Episode 159: Transcranial Magnetic Stimulation Basics
Future Dr. Ameri explains how transcranial magnetic stimulation can be useful in the treatment of certain mental conditions.
Written by Omeed Ameri, MS-IV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.
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Transcranial Magnetic Stimulation (TMS)
TMS is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression and Obsessive-compulsive disorder (OCD). TMS uses the principles of electromagnetic inductions as described by Faraday’s Law. When an electric current passes through the TMS coil, it creates a rapidly charging magnetic field, which passes unimpeded through the scalp and skull, inducing a secondary current in neural tissues of the brain, causing depolarization of neuronal membranes in targeted brain regions, mainly in the superficial layers of the cortex 1.5 to 2.5 cm beneath the coil.
How it works.
Depending on the frequency and pattern of magnetic pulses, TMS can either increase or decrease cortical excitability. High-frequency TMS (Generally > 1 Hz) is associated with increased cortical excitability and is often used for depression treatment. In contrast, low-frequency TMS (< 1 Hz) is typically used for anxiety and pain.
This stimulation alters neurotransmitter release such as dopamine, serotonin, and norepinephrine. The repeated stimulation over sessions promotes synaptic plasticity, leading to more lasting changes in brain activity patterns associated with improved clinical outcomes. This is thought to have cascading effects throughout brain networks, and modulate dysfunctional circuits implicated in depression and restoring normal function.
Effectiveness.
The effectiveness of TMS can vary widely between individuals due to differences in anatomy, age, and specific conditions being treated. As such, ongoing research into how to personalize and optimize TMS parameters is ongoing.
Research supporting the use of TMS in treatment-resistant depression.
Research into the effectiveness of TMS and other therapy modalities targeting Treatment-Resistant Depression has been an ongoing effort for many years. In 2009, the American Academy of Family Physicians published Dr. Little’s article titled “Treatment-Resistant Depression,” which noted that there was little evidence that TMS could significantly treat patients with treatment-resistant depression.
Since that time, the American Journal of Psychiatry published a groundbreaking study in 2020, led by Dr. Cole, which explores the effectiveness of a novel treatment for treatment-resistant depression. This trial, known as Stanford Accelerated Intelligent Neuromodulation Therapy or SAINT, which demonstrates promising results in combating depression where traditional methods have failed.
It was an open-label study that provides a new perspective on depression treatment, emphasizing rapid and targeted intervention. Twenty-two participants received 50 intermittent theta burst stimulation (iTBS), which is a more recent protocol for TMS treatment, over the course of five days. Each session included 1,800 pulses per session, with a 50-minute intersession interval, ten times a day. As a result of this intensive regimen, one participant withdrew from treatment, and 19 of the remaining 21 met remission criteria, with a score of less than 11 on the Montgomery-Asberg Depression Rating Scale.
There were no serious adverse events reported, the participant who withdrew did so due to anxiety. Side effects included fatigue and some discomfort. 70% of participants continued to meet response criteria one-month post-treatment.
TMS application for patients with OCD.
Studies have shown promising results for the treatment of OCD with TMS. Typically, OCD is difficult to manage and requires the highest doses of SSRIs. In 2019, The American Journal of Psychiatry published Dr. Carmi’s Article titled: “Efficacy and Safety of Deep Transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A Prospective Multicenter Randomized Double-Blind Placebo-Controlled Trial”, which presents a comprehensive study on the effectiveness of dTMS in treating OCD. This multicenter, randomized, double-blind, placebo-controlled trial involved 99 OCD patients across 11 centers, who were treated with either high-frequency dTMS or sham dTMS, and focused on changes in the Yale-Brown Obsessive Compulsive Scale (YBOCS) scores.
The treatment phase extended to 6 weeks with a total of 29 treatment sessions, following a 3-week screening phase and a 4-week follow-up phase. Patients were aged 22-68, with YBOCS scores greater than or equal to 20. At the start of the study, patients were already on a maintenance treatment with therapeutic dosages of SSRIs, or previously failed an SSRI and were currently being treated with Cognitive Behavioral Therapy. The results revealed that dTMS treatment participants showed a significantly greater reduction in YBOCS score compared to sham treatment (6.0 points vs. 3.3 points).
The most frequent adverse effect was headaches. There was one incident of severe suicide ideation. On investigation, it was revealed that the suicide ideation preceded the treatment and required hospitalization for the patient.
TMS therapy has shown promising results in treating both treatment-resistant depression and OCD. More research is required to assess the long-term viability of the treatment modality, and which treatment regimens have the greatest efficacy for various psychiatric disorders. I hope our listeners will keep TMS in mind when confronted with treatment-resistant depression and OCD.
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Conclusion: Now we conclude episode number 159, “Transcranial Magnetic Stimulation,” also known as TMS. We learned from future Dr. Ameri that TMS has proven to be an effective option for treatment-resistant depression and Obsessive-compulsive disorder. When medications and therapy are not enough, you may consider this therapy for your patients.
This week we thank Hector Arreaza and Omeed Ameri. Audio editing by Adrianne Silva.
Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!
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References:
- Cole, E., Stimpson, K. H., Bentzley, B. S., Gulser, M., Cherian, K., Tischler, C., Nejad, R., Pankow, H., Choi, E., Aaron, H., Espil, F. M., Pannu, J., Xiao, X., Duvio, D., Solvason, H. B., Hawkins, J., Guerra, A. T., Jo, B., Raj, K. S., . . .Williams, N. (2020). Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression. American Journal of Psychiatry, 177(8), 716–726. https://doi.org/10.1176/appi.ajp.2019.19070720
- Carmi, L., Tendler, A., Bystritsky, A., Hollander, E., Blumberger, D. M., Daskalakis, J., Ward, H. E., Lapidus, K., Goodman, W. K., Casuto, L., Feifel, D., Barnea‐Ygael, N., Roth, Y., Zangen, A., & Zohar, J. (2019). Efficacy and Safety of Deep transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A prospective multicenter randomized Double-Blind Placebo-Controlled Trial. American Journal of Psychiatry, 176(11), 931–938. https://doi.org/10.1176/appi.ajp.2019.18101180
- Little, A. (2009, July 15). Treatment-Resistant depression. AAFP. https://www.aafp.org/pubs/afp/issues/2009/0715/p167.html
- Royalty-free music used for this episode: If You Were the One, downloaded on November 15, 2023, from https://www.videvo.net/
