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Basics of Transcranial Magnetic Stimulation

Transcranial Magnetic Stimulation (TMS)

TMS has been studied and approved by the Food and Drug Administration (as of 2008) for treatment resistant depression.  Individuals suffering from major depressive disorder who have not seen adequate treatment with standard medications may be candidates for TMS.  TMS is considered quite safe as a treatment option.  Cost is usually the major deterrent to treatment.

What are Success Rates?

Studies typically show very good results given the treatment population is one that has failed a series of standard medications and therapy.  Open-label studies are closest to real-world settings of a clinic one may visit.  In these circumstances, roughly 2/3 of patients completing treatment reported little to no depression at the completion.  Standard rating scales done by clinicians showed about ½ of the participants had significant improvement in depression and 1/3 were in remission with their depression at the completion.

How does TMS work?

TMS involves utilizing magnetic resonance imaging (MRI) strength magnets to activate the surface of the brain inside the skull.  Magnetic fields are able to pass through the skull without losing much energy to trigger neurons to fire.  The TMS treatment is done at a specific strength and sequence just behind the left forehead over the course of about 40 minutes.  This is done daily, Monday to Friday, for four to six weeks.  For most people, the treatment is painless and is done in a reclining medical chair while wide awake.  The antidepressant effect is believed to be modulated through the activation of neurotransmitters like serotonin, dopamine and norepinephrine.  Increased neuronal firing also increases blood flow to specific areas of the brain involved in regulation of depressed mood.  Deeper brain structures are also activated through these processes.

What are the side effects?

There are incredibly few side effects with TMS.  It is a local treatment that is devoid of systemic risks.  Side effects to TMS are most commonly scalp discomfort or headaches due to localized magnetic stimulation.  For some, pulses through the scalp are uncomfortable and   may cause twitching of local muscles.  Headaches can be as much a component of holding tension in the muscles around the scalp in anticipation of the pulses.  Therefore, those who are able to remain relaxed seem to have fewer risks of headaches.  Treatment with TMS does not cause memory impairment.  In fact, it may sometimes even be the opposite where memory is slightly better with treatment.

Seizures are the most concerning risks with any brain stimulation.  As opposed to electoconvulsive Treatment (ECT) where seizures are the goal, the goal is to not cause seizures in TMS.  In fact, seizures are very rare occurring only once in about every 10,000 treatments.  Most commonly this seems to happen when someone already has a seizure disorder, is taking medications that can increase the risk of seizures, the pulse energy is very high, or any combination of the above.

How long do effects last?

Effects from TMS will last from months to years.  That said, one must understand that major depression is a recurrent illness and there is no cure.  One study followed people for 6 months after treatment and a small percent required further TMS sessions.  This may involve anywhere from 5 to 15 sessions.  Of those who needed follow up sessions, more than 85% had a good response to the subsequent sessions.  This is promising knowing that depression is a recurrent illness and TMS represents a treatment option that has the potential to recreate a good response on subsequent sessions.

Is TMS covered by insurance and what is the cost?

TMS is covered by a small number of insurance companies.  Very few have created treatment policies around TMS.  Some have and may cover TMS after a series of medical appeals are made.  It may help to call your insurance and inquire if TMS is covered and ask if TMS has ever been paid for after appeals were made.  Some clinics may even help with the appeals process.  Often insurance now are refusing to cover TMS unless the patient has already pursued treatment.  Treatment generally costs $8,000 to $12,000 for the four to six week course.  This may pale in comparison to the cost burden of the depression when one sums lost productivity and healthcare costs, not to mention the intangibles of lost time.  Besides personal resources, individuals may apply for healthcare financing which can reduce the cost to manageable monthly premiums.

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