Transcranial Magnetic Stimulation TMS

Repetitive Transcranial Magnetic Stimulation (rTMS) is a cutting-edge treatment that has been FDA approved for the treatment of depression in adults and adolescents and Obsessive Compulsive Disorder (OCD) in adults. TMS is a game changer in psychiatry.  Unlike medications that are imprecise, it is the only treatment in psychiatry that directly targets the circuits involved in psychiatric conditions. TMS is a non-invasive office procedure. During a TMS session, a special coil is placed on your head, and it sends magnetic pulses to your brain that activate neurons and brain circuits that help with the normalization of mood.  TMS treatment involves a series of sessions over a few weeks. It creates long-lasting changes in brain activity that improve symptoms. TMS is safe and conducted under the guidance of our highly skilled medical professionals, tailored to each person’s individual needs. 

While standard MRIs are scans of brain structure, functional MRIs (fMRI) are x-rays of the mind. By indicating where blood is flowing or oxygen is consumed fMRIs reveal the regions of the brain that fire when people think certain thoughts, experience certain feelings, or perform specific tasks. One of the most consistent fMRI findings seen in depressed people is decreased activity in the left prefrontal cortex (PFC) – the frontal part of the brain which is important for many things, including the appreciation of pleasure. If that area is underactive, the individual cannot enjoy activities, and may experience anhedonia – one of the core symptoms of depression. Decreased left PFC function, in turn, triggers a whole circuit across the brain that results in the full complement of depression symptoms. TMS is a revolutionary treatment that grabs the bull by the horns by directly stimulating the left PFC until its activity normalizes and the symptoms of depression dissipate.  The concept behind TMS is based on Faraday’s law – if an electrical field is moving in a certain direction, it creates a magnetic field perpendicular to it. The device is placed over the head, and a magnetic field of about 4 cm is activated. The field enters the brain and is converted back into electrical impulses, activating brain circuitry in deeper regions.  

When depression is successfully treated with drugs or electroconvulsive therapy (ECT) the activity in the left PFC normalizes. However, medications and ECT very nonspecific. ECT shocks the whole brain while medications go all over the brain and body.  Consequently, ECT causes memory problems and drugs take several weeks for the onset of therapeutic effects and cause numerous side effects such as weight gain and sexual dysfunction. The pivotal, NIH-sponsored STAR*D antidepressant trial showed that only a quarter of patients respond to the first antidepressant, and a mere 6.9% respond after  failing three medications. Since TMS directly stimulates the left PFC, it is far more effective in treating depression in people who have failed multiple medication trials (~80% response and ~60% remission with TMS compared to ~7% remission with medications) and works far more rapidly (4-6 weeks with TMS compared to 6-12 weeks with medications). Medications cause chemical changes in the brain that are transient, leading to  relapse of depression when the drug is stopped. TMS, by contrast, produces changes in brain circuitry and has far more durable therapeutic effects that are preserved long after the treatment is stopped. Only 30% of TMS responders require for additional treatment, and even then, it is typically 6 months to a year later. Since TMS is applied specifically to the left PFC, it does not cause systemic side effects throughout the body like medications or lead to memory loss like ECT.  It is safe and essentially side-effects-free. Thus, compared to conventional antidepressants, TMS is significantly more effective, rapid, durable, safer, and tolerable.   

The technology for TMS has been around for over a century. I became involved in TMS research at Columbia in the 1990s and treated my first patient over three decades ago. The clinical benefits and safety were confirmed by over a hundred studies including several large multicenter randomized controlled trials conducted at several leading academic centers of the world including Harvard, Columbia, Cornell, Stanford, Yale, Duke, Oxford, and the Max Planck Institute just to name a few. While antidepressant medications were discovered by serendipity TMS is the first scientifically based, rationally designed treatment in the history of psychiatry. The scientific basis and biological underpinnings of TMS are better understood than any other psychiatric treatment available.  

The typical TMS therapy session is an outpatient treatment that does not involve any medications or anesthetics. You can drive yourself to and from appointments. You sit in a comfortable reclining chair, and a curved TMS coil is gently placed over the left frontal part of your head. At the first session, we will stimulate your motor cortex to find the exact location and dose required for treatment. Hence, each treatment is customized based on the anatomy and neurobiology of each and every patient.  As the treatment is administered a gentle tapping sensation is felt as the magnetic waves stimulate your brain. You may watch TV, listen to music, or chat with our highly trained, deeply empathic TMS treaters during each session. Each standard treatment is around 20 minutes in duration, while Theta Burst TMS is just 3 minutes long. If anxiety is also present, we will treat the left side for depression and the right side for anxiety. These sessions may last a little longer (~35 minutes). We usually begin with standard TMS and graduate to two back-to-back 3-minute sessions of Theta Burst if there is no response within three weeks. There is no need for recovery time afterward; you can get straight back to your daily activities. We will perform weekly depression rating scales to assess your progress. 

TMS therapy involves one daily session, 5-6 days per week, for 6-7 weeks, for a total of 34 sessions. Some people respond more quickly and require fewer sessions. Doing fewer session per week (3-3 sessions) or missing a few sessions during the treatment course is not a problem. Since this is a substantial time commitment, our team will make every effort to accommodate you at a time that is most convenient to you. We offer early morning, late evening, and Saturday sessions.  

TMS is far safer than ECT or medications. Since it is a precision treatment, it does not cause systemic side effects such as sexual dysfunction, weight gain, or fatigue associated with medications or memory loss associated with ECT. The only discomfort is mild tenderness around the area of treatment during the sessions. The risk of persistent headaches is less than 3%. If this occurs, we will immediately readjust the coil and lower the dose. Indeed, it has been shown to be a highly effective treatment for migraines. The only people who cannot do TMS are those with ferromagnetic metal inside their skull. Non-magnetic nickel and titanium shunts as well as dental fillings, are safe. If it is safe for you to have a head MRI, you can have TMS. The only serious complication is a seizure that could occur during the session. This is an extremely rare risk, seen in less than 1 in 200,000 sessions. If a seizure occurs our staff is trained to take safety measures and get immediate assistance by calling 911. Since 2010, we have safely treated thousands of patients without complications. There are no long-term adverse consequences of TMS based on 30 years of data from millions of patients worldwide. TMS uses less magnetic energy than MRI scans. There is no radiation involved. There are no cognitive issues, such as concentration difficulties or memory loss, from the treatment. TMS will not make your illness worse. The only poor outcome is the lack of efficacy seen in around 15-20% of patients.  

Your mental health influences your identity and shapes the trajectory of your life. It also has a ripple effect on those around you. If you suffer from depression, anxiety, or OCD, getting effective treatment early is paramount. The longer you go with no therapy or ineffective treatment, the more resistant your illness gets and the more brain damage it causes. In addition, depression is one of the world’s leading causes of morbidity and mortality. Job loss, relationship difficulties, and medical illness are common among those afflicted with depression. If you have unipolar depression or OCD and have failed to respond to two or more antidepressants TMS may be the right choice for you. Antidepressants and therapy get most people halfway better but not fully well, and they live the rest of their lives with partial depression. Do not settle for this. seek to get well and get off all medications. Indecisiveness and hopelessness are common symptoms of depression that make people skeptical. Do not let these feelings get in the way. Some are concerned that TMS has not been around for a long time. This is true, but it is vastly superior and more scientifically sound than medications that have been around for 80 years. Would you drive the 2024 Ford Taurus or the Ford Model T that has been around for 120 years? Sadly, many ‘old school’ mental health practitioners are unfamiliar with the treatment and have not made the effort to learn the science and clinical data in support of TMS. In such situations, you need to advocate for yourself. Getting a TMS consultation does not mean you need to commit to the treatment. At the consultation, you can get more information and then decide if it is right for you. TMS has had a life-changing effect on over 6,000 patients we have treated, and it certainly can be one of the ten best decisions you have made.