What is TMS?
TMS (transcranial magnetic stimulation) is a non-invasive treatment for major depression. It has also been studied for many other illnesses.
How does TMS work?
A magnetic coil is placed over the skull in the targeted area and a series of rapid magnetic pulses are administered. These pulses are of the same type and strength as those used in MRI machines. The magnetic pulses pass through the skull and go a short distance into the brain. There they are thought to activate the neurons, cause chemical changes as well as induce the neurons to connect and signal more with each other. This in turn improves mood and cognition. TMS does NOT administer electricity. It administers magnetic pulses.
Is TMS FDA-approved?
TMS was first approved by the FDA for treatment of adults with TRD (treatment-resistant depression) in 2008. Since then TMS has also been approved for OCD and smoking cessation. It is being investigated for many other disorders including PTSD, anxiety, bipolar disorder, fibromyalgia, tinnitus, chronic pain, autism, ADHD, Parkinson’s, post-stroke and more, but has not yet been approved by the FDA for these disorders.
Is TMS safe?
With over 1.5 million treatments to 60,000 patients TMS has a long safety record. It has few risks and side-effects.
What are the risks of TMS?
Every medical treatment has risks, benefits and side effects. The most serious risk of TMS is that it can cause a seizure. This is extremely rare. The older statistics estimated the risk at 1/30,000 treatments. Newer data show an even lower risk of 1/89,000 treatments. Therefore seizures are more common from medications than from TMS. For example, the risk of seizures with bupropion (Wellbutrin) is 4/1,000.
Seizures from TMS are usually in patients with a predisposing condition like severe head trauma, usually last less than 5 minutes and do not usually cause long-term medical complications.
While not a side effect of TMS, patients struggling with depression can have suicidal thinking or behavior. If you develop suicidal thinking and may act on it, you should call 911 or go to the ER.
As with medication and light therapy treatments for depression, TMS can cause hypomania or mania. This uncommon side effect tends to occur in patients with an underlying genetic predisposition due to a family history of manic depression (also called bipolar disorder). We will screen for this and watch for any signs of this.
Can TMS be administered to a patient on medication?
Yes. Most patients continue their medications during TMS. In fact, we try to minimize medication changes during TMS for the stimulation level to remain constant. After TMS, some patients taper off some or all of their medications. This would depend on your provider’s recommendation based on your history and prognosis as well as on your response to TMS.
Is TMS invasive?
No. TMS is non-invasive, so there is no anesthesia and no systemic side effects.
Can TMS be done during pregnancy or breastfeeding?
Yes. The magnetic coil is placed far enough away so as not to cause any harm to the fetus. However, because the initial clinical trials excluded pregnant women, there is no specific FDA clearance for TMS in pregnancy. However, later trials evaluated safety and efficacy of TMS in pregnant women, and no absolute contraindication was assigned.
What are the common side effects of TMS?
The most common side effect is scalp discomfort during TMS treatment in about 5-30% of patients. Some patients describe it as a tapping sensation under the coil. As the treatment progresses during the first week, most patients no longer complain of discomfort as their scalp adjusts to the sensation. We always recommend pre-treating with Tylenol or Advil 30 minutes before your TMS session for the first week or so till your scalp adjusts (unless these medications are contraindicated for you). We also turn down the intensity level in the beginning of TMS and only gradually increase it as tolerated.
Up to one half of patients report tension-type headaches after the initial TMS sessions. The headaches usually resolve in 30 minutes to two hours. They can be treated with OTC pain medications. It can also uncommonly cause light-headedness, especially in patients with postural hypotension.
Patients may also report muscle twitching during the TMS session due to stimulation of superficial nerves. If this occurs, we make adjustments to minimize this.
Because the TMS machine makes a tapping noise similar to an MRI machine, it could damage hearing. We give each patient either ear buds or foam ear plugs to protect hearing and to also lessen the risk of headache. You may bring your own noise cancelling ear buds if you prefer.
TMS does NOT cause brain damage, weight gain, sexual dysfunction, memory impairment, dry mouth, nausea, urinary retention or constipation. TMS is not addictive or habit-forming.
How effective is TMS at treating depression?
TMS is more effective than medication. Older studies indicate that two out of three patients get better with TMS (response) and 1 out of three patients get well with TMS (remission). Some of the newer studies show even better results. Compare this with the results of the STAR-D trial: the first antidepressant had a 27% chance of helping. By the time the patient started a fourth antidepressant, the chance of response had dropped to 6.9%.
If TMS is so effective, why isn’t it tried before medication?
The simple answer is cost. The initial trials evaluating TMS only included patients who had failed one or more antidepressants. Thus the FDA only approved TMS for the treatment of adult patients who had failed one of more medications (treatment resistant depression or TRD). It doesn’t mean TMS can’t work as a first line treatment for depression, only that insurance will only pay for it for TRD at this time.
What can make TMS less effective?
- Illicit drugs and excessive alcohol use. These also increase the risk of seizures.
- Adjustment of prescribed medications or addition of supplements or OTC medications during TMS.
- Sleep, diet or caffeine changes
- Missing too many TMS sessions
- Severe stress
- Comorbidity (although common, comorbid anxiety, etc. makes the depression harder to treat).
How long does the benefit from TMS last?
Two out of three patients will maintain their response or remission 6-12 months after their course of TMS. About one third could see a return of their depressive symptoms. Thankfully, insurance usually covers another course of TMS and patients who achieved response or remission with their first course typically have a similar response or remission with the subsequent course.
What can make TMS more effective?
- Being on an antidepressant
- Being younger
- Having the personality trait of persistence when frustrated
- Keeping sleep, exercise, caffeine and stress as stable as possible
- Not adjusting psychiatric medications until after the course of TMS is completed. We ask that you not have a regular follow-up appointment with your regular provider till after you have completed your course of TMS to minimize the chance of a medication change.
- Eating and exercising before a TMS session
- Focusing on a cognitive task during the TMS session can also help, so try not to fall asleep.
- There is some evidence that doing CBT (cognitive behavioral therapy) during TMS can also help.
Can TMS be used with Spravato® or Ketamine ?
Yes. All of these treatments increase the neuroplasticity (connectivity of neurons) of the brain. While insurance usually covers both TMS and Spravato® treatments, they won’t cover them concurrently. We can help you figure out which treatment you should try first. Insurance doesn’t cover Ketamine treatment, so TMS and Ketamine can be done concurrently if you want to pay out of pocket for the Ketamine. (Magnetic Hope does not prescribe Ketamine. You would have to go to another provider for it. There are some important treatment considerations, so we will help you plan for the most effective treatments if you are doing both.)
How much does TMS cost?
If you have been to the Apple store recently you know that cutting-edge technology is expensive. The average cost for TMS is about $300/session. For 36 sessions this works out to be almost $11,000. Thankfully, insurance now covers TMS for most insured patients with treatment-resistant major depression. In weighing a cost/benefit analysis, you have to also compare the “cost” of the depression and its effect on your life in terms of work, home-life and relationships. For our patients who have gotten their lives back, they have expressed that it was money well-spent.
What are the typical criteria that insurance companies require in order to cover the TMS?
Is TMS contraindicated in some patients?
Yes: Patients who have magnet-sensitive metals such as ferrous (iron) in their head or neck cannot do TMS. This would include bullet fragments, metal plates and medical devices such as a brain shunt, cochlear implant, aneurysm clips, electrodes, pumps or a deep brain stimulator. Standard amalgam dental fillings and permanent retainers are usually ok as they are not reactive to magnets.
- If a patient has an implanted medical device that could be affected by a magnet such as a pacemaker, they should not receive TMS.
- A patient with a history of a seizure disorder, or a history of severe head trauma are other contraindications.
- Facial tattoos or permanent (tattoo) make-up are other contraindications as these inks often contain iron.
- Patients who have a significant substance use disorder will need to have treatment for this before doing TMS as well.
- Insurance will not pay for TMS in patients with psychosis.
- Patients who have a suicide plan or have recently attempted suicide need closer monitoring than is available with TMS.
How can a provider refer a patient?
We would love to help your patient! Please contact us to begin the process. 205-637-3055 or 205-825-HOPE or email@example.com. Also please have your staff gather your patient’s records documenting the medication and therapy trials which are needed for insurance coverage if applicable.
Would you like to know more?
At Magnetic Hope, your care is our highest priority. We are dedicated to providing you with all the necessary tools and information that will make your TMS therapy in Birmingham, Alabama as comfortable and effective as possible. Our friendly staff is available to address any of your questions or concerns every step of the way.