Major depressive disorder is a serious illness from which, it is believed, more than 300 million people around the globe suffer.
The WHO classifies depression as a leading cause of disability in the world today (1).
In the U.S. alone, more than 30,000 people die by suicide every year.
At least 60% of that number are people who are affected by major depression (2).
This puts suicide in 11th place as one of the major causes of death in the U.S. and worldwide.
Even though the problem is recognized, the reaction of medical specialists is not always appropriate.
Often, depression is approached cautiously and the treatment that patients receive is suboptimal, to say the least.
This may mean their disease continues or even worsens.
Antidepressants can be a good place to start, and they can help many people.
However, as it is well-known, they do not work well enough for everyone (3).
But for all those who do not respond well to antidepressants and are maybe losing hope in this conventional treatment, there is light at the end of the tunnel.
Electromagnetic Therapy, that is, transcranial magnetic stimulation (TMS), has been recommended by the American Psychiatric Association in 2010 as a second-line choice for patients suffering from depression who feel no benefits from treatment with antidepressants.
Even though this is a relatively new treatment, considering that the first device was approved by the FDA in 2008, TMS is a treatment supported by studies that show great efficacy and results.
Since then, TMS treatment facilities have started appearing everywhere across the country.
Nowadays, insurance companies have recognized the treatment and even cover these costly sessions.
There are still, however, many questions regarding TMS that need to be answered.
How should the treatment be delivered? Who are the ideal candidates?
What is the device really doing to the brain?
Nonetheless, the therapy is gaining traction, and becoming more and more recognized by both patients and health specialists.
How Does TMS Work?
Usually, TMS therapy is administered by a nurse or a trained physician.
The device works by sending short and intense magnetic pulses to the brain, and in that way generates an electric current within the affected area.
During the procedure, a non-invasive TMS machine is placed right against the head.
These magnetic waves are aimed at the left prefrontal area of the brain, which is the part of the brain that usually shows abnormal activity in patients who suffer from depression.
One treatment with TMS for depression usually takes 4-6 weeks to complete.
During that time, the patient undergoes 20-30 sessions, usually 3-5 sessions a week.
The machines that are used for the treatment are very expensive, so the treatment is pricey, as well.
The total cost of the therapy can end up being anywhere between $6,000 and $12,000.
During the whole session, patients are awake and sitting in a chair, feeling no discomfort or pain.
However, there are some contraindications for this type of treatment.
For example, TMS therapy should not be administered to patients who have metal implants or stimulators in their head or near their head.
Moreover, patients who have implants such as cochlear implants, deep brain stimulators, or vagus nerve stimulators should also be exempted from the treatment.
TMS Compared to ECT
For 30-50% of people who do not respond well enough to antidepressants, TMS is a new and promising alternative treatment.
However, there is another choice that is often offered to such patients, which is ECT, or electroconvulsive therapy.
During this procedure, electrical shocks are sent to the brain with the aim of producing a short seizure.
In the U.S., this treatment has been around for more than 70 years.
The therapy is administered multiple times in one week, usually for up to one month.
It has been proven also to be effective against serious depressive disorders.
However, unlike TMS, ECT has some serious side effects.
Patients report feeling confusion or experiencing memory loss after the treatment.
Moreover, because of the electric stimulus, the patient needs to be under anesthesia during the treatment.
This alone increases the risk and makes the therapy more invasive.
It also prolongs the recovery, as well as the time needed for preparation for one session.
Patients report losing memory of the whole period during which the therapy has been administered, sometimes failing to remember two or more whole weeks.
This can be very intimidating.
When you compare this treatment to TMS, you can see that TMS is much less invasive, since the patients are alert during the whole process.
During the treatment, which lasts for about half an hour, you just sit in a chair; after that, you can drive back home.
The possible side effects are not at all intense or serious.
The most common side effects reported by patients are muscle soreness and headaches.
There are some concerns that TMS can cause seizures, but this probability is estimated to be the same as that of seizures occurring when taking antidepressants.
Therefore, TMS is much less severe, compared to ECT.
It is still not completely clear what happens in the brain when we administer TMS, and why it works.
One theory states that it has to do with the deeper parts of our brain below the left frontal cortex.
These areas regulate our mood, so when we administer TMS we most likely bring balance back to those neural circuits that have an effect on depression.
Transcranial Magnetic Stimulation Results
In the early 1990s, doctors generally believed that brain stimulation could help patients with depression only if it was strong enough to cause a seizure.
However, today we know that the currents of lesser intensity that TMS generates can be very effective if they are administered repeatedly.
This way, the brain changes little by little, just as a weak muscle becomes stronger with gradual exercise.
Psychotherapy works in a similar way, by slowly retraining the neural pathways that control how you think about and deal with certain situations.
A study conducted with the help of the National Institute of Mental Health between 2004 and 2009 aimed to prove the beneficial effects of TMS on major depression.
The patients who took part in the study were all suffering from depression and proved to be resistant to antidepressant drugs.
During the first three weeks, patients received either active or sham TMS treatment.
After that, all of the patients received three weeks more of guaranteed transcranial magnetic stimulation.
The research found that those patients who received real TMS treatment were four times more likely to reach remission from depression, compared to those who received sham therapy (4).
The results showed a 30% improvement in those patients who received TMS treatment by the end of 6 weeks of treatment.
ECT, on the other hand, shows 60% remission, but it does carry more potential side effects and risks.
New Promising Results
After the initial study, more studies were done that prove that TMS is even more effective than was believed.
In 2012, research was completed by Brown University School of Medicine which aimed to study TMS the way it is used in the real world.
Forty-two clinics that offered TMS treatment in the U.S. were included in the study, and the results showed that 58% of affected patients showed some remission, while 37% of patients reached full remission (5).
Even many medical practitioners are surprised by the results of the treatment that they are seeing at their clinics and say that these results surpass their expectations and what the studies are showing.
The reason for this is that the standards and protocols in clinical trials are higher and more stringent than those in real life.
During these trials, patients were required not to take antidepressants anymore.
Moreover, they could keep going to psychotherapy, but not increase the number of weekly or monthly sessions.
In the real world, on the other hand, patients can continue using antidepressants if they had some amount of response in the past, and they can see their therapist as much as they like.
This way, the chances that these patients see benefits are increased significantly.
Even though TMS shows some promise, it is by no means a miracle.
After the initial positive effects of the treatment, a relapse is possible.
Therefore, follow-up sessions are needed every now and then to prevent it.
Results also show that after the first treatment, the following ones show more modest results.
Therefore, the treatments need to become more intense and more frequent, but this costs a lot of money.
However, now that the FDA has approved TMS treatment, it is possible to get your insurance company to cover the expense, so this can be very helpful.
These follow-up maintenance treatments show some promise.
However, it is based on results coming from small studies.
Studies show that those patients who receive follow-up treatments are much less likely to relapse.
However, there are no official protocols for these booster treatments, so their efficacy is uncertain.
And there are other, unanswered questions about TMS.
What are the best frequency and intensity at which it should be given?
How many treatments are needed, and how often should the patient receive them?
Where is the best place to administer it?
There is a significant amount of information available right now, but still, a lot of points need to be clarified.
Some studies show that the total amount of stimulation on the brain is what is most important, and not how many days over which the treatment was administered.
In a recent study, TMS was tested on patients who recently suffered a suicidal crisis.
In three days, these patients received nine treatments.
There were no side effects to this fast treatment, and those patients who received TMS treatment showed more improvement than those who received sham treatment (6).
Even though there are many unanswered questions, TMS treatment has shown promising results, and should definitely be considered as a possible solution.
It could be a good alternative for patients who do not respond well to medication, but it could also work well in conjunction with medication and psychotherapy.
TMS as an Add-On Therapy
The benefits of TMS are becoming clearer and clearer, and more and more patients and practitioners are recognizing them.
Nowadays, doctors are considering the possibilities of TMS as an add-on treatment.
Since both antidepressants and psychotherapy are very effective for many people, as well as much more cost-effective, TMS treatment is not likely to become patients’ first choice.
However, it can potentially work in conjunction with these treatments, as well as to treat other health issues.
For example, TMS has shown promise as an effective treatment for vascular depression after a stroke (7).
Other studies are on the way to find a link between TMS treatment and improvement of schizophrenia, ADHD, PTSD, and other illnesses.
Basically, after its success in treating depression, scientists are considering what other effects TMS can have on the brain and its various diseases.
So far, the results are still not completely clear.
But when it comes to pain, both chronic and acute, some results are reassuring.
No companies have yet asked for FDA approval for that use.
In the meantime, scientists are trying to figure out how to increase this treatment’s effectiveness for depression.
There are indications that it could be more effective if the neurons that are under treatment are engaged in some kind of activity.
For example, some research shows that the effect of TMS could be greatly improved if the patient receives CBT (cognitive behavioral therapy) at the same time.
If this is proven to be true, psychologists could serve as an important link during the treatment process.
Another importance of TMS is that it is opening new doors and new possibilities to related treatment methods.
Scientists are now taking into consideration other means of brain stimulation, encouraged by the success of TMS.
Some such treatment methods include optogenetic stimulation and pulsed ultrasound.