Major depressive disorder is a debilitating disease believed to affect more than 300 million people worldwide. Researchers estimate that by the year 2020, depression will be the second leading cause of disability worldwide (1, 2).
Every year in the United States, more than 30,000 people die from suicide, and 60 percent of these victims suffer from major depression (3). As clinicians, we need to be doing everything we can for our patients who are affected by this lethal disease. All too often, a slow approach is taken to address the problem, and patients end up receiving suboptimal treatments for far too long without success.
It is well known that antidepressants do not work for everyone. In fact, a study published in the Journal of the American Medical Association revealed that 4.5 million people in the United States who suffer from depression do not respond fully to prescription antidepressants (4). Because antidepressants are often a first-line treatment option, this figure can be disheartening.
The good news is that there are proven, drug-free treatments, such as transcranial magnetic stimulation (TMS), that can be part of the discussion from the start. Since 2010, the American Psychiatric Association has recommended TMS as a second-line treatment for adult patients with depression who have not benefited from initial antidepressant medication.
Despite being a newer treatment for depression (the first machine from NeuroStar was cleared by the FDA in 2008), TMS is a proven option with impressive efficacy rates and research results. (In addition to NeuroStar, several other companies, including Brainsway and MagVenture, specialize in non-invasive magnetic stimulation systems).
I have had great success using NeuroStar TMS as part of my patients’ treatment plans, when appropriate, and I have seen that remission from depression is possible.
How does TMS work?
Unlike electroconvulsive therapy, which applies electricity directly to the brain to induce seizures, TMS is a non-drug, non-invasive treatment that uses magnetic pulses to stimulate areas of the brain that are underactive in depression such as the prefrontal cortex. Patients are awake during the treatment and can get back to daily activities, including driving, immediately following the session.
During the first treatment session, doctors identify a patient’s motor threshold, which is the amount of magnetic field strength that will be administered throughout the course of treatment. This field strength is customized for each patient to deliver the correct treatment dose.
Individual TMS sessions do not take that long. The most recently approved device from NeuroStar can deliver the right dose in as little as 19 minutes. Therapy is usually administered five days a week for four to six weeks. At the end of the treatment, there may be a taper period where the number of treatments is gradually reduced.
Who is most likely to benefit from TMS?
TMS is indicated for the treatment of adult patients with major depression who have not responded to at least one antidepressant. TMS may not be right for everyone and patients are encouraged to talk with their doctors about the treatment. NeuroStar should not be used with patients who have non-removable conductive metal or stimulator implants in or near the head or patients who have active or inactive implants such as deep brain stimulators, cochlear implants, or vagus nerve stimulators.
For those who do not respond to medication, or who cannot tolerate the negative side effects from medication and want to explore other treatments, TMS may be a viable option. The most common side effect from TMS is mild to moderate pain or discomfort at or near the treatment site, which is a temporary side effect that typically only occurs during the first week of treatment (5).
TMS is covered by many commercial and government health plans, such as Medicare and Tricare, making the treatment a reality for many who need it.
Is TMS effective?
Multiple studies support the efficacy of TMS for depression. A randomized control trial of 199 patients found that TMS quadrupled the odds of remission after six weeks when compared with a sham procedure (6). An open-label study performed with NeuroStar found that 58 percent of patients significantly responded to treatment, and 37 percent achieved complete remission of their depression symptoms (7).
Patient response to treatment varies, with some reporting positive effects within the first couple of weeks. In my practice, the effectiveness of TMS mirrors results from the clinical trials. About 65 percent of patients respond to the treatment and 35 percent go to remission of their symptoms. On average, these patients have not seen success with upwards of nine antidepressants, and the average length of their current depressive episode is three to five years. We have seen a good treatment response in people who have tried fewer antidepressant medications and those who have tried more.
I work with patients over the course of their TMS treatment and assess for tolerability as well as benefit early on. Around the three-to-four-week mark, I reassess the motor threshold to ensure we are giving optimal treatment. For patients who are not responding, changing the treatment protocol may help (8). Staying on top of patient progress and monitoring for external stressors that may impact their response is crucial to a successful outcome.
What if patients are interested in TMS as an add-on therapy?
It has been my experience that patients who are asking for and being prescribed TMS have already discontinued medications because of their ineffectiveness.
When that is not the situation, my approach is to initiate TMS and leave the patient’s medication treatment in place. In certain cases, patients seem to do best with a combination of medications and augmentative TMS (9). Ultimately, I assess the patient after treatment and determine what, if any, changes need to be made. ■
1. World Health Organization. Depression Fact Sheet. Accessed October 2017.
2. Murray CJ, Lopez AD. Evidence-based health policy – lessons from the Global Burden of Disease Study. Science. 1996; 274 (5288): 740-743.
3. Heron, Melonie, et al. Deaths: Final Data for 2006. 2009. National Vital Statistics Reports, 57 (14).
4. Kessler RC, Berglund P, Demler O et al. JAMA. 2003;289(23):3095-105.
5. Janicak PG, O’Reardon JP, Sampson SM, et al. Transcranial magnetic stimulation in the treatment of major depressive disorder: a comprehensive summary of safety experience from acute exposure, extended exposure, and during reintroduction treatment. J Clin Psychiatry. 2008;69(2):222-32.
6. George MS, Lisanby SH, Avery D, et al. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Arch Gen Psychiatry. 2010;67(5):507-16.
7. Carpenter LL, Janicak PG, Aaronson ST, et al. Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depress Anxiety. 2012;29(7):587-96.
8. McDonald WM, Durkalski V, Ball ER, et al. Improving the antidepressant efficacy of transcranial magnetic stimulation: maximizing the number of stimulations and treatment location in treatment-resistant depression. Depress Anxiety. 2011;28(11):973-80.
9. Herwig U, Fallgatter AJ, Höppner J, et al. Antidepressant effects of augmentative transcranial magnetic stimulation: randomised multicentre trial. Br J Psychiatry. 2007;191:441-8.