Transcranial magnetic stimulation (TMS), also called repetitive TMS or rTMS, is a relatively new treatment option for patients diagnosed with major depressive disorder (MDD). TMS was approved by the FDA in 2008 for treating patients with depression who do not respond to antidepressants and are diagnosed with treatment-resistant depression. (1)
Antidepressants help many patients with depression, even those with severe symptoms. (2) But many physicians including myself know, and numerous research efforts show, that antidepressants don’t relieve depression symptoms for everyone. (3,4) My clinic for depression treatment in NYC offers TMS to patients who struggle to find relief from their depression symptoms.
TMS (rTMS) is a Noninvasive Medication-Free Solution for Depression
TMS works by stimulating specific regions of the brain associated with depression while the patient is awake and alert. During a TMS session, a coil is positioned over the patient’s head. This coil emits short magnetic pulses that electrically stimulate brain cells and increase blood flow in the targeted area. These magnetic pulses are similar to those of a magnetic resonance imaging (MRI) machine. (5)
TMS gives patients an alternative treatment option when antidepressants and talk therapy don’t improve depression symptoms and it provides many benefits to patients who may opt for TMS even if they aren’t resistant to antidepressants.
TMS Has Fewer Side Effects Than Antidepressants
One of the most notable differences between TMS and antidepressants is the side effects. TMS has very few and mild reported side effects, including mild headache, lightheadedness, and tingling and/or twitching of the face muscles. (6,7) These side effects oftentimes go away within a few hours after a treatment session. Patients can treat their headache by taking an over-the-counter pain reliever. TMS may even improve certain side effects of depression and antidepressant medications, like insomnia. (8)
Patients who take antidepressants report a wide range of side effects, including insomnia, constipation, dizziness, headaches, and decreased sexual interest and/or satisfaction. (2,9) Sometimes, these side effects can interfere so much with a patient’s quality of life that they stop taking their medication without talking to their doctor, which can make their depression worse and can make their medication less effective if they start to take it again.
A TMS Treatment Course is Shorter Compared to That of Antidepressants
A full course of TMS therapy lasts a total of 9 weeks. Regular treatment sessions are administered for the first 6 weeks. Then, during a tapering period, treatment sessions are slowly decreased for the final 3 weeks, until the patient no longer needs to come in for sessions. Once the treatment course is over, patients generally report an improvement or overall elimination in their symptoms. Sometimes, the patient’s doctor may recommend a maintenance session to prolong the positive effects of the TMS treatment course.
Patients must take antidepressants for months or even years to achieve desired results. If patients enter into remission (complete relief of symptoms), their doctor generally recommends that they continue to take the antidepressant for 4 to 9 months to maintain results and reduce the risk of relapse. (2)
Patients See Quicker Results With TMS
Because TMS therapy requires a shorter treatment course compared to that of antidepressants, patients will also see quicker results with TMS. Patients typically notice an improvement in their symptoms between 2 to 4 weeks of treatment.
The time it takes to see results from an antidepressant depends on what type you’re taking (e.g., SSRIs, SNRIs, or tricyclics). There are many different types of antidepressants and each type works in a different way to relieve depression symptoms. Although antidepressants can take as little as 2 weeks to start working in the body, patients typically start to feel an improvement in their symptoms between 6 to 8 weeks, but can take up to 14 weeks for patients to see results. (2,10,11)
TMS Provides Long-Lasting Results With Just One Treatment Course
The positive effects of TMS continue one year after treatment completion. One study observed the longevity of TMS results by following up with patients throughout one year after they received 1 course of TMS therapy. Researchers noted that 65.8% of patients who were symptom-free (in remission) after TMS treatment continued to show improvement in depression symptoms, even one year after treatment, while 50% continued to be symptom-free. (12) In some cases, patients may require maintenance sessions to boost the effects of their initial treatment.
If patients achieve remission with antidepressants, they’ll still need to continue taking their medication for at least 4 months to reduce the risk of relapse. (2) In some cases, doctors will recommend that patients continue taking antidepressants indefinitely.
TMS is Safe for Pregnant Patients
Depression in pregnant women can lead to an increased risk of miscarriage, premature birth, and low birth weight in the baby. (13) Depression should be treated, even when pregnant. Antidepressants can be very beneficial for depression, but they can also pose significant risks when taken during pregnancy. Some antidepressants, if taken during the third trimester, can cause withdrawal-like symptoms, like respiratory stress, in newborn babies. (14) Other antidepressants, although considered safe to take during pregnancy, may contribute to a higher risk of birth defects. (15,16)
Early studies show that TMS is effective in decreasing depression symptoms in pregnant women without causing adverse effects to the pregnancy or baby. (17,18,19) More research will be conducted to study the safety of TMS in pregnant women, but preliminary studies suggest that TMS is safe and effective for pregnant women without causing adverse side effects.
TMS Treatment Can Be Combined With Antidepressants
TMS therapy can be combined with most antidepressants, and some patients may even benefit from combining the two. TMS can be used to increase the effects of an antidepressant. Studies show that when TMS is administered at the same time patients are taking an antidepressant, it increases the effects of the antidepressant and decreases the severity of depression symptoms. (20,21)
TMS cannot be used with all types of antidepressants. For example, TMS may increase the risk of seizure if administered while patients are taking tricyclic antidepressants. (22)
TMS Works When Antidepressants Don’t
Research tells us that antidepressants are ineffective in up to one-third of patients diagnosed with major depressive disorder (MDD). (23) TMS is specifically beneficial to patients who do not find relief from depression symptoms with first-line treatments such as antidepressants and talk therapy. Numerous studies prove that rTMS is effective in patients with treatment-resistant depression. (24)
Comparing two major studies (the STAR*D study and the Carpenter study) shows that when patients are considered treatment-resistant, TMS offers a more effective treatment option compared to antidepressants. (25,26) Results from the STAR*D study show that 33% of patients achieve remission with the first antidepressant they try (more specifically, with Citalopram). In this same study, researchers found that after patients tried 2 antidepressants, their probability of remission when trying a third antidepressant reduced to 13 and 20%. After trying 3 antidepressants their probability of remission when trying a fourth antidepressant reduced to between 7 and 14%. (25) The Carpenter study observed the effects of TMS in patients who had tried an average of 2.5 antidepressants. After a 6-week treatment course of TMS, 26.5% to 28.7% of patients achieved remission, and 41.5% to 56.4% reported an improvement in their depressive symptoms. (26)
Overall, TMS is a Great Option for Patients With Depression
Transcranial magnetic stimulation provides numerous benefits to patients compared to antidepressants, including a shorter treatment course, fewer side effects, and long-lasting results. TMS therapy is more effective than antidepressants in patients diagnosed with treatment-resistant depression.
Like antidepressant medications, TMS for depression is covered by most insurance plans. If you’re looking for depression treatment, NYC and other major cities in the United States offer alternative options to antidepressants, like TMS.
If you’re currently taking antidepressants and haven’t noticed a change in your symptoms, or if your symptoms are getting worse, talk to your doctor. TMS may help you find relief from depression. Do not reduce your dose or stop taking your medication on your own. Doing so may make the medication less effective and can make depressive symptoms much worse.
- Horvath JC, Mathews J, Demitrack MA, and Pascual-Leone A. The NeuroStar TMS device: conducting the FDA approved protocol for treatment of depression. Journal of Visualized Experiments. 2010;(45):2345. https://pubmed.ncbi.nlm.nih.gov/21189465/. Accessed July 20, 2020.
- Depression: How effective are antidepressants? InformedHealth.org — Institute for Quality and Efficiency in Health Care (IQWiG). Published January 28, 2015. Updated June 18, 2020. https://www.ncbi.nlm.nih.gov/books/NBK361016/. Accessed July 20, 2020.
- Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, and Wang PS. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). The Journal of the American Medical Association. 2003;289(23):3095-3105. https://pubmed.ncbi.nlm.nih.gov/12813115/. Accessed July 20, 2020.
- Ionescu DF, Rosenbaum JF, and Alpert JE. Pharmacological approaches to the challenge of treatment-resistant depression. Dialogues in Clinical Neuroscience. 2015;17(2):111–126. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518696/. Accessed July 20, 2020.
- NeuroStar TMS Therapy® — Unique Mechanism of Action. Publication Date Unavailable. http://neurostar.com/en/how-neurostar-works/. Accessed July 22, 2020.
- Transcranial magnetic stimulation. The Mayo Clinic. Updated Nov. 27, 2018. https://www.mayoclinic.org/tests-procedures/transcranial-magnetic-stimulation/about/pac-20384625. Accessed July 21, 2020.
- Rossi S, Hallett M, Rossini PM, and Pascual-Leone A. The Safety of TMS Consensus Group. Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clinical Neurophysiology. 2009;120(12):2008–2039. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3260536/. Accessed July 21, 2020.
- Massimini M, Ferrarelli F, Esser SK, Riedner BA, Huber R, Murphy M, Peterson MJ, and Tononi G. Triggering sleep slow waves by transcranial magnetic stimulation. PNAS. 2007;104(20):8496-8501. https://www.pnas.org/content/104/20/8496. Accessed July 20, 2020.
- Harvard Health Publishing. What are the real risks of antidepressants? Published March 2014. Updated March 19, 2019. https://www.health.harvard.edu/mind-and-mood/what-are-the-real-risks-of-antidepressants. Accessed July 20, 2020.
- Machado-Vieira R, Baumann J, Wheeler-Castillo C, Latov D, Henter ID, Salvadore G, and Zarate CA. The timing of antidepressant effects: A comparison of diverse pharmacological and somatic treatments. Pharmaceuticals. 2010 6;3(1):19-41. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3991019/. Accessed July 21, 2020.
- Henssler J, Kurschus M, Franklin J, Bschor T, and Baethge C. Trajectories of Acute Antidepressant Efficacy: How Long to Wait for Response? A Systematic Review and Meta-Analysis of Long-Term, Placebo-Controlled Acute Treatment Trials. The Journal of Clinical Psychology. 2018;79(3). https://pubmed.ncbi.nlm.nih.gov/29659207/. Accessed July 22, 2020.
- Dunner, DL, Aaronson ST, Sackeim HA, Janicak PG, Carpenter LL, Boyadjis T, Brock DG, Bonneh-Barkay D, Cook IA, Lanocha K, Solvason HB, and Demitrack MA. A multisite, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: Durability of benefit over a 1-year follow-up period. The Journal of Clinical Psychiatry. 2014;75(12):1394-401. https://pubmed.ncbi.nlm.nih.gov/25271871/. Accessed July 20, 2020.
- Depression in pregnant women and mothers: How children are affected. The Journal of Paediatrics and Child Health. 2004;9(8):584-601. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724170/. Accessed July 22, 2020.
- Kalra S, Einarson A, and Koren G. Taking antidepressants during late pregnancy: How should we advise women? Canadian Family Physician. 2005;10:51(8):1077–1078. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1479505/. Accessed July 22, 2020.
- Key findings—A closer look at the link between specific SSRIs and birth defects. The Centers for Disease Control and Prevention. Updated July 16, 2020. https://www.cdc.gov/pregnancy/meds/treatingfortwo/features/ssrisandbirthdefects.html. Accessed July 22, 2020.
- Dubovicky M, Belovicova K, Csatlosova K, and Bogi E. Risks of using SSRI / SNRI antidepressants during pregnancy and lactation. Interdisciplinary Toxicology. 2017;10(1): \30–34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6096863/. Accessed July 22, 2020.
- Kim DR, Epperson N, Paré E, Gonzalez JM, Parry S, Thase ME, Cristancho P, Sammel MD, and O’Reardon JP. An open label pilot study of transcranial magnetic stimulation for pregnant women with major depressive disorder. Journal of Women’s Health. 2011;20(2):255-61. https://pubmed.ncbi.nlm.nih.gov/21314450/. Accessed July 22, 2020.
- Hızlı Sayar G, Ozten E, Tufan E, Cerit C, Kağan G, Dilbaz N, and Tarhan N. Transcranial magnetic stimulation during pregnancy. Archives of Women’s Mental Health. 2014;17(4):311-315. https://pubmed.ncbi.nlm.nih.gov/24248413/. Accessed July 22, 2020.
- Kim DR, Wang E, McGeehan B, Snell J, Ewing G, Iannelli C, O’Reardon JP, Sammel MD, and Epperson CN. Randomized controlled trial of transcranial magnetic stimulation in pregnant women with major depressive disorder. Brain Stimulation. 2019;12(1):96-102. https://pubmed.ncbi.nlm.nih.gov/30249416/. Accessed July 22, 2020.
- L Bangshan, Zhang Y, Zhang L, and Li L. Repetitive transcranial magnetic stimulation as an augmentative strategy for treatment-resistant depression, a meta-analysis of randomized, double-blind and sham-controlled study. BMC Psychiatry. 2014;14:342. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4264336/. Accessed July 22, 2020.
- Rumi DO, Gattaz WF, Rigonatti SP, Rosa MA, Fregni F, Rosa MO, Mansur C, Myczkowski ML, Moreno RA, Marcolin MA. Transcranial magnetic stimulation accelerates the antidepressant effect of amitriptyline in severe depression: a double-blind placebo-controlled study. Biological Psychiatry. 2005;57(2):162-6. https://pubmed.ncbi.nlm.nih.gov/15652875/. Accessed July 22, 2020.
- NeuroStar Prescribing Information. NeuroStar. Page 8. https://neurostar.com/wp-content/uploads/NeuroStar-Prescribing-Information.pdf. Publication date unknown. Accessed July 22, 2020.
- Ionescu DF, Rosenbaum JF, and Alpert JE. Pharmacological approaches to the challenge of treatment-resistant depression. Dialogues in Clinical Neuroscience. 2015;17(2):111–126. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518696/. Accessed July 22, 2020.
- Somani A, Kar SK. Efficacy of repetitive transcranial magnetic stimulation in treatment-resistant depression: the evidence thus far. General Psychiatry. 2019;32(4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6738665/. Accessed July 22, 2020.
- Gaynes BM, Rush AJ, Madhukar HT, Wisniewski SR, Spencer D, and Maurizio F. The STAR*D study: Treating depression in the real world. Cleveland Clinic Journal of Medicine. 2008;75(1):57-66. https://pubmed.ncbi.nlm.nih.gov/18236731/. Accessed July 22, 2020.
- Carpenter LL, Janicak PG, Aaronson ST, Boyadjis T, Brock DG, Cook IA, Dunner DL, Lanocha K, Solvason HB, Demitrack MA. Transcranial magnetic stimulation (TMS) for major depression: A multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depression and Anxiety. 2012;29(7):587-96. https://pubmed.ncbi.nlm.nih.gov/22689344/. Accessed July 22, 2020.