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The Ultimate Patient's Guide to TMS Therapy

October 14, 2019

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Transcranial-magnetic stimulation (TMS) is a treatment in interventional psychiatry that has steadily been gaining traction in the mental health community since it was approved by the FDA in 2008 to treat major depressive disorder. TMS therapy is a non-invasive, non-pharmaceutical treatment that has been proven to help patients with treatment-resistant depression

If you have major depressive disorder and have not responded to treatment with one or more antidepressants, TMS might be a logical next step in your treatment process. Keep reading for more information about TMS, including:

  • Background information about the treatment
  • What it’s like to undergo TMS therapy
  • Results that TMS has had in the past

Background Information about TMS 

When people think of interventional psychiatry, the first treatment that usually comes to mind is electroconvulsive therapy (ECT). TMS is similar to ECT in that it stimulates the brain and can help relieve symptoms of depression, but that’s pretty much where the similarities end. TMS is considerably more tolerable and safer than ECT. It does not require anesthesia, and the patient is fully conscious throughout the entire treatment. 

TMS uses electromagnetic pulses to penetrate the skull and activate brain cells. Because the brain uses electrical currents to communicate within itself and send signals to the rest of the body, the magnetic waves emitted during TMS interact with the brain’s natural chemistry to affect the way the patient’s brain operates on a physical level. 

Diagram showing how TMS works to treat depression.
During TMS therapy, the main unit of the machine produces pulses, which travel through an electromagnetic coil to create targeted magnetic fields.

The History

The basic principles of TMS were first developed in 1771 by the Italian physician Luigi Galvani, who is credited with founding the field of electrophysiology, or the study of electricity in the body. Another major milestone in TMS history occurred in 1881 when the English physicist Michael Faraday realized that he could create magnetic fields using electrical currents

Though early attempts at brain stimulation using electromagnetism can be traced back to 1896, the first successful demonstration of TMS did not take place until 1985. In other words, while the foundations of TMS have origins hundreds of years old, implementing them in a clinical setting is a relatively recent achievement, which is why TMS therapy was only first approved by the FDA in 2008. 

The Science

Though the underlying concepts of TMS have long-been established, the scientific community still doesn’t quite understand why TMS has the effects on the brain that it does. This is largely due to the complexity of the brain and corresponding psychological conditions, which is part of the reason that depression is so hard to treat in the first place. 

For now, researchers theorize that TMS causes areas of the brain rendered underactive by depression to become active again, prompting the release of a higher number of neurotransmitters and thus improving a patient’s mood. 

How neurotransmitters communicate with each other in the brain.
Neurotransmitters are chemical messengers in the brain that release electricity as they communicate.

The Possibilities 

TMS has a wide range of potential applications in addition to treating depression. In fact, it was just approved by the FDA in 2018 to treat obsessive compulsive disorder. Other conditions that it could possibly have positive implications for include:

  •  Attention-deficit/hyperactivity disorder
  • Post-traumatic stress disorder
  • Parkinson’s disease
  • Autism spectrum disorder

Beyond the clinical setting, TMS serves as a versatile tool for many areas of research, especially those pertaining to the brain and the nervous system. This is because researchers can use TMS to create temporary changes in the body, and subjects can be safely exposed to TMS with few side effects. 

Undergoing TMS Therapy: What Is It Like to Be a TMS Patient? 

Because TMS is still emerging as a mainstream treatment option, not many people know too much about it. The first line of treatment for depression is psychotherapy, followed by medication. TMS is usually recommended for patients who have not responded to at least one antidepressant. 

It’s important to understand that TMS is a repetitive treatment that must be administered five times a week for around six weeks. While the average length of each session is 30 minutes, TMS is still a time commitment that must be met consistently in order for it to work. 

Logistics and Pre-Treatment Steps 

Your primary psychiatrist will most likely not offer TMS as a treatment option, and you will need a referral from them to start the therapy with a TMS provider. Your psychiatrist can help you find a provider in your area who will accept your insurance (TMS is now covered by most major insurance companies). 

The TMS provider will request patient information from your psychiatrist, including your treatment history and your psychiatrist’s notes from your recent sessions. You will then meet with a representative from the TMS provider, usually a staff psychiatrist, for a consultation to review your mental health history. If you have any specific questions about the treatment, you’ll be able to ask them during this consultation. 

Most patients with major depressive disorder that has proven to be treatment-resistant are approved to start TMS therapy. You might not be approved for treatment if you: 

  • Have a nonremovable conductive metal implant in or around your head (brain stimulators, cochlear implants, vagus nerve stimulators, etc.)
  • Have a history of seizures or a seizure disorder
  • Have experienced severe head trauma, a brain tumor, or increased intracranial pressure
  • Have dementia or cerebrovascular disease

The Treatment Process: What to Expect 

After the consultation, you will undergo a mapping session to determine the position of the electromagnetic coil and the frequency of the pulses. These two elements of the treatment vary from patient to patient. In order to find the most effective position and frequency, the staff psychiatrist and a TMS technician will attempt to stimulate the motor strip, a part of the brain that is near the target-treatment-area, the prefrontal cortex. As they test different positions and frequencies, they will look for movement in your hand as an indication that they are creating a response. 

Diagram showing how TMS placement is determined.
TMS targets the part of the brain where depression is thought to be most localized, the dorsolateral prefrontal cortex

TMS should not be painful, but it can be uncomfortable, especially as your body is first adjusting to feeling magnetic stimulation, a sensation that is alien to most patients. As the treatments progress, you will gradually grow accustomed to the therapy, and it should become increasingly tolerable. 

As the magnetic pulses are administered, you will feel a tapping against your skull, sometimes accompanied by what feels like a mild headache. During the treatment, you’ll have to remain still to maintain the electromagnetic coil’s place of contact. If the machine is unable to establish effective contact, time might be added at the end of your treatment to make up for any missed pulses. 

The length of each treatment session is another variable that differs from patient to patient. However, as mentioned earlier, it’s usually around 30 minutes. Again, you must remain still in order to ensure that the coil stays in the right position, but the technician can pause the treatment if you need to move or go to the bathroom. 

Side Effects and Restrictions

Unlike antidepressants, TMS does not have a long list of side effects. In fact, there are only two only conclusive side effects attributed to TMS: headaches during and after treatment and scalp irritation around the treatment site. TMS does not affect cognition, which means the patient can go to and leave from every session without assistance and resume daily activity afterward. 

Comparing the side effects of antidepressants to the side effects of TMS
For patients who are suffering from the adverse effects of antidepressants, TMS is a promising alternative with considerably fewer potential side effects. Image courtesy of Awakenings KC

Because TMS is a non-pharmaceutical therapy, most patients can continue to take their medications while undergoing treatment. You will continue to see your regular psychiatrist during TMS and might even decide to adjust or reduce your dosages afterward. 

Treatment Timeline

Patients typically begin to feel the results of TMS three to four weeks after starting treatment, although some patients have reported feeling effects before then. If you have not felt any significant changes in your mood by the fourth week, your TMS provider might schedule a remapping session in order to see if they can find a more effective position and frequency. If you undergo remapping, your TMS provider will reassess your case after two weeks to determine whether to continue with treatment or end the therapy. 

In order to measure your progress, your TMS technician will conduct a verbal questionnaire on a weekly basis. These questions, usually taken from the Hamilton Depression Rating Scale, are designed to score the severity of your depression. The technician will also look for physical indications of decreasing depression symptoms, as they will be seeing you every day throughout your treatment. 

Depending on your response to the treatment, TMS usually lasts around six to eight weeks. If you respond positively to the treatment, your TMS provider might recommend a tapering period of approximately two weeks to gradually reduce the frequency of your sessions in order to give your body time to adjust to not receiving treatment every day. 

The effects of TMS should last a minimum of six months to a year, though they do last longer for some patients. If you feel like your depression symptoms worsen again after this period of time, you can contact your TMS provider again to schedule maintenance treatments to renew your results. 

Chart showing the response rate to TMS, and its long-term durability for treating depression.
TMS has long-term durability, which means patients can go 12 months or more without needing additional treatments.

TMS Efficacy and Results 

Currently, there’s no real way to determine whether a patient will respond to TMS. However, if you’ve tried ECT in the past and not responded to it, you’re less likely to respond to TMS. 

Nearly 60 percent of people whose depression has not benefited from medication report significant improvement after completing TMS therapy, and of that percentage, an estimated 30 percent experience full remission from their depression symptoms

Response and remission rates for patients with treatment-resistant depression who were treated using TMS therapy.
TMS is considered to have a similar efficacy rate as antidepressants, which is also around 60 percent.

How Long Have You Been Suffering? 

Major depressive disorder affects around seven percent of the general population. Despite it being so (relatively) common, the mental health community has not yet found a totally effective means by which to treat depression: As many as 30 percent of patients do not respond to treatment

Unfortunately, major depressive disorder is a long-term condition that can last a lifetime. This makes finding the right treatment essential. If you’re someone who has tried therapy and antidepressants to no avail, you might feel as though you are destined to suffer. It’s time to take your recovery in a new direction—TMS could be the answer that you’ve been looking for.

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