How Does TMS Work?

It would seem this area is overactive and TMS can reduce the electrical activity returning it to an appropriate level. A brain ‘circuit breaker’.

TMS is more effective for depression than any pharmaceutical remedies for treatment-resistant depression. Approximately two out of three patients respond positively to TMS and approximately a third will go into remission.

Although the TMS trials into anxiety were not large enough to conclude results, There is a wealth of data to support its efficacy.

All TMS therapy studies had shown a good success rate. The main pivotal randomized controlled trial that was submitted for FDA approval in 2007 showed that 58% of patients showed a response and 37% of patients had a remission after 30 treatment sessions of TMS. An NIH spNIH- sponsored trial in 2010 showed a similar outcome. Many other randomized controlled trials replicated the same outcome. Nowadays, it is a given that TMS is effective for depression.

The success rate of TMS therapy is an important topic for anyone looking into TMS therapy for depression treatment. This is particularly true when we look at the high success rate reported in real-life clinical practices. You will learn the numbers of how successful TMS is. Please remember that TMS is a medical treatment.

As you might have already guessed, there is nothing 100% in medicine. When you read that 58% of patients receiving TMS show a response, your mind might jump to ask about the 42% who did respond to the treatment. I would like you to keep the following points in your mind:

• These numbers are our randomized controlled trials to eliminate the effect of placebo. Meaning the patients receiving the treatment wouldn’t know whether they are receiving actual magnetic stimulation or just a machine that makes noise to make it sound as if they are receiving magnetic stimulation. This inherently will show a lower response rate when compared to open-label (actual real-life clinical practice).

• Patients recruited in clinical trials usually have severe resistant depression. This means that the number of medication trials they had before is significantly high. Some are in the 20+ medication trials. That by itself tells you how severe and stubborn their depression is.

• 58% is a great response rate when compared to antidepressants. To put it in perspective, The chances of improving with the first trial of a medication antidepressant is 27%. By the fourth trial of antidepressants, the chance of response plummets down to 6.9% only.

• TMS therapy technology is evolving and improving. The reported success rate of 58% in 2007 and 67% in 2010 can be lower than what we have nowadays especially with navigated accelerated TMS success rate. The latter is 90% in 2019.

TMS research had shown great results. Especially when compared with the low success we have with medications. In randomized controlled trials the success rate ranges from ⅔ to ½ of patients receiving TMS. In open-label trials, when people know for a fact that they are actually receiving the TMS therapy, the response rate is higher. It is worth mentioning that accelerated TMS therapy showed a 90% response rate in the SAINT-TRD trial. We at Florida TMS Clinic have achieved this high success rate with accelerated TMS.

Typically when exhibiting symptoms of any mental illness, medications will be prescribed subsequent to the initial prognosis. These could be in parallel with talking or behavior therapies if antidepressants prove ineffective.

This process is protracted and medications can be changed on multiple occasions to achieve some kind of result.

Many sufferers are resistant to pharmaceutical solutions and/or struggle with the trade-off caused by unpleasant and life-limiting side effects.

Currently, TMS is an option when all others have been exhausted or experience intolerable side effects from medication. Many patients suffering from treatment-resistant depression are responsive to TMS.

Given the TMS non-invasive nature; the speed of relief and recovery; the ease of treatment delivery and NO medication, it wouldn't be unreasonable to suggest that TMS will become the future ‘go-to’ treatment for mood disorders and conditions in the near future.

Prior to commencing TMS treatment, you will have a comprehensive consultation and a depression test if not already completed;

• To explain how TMS works.

• Confirm it is the correct treatment for your condition.

• Familiarisation of you, your needs as a patient, and how to effectively meet required outcomes.

• Assessment of how many sessions would be needed to address your symptoms.

• To meet your practitioner and discuss any questions about TMS and other concerns.

• To describe and explain the exact process of receiving TMS therapy.

• Discuss health insurance.

TMS requires no medication and has little or no significant side effects.

You are able to drive to and from appointments without any other support.

All treatment sessions are taken seated in a very comfortable chair in a room with a deliberately calm and tranquil environment. Dr. Bowarshi, your TMS practitioner, will then complete your ‘mind-mapping’ to accurately identify the exact locations of your brain to be treated and clarify the appropriate dose or intensity. He will also determine your ‘motor threshold’ or the level that you can comfortably tolerate magnetic stimulation.

You will remain awake and alert during the session and you are welcome to bring your phone for games, music, or a book to read. A TV is provided for those wishing to catch up on their favorite programs.

Given the nature of the conditions treated by TMS, it is recommended that you avoid stimulating movies including high-action, horror, or thrillers.

Focus on entertainment that brings you feelings of contentment, peace, and happiness.

During the session, you will become aware of a tapping sensation or clicking sound as the stimulation is administered. The majority of patients get used to it very quickly and it becomes ambient or unnoticeable. A tiny number of patients report discomfort and this further reduces after a few more sessions as they acclimatize.

Sessions can range from three to thirty-seven minutes and the number of sessions depends on your condition.

The number of TMS sessions depends on the patient, condition, contraindications, and system protocols.

On average Thirty to Thirty-six sessions ensure optimum efficacy.

*The typical schedule of TMS therapy for depression is 30 sessions. We follow that with 6 sessions of taper off. The schedule is usually as follows:

• One session a day, 5 days a week for 6 weeks.

• Then one session a day 3 days a week in week #1.

• Then one session a day 2 days a week in week #2.

• Then one session in week #3.

The typical schedule of accelerated TMS therapy for depression is 10 sessions a day for 5 days for a total of 50 sessions.*

TMS will be administered by a fully qualified, experienced Doctor of medicine and psychiatry who is also a TMS practitioner and is passionate about the impact of TMS on sufferers of mental health disorders.

A qualified TMS consultant will then take over repeated sessions with close monitoring

Post-traumatic stress disorder or PTSD activates both the Prefrontal Cortex and the Amygdala in reaction to trauma.

Physical trauma by definition triggers emotional stress, but PTSD can also have an emotional cause.

The brain struggles with processing the emotional memories and continues in a ‘hypervigilant’ state or on red alert AFTER the danger has passed. Further, the brain releases the hormone cortisol to give you the strength to fight or stamina to run.

PTSD is essentially the brain and the body working at high emergency with no respite.

PTSD is frequently treatment-resistant including medication and talking therapies.

TMS may not fully address your symptoms, but it can undoubtedly relieve and lessen the intensity of hypervigilance; flashbacks; difficulties with sleep; nightmares, and aggressive irritability.

Studies have shown that many patients demonstrate an increase in the connections between the amygdala and the Prefrontal Cortex.

Obsessive-Compulsive Disorder or OCD is a highly disruptive condition prompted by extreme anxiety and is essentially an anxiety disorder. Obsessions drive compulsions in an effort to prevent imagined but very real emotional fears, for example, of illness or accident. The compulsion also triggers the reward mechanisms in the brain.

There is still a long way to a coherent medical comprehension of OCD but the Basal Ganglia region is showing evidence of some involvement in OCD. The Basal Ganglia manages motor controls or unconscious activities such as breathing.

As with other conditions, TMS concentrates magnetic pulses to the areas of the brain considered to contribute to OCD in order to disrupt and return functional connectivity to a regular pattern.

Deep Transcranial Magnetic Stimulation has been cleared by the FDA for the specific treatment of OCD.

Defining the causes of Bipolar Disorder, also known as Manic Depression, continues to be elusive to the medical research community which eludes which brain region to target treatment. Nevertheless, depression can be treated whilst the catalysts and origin of mania continue to be a work in progress.

Bipolar sufferers struggle with levels of depression punctuated by mania. During episodes of extreme depression, sufferers have shown affirmative responses to TMS when previously conventional medication has been ineffective.

Yes. TMS can be helpful in postpartum depression. There is no contraindication for TMS in the postpartum phase or with breastfeeding mothers. That being said, there is no specific FDA clearance for TMS for the indication of postpartum depression.

Depression could happen during pregnancy not only postpartum. That’s why we are using a new terminology now for depression related to pregnancy as peripartum depression.

It is very common that we get asked if TMS can help depressed pregnant women. The answer is; Yes. TMS can be used during pregnancy. The initial clinical trials for TMS excluded pregnant women, later trials looked into the safety and efficacy of TMS during pregnancy and no absolute contraindication was reported.

The magnetic coil is far enough not to cause any harm to the fetus. That being said, there is no specific FDA clearance for TMS for the indication of peripartum depression.

TMS could cause mild head discomfort in about 5% of patients. Rarely some patients could experience a headache. It is usually more of a tension-type of headache, not a migraine headache. Also, there is a single pulse TMS device that is actually FDA-cleared for migraine headache treatment. See the section for TMS Therapy Uses above.

Constant exposure to loud noise could cause some hearing damage. It is highly recommended that patients wear earplugs during their TMS sessions to avoid hearing loss. In fact, we ask all of our patients to do so. Earplugs decrease the level of noise by about 30 dB which puts it in the safe range.

No. TMS doesn’t cause brain damage. This is assuming that all the screening measures are taken and there are no contraindications to the magnetic treatment (no ferromagnetic metals in the brain).

There is no clinical evidence that TMS causes memory loss. On the other hand, there is clinical evidence to the contrary. TMS could actually enhance memory and cognition. Many researchers are looking into the use of TMS for cognitive enhancement and treatment of early dementia.

Not directly. On the contrary, many patients report improvement in sleep after a few sessions. There are trials looking into using TMS for insomnia.

Possibly. Some patients report lucid dreams especially in the first week of treatment. We don’t have reports of nightmares though.

Yes. For the vast majority of cases, TMS therapy can be performed with dental implants. Please share with your TMS doctor where and what dental implants you have to discuss more and monitor.

Possibly, but with extra care, TMS can be done with a cardiac pacemaker. It requires a very detailed evaluation. Coordination with the cardiologist and electrophysiologist to make sure the pacer and battery interrogated recently. We also would need to contact the manufacturer (Medtronic for example), depending on the model, they might recommend and send us a "shield".

No. TMS is contraindicated with a brain pacemaker (deep brain stimulator). Brain pacemakers are used for deep brain stimulation in some cases of refractory Parkinson’s disease and resistant depression.

Yes, one can have TMS with a spinal stimulator. Assuming the stimulator in the thoracic or lumbar spine.