TMS for Depression: ‘A Pre-Eminent Intervention’

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Review the uses and forms of transcranial magnetic stimulation.

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Treatments for depression have evolved over the years, helping individuals with symptoms overcome challenging conditions. Transcranial magnetic stimulation (TMS) is a US Food and Drug Administration (FDA)-approved, noninvasive procedure that uses electric currents to target specific areas of the brain.

“TMS is generally used in patients who have failed to respond to psychotherapy and at least a couple of trials of medications,” said Sina Nikayin, MD, psychiatrist and assistant professor of psychiatry at the Yale School of Medicine.

Below, find a brief overview of TMS.

History of TMS

TMS originated in the 18th century when scientists experimented with using electricity to modulate brain activity.Pioneers in the field include Luigi Galvani, Alessandro Volta, and Giovanni Aldini.

Galvani experimented on frog legs and found electrical activity inside, leading to further research on this concept in animals.1 Later, Aldini discovered electricity as a possibility to treat humans with diseases. Aldini experimented with a device touching his hand, sending a strong shock into his body. The Italian physician said the shock gave him a head stroke and made him an insomniac for several days.1 Obviously, this procedure has significantly improved since the days of Aldini, Galvani, and Volta.

The Role of TMS in Depression

TMS’ primary use is in mitigating depression. Eugene Lipov, MD, a physician researcher and chief medical officer at the Stella Center, shared his thoughts about TMS utilization.

“The magnetic pulses induce small electric currents that change the firing pattern of neurons, altering dysfunctional brain patterns associated with depression,” said Lipov.

TMS has a significant role in the brain’s neural network, affecting brain plasticity.

“TMS can encourage neuroplasticity and metaplasticity and modify functional connectivity in the brain; in other words, it can cause new brain pathways in a positive way, which can result in improvement in mood, ability to find joy, frustration, and tolerance,” said Nikayin. “The latter effects are believed to be among the reasons benefits of TMS can last long after a treatment course is complete. TMS works by changing the activity of the neurons in specific regions of the brain and can increase or decrease activity as appropriate based on the diagnosis and symptoms.”

The FDA first approved devices for TMS in 2009 with the Nexstim eXimia NBS system. Three years later, the agency approved the Nexstim NBA System 4 intended for cortical mapping. Additionally, the FDA cleared NEXSPEECH for pre-surgical planning in the cortical regions.2

In 2013, the FDA approved BrainsWay Deep TMS as a treatment for individuals with major depressive disorder (MDD).2

Then, 2 more devices received FDA approval to help those who did not receive sufficient improvement from antidepressant medications. Magstim’s Rapid2 System and Tonica Elektronik’s MagVita TMS received approval in 2015, while Tele-EMG’s Neurosoft TMS received its approval in 2016.2

Types of TMS

While TMS is a relatively new concept, researchers are investigating various forms of TMS as mental health treatments.

Repetitive TMS

Repetitive transcranial magnetic stimulation (rTMS) may be used when treating obsessive-compulsive disorder (OCD) or in smoking cessation. rTMS is the most common TMS procedure, doling brief magnetic pulses to the brain. The repeated pulses aid nerve cells and relieve depression by improving mood.

Accelerated TMS

In the past few years, accelerated TMS has emerged to trim the length of treatment and assist response time. The FDA has not approved this procedure yet, but van Rooij et al showed promising results comparable to typical TMS protocols.3

Accelerated TMS helps shorten response time by administering more than 1 TMS session daily, thus reducing treatment duration. Additionally, accelerated TMS helps reduce staffing requirements and the time required for administration over weeks-long spans.3

Deep TMS

Deep TMS, as the name suggests, targets deeper regions of the brain. Deep TMS coils are H-shaped, contrasting with the circular-shaped coils of rTMS. Deep TMS methods are typically used to treat conditions like OCD.

TMS Uses

While TMS is an effective depression treatment, it is a viable option for other conditions. For example, Lefaucheur et al examined rTMS when treating epilepsy, schizophrenia, and miscellaneous psychiatric disorders.4

OCD

Using TMS for OCD has been in practice since 2017. Patients with OCD typically receive multiple sessions of dTMS for OCD to relieve symptoms. Roth et al analyzed treatment details across 22 clinical sites using H7-coils on 219 participants. The results show improvement in OCD symptoms within 20 sessions for most individuals. Exceeding 30 sessions provides even better results.5

Migraines

About 3% of the population has migraines, causing numbness, trouble speaking, and fatigue.6 TMS has proved to be effective at assisting individuals with episodic and chronic migraines.

A 2022 review and meta-analysis examined rTMS in decreasing pain severity and migraine frequency, using the Cochrane domain-based quality assessment tool for the risk of systematic bias. Investigators found rTMS positively affects migraine pain severity and frequency compared with the control groups. rTMS reduced migraine pain frequency by about 8 days each month.7

Smoking Cessation

Quitting smoking is challenging, so some clinicians recommend using rTMS. Zangen et al conducted a randomized controlled trial with 262 chronic smokers. The researchers used daily bilateral active rTMS for 3 weeks after induced craving procedures.8

Investigators concluded that cigarette craving was much lower in the rTMS group than in the control group after only 2 weeks of treatment. This study led to the FDA’s approval of rTMS for adult smoking cessation. The rTMS trials effectively stimulated the relevant brain circuits and aided chronic smokers.8

Benefits of TMS

TMS can offer a variety of benefits to both patient and clinician.

Efficiency

Treatment can be time-consuming for patients. Fortunately, TMS treatments are outpatient procedures, letting them dive back into their routines.

“Patients can generally get back to their life immediately, immediately after each session and go to work or school,” said Nikayin. “For this reason, many patients with active lifestyles prefer this treatment to other modalities that require some time for recovery after each treatment.”

Tolerability

Some treatments can be intimidating because they require surgical procedures or anesthesia. Fortunately, TMS procedures are more tolerable and less invasive.

Range of Uses

As previously iterated, TMS has become a legitimate treatment for depression while demonstrating effectiveness in other areas. To provide another example, investigators have examined the potential of rTMS for Parkinson disease. rTMS sessions improved global motor performance and helped patients complete the standing-start 180° turn test.4 Investigators also found improvements for individuals with atypical parkinsonism by aiding in freezing-of-gait.4

Adverse Effects

TMS has a range of adverse effects. After the session, patients may feel lightheaded or feel pain on their scalp. Some get headaches or spasms in their facial muscles. If these adverse effects persist, reduce the stimulation level.9

While it effectively treats migraines, TMS may also induce headaches during brain stimulation. In this instance, you may need to cease TMS treatment. Additionally, TMS may induce may seizures or hearing loss in some patients, though rare.9

Preparing Patients for TMS Procedures

Before the procedure, consider preparing your patients for TMS procedures with these steps.

1. Speak with your patient.

After exhausting other treatment options, walk patients through the benefits and risks of the procedure to allow them decide what is right for them.

2. Manage your schedule and patience.

TMS treatment requires commitment from your patients. Most people undergoing TMS receive 30 minutes daily, 5 days a week, for about a month. Patients can expect between 20 and 30 sessions, so wisely managing schedules is essential.

Patience is essential when undergoing TMS. It may take 2 weeks or more to begin seeing results. Lacroix et al found TMS’ effectiveness is between 30% and 64%.10 The success rate depends on the type of TMS, the length of treatment, and the severity of the patient’s condition.

3. Ensure patients document adverse effects.

While TMS can be effective, it can also come with adverse effects. Encourage patients to document what they are feeling. With this information, you can determine whether to reduce treatment or cease TMS completely.

Ms Rush is a writer, editor, and content manager at Body+Mind.

References

1. Hamlin D, Garman J. A brief history of transcranial magnetic stimulation. Am J Psychiatry. 2023;18(3):8-10.

2. Cohen SL, Bikson M, Badran BW, George MS. A visual and narrative timeline of US FDA milestones for transcranial magnetic stimulation (TMS) devices. Brain Stimul. 202115(1):73-75.

3. van Rooij SJH, Arulpgragasam AR, McDonald WM, Philip NS. Accelerated TMS - moving quickly into the future of depression treatment. Neuropsychopharmacology. 2024;49(1):128-137.

4. Lefaucheur JP, Aleman A, Baeken C, et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): an update (2014–2018). Clin Neurophysiol. 2020;131(2):474-528.

5. Roth Y, Tendler A, Arikan MK, et al. Real-world efficacy of deep TMS for obsessive-compulsive disorder: post-marketing data collected from twenty-two clinical sites. J Psychiatr Res. 2021;137:667-672.

6. Kuruvilla DE. The prevalence of migraine among military veterans. Cefaly. July 6, 2022. Accessed December 13, 2023. https://blog.cefaly.com/the-prevalence-of-migraine-among-military-veterans/

7. Saltychev M, Juhola J. Effectiveness of high-frequency repetitive transcranial magnetic stimulation in migraine: a systematic review and meta-analysis. Am J Phys Med Rehabil. 2022;101(11):1001-1006.

8. Zangen A, Moshe H, Martinez D, et al. Repetitive transcranial magnetic stimulation for smoking cessation: a pivotal multicenter double-blind randomized controlled trial. World Psychiatry. 2021;20(3):397-404.

9. Transcranial magnetic stimulation. The Mayo Clinic. Accessed December 13, 2023. https://www.mayoclinic.org/tests-procedures/transcranial-magnetic-stimulation/about/pac-20384625

10. Lacroix A, Calvet B, Laplace B, et al. Predictors of clinical response after rTMS treatment of patients suffering from drug-resistant depression. Transl Psychiatry. 2021;11(1):587.

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