TMS (Transcranial Magnetic Stimulation) Compared to Medication

1) Works Well, very effective

(37% of people no symptoms and do not need medications after 6 weeks treatment, 54% no symptoms and fewer medications +/- lower dose)

Medications (32% Of People no symptoms but must continue medications, 24% fewer symptoms must continue medications) more than half not any better

2) Much, Much fewer side effects

 

 

Transcranial Magnetic Stimulation (TMS)

Is a remarkable new treatment for depression and other psychiatric and neurological disorders. It has been used since the early 1990s, and was FDA approved in 2008. Long-term follow-up of patients who TMS has shown no long-term negative effects. The standard course of treatment involves six weeks of daily sessions five days per week. Each treatment lasts 8 to 40 minutes.

Eligible patients include anyone who does not have a history of seizures and does not have any iron-like metal in their brain.

In addition to improving symptoms, other beneficial effects have been observed. These include improved memory, executive function and reduced impulsivity. In some cases patients who have received magnetic therapy for depression have noticed that their desire to drink alcohol, use drugs, or engage in self-destructive behavior has been reduced or disappeared.

Using a longer course of treatment (three or four months) some clinicians have reported significant reduction in symptoms of autism with some children becoming symptom free. We have seen remarkable reduction of symptoms and improvement of function in Parkinson's Disease also.

As with other forms of brain stimulation, the benefits of treatment are usually permanent meaning ongoing treatment can be reduced (Fewer medications 58%) or eliminated (no medications 37%). 

About 2.5% of patients who do a six week course of treatment require an additional set of weekly treatments for one month and monthly treatments for four months.

Approximately one in 20 patients who undergo the treatment notice no benefit. Fortunately these individuals can now be identified before beginning treatment by performing a brain scan EEG (Arns 2012).

The cost of treatment ranges from $8,000 to $16,000. Some insurance programs reimburse 40-90%. Currently, Medicare covers this but only in the Eastern half of the US.

In addition to depression treatment, other conditions respond to rTMS including...

Some Conditions That Have Evidence to Support the use of rTMS as Treatment

ADHD (Attention Deficit) (Zaman 2014, Bloch 2010)

Autism Spectrum Disorders (Casanova 2014, Oberman 2013, Oberman 2014, Sokhadze 2014)

Bipolar Disorders (Canali 2014, Zendjidjian 2014, Harel 2010, Dell'Osso 2009, Li 2004, Michael 2004, Nahas 2003)

Generalized Anxiety, Panic Disorder, Social Anxiety & PTSD (White 2015, Paes 2011, Pallanti 2009)

Dementia (Alzheimer's Disease or Vascular) (Cantone 2014, Isaac 2013, Pennisi 2011)

Tinnitus (Ringing in the Ears) (Yilmaz 2014, Forogh 2014, Peng 2012, De Ritter 2013)

Headache (Migraine, Stress & Cluster) (Lipton 2010, Dodick 2010, Brighina 2013, Schwedt 2014)

Parkinson's Disease (Vonloh 2013, Rothwell 2013)

ALS - Amyotrophic Lateral Sclerosis (Di Lazarro 2006, Di Lazarro 2009, Zanet 2008)

Working Memory & Executive Function 

Chronic Traumatic Encephalopathy (CTE) in Football Players and other athletes with concussions (Pape 2006, Demirtas-Tatlidede 2012, Rodger 2015, Lu 2015, Li 2015)*

*only Depression is an FDA approved indication, the rest are off-label uses of rTMS

Some clinicians have also reported success with Addiction, Schizophrenia and OCD (Obsessive Compulsive Disorder)

Side effects are mild, 10% experience mild headache (3/10) lasting 5-10 minutes, 1-3% rate of Hypomania or Mania, 1/30,000 chance of seizure (none since 2008)

- • . -

rTMS (Repetitive Transcranial Magnetic Stimulation) is a treatment for patients Who have not responded to pharmaceutical solutions - it is estimated that up to 40% of patients do not benefit from, or cannot tolerate, antidepressant medications - even after repeated attempts.

A recent study has shown that rTMS has a 58% response rate and 37% remission rate and has shown efficacy as a well-tolerated therapeutic option (Carpenter et al 2012)

 

TRANSCRANIAL MAGNETIC STIMULATION (TMS) FOR MAJOR DEPRESSION: A MULTISITE, NATURALISTIC, OBSERVATIONAL STUDY OF ACUTE TREATMENT OUTCOMES IN CLINICAL PRACTICE

Carpenter et al 2012

Background: Few studies have examined the effectiveness of transcranial magnetic stimulation (TMS) in real-world clinical practice settings. Methods: Forty-two US-based clinical TMS practice sites treated 307 outpatients with Major Depressive Disorder (MDD), and persistent symptoms despite antidepressant pharmacotherapy. Treatment was based on the labeled procedures of the approved TMS device. Assessments were performed at baseline, week 2, at the point of maximal acute benefit, and at week 6 when the acute course extended beyond 6 weeks. The primary outcome was change in the Clinician Global Impressions-Severity of Illness from baseline to end of acute phase. Secondary outcomes were change in continuous and categorical outcomes on self-report depression scales (9-Item Patient Health Questionnaire [PHQ-9], and Inventory of Depressive Symptoms-Self Report [IDS-SR]).

Results: Patients had a mean ± SD age of 48.6 ± 14.2 years and 66.8% were female. Patients received an average of 2.5 (± 2.4) antidepressant treatments of adequate dose and duration without satisfactory improvement in this episode. There was a significant change in CGI-S from baseline to end of treatment (−1.9 ± 1.4, P <.0001). Clinician-assessed response rate (CGI-S) was 58.0% and remission rate was 37.1%. Patient-reported response rate ranged from 56.4 to 41.5% and remission rate ranged from 28.7 to 26.5%, (PHQ-9 and IDS-SR, respectively).

Conclusion: Outcomes demonstrated response and adherence rates similar to research populations. These data indicate that TMS is an effective treatment for those unable to benefit from initial antidepressant medication. Depression and Anxiety 29:587–596, 2012

 

Benefits of rTMS

• Treatment with rTMS has a fast onset of action with significant patient improvement

• Treatment is provided as an outpatient procedure

• Patients can return to normal activities after treatment

• No anaesthesia or sedation required

• 20-30 treatments over 4-6 weeks

 

 

Is rTMS right for you?

rTMS is a treatment that can be used as an adjunct with medication, or as a drug free treatment.

This therapy avoids the side effects associated with antidepressant medication.

rTMS is the future for depressed patients who are proving resistant to traditional pharmaceutical solutions.

 

Transcranial Magnetic Stimulation (rTMS)

 

Stimulating Brain & Nerve

Because the Neuron (brain cell) communicates by converting energy into chemical and electrical signals, external application of electrical current  - increases brain activity. When carefully applied, certain areas of the brain can be activated and this can improve mood and function. 

How does Transcranial Magnetic Stimulation (rTMS) work?

 

Using a special magnetic coil, at a certain frequency and pattern, a small and gentle electric current is created which activates neurons to fire in the outer part of the brain (cerebral cortex). This is not painful, no anesthesia is needed. It is so safe, that there are almost no side effects. While the treatment is in progress, there is a series of clicking sounds (like a woodpecker). Sometimes a twitch is felt or a slight headache is experienced. The treatment lasts less than 10 minutes (theta burst) or 40 minutes (standard 10Hz protocol). 



The newest technology in rTMS is called NeuroNavigation (sometimes called Frameless Stereotaxy). Using 3-D localization on both the person and the magnet, a special, dedicated computer calculates the exact part of the brain being stimulated. This increases precision and makes brain mapping more exact. 

The system operates either using the data from a patients unique MRI, or an average estimation if MRI is not available.

We are the first (and only) clinic south of Los Angeles to implement this technology, beginning 10/27/2015.

The increase in accuracy of stimulation of brain targets is astonishing. This improved treatment may be more effective and improve the quality of life for some patients.

Neuronavigation allows extraordinary precision in targeting TMS. The red circle is the target in the Dorsolateral Prefrontal Cortex (DLPFC), The green is the optimal coil position for stimulation

Neuronavigation allows extraordinary precision in targeting TMS. The red circle is the target in the Dorsolateral Prefrontal Cortex (DLPFC), The green is the optimal coil position for stimulation

Neuronavigated TMS: Dorsolateral View of the Dorsolateral Cortex

Neuronavigated TMS: Dorsolateral View of the Dorsolateral Cortex

 

From Localite.DE for more information on the TMS Navigator, click here or on the photo

Neuronavigation is a precision-based Brain Stimulation technology performed with the help of a group of computer-assisted systems that enable the physician to locate targets within the the human skull. It is the latest in image-guided and non-invasive Brain Stimulation techniques. It provides orientation to the psychiatrist during treatment to map a precise and suitable Brain Stimulation plan. Psychiatrists who do rTMS require high levels of accuracy while performing Stimulation Therapy.

Neuronavigation is the newest and most sophisticated method available in the field of brain stimulation. This technique is also cost-effective and user-friendly. It is also a very useful tool to the psychiatrist

Deep rTMS

th MagPro Cool D-B80 Butterfly Coil

for more information about the D-B80 click on the photo above or below

"Electrical and magnetic properties like the D-B80. Suitable for deep stimulation. Designed for demanding stimulation protocols requiring a very high number of stimuli. "

We began using this advanced method on Wed 12/02/2015

 

the Deep Magstim 110mm Double Cone Coil 9902-00 in use since 3/29/2016

the Deep Magstim 110mm Double Cone Coil 9902-00 in use since 3/29/2016

 

 

ARTICLE:

Deep transcranial magnetic stimulation as a treatment for psychiatric disorders: A comprehensive review 

Deep transcranial magnetic stimulation (TMS) is a technique of neuromodulation and neurostimulation based on the principle of electromagnetic induction of an electric field in the brain. The coil (H-coil) used in deep TMS is able to modulate cortical excitability up to a maximum depth of 6 cm and is therefore able not only to modulate the activity of the cerebral cortex but also the activity of deeper neural circuits. Deep TMS is largely used for the treatment of drug-resistant major depressive disorder (MDD) and is being tested to treat a very wide range of neurological, psychiatric and medical conditions. The aim of this review is to illustrate the biophysical principles of deep TMS, to explain the pathophysiological basis for its utilization in each psychiatric disorder (major depression, autism, bipolar depression, auditory hallucinations, negative symptoms of schizophrenia), to summarize the results presented thus far in the international scientific literature regarding the use of deep TMS in psychiatry, its side effects and its effects on cognitive functions. 

Bersani et al European Psychiatry 28 (2013) 30–39 

To download the full text PDF - click here:

We use Magnets made by MagPro (Denmark) and MagStim (UK)

Both are FDA approved (July 2015 and May 2015.  

According to a review (Kedzior 2014) 

The Following Magnets were used in the 40 studies of Depression (Randomized Controlled Clinical Trials)

MagStim    22

MagPro      9

Cadwell      6

Neotonus    1

MagLite    1

Neuronetics 1

Although Neuronetics (NeuroStar) and BrainsWay were the first to get FDA Approval, they have not been studied as long, or proven effective over as much time as the MagPro and MagStim. Also, Neuronetics (NeuroStar) and BrainsWay require a fee for every session to be sent to the company which increases the cost by about $100 per treatment and $3,000 per total course. 

 

Factors that influence the effects of transcranial magnetic stimulation (TMS). Mechanical factors (yellow labels) describe TMS parameters that may be adjusted for a desired outcome. Biological factors (green labels) determine where to stimulate and may help guide the selection of specific TMS parameters. All of these factors comprise a TMS protocol, and manipulating any one of them may result in differential outcomes (for details, see text). However, mechanical factors are the most straightforward to address when planning a study, whereas biological factors require a priori knowledge of the neural system to be stimulated.

Factors that influence the effects of transcranial magnetic stimulation (TMS). Mechanical factors (yellow labels) describe TMS parameters that may be adjusted for a desired outcome. Biological factors (green labels) determine where to stimulate and may help guide the selection of specific TMS parameters. All of these factors comprise a TMS protocol, and manipulating any one of them may result in differential outcomes (for details, see text). However, mechanical factors are the most straightforward to address when planning a study, whereas biological factors require a priori knowledge of the neural system to be stimulated.

You may be just learning about it, 

but TMS is NOT "new" or "experimental" 

Time Line of Events in the history of TMS

1985   Barker & Jalinous Letter to Lancet introducing technology

1994   Mark George, MD Published first observations about using TMS for Treatment of depression

2007 4,392 Studies have been published (MedLine). In addition to Depression, TMS is found to be effective for other psychiatric and neurological conditions. Of the 60,000 people who have had TMS, only 2 experienced seizures. Improved safety measures to prevent seizures are introduced. (No seizures have been reported since 2008) Other side effects such as headache or skin discomfort is mild and usually lasts less than 15 minutes.  Long term follow up 2, 3, 4 and 10 years shows safety (no late onset problems) and long lasting positive effects. TMS is demonstrated to be 50-100 times safer than treatment with medication. 

2008 FDA approves TMS as treatment for Major Depression

2010 the journal: Brain Stimulation - founded by Sackheim & others, publishes 1st issue, 

2013 FDA Approves second device (BrainsWay) as treatment for Major Depression

2015 FDA Approves third (MagSTim) and 4th device (MagPro)

By 2015 more than 11,000 scientific studies and reviews have been published. The fact that TMS is safe and effective is a settled issue.

Theta Burst Stimulation (TBS)

Theta Burst Stimulation (TBS) is a new kind of TMS that has significant advantages

1.  More natural and physiological - it is developed and based on the rhythms of the hippocampus and cerebral cortex which lead to long term change (LTP). 

2.  Because it takes less time to administer, it may cost much less (1/2 to 1/4 as much)

3.  Even though the time of treatment is much shorter - the healing benefits are equal

•  Theta Burst Stimulation was approved in the European Union for the treatment of depression in 2015  •

 

The following graphs are from a study done by Nathan Bakker at the University of Toronto in Canada. They assessed response of 185 patients, 98 who had the old 10Hz method (30 minutes), and 87 who did the new Theta Burst Stimulation (6 minutes). In both groups the treatment was safe and effective.

(If you would like to read the whole research paper, just click on the image to download the pdf)

rTMS of the Dorsomedial Prefrontal Cortex for Major Depression: Safety, Tolerability, Effectiveness, and Outcome Predictors for 10 Hz Versus Intermittent Theta-burst Stimulation 

Bakker et al, "Brain Stimulation: Basic, Translational, and Clinical Research" in Neuromodulation 

Volume 8, Issue 2, Pages 208-215 (March 2015) 

rTMS vs DBS

Repetitive Transcranial Magnetic Stimulation?

or Deep Brain Stimulation (DBS)?

Executive function and working memory are the foundation of a coherent and meaningful life. Before considering surgical brain stimulation for depression and Parkinson's Disease, remember that Magnetic Brain Stimulation increases executive function while Surgical (DBS) impairs executive function

Although there is a role for both methods, Surgical (DBS) is a last resort - after all other options have been tried. Outpatient brain stimulation is one option to try before surgery. 

for more information - see the following

Pham (2015) Self-Reported Executive Functioning in Everyday Life in Parkinson's Disease after Three Months of Subthalamic Deep Brain Stimulation.

Yamanaka (2012) Temporary deterioration of executive function after subthalamic deep brain stimulation inParkinson's disease.

Adam (2012) Executive control in Parkinson's disease: effects of dopaminergic medication and deep brain stimulation on anti-cue keypress performance.

Smeding (2011) Predictors of cognitive and psychosocial outcome after STN DBS in Parkinson's Disease. 

Daniels (2010) Risk factors for executive dysfunction after subthalamic nucleus stimulation in Parkinson's disease. 

Zahodne (2009) Cognitive Declines One Year After Unilateral Deep Brain Stimulation Surgery In Parkinson’s Disease: A Controlled Study Using Reliable Change (Part I)

Mikos Cognitive declines after unilateral deep brain stimulation surgery in Parkinson's disease: a controlled study using Reliable Change  (Part II)

Witt (2008) Neuropsychological and psychiatric changes after deep brain stimulation for Parkinson's disease: a randomised, multicentre study.

Jahanshahi (2000) The impact of deep brain stimulation on executive function in Parkinson's disease.