Transcranial magnetic stimulation (TMS) is a treatment to consider for depression only after other conventional treatments have been found to be ineffective. While TMS has shown some promise for improving depressive symptoms, it is time-intensive and requires daily sessions for several weeks to months to achieve improvement. It can take about three weeks before symptoms improve.
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What Is Depression?
The term “depression” is used so often and in so many different ways that it can cause confusion and invalidation for those experiencing a depressive disorder. Clinical depression, as determined by the DSM 5, needs to occur for at least two weeks, with symptoms manifesting daily. Though sadness is a necessary component for a diagnosis of depression, it is not sufficient.1
In addition to sadness (or irritability), several other symptoms must be present, such as fatigue and inability to concentrate. One must also be affected to the extent that they are having problems with functioning on either an academic, occupational, or social level.
Common symptoms of depression include:
- Frequent sadness
- Fatigue
- Loss of interest in daily activities
- Disturbance in sleep (either too much or too little)
- Disturbance in appetite and weight (i.e., a 5% change in either direction)
- Diminished ability to concentrate and make decisions
- Feelings of worthlessness and guilt
- Recurrent thoughts of death and/or suicide
What Is Transcranial Magnetic Stimulation (TMS)?
Transcranial magnetic stimulation (TMS) is a relatively safe, non-invasive procedure in which a coil that carries an electric current is placed against the head, producing a magnetic field that penetrates the scalp, skull, cerebrospinal fluid (CSF) and stimulates neurons in the brain to activate (i.e., fire). Activating groups of neurons in specific brain areas is believed to stimulate underperforming brain regions that underlie mental health disorders.
Despite being generally well-tolerated and FDA-approved to treat major depressive disorder (MDD), it is usually only recommended by providers and covered by insurance after traditional treatment methods (e.g., medication, psychotherapy, etc.) have been shown to be ineffective. The use of magnets and electric current preclude some people from receiving this treatment — e.g., those with epilepsy or pacemakers — but TMS providers can help determine if you meet the criteria.
Headaches are the most common side effect of a TMS session but tend to alleviate with successive treatments and are usually treatable with over-the-counter medication. Despite this side effect, TMS has also been found to be helpful in treating migraine pain.
Additional potential side effects of a TMS session include:
- Seizures (the risk is similar to seizure side effects from medication; one study estimated that 2 in 10,000 patients may experience a seizure2
- Dizziness
- Syncope (passing out)
- Tingling sensations
- Scalp discomfort and mild pain
- Muscle twitching
- Fatigue
- Anxiety
- Insomnia
- Jaw pain
- Back and neck pain
- Dislodging or heating of metal located in head or neck (but having ferrous metal in the body would most likely disqualify one from receiving treatment)
- Damage to implanted device (e.g., pacemaker)
- Hearing loss (although earplugs are worn to prevent this)
- Manic episodes (in individuals with bipolar disorder)
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Does TMS Work for Depression?
Traditional treatment methods like psychotherapy or medication are not always effective for relieving symptoms of depression. For individuals with treatment-resistant depression, TMS was cleared by the FDA as a treatment in 2013.3 By sending pulses of magnetic current to an area of the brain called the left prefrontal cortex, TMS increases activity in neural circuits that are dysregulated in depressed individuals.
How Effective Is TMS for Depression?
TMS has been extensively studied clinically for the treatment of depressive symptoms. It is most effective when used in conjunction with antidepressant medication (in the case of MDD) or psychotherapy, suggesting a synergistic effect when coupled with other treatments, even if they weren’t effective individually.4, 5
As with medication and therapy, the effects of TMS are not felt immediately. Symptom relief can take several weeks of treatment and has only been documented to last for a few months, although it remains possible that the effects last longer.
TMS Vs. dTMS for Depression
Research suggests that when used together with medication, deep TMS (dTMS) is more effective than conventional TMS. Deep TMS has a 60% symptom remission, whereas conventional TMS has a 43% symptom remission.6, 7 Remission rates for dTMS are similar to those reported for therapeutic psychedelic intervention (58% remission rate for psilocybin treatment), but are more time-intensive (weeks to months of daily TMS sessions vs. 2-3 doses of psilocybin).8, 9
Who Should Avoid TMS for Depression?
Before receiving TMS, individuals must be screened to ensure eligibility and safety. The healthcare professional will ask a series of questions prior to treatment, and in some cases, clearance from one’s medical team is required to determine if TMS is a viable option.
Populations who should avoid TMS treatment for depression include those who:
- Are pregnant or nursing
- Have implanted medical and electronic devices (stents, stimulators, pacemakers, cardioverter defibrillators, cochlear implants, etc.)
- Have any other metal device or object in the body (bullet fragments, metal plate, etc.), although amalgam dental fillings are okay. Many current metal implants are non-ferrous (e.g., titanium) and may be safe as well.
- Have a history of seizures/epilepsy
- Have another medical condition associated with a risk for seizures
- Have brain damage from illness or injury
- Experience frequent or severe headaches (though sometimes dTMS can paradoxically be a treatment for migraine pain)
- Do not meet DSM criteria to meet the FDA or ICD indications for the CE Marked (Europe) approved condition to be treated
- Have not already tried and shown resistance to traditional treatments
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What to Expect From TMS for Depression
TMS treatment for depression is an intensive daily treatment that can be time-consuming and requires commitment. The treatment course may vary slightly, depending on the symptom(s) being treated. Still, it typically consists of daily, 20-minute sessions, five days per week, for up to six weeks, followed by a taper period of fewer weekly sessions for three weeks.
Here are some things to expect during TMS treatment for depression:
- Location: TMS usually takes place in an outpatient office or clinic setting, though it can be a hospital setting, especially for clinical research trials.
- Evaluation: Before treatment, you will be asked a series of questions to help the clinicians determine if TMS is a safe and effective treatment for you.
- Procedure preparation: This procedure is non-invasive and does not require any surgery, needles, or other penetration of skin, nor anesthesia. You will be awake for the entire procedure. Measurements of your head may be taken to help identify your personal target location for stimulation.
- Setting: During a treatment session, you will be seated in a comfortable chair. As the procedure involves a magnetic field, you will not be able to bring any ferrous metal (jewelry, keys, glasses) into the room. At this point, earplugs will be placed since the treatment can be loud.
- Device placement: The TMS coil in the form of a cushioned helmet or panel will be placed against your scalp at a location specified to treat your symptom(s). Once the coil is placed, it is crucial that you stay still, but you may be allowed to talk or read as long as your head doesn’t move.
- Personalized target: As brain shape and size vary between individuals, there are several methods that the clinician may use to determine the target to stimulate. Some methods require head measurements, while others require prior neuroimaging.
- Determining intensity: The clinician will stimulate your motor cortex to identify your “motor threshold” – i.e., the pulse intensity that will cause your hand to contract. Your treatment intensity will be relative to this value (usually 80% to 120% depending on the condition). This threshold can change with sleep deprivation, medication, alcohol or drug use, so it is important that you notify the clinician before a session if there’s been a change to any of these factors between sessions.10
- Sensations: As the treatment begins, you will hear loud, repetitive noises despite wearing earplugs. You may experience tapping or clicking sensations against your scalp. Some individuals have described this as a light, repetitive tapping or knocking on the head.
- Daily activity: You can resume your daily activities immediately after each session, and generally, there is no recovery period or restrictions on driving or operating machinery unless a seizure occurs as a side effect.
- Subsequent sessions: The stimulation parameters are determined during the first session and need not be repeated every session unless there have been changes to sleep or substance use (including medications) that may impact the motor threshold.10 Subsequent daily sessions are usually briefer than the first session.
- Monitoring effects of treatment: There is variation in how different people respond to treatment. With feedback, parameters may be adjusted, but generally, improvement is not felt for the first few weeks of treatment. After the final session, symptom relief may last anywhere from weeks to months, with some reporting lasting effects for 1 year. In some cases, brush-up sessions may be recommended when treatment effects wane.
How to Find a TMS Therapist for Depression
The main company providing dTMS devices (which have shown greater efficacy than conventional TMS) is BrainsWay and they offer a directory for finding a dTMS provider near you. You may want to consult a psychiatrist to determine if TMS is a viable option for you. If you have trouble finding a psychiatrist near you, there are online psychiatry services or ask your healthcare provider. Lastly, you can search a clinical trial database for research studies to participate in if you find that clinical options for your condition are not available.
In My Experience
The first mode of treatment for depression is almost always psychotherapy, and depending on severity, medication. In psychotherapy, a skilled clinician can help an individual determine which, among four main types of depression – situational depression, biological depression, psychological depression, or existential depression – their depression most closely aligns with, and if a biological cause is identified, medication and TMS would be two options for additional treatment.
TMS is an intensive course of treatment, requiring daily visits to a treatment location for weeks to months, and even though many of my patients with treatment-resistant depression could benefit from it, a significant percentage have occupational, familial, or other obligations that make it logistically challenging to commit to. In contrast, both psychotherapy and pharmacotherapy are much easier to access and adhere to, especially with the rise of telehealth visits as an option since the beginning of the COVID pandemic.
TMS is typically reserved for severe cases of depression, whereby psychotherapy and medication have not been effective. In addition to TMS, there are other alternative treatments for depression, such as ketamine and psilocybin-assisted treatment, that have recently shown promising results in research studies. With the exception of psychotherapy, each treatment approach has limitations and may not be safe for everyone. I recommend speaking with your healthcare providers about what treatment(s) would be safe for you.
Additional Resources
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For Further Reading
Online Depression Test
A few questions from Talkiatry can help you understand your symptoms and give you a recommendation for what to do next.
Best Online Psychiatry Services
Online psychiatry, sometimes called telepsychiatry, platforms offer medication management by phone, video, or secure messaging for a variety of mental health conditions. In some cases, online psychiatry may be more affordable than seeing an in-person provider. Mental health treatment has expanded to include many online psychiatry and therapy services. With so many choices, it can feel overwhelming to find the one that is right for you.