People suffering from depression often feel a sense of overwhelming hopelessness as though life isn’t worth living.
They lose interest in their careers, their family and their friends. It is as if a dark cloud is hanging over their heads and weighing down their bodies and souls. For most people suffering from depression, medication and psychotherapy (especially CBT –Cognitive Behavioral Therapy) make a world of difference. For others, these traditional approaches make little difference and in some cases make the symptoms of depression worse.
For those who find traditional depression treatment ineffective or who suffer intolerable side effects from medications, there is new hope. This new treatment is TMS (Transcranial Magnetic Stimulation). It does not require the patient to take medication or undergo electroconvulsive therapy.
What are TMS and How Does it Work?
TMS stands for Transcranial Magnetic Stimulation. It works by using powerful magnetic pulses which easily cross the cranium (skull) to stimulate nerve cells in the brain. Over time this stimulation begins to relieve the symptoms of depression and lifts the patient’s mood, giving them a new outlook and a new lease on life.
TMS was first developed in the late 1980s. It was only in 2008 that Food and Drug Administration approved it as an antidepressant treatment —for patients who had unsuccessfully tried one or more traditional depression therapies and drugs.
In most depressions, the left side of the brain has lowered activity compared to the right side. The main TMS treatment for depression is excitatory treatment to the left forehead –the left DLPFC (dorsolateral prefrontal cortex). This supports the theory that TMS works by increasing the activity of a hypoactive left brain.
However, the reasons it works are probably more complicated, because different forms of stimulation in a few different areas of the brain can be effective. TMS allows doctors to non-invasively stimulate various area of the brain. The patient is fully awake and alert during the entire treatment
There are also invasive procedures that are used [rarely] for intractable depression: brain surgery involving #1 cutting some brain tissue or # 2 implanting wires in the brain that give continual electrical stimulation from a battery pack implanted in the body.
During TMS treatment patients sit comfortably in a chair while the doctor holds an electromagnetic coil against the patient’s left forehead. The magnetic field going on and off in the patient’s prefrontal cortex causes the neurons in the brain to fire more easily. For reasons we do not entirely understand, this activity upon the neurons gradually changes the way neurons communicate and the symptoms of depression are relieved.
There is no memory loss with TMS. Neither are there any side effects such as weight gain, nausea, or worsening depression.
The treatment lasts 20 to 40 minutes per session. Patients can read, watch television and even have visits with friends. Some people fall asleep, but we THINK that remaining awake makes the treatment more effective. We insist that patients wear ear plugs because the noise of the pulse is louder than it sounds. There is only one report of TMS damaging hearing. We do not want you to be the second report. The sound is caused by the same thing as the sound of an MRI—which is a much more powerful magnetic device. . . . Many patients say it feels and sounds like a woodpecker pecking on their skull. It causes the muscles of the scalp to contract. We go up slowly with the intensity, and stay lower it if it is uncomfortable. Some people have a headache the first couple of treatments, but the scalp muscles soon accommodate. Usually within 2 to 4 weeks of treatment patients feel a lightening of their mood—which is reflected in the depression scales we have them fill out.
What are the Side Effects of TMS?
The main side effect we worry about is an epileptic seizure, so we are very careful with placement and intensity. A seizure only happens in 1 out of 10,000 treatments. We have never had one. Some patients have a mild headache the first few treatments, for which we use an NSAID like ibuprofen. About 1/100 of our patients felt tired for a day or two after each TMS treatment.
Who Does TMS Work For?
Like anything, TMS therapy doesn’t work for everyone. Depression with psychotic symptoms [“my sins have caused the war in Afghanistan, and I am being punished”] will see much better results with ECT (electroconvulsive therapy). Many patients who could benefit from ECT are afraid of this treatment because they don’t want to suffer memory loss or be out of commission for the entire day each time they get a treatment. And, in fact, there are uncommon cases where patients have had permanent memory loss from ECT.
In depression without psychotic symptoms, TMS works as well or better than ECT.
According to some studies one third of TMS patients have complete recovery from their depression while between 50% and 60% show significant improvement in symptoms. There is no way of knowing which patients will respond to this treatment and which won’t. Like any treatment, TMS simply works for some people and not for others, but this treatment does offer hope for those patients who have tried the more traditional therapies to no avail.
There is one predictor of a better prognosis with TMS: those people who responded fairly well to antidepressants in the past, even if they are not responding now
Can Anyone with Depression have TMS?
Almost anyone with depression can have TMS.
TMS is contraindicated for people who have metal in their brain—e.g., from previous brain surgery.
A history of seizures is a relative contraindication. There is a 1 or 2% chance that the TMS will induce a seizure in such patients. But the treatment can be done in a way to minimize the risk.
Because TMS is so benign, even people who are not in good health are usually good candidates for TMS. In fact, it is far easier for the physically ill and the elderly to tolerate TMS rather than medication.
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While this has raised the issue for clinicians to try to improve communication, it is still important for patients to conduct as much research as possible prior to making any decisions.