the US Food and Drug Administration in 2008, TMS uses an alternating current passed through a metal coil placed against the scalp to generate rapidly alternating magnetic fields. These pass through the skull nearly unimpeded and induce electric currents that depolarize neurons in a focal area of the surface cortex.

One hypothesis on how TMS works is that the 

stimulation of discrete cortical regions alters pathologic activity

 within a network of gray matter brain regions, specifically those involved in mood regulation and connected to the targeted cortical sites.

support this hypothesis by showing TMS can change activity in brain regions remote from the site of stimulation.

molecular effects comparable to electroconvulsive therapy

 (ECT), including increased monoamine turnover and normalization of the hypothalamic pituitary axis.

 Additionally, in one neuroimaging study of depressed patients, a prefrontal serotonin deficiency at baseline normalized after treatment with TMS.

 examined 66 studies in depressed patients who were treated with TMS targeting the dorsolateral prefrontal cortex. It found that high-frequency TMS generally increased regional cerebral blood flow, whereas low-frequency TMS generally decreased regional cerebral blood flow, which is reduced in a depressed brain.

TMS is indicated for patients with unipolar major depression who have failed at least 1 antidepressant medication. In addition, 

TMS is indicated for patients who responded to a prior course of TMS

Use of TMS for treatment-resistant or refractory depression is consistent with treatment guidelines from the American Psychiatric Association, Canadian Network for Mood and Anxiety Treatments, and the Royal Australian and New Zealand College of Psychiatrists.

When conducting a patient assessment for TMS, the purpose of the evaluation is to confirm the primary diagnosis of treatment-resistant depression and determine whether the TMS intervention can be used safely. The assessment includes examinations of psychiatric history, general medical history, physical health, and mental status with emphasis upon depressive symptoms. This should emphasize risk factors for seizures and preexisting neurologic disease, such as epilepsy, intracranial masses, and vascular abnormalities.

TMS is contraindicated in patients with: increased risks for seizures, implanted metallic hardware (aneurysm clips, bullet fragments, etc), cochlear implants, implanted electrical devices (pacemakers, intracardiac lines, medication pumps, etc), and unstable general medical disorders. See the 

 for a 12-item questionnaire for TMS candidates.

1. Do you have epilepsy or have you ever had a convulsion or seizure?

2. Have you ever had a fainting spell or syncope?

3. Have you ever had a head trauma that was diagnosed as a concussion or was associated with loss of consciousness?

4. Do you have any hearing problems or ringing in your ears? Small eustachian tubes, some ringing?

6. Are you pregnant or is there any chance that you might be?

7. Do you have metal in the brain, skull, or elsewhere in your body (for example, splinters, fragments, clips, etc)? If so, specify the type of metal.

8. Do you have a cardiac pacemaker or intracardiac lines?

9. Do you have a medication infusion device?

10. Are you taking any medications? Please list them.

11. Did you ever undergo TMS in the past? If so, were there any problems?

12. Did you ever undergo an MRI in the past? If so, were there any problems?

Multiple reviews have found consistent evidence that TMS provides a clinically relevant benefit to patients with treatment-resistant depression. In patients with acute major depression who have not responded to at least 1 antidepressant medication, numerous meta-analyses of randomized trials have found that TMS is superior to placebo treatment.

 It is not known if maintenance treatment with TMS for unipolar major depression is beneficial. 

 of 34 randomized trials compared TMS with placebo treatment in 1383 patients with treatment-resistant major depression. It found that improvement was greater with active treatment.

TMS is less effective than ECT; however, TMS does not require general anesthesia, and it can be done in an outpatient setting. Unlike with ECT, patients with major depression do not experience impaired cognition with TMS.

No consistent predictors have been identified in meta-analyses. A 

 of 120 patients who responded or remitted with acute TMS found that the durability of response to TMS was not associated with age, sex, severity of depressive symptoms prior to TMS, nor the number of failed antidepressant trials prior to TMS.

For treatment of major depression, TMS is less efficacious than ECT. Follow-up studies of patients with major depression who were treated acutely with TMS in randomized trials indicate that the 

For patients with unipolar major depression who improve with a course of TMS and subsequently deteriorate or relapse, 

 using the same stimulation parameters may be helpful.

 It is not known if maintenance treatment with TMS for unipolar major depression is beneficial, as few randomized trials using standard protocols have been conducted. However, in several small, observational studies of patients, the results suggest that 

maintenance TMS may, perhaps, be beneficial

TMS is generally safe and well-tolerated. As an example, 

 of 301 patients found that study discontinuation due to adverse effects was comparable for active and placebo TMS (5% and 3%, respectively).

The most serious adverse effect of TMS is a generalized tonic-clonic seizure. However, the risk of seizure appears to be comparable to that for antidepressant medications. Seizures probably occur in less than 0.1 to 0.5% of patients when safety guidelines are followed regarding patient selection and stimulation parameters. 

 that have occurred were self-limited, required no medications, and did not recur.

Table. Factors That Increase Risk of Seizure

Other side effects include hypomania and mania, described in randomized trials,

 as well as case reports of patients with major depression (both unipolar and bipolar) who were treated with TMS.

However, the clinical significance is not known, because patients with bipolar major depression can switch to mood-elevated states in the absence of an antidepressant treatment. Treatment of unipolar major depression with TMS 

does not appear to increase suicidal ideation or behavior

 in patients with major depression found that the incidence of headache with active treatment and placebo treatment was 28% and 16%, respectively. The incidence of scalp pain with active and placebo treatment was 39% and 15%, respectively. No migraine headaches have been reported. Headache and scalp pain may be more pronounced when higher stimulation frequencies and intensities are used. Topical lidocaine may reduce scalp pain. Reducing stimulation intensity can decrease scalp discomfort, but this can also reduce efficacy of treatment. For sensitive patients, the dose of TMS can be titrated up during the first week. Headache and scalp pain generally resolve over the first 2 weeks, although some patients may require an analgesic, such as acetaminophen or ibuprofen.

 For elderly patients with major depression, TMS can be beneficial if the stimulation intensity is sufficient.

 Depression frequently occurs after stroke, and TMS may help these patients.

 For these patients with major depression, 

 suggest that TMS may possibly be safe and effective. It appears unlikely that the fetus is directly affected by TMS because magnetic fields rapidly attenuate with distance.

TMS is an exciting and promising therapy that can provide real and lasting relief for patients suffering from treatment-resistant depression. Conducted in an out-patient setting, TMS is a noninvasive procedure that is generally safe and well-tolerated. This provides patients with the flexibility to seek treatment in a way that does not disrupt their daily lives. TMS has an equally promising future, with studies exploring its expanded applications, as well as its use as an ongoing maintenance treatment.

 is a psychiatrist and Regional Medical Director at Community Psychiatry + MindPath Care Centers.

Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice.

Neurobiological mechanisms of repetitive transcranial magnetic stimulation on the underlying neurocircuitry in unipolar depression.

Regional cerebral blood flow changes after low-frequency transcranial magnetic stimulation of the right dorsolateral prefrontal cortex in treatment-resistant depression.

A functional magnetic resonance imaging study of the effects of low frequency right prefrontal transcranial magnetic stimulation in depression.

Daily left prefrontal repetitive transcranial magnetic stimulation for acute treatment of medication-resistant depression.

Neurobiological mechanisms of repetitive transcranial magnetic stimulation of the dorsolateral prefrontal cortex in depression: a systematic review. 

7. Perera T, George MS, Grammer G, et al. 

The Clinical TMS Society consensus review and treatment recommendations for TMS therapy for major depressive disorder.

Quantitative review of the efficacy of slow-frequency magnetic brain stimulation in major depressive disorder.

Clinically meaningful efficacy and acceptability of low-frequency repetitive transcranial magnetic stimulation (rTMS) for treating primary major depression: a meta-analysis of randomized, double-blind and sham-controlled trials. 

A systematic review and meta-analysis on the efficacy and acceptability of bilateral repetitive transcranial magnetic stimulation (rTMS) for treating major depression.

 Transcranial magnetic stimulation in the management of mood disorders.

Transcranial magnetic stimulation for the treatment of major depression.

Antidepressant efficacy of high-frequency transcranial magnetic stimulation over the left dorsolateral prefrontal cortex in double-blind sham-controlled designs: a meta-analysis.

A clinical review of an effective approach for treatment-resistant depression.

Examining the Benefits of TMS

Abhijit Ramanujam, MD, introduces Transcranial Magnetic Stimulation (TMS) as an option for treating your patients with hard-to-treat depression.

is a practicing child and adolescent psychiatrist in Sacramento, California, and the Regional Medical Director of

Videos

What are the clinical benefits of TMS? How can you talk to your patients about this option?

Talking to Patients About Transcranial Magnetic Stimulation 

The year 2020 has proven to be a year of challenges and uncertainties thanks to 

 (COVID-19). We started the year relatively unaware of the virus, and now it impacts every aspect of our lives. Although the initial concern was aimed at the oldest and most frail segments of the population, we must not forget our younger patients and the unique psychological challenges that children face during this pandemic.

The reopening debate: in-person versus online learning

One of the most contested issues in the country revolves around the reopening of schools. On the one hand, there are concerns over the social and learning needs of children; on the other are the health risks facing students, teachers, other school personnel, and their respective families.

for in-person school and learning, since schools provide academic, social, and emotional skills and support that are hard to replicate at home.

 However, the AAP also affirmed “science should drive decision-making on safely reopening schools,” and noted “a one-size-fits-all approach is not appropriate for return to school decisions.” The AAP added:

“Reopening schools in a way that maximizes safety, learning, and the well-being of children, teachers, and staff will clearly require substantial new investments in our schools and campuses. We call on Congress and the administration to provide the federal resources needed to ensure that inadequate funding does not stand in the way of safely educating and caring for children in our schools. Withholding funding from schools that do not open in person full-time would be a misguided approach, putting already financially strapped schools in an impossible position that would threaten the health of students and teachers.”

American Academy of Child & Adolescent Psychiatry 

 similarly stated, “In these uncertain times, making educational decisions based on science and community circumstances ensures the mental health needs of our children and adolescents are being addressed, allowing them to feel engaged, safe, secure, supported, and loved.”

 They also acknowledged that “education, including school attendance, is an essential component of successful and healthy development for all children and adolescents” and offered guidelines for reopening. They mentioned ensuring the well-being and educational needs of vulnerable populations like “children with emotional, learning, and physical disabilities as well as those in foster care, poverty, and for whom English is a second language, to mention but a few.”

What is “safe”? Lessons from around the world

The push to open schools in-person was originally based on the theory that children were largely not affected by COVID-19 and that transmission from asymptomatic children was uncommon. However, this assumption came after the strict physical distancing measures and school closures, and the story appears to have changed. The appearance of multisystem inflammatory syndrome, which causes serious, even life-threatening illness in previously healthy children and adolescents, served as a rude wake-up call.

 By August 6, 2020, the Centers for Disease Control received reports of 570 cases and 10 deaths across 40 jurisdictions (

 The affected children were aged 1 to 14 years; their average age was 8 years. Almost all children (96%) with the syndrome tested positive for SARS CoV-2, the virus responsible for COVID-19; the others had been in the vicinity of someone infected with the virus.

New data also show that children are not invulnerable to COVID-19. In the United States, the number of cases in children rose 44% between July 9 and July 23, according to a report which also found that children accounted for 8.4% of US cases.

 With 20 states reporting, researchers found between 0.6% and 9.0% of all juvenile COVID-19 cases resulted in hospitalization, confirming that severe illness was possible in children, albeit rarer than in adults. Similarly, in 8 days in July, Florida saw a 34% increase in new cases and a 23% increase in hospitalizations among children; the test positivity rate among children also increased.

 Recent news reports also tell of thousands of students and teachers quarantined as the number of COVID-19 infections rip through schools in several states after re-opening in person.

Some proponents of a wider in-person school opening have noted that children are less likely to spread the virus, but a new report in 

 The authors found that replication of SARS-CoV-2 in older children resulted in similar levels of viral nucleic acid as in adults, but found significantly greater amounts of viral nucleic acid in children younger than 5 years. Considering behavior and hygiene issues in younger children, the authors said, “Young children can potentially be important drivers of SARS-CoV-2 spread in the general population.”

Lessons can also be learned by looking abroad. Two weeks after reopening schools, Israel saw a spike in COVID-19 cases, with more than 200 cases among students, and 130 cases at a single school.

 Countries including Singapore and South Korea also experienced spikes in cases when schools were reopened.

Guiding parents and supporting young patients

This is new territory for everyone, and young patients and their parents are likely to experience stress and anxiety as the school year begins. There are several ways parents can prepare themselves and their children for a relatively smooth transition.

First and foremost, clinicians should counsel parents to consider their individual family needs and issues, then develop a clear plan in terms of social distancing.

 Families with at-risk individuals may prefer more stringent rules, while others may err on the side of socialization. Once parents have determined what works best for their family, they should make the socialization rules very clear to their children, discussing realistic and practical strategies to mitigate the chances of infection.

 The approach and discussion should be tailored to the age and maturity of the child.

Children need a sense of safety and stability, so navigating these waters can be tricky. Parents should explain that although schools are reopening, socialization will be a step-by-step process. Regroup as needed with children and adolescents to provide updates, share reminders, and allow for questions.

Children in upper elementary and middle school grades are prone to receiving misinformation, either via friends or social media. Parents should facilitate family conversations, listening carefully to their children’s concerns and helping them separate fact from fiction.

Finally, role play may assist children and adolescents as they negotiate this new school year. It can be difficult even for adults to request that someone maintain their distance or ensure that their mask is properly covering their mouth and nose. Share ways to make the conversations easier. For younger children, you can even make it a game. Act out correct and incorrect behaviors, and see if they can pick out the mistakes.

Special issues associated with psychiatric disorders

Children and adolescents with pre-existing psychiatric disorders may have additional struggles with social distancing, online learning, and the resulting changes and lack of consistency. Although in-person learning is ideal, not all schools will be able to do so. Similarly, even those schools that initially begin in-person learning may need to move to remote learning. Fortunately, there are strategies to help support students with various psychiatric symptoms and disorders.

Children with an attention-deficit/hyperactivity disorder (ADHD) diagnosis. Family confinement and physical distancing may exacerbate ADHD-related risk-taking behavior.

 As much as feasible, additional medication doses should not be used to manage stress related to confinement. Also, steer clear of using any antipsychotic medication to manage disruptive behavior. Instead, use behavioral parenting strategies that have a beneficial effect for children with ADHD and disruptive behavior (

Treatment adherence may become an issue for these patients. Unfortunately, current evidence does not support the use of outpatient telepsychiatry to improve adherence. For 

who are acutely ill, daily home visits by a treatment team member is recommended as an alternative to hospitalization. This allows the child and their family to maintain physical distancing and minimize exposure to COVID-19.

It is quite likely that socially anxious children will refuse to return to school; even under ideal conditions, a new academic year can be a trigger. It is important to validate their feelings and answer questions truthfully, while not offering unnecessary details. Always try to remain calm during these discussions. Whenever possible, parents should avoid excessive reassurance and instead encourage self-reliance. Parents should model how to manage difficult emotions.

It is also important to frame statements in a positive way. For example, avoid phrases like, “There’s nothing to be afraid of,” “It’s not a big deal,” or “You’ll be just fine.” Instead, try, “I would really like for you to go on a bike ride around the neighborhood. The streets are safe.” Additional tips can be found online at the 

Since the world has become a scarier place with so many risks outside of the home, it is important that parents inform their child with anxiety every time they leave the house for work or essential errands. It is also helpful to remind them that frontline workers are addressing the situation.

It is important that parents are fully aware of warning signs and symptoms (

). Children with depression have a tendency to isolate, and social distancing can worsen such. Parents should ensure that their child joins them for family meals. Work with the child to come up with a list of family activities and regularly keep them engaged. Have regular check-ins and monitor media content. Discuss news stories that emphasize strength, hope, and positivity.

It also is important to teach child- ren to recognize their health risk behaviors, such as isolating, excessive sleeping, or lethargy. Encourage them to check in with family or friends. Acknowledge and normalize their distress reactions. For example, parents can share, “I can see that you are very stressed, which is very understandable. Many people are feeling that way.” Other coping strategies are listed in 

The pandemic is causing specific challenges for children with concerns around eating or body image. Disruption in important daily routines such as grocery shopping and exercise can lead to increased anxiety and worsen unhealthy food-related behaviors. These children should remain connected with their therapists, dietitians, and clinicians to create a relapse prevention plan.

Younger patients are facing unique psychological challenges during this pandemic.

Abhijit Ramanujam, MD

Articles

TMS: A Useful Clinical Tool for Treatment-Resistant Depression

Examining the Benefits of TMS

Talking to Patients About Transcranial Magnetic Stimulation

For Whom the School Bell Tolls: Helping Youth During the COVID-19 Crisis

The Realities of Childhood Schizophrenia

Depression in Children and Teens During COVID-19