Spotlight: Transcranial Magnetic Stimulation (TMS)

We’ve recently had some questions about Transcranial magnetic stimulation or TMS and have put together some helpful information.  TMS is used in the treatment of depression when typical antidepressants like SSRI’s haven’t worked or worked well enough.  It may also be used when the side effects of these medications are too significant.

What is TMS and how does it work? Who benefits the most?

According to Neurostar, Transcranial magnetic stimulation or TMS, is a noninvasive procedure that uses a magnetic pulse to increase brain connectivity and stimulate neurotransmitters related to mood regulation to decrease the symptoms of depression.  TMS is typically suggested when other depression treatments haven’t been effective. 

The best candidates for TMS are currently in a recurrent depressive episode, have tried multiple antidepressants, and are highly motivated to get well.  Some insurance companies will cover the treatment.

What happens during a TMS session?

How does it feel afterwards?

Your first appointment will likely last a full hour as the physician learns the best position for the magnets on your head.  During a TMS session, you’ll sit comfortably in a reclining chair while an electromagnetic coil is placed against your scalp near your forehead. The electromagnet delivers a magnetic pulse that stimulates nerve cells in the region of your brain involved in mood control and depression. You’ll hear a clicking sound and feel a tap on your head.  The feeling has been commonly described as a “weak woodpecker” and is usually more annoying than painful if anything.  Each session lasts between a half hour to an hour and treatment is five days a week for approximately 4-6 weeks for 30-40 sessions.

Here is a quick overview of Transcranial Magnetic Stimulation and demonstration of a session:

TMS isn’t invasive, doesn’t require anesthesia and can be performed in an outpatient office or clinic.  You can drive yourself home after a session.  Side effects are generally mild to moderate and improve shortly after an individual session and decrease over time with additional sessions. They may include:

  • Headache
  • Scalp discomfort/mild pain at the site of stimulation
  • Tingling, spasms or twitching of facial muscles
  • Lightheadedness

More research is needed to determine whether TMS may have any long-term side effects.

Who should be cautious when considering TMS?

  • Pregnant or thinking of becoming pregnant.
  • Any metal or implanted medical devices.
  • History of seizures or a family history of epilepsy.
  • Substance misuse, bipolar disorder or psychosis.
  • Brain damage from illness or injury, such as a brain tumor, a stroke or a traumatic brain injury.
  • Frequent or severe headaches.

When do I start to feel better?  How do I know it is working?

An NIMH-funded study found significant improvement from baseline with TMS therapy as early as 2 weeks after treatment as well as at 4 and 6 weeks.  After treatment, 62.3% of patients saw improvement and 41.2% were in complete remission from depression.  These results lasted, and even improved, through the year following treatment.

You will know TMS is working when you start to get relief from your depression.  Depression looks differently in everyone but generally include five or more of the following symptoms nearly every day for the past two or more weeks:

  1. Depressed mood most of the day (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day (anhedonia).
  3. Significant weight loss when not dieting or weight gain (> 5% of body weight in a month) or decrease or increase in appetite.
  4. Insomnia or hypersomnia nearly every day.
  5. Physical agitation or slowing (observable by others).
  6. Fatigue or loss of energy.
  7. Feelings of worthlessness or excessive or inappropriate guilt.
  8. Diminished ability to think or concentrate, or indecisiveness.
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with or without a specific plan or attempt.

Sometimes people have what’s called ‘double depression’ where the intensity of the depressive episode may lift but the person doesn’t feel completely better.  This may be due to lingering Persistent Depressive Disorder, formerly known as Dysthymic Disorder, or low-level depression and mood symptoms.  Additionally, if TMS works during a depressive episode and at a later time, there is a recurrence of symptoms, another round of TMS therapy may be helpful.

Relief from a depressive episode may be more good days than bad, more energy, beginning to have interest in or enjoy activities, an ability to think about the future and plan, less negative thoughts or control of negative thought patterns, making progress on small goals, or tolerating frustration.  Often friends and family may notice changes before you do.  Even if your depression begins to lift or even stops all together, it is still important to take care of yourself, maintain your support network, and continue to evolve your mental health.  Wellness is a continuing lifetime process – depression is about surviving but living is thriving.

Comedian Neal Brennan tried Ketamine and micro-doses of psychedelic mushrooms before finally finding relief with TMS.  See a clip from an interview with him here:

What are the other options for treatment?

Also published on Medium.

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