Approximately 18 million people in the US alone are affected by major depressive disorder (MDD). More than half of those affected react well to pharmacotherapy, while 20-30% of individuals that suffer from depression may have “treatment-resistant depression” (TRD). TRD is a term used in psychiatry to describe cases of MDD patients who were treated unsuccessfully with at least two antidepressants. The condition has been associated with poor clinical outcomes, impaired long-term social functioning and high rates of medical comorbidity and mortality. As such, Transcranial Magnetic Stimulation (TMS) has been gaining ground as a therapy for TRD over the past few years. It is the latest therapy to be cleared by the Food and Drug Administration (FDA) for depression, and it has proven to be a much more desirable treatment method compared to the classic TRD treatments.
In 2008, TMS obtained approval from the FDA for the treatment of major depression in the 30% to 50% of patients who had at least one unsuccessful antidepressant treatment course. FDA initially approved just one TMS device, the NeuroStar, that is manufactured by Neuronetics. A second device, manufactured by Brainsway, gained FDA approval in 2013. TMS treatment centers have been established across the country ever since, and insurance companies followed suit by covering the non-invasive yet expensive treatment.
During a TMS procedure, a physician or a nurse place a non-invasive machine against the scalp, more specifically, over the left prefrontal cortex area, a region of the brain that emits abnormal electrical activity in depressed patients. The non-invasive device then sends generates electric current by sending short intense magnetic signals to the brain of the patient. During TMS treatments, patients remain awake during the course of the treatment, while seated in a chair. Briefly, the device itself is a high powered magnetic coil that generates energy across the cortex as means to modulate groups of neurons. Essentially, the machine entails a stimulator with a bank of capacitors that allow energy to be stored and released in milliseconds. This movement of energy, or current, goes through a coil. Perpendicular to that coil a high powered magnetic field turns on and then off, and this fluctuation affects neuronal functioning at the molecular level.
TMS is different from electroconvulsive therapy (ECT), which has been an available procedure in the United States for more than 70 years. Basically, an ECT procedure involves the placement of an electric stimulus to the patient’s skull in order to induce a seizure. The clinical efficacy of ECT in TRD is impressive – a rate of 60% to 90% of acute response, making the procedure particularly suitable for psychotic depression, catatonia and delirious mania.
While ECT is effective at alleviating major depressive disorder, it does have some drawbacks. It must be administered under anesthesia, thereby prolonging preparation as well as recovery, and its side effects include confusion and memory loss. It is associated with several common adverse effects, including arrhythmias, headaches, muscle aches and nausea. The most common side effect is acute cognitive impairment, such as either anterograde or retrograde amnesia. All adverse effects can last anywhere from a few minutes to a a few days, and even though they are temporary, they are not associated with TMS.
William McDonald, MD, a psychiatrist at Emory University School of Medicine who was involved in the clinical trials that led to the approval of the NeuroStar device, one of the first to be FDA approved for TMS purposes explains the actual procedure simply. “You sit in a chair, it takes about 30 minutes, and then you can get up and drive yourself home,” he says. TMS’ minimal side effects include headache and muscle soreness as the most common patient complaints. This is a stark contrast to ECT, as patients are advised to be accompanied by an escort due to the driving restrictions following treatment. There is a small risk of seizure associated with TMS, but it is reportedly comparable to the seizure risk associated with antidepressant medications. Compared to ECT, Gray says, “TMS is a walk in the park.”
Despite TMS being a conveniently non-invasive and fairly side effect free procedure, one major obstacle is the time commitment for patients. One TMS session lasts between 30 and 60 minutes; sessions take place 5 times a week over the course of 4 to 5 weeks, totaling to 20 to 30 sessions all together. However, given its success rates of 75%, fewer than 1% of patients have discontinued treatment due to the long commitment or the adverse side effects.
Patients suffering from TRD have access to TMS therapy via several practices across the nation. One of them is TMS Health Solutions, a group psychiatric practice that provides innovative and patient centric care with a focus of an academic institution, with Richard Bermudes, MD as the founder and chief medical officer. Relying on the most advanced therapies that are continually incorporating new and groundbreaking treatment methods, TMS Health Solutions offers a unique, patient-centered experience as it aims to help those with mental health conditions. In particular, TMS Health Solutions is passionate about helping individuals with TRD by offering TMS.
According to Dr. Bermudes, TMS is a non-invasive therapy, whereby “We’re not generating a seizure. This is sub-seizure threshold. TMS actually introduced the idea that we could do neuro-modulation without generating a seizure and improve mood.”
Dr. Bermudes is board certified by the American Board of Neurology and Psychiatry, having completed a fellowship in cognitive therapy and cognitive therapy supervision at the Beck Institute for Cognitive Therapy and Research in Philadelphia, Pennsylvania. Following a specialized training in TMS, he was the first provider of TMS therapy for depression in the Sacramento area. Dr. Bermudes is the founding member of a clinical TMS society, and he chaired the first annual meeting in 2013. He was elected president of the society in 2015.