Hope for Depression Treatment: Non-invasive TMS Proving Effective
The most exciting thing about TMS is that we’ve been able to treat patients with very severe and resistant depression—even those who failed ECT, many medications and psychotherapy.David Eiler, MD
There’s optimistic news for individuals living with treatment-resistant depression (TRD) and major depressive disorder (MDD). A breakthrough non-medication treatment for depression, Transcranial Magnetic Stimulation (TMS), has proven effective in half of patients—providing symptomatic relief even when other treatments fail.
“About 50 percent of people will respond to TMS treatment, and that response rate is better than medication. It’s gentle and well-tolerated compared to medications, and doesn’t have the side effects associated with them, which include fatigue, weight gain and reduced libido,” explains Julia Knight, MD, PhD, director, Mood Disorders and Interventional Psychiatry Clinic at Dartmouth-Hitchcock Medical Center (DHMC). “It’s not as effective as Electroconvulsive Therapy (ECT) but it still helps a lot of people. There aren’t as many side effects [as with ECT], and I personally think it’s the best treatment other than ECT,” she says.
TMS works by stimulating neurons in the brain using a non-invasive magnet cleared by the U.S. Food and Drug Administration (FDA). TMS treatment is one of the focuses of DHMC’s Mood Disorders Clinic, which studies and addresses bipolar disorder, major depression and dysthymia (persistent mild depression). DHMC has treated more than 50 patients with TMS since its program initiated in November 2018.
“The most exciting thing about TMS is that we’ve been able to treat patients with very severe and resistant depression—even those who failed ECT, many medications and psychotherapy,” says David Eiler, MD, director of the TMS service. “It has an excellent risk-benefit profile, and helps half of patients. It’s very low-risk.”
Sylvia is one of the TMS patients who experienced benefits. A former DHMC patient who sought TMS treatment related to post-traumatic stress disorder (PTSD), she feels it was one of the easiest treatment decisions she’s ever made. She describes the treatment sessions as private and supportive, as patients are able to have someone with them. Most importantly, TMS helped her.
“I felt like a cloud was lifted; like I was coming out of a fog. It made me more accessible to my therapy and to my family, and able to engage in my surroundings and with the people that want to support and help me,” she says. “It gave me some hope and a little more zip. It’s so accessible and I am so grateful it was there for me to try.”
Short, frequent treatments
TMS protocol consists of 36 treatments over nine weeks. The first visit takes 30 minutes to one hour to tailor the magnet settings to the patient’s brain. Each subsequent visit is only five minutes long. However, patients must have them five days per week for six weeks, and then taper to three visits for one week, two the following and finally one visit during the final week.
“The magnet creates an electrical field that stimulates cells in the specific part of the brain that tends to be affected by depression,” Knight says. “It corrects and normalizes the pathways that depression disrupts.”
She reports many patients feel better and more energized after their treatments, and there are no memory-related side effects. Some patients do well for a long time after treatment is complete, but some may eventually require additional treatments. “There’s not a lot of data about retreatment, but it is helpful for some people, as depression is chronic and must be managed over time,” Knight notes.
There are negligible side-effects during treatment. Some patients have headaches and facial twitching during them, or a mild headache or nausea immediately afterward. Typically there are no side-effects reported between treatments.
People with a history of seizures cannot undergo TMS because of a very small risk–0.1 percent–of seizure. Also individuals with aneurism clips, brain stents or cardiac pacemakers cannot participate because of the magnetic technology. Knight explains that patients with other non-magnetic sensitive implants, such as c-spine hardware have been treated.
The future of TMS
The Mood Disorders Clinic has the capacity to treat more patients using TMS. The consultation-based clinic provides recommendations to referring providers and individualized treatment plans for each patient.
“TMS is underutilized because of a lack of awareness and training,” says Eiler. “It requires continuing education and credentials for psychiatrists, and that’s easier to obtain if providers are associated with a hospital. DHMC offers training to our residents and staff, so participation will grow over time.”
Eiler predicts current insurance requirements around TMS treatment will be less restrictive, as evidence is expanding about its efficacy for people with mild and moderate depression. Also, many patients don’t want to take medication and this provides an alternative.
“While TMS is used primarily to treat resistant-depression, there’s a lot of research on using it to treat other neurological and psychological ailments,” Eiler shares. “I expect TMS to be an area of great growth to treat pain, substance abuse, recovery from brain injury, dementia, obsessive compulsive disorder (OCD) and bipolar disease. Even if a portion of the research turns out, we may have FDA-approved indications for other conditions in a few years.”
If you are a good candidate, “There’s really no reason not to try TMS, given how safe and well tolerated it is,” Knight encourages. “When no other treatments have worked, it can impact a patient’s life in a way they never imagined.”
For additional information about TMS treatment at DHMC, visit https://www.dartmouth-hitchcock.org/psychiatry/transcranial-magnetic-stimulation-tms.html. To schedule an appointment, call the Mood Disorder Clinic at (603) 650-0625.