rTMS
Transcranial Magnetic Stimulation
First and only non-systemic and non-invasive treatment cleared for patients who have not benefited from prior antidepressant treatment.
Transcranial Magnetic Stimulation (TMS) or Repetitive Transcranial Magnetic Stimulation (rTMS) is a noninvasive method to excite neurons in the brain to weak electric currents are induced in the tissue by magnetic fields (electromagnetic induction). This way, brain activity can be triggered with minimal discomfort, and the functionality of the circuitry and connectivity of the brain can be restored.
FDA Approved
As of October 8, 2008, an rTMS device manufactured by Neuronetics Inc., NeuroStar, was approved by the US Food and Drug Administration (FDA) for use in adult patients with major depression who have previously tried medication and not improved satisfactorily.
The NeuroStar TMS Therapy system is the first and only TMS Therapy® device cleared by the FDA for the treatment of depression. TMS Therapy is a non-systemic (does not circulate in the bloodstream throughout the body) and non-invasive (does not involve surgery) form of neuromodulation that stimulates nerve cells in an area of the brain linked to depression by delivering highly-focused MRI-strength magnetic pulses.
How TMS Therapy Works
The short pulses of magnetic energy are aimed at the structures in the brain to control mood. (i.e., Limbic System Structures – many of which are involved in mood regulation). The left prefrontal cortex is used to access these structures non-invasively from outside the brain with TMS Therapy. The unique nature of magnetic fields allows them to pass through the skull and into the cortex without being distorted in any way. This facilitates a very focal type of stimulation, minimizing stimulation of brain tissue not involved in mood.
Once inside the brain, the dynamic (rapidly changing) nature of the magnetic pulses induces electrical charges to flow. The amount of electricity created in the brain is very small and cannot be felt by the patient. When in the correct orientation relative to brain cells (neurons), these very small electric charges can cause the neurons to fire or become active. The objective of TMS therapy is to stimulate conduction (or activate) in neurons. This occurs in the circuits that have been under-active during depression (the prefrontal circuit). Patients remain awake and alert during a TMS Therapy procedure.
Advanced Mental Health Care Inc. has treated more patients with rTMS than any other location south of the Carolinas. We have extensive experience with rTMS treatment for Depression, OCD, PTSD, Borderline Personality Disorder and Bipolar Disorder. Our current remission rates are above eighty percent.
rTMS is a novel, non-invasive form of brain stimulation therapy for mood disorders using focused pulsed magnetic fields. A session is typically delivered in a physician’s office on an outpatient basis and lasts about 45 minutes. You will be fully conscious and aware throughout the procedure and no post-session recovery period is needed. You will be able to resume your normal activities like work or driving without interruption. A course of rTMS can be anywhere from 20 to 35 sessions depending on the disorder and its severity to provide acute relief of symptoms.
It is a very safe procedure and lacks side effects that are common with some medications such as weight gain, sedation, and sexual dysfunction. Its most common side effect is a mild headache in 10-30% of patients which is usually limited to the treatment time during the first week, after which accommodation to the stimulation occurs.
Initial Assessment:
Patients are initially seen by a psychiatrist for a comprehensive evaluation and to assess the clinical appropriateness of rTMS. The initial assessment is conducted to allow sufficient time to fully assess each case. This includes arriving at the correct diagnosis (usually several), evaluating the appropriateness of rTMS as the next step in treatment in your case, as well as determining the risk benefit of rTMS and the other available treatments for your condition. If you are traveling from a long distance, this appointment can be initiated over the phone in the course of an hour. We will want as much detail about your previous medication treatments as possible including maximum dosage, duration of treatment and the reason for discontinuation (e.g., ineffective or side effects). At this time, there is no standard insurance coverage for rTMS. Thus you will be fully responsible for payment for the rTMS course of treatment.
The next appointment will last two hours and Dr. Tendler or Dr. DeLuca will identify the location on the skull to stimulate and the amount of energy necessary to increase blood flow in the area of the brain necessary for anti-depressant activity. They do this by initially stimulating the motor cortex, getting the patients thumb to move, and then move the machine stimulating the “prefrontal cortex.” After mapping the location for future sessions the patient will have a treatment session using very focused short pulses of magnetic energy.
rTMS Delivery:
The sessions are usually offered in 5 day blocks (Monday to Friday), but sometimes are conducted differently (7 days a week) depending on the individual case. Patients are reassessed for clinical progress by the treating psychiatrist on a weekly basis. Additionally, patients are assessed for side effects before and after each TMS session.
rTMS benefits can be noticed anytime from treatment 1-20. If there are no benefits by the 20th treatment we will stop. If benefits are obtained, treatment can continue and we will monitor symptoms progress on a weekly basis. Once the maximal benefit is achieved, a tapering is necessary to maintain the benefit. In some patients, maintenance medication is utilized as an alternative to a taper. In the first 20 sessions, there cannot be an interruption of greater than four days without a treatment. The benefits typically last anywhere from six months to two years. At that time, a booster of 2-10 treatments may be given to maintain remission.
Our experience indicates that most patients need 20 to 35 sessions of TMS to derive the most benefit in the treatment of depression. If you do not respond or only have a partial response to rTMS, we will discuss with you what are the next best treatment options and make appropriate referrals for further treatment. If you do benefit from TMS, we will discuss with you how best this improvement can be sustained, including the possibility of intermittent TMS sessions as a maintenance treatment for your condition.
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