Tag Archive for: TMS

How TMS treats depression

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Transcranial Magnetic Stimulation (TMS) is a procedure that generates magnetic fields to stimulate nerve cells in the brain. The goal: to improve symptoms of major depression. The approach is considered a “noninvasive” procedure because it’s done without surgery. In research, TMS has shown promise in treating multiple conditions when symptoms don’t respond to other treatments, including migraines, smoking cessation, PTSD, OCD, Tourette’s Generalized Anxiety Disorder, and movement disorders such as Parkinson’s. TMS, which is notably different from Electroconvulsive Therapy (ECT), is now used most often as a treatment for depression when other treatments haven’t been effective. Dr. Zafiris “Jeff” Daskalakis knows all about TMS. Dr. Daskalakis is chair of the University of California San Diego Psychiatry Department and director of the University of California San Diego Health’s Interventional Psychiatry Clinic. He has become an internationally recognized expert in treating severe psychiatric disorders with TMS. As a sidebar to this essay about a patient’s experience with TMS, BrainWise Managing Editor Matt Villano recently sat down with Dr. Daskalakis to understand more about the science behind the treatment. What follows is an edited transcript of their interview.

BrainWise: What is happening during a TMS treatment?

Dr. Zafiris “Jeff” Daskalakis: Basically, we’re causing millions of neurons to fire together, all at once. And when those neurons fire in synchronicity, it results in neuroplasticity. Of course, it’s much more complicated than that. To do TMS, an electric pulse generator, or stimulator, is connected to a magnetic coil connected to the scalp. The coil is about two laptops thick and about half a laptop in width. The machine takes electrical charge from the wall and stores that electrical charge in a large capacitor. When that capacitor triggers, it sends the electrical current through the coil for an instant. It’s less than 50 microseconds in duration. That very brief instant of time translates into a magnetic field, which travels through the coil, across the skull, and activates neurons in the brain. There’s no actual electrical conduction; it’s a magnetic field. The magnetic field is much less painful, much better in terms of tolerance. And the magnetic field generates neuronal change. We’re able to get neurons to fire in a certain rhythmic pattern. Why is this important? The old expression is, ‘When neurons fire together, they wire together.’ These neurons firing together and wiring together creates neuroplasticity. Which leads to change.

BrainWise: To be clear, TMS does not involve an electrical charge going into the brain? It’s only a magnetic charge?

Dr. Daskalakis: That’s correct.

BrainWise: How finely targeted is the directionality of this magnetic charge?

Dr. Daskalakis: The area of activation depends on the size of the coil. The larger coil size, the higher the area of activation, the larger the area of activation. The smaller the coil size, the smaller the area of activation. By and large, the coils’ area of activation is elliptical, around three centimeters in diameter. The depth of the impact also depends on the amount of stimulation charge, but at standard stimulation charges, on average, they get about 2 to 2.5 centimeters deep. It’s really that top layer of the brain that is most affected.

BrainWise: Why is this such a big deal?

Dr. Daskalakis: Whenever we look at the brain, there’s always an outer and an inner shell. The inner shell tends to be a lot paler, and the outer shell tends to be a little darker. That’s because the inner shell is associated with lots of neuronal output connections, and the outer shell is really the cell body; it’s where all the action happens. The outer shell allows us to think and function and navigate and interact with our world, think logically, be future minded, and play instruments. And the outer shell just so happens to be that same area that we target with TMS. By stimulating that outer shell repetitively with magnetic fields, we are causing neurons to align. And when those neurons align, that neuroplastic effect takes place. It doesn’t happen right away, and it doesn’t happen with just one treatment, but it happens when you bring people in repeatedly over the course of days to weeks and aim to improve their symptoms.

BrainWise: Can this work for everyone?

Dr. Daskalakis: Not exactly. A certain proportion respond to psychotherapy and a certain proportion don’t. We think that up to a third, perhaps as many as 40% of patients do not respond to conventional treatments, conventional meaning medications or psychotherapy. Of those, about two or three patients out of 100 not only have depression, but also have the type of depression that doesn’t respond to conventional treatment. [Editor’s note: For more on this, click here or here.] This proportion of the population tends to be labored with suicidal thinking oftentimes, because the longer it takes for you to get better, the worse you are. That’s where TMS comes in. TMS is singularly used for that patient population. And we believe that roughly out of those patients who choose to receive TMS, one out of every two or three will achieve a significant clinical benefit.

BrainWise: To what extent are there negative impacts of this treatment? What are the side effects?

Dr. Daskalakis: Lots of groups have looked at this very closely. We have learned that TMS represents one of the safest treatments that we have. There’s an extremely remote risk of seizures. In fact, the only population that we do not have TMS available to is patients who’ve had a seizure disorder. [Editor’s note: Some sources also point out that TMS can be a bad idea in patients who have metallic implants in the brain or skull.] Outside of that, the major side effect associated with TMS is a bit of a headache and some discomfort at the stimulation site, which isn’t profound. And usually, it’s very well-tolerated.

BrainWise: What’s the next frontier of TMS? What questions will you be asking next?

Dr. Daskalakis: There are several areas that we can advance. One of them is how do we make the treatment more efficient? It’s already an extremely efficient treatment, but the treatment requires people to drive into a clinic to get treatment a certain amount of time for a certain number of days. Can we make people better within a week? Can we make people better within a day? These are all hot topics that we need to continue to explore.

The second piece, which goes hand in hand with the first piece, is how do we make the treatment more effective? How do we enhance the efficacy? That leads to the third piece, which is understanding the brain. We have a treatment, and we are narrowing in on the ways that this treatment works in the brain.

I’ve mentioned one mechanism called neuroplasticity, but there’s other mechanisms that are also being considered. One of those mechanisms is connectivity—how different parts of the brain connect to one another. That’s really about the threads of connections between different parts of the brain that may be responsible for inducing depression. Understanding those brain mechanisms is the third piece of the puzzle.

Finally, the fourth piece of the puzzle, I think, is how do we maintain people’s wellness? What do we need to do to continue to treat people so that once they respond, they stay better for longer periods of time? Relapse rates are high. When you go on a medication, you’re not out of the woods just yet. The chances that you’re going to get depressed again could come up down the road. And, similarly with TMS, if you respond, how do we maintain your wellness so that you don’t relapse? Understanding how it works, understanding how we can make it work better, understanding how to make it more efficient, and understanding how we can make the effects more durable are all key pieces of this treatment that we need to continue to pursue.

For more about TMS, read this essay by a patient who recently completed 37 sessions of the treatment for depression.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

My experience treating depression with magnetic waves

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Editor’s note: Sandra Haney lives in Waynesboro, Virginia, and recently turned to Transcranial Magnetic Stimulation (TMS) to treat chronic depression. BrainWise Managing Editor Matt Villano wrote this story in her voice after an extensive interview with her about the experience. For more on the science of TMS, click here.

Depression is like an old friend at this point; I’m 41 years old, and I’ve been dealing with depressive episodes since I was about 15.

It was episodic early on. Things came and went. I had more prevalent anxiety than I did depression. Pretty severe panic attacks. Really frequent intrusive thoughts of death—not so much suicidal ideation but more thoughts about my eventual demise. Throughout my teens and twenties, I did therapy. I tried tons of different medications. Some worked a little. Most didn’t. There were a lot of side effects. I was about 28 when I found a combo of meds that worked: Paxil and Wellbutrin. I still had lots of side effects.

By the time I was 32, I said, “This is ridiculous.” I was tired all the time. I had gained about 30 pounds. Finally, I did a GeneSight test. It turned out I have a very rare triple copy of an enzyme called CYP2D6. That makes me an ultra-rapid metabolizer, which means roughly 80 percent of medications won’t work on me like they should. I metabolize them too quickly.

It’s not a great thing to have if you’re battling depression like I am.

When I learned about being an ultra-metabolizer, when I realized that meds basically weren’t going to work for me, I started thinking about Transcranial Magnetic Stimulation (TMS). From what providers had told me, this is a type of treatment that can work for people who can’t do meds—people like me. I didn’t know anybody who’d done it TMS. I did some research. I got a packet of literature. That was basically it—at the time, I was deeply depressed and could barely make it to my appointments, much less seriously consider something like that. So, I didn’t pursue it.

Fast-forward to 2022. I started sleeping extremely poorly. I was getting more and more depressed. I had a severe bout of anxiety that lasted for four months. As the anxiety subsided, I started experiencing suicidal ideation. It was becoming more and more severe. It reached a point where things were going south quickly. I talked to my psychiatrist. Together, we decided it was time to give TMS a try.

I started the treatment in August. I finished in October. All told, I did 37 sessions. And it helped. But more on that later.

Understanding the basics

When you get the treatment, a machine sends magnetic waves through your skull into your brain. The idea is to stimulate neurons to change the way they’ve handled things in the past—kind of like rewiring the brain. For more about the science behind it, check out the sidebar that BrainWise published in conjunction with my story.

My TMS sessions started out at 21 minutes long. By the end they were at 31 minutes. It’s kind of boring to sit there while the treatment is happening. The doctors told me I needed to stay fully conscious. They let me talk. There was a TV in the room so I could watch TV. They were clear that they wanted me to keep my brain active.

Every time I went it felt like an electric zap. Like a static shock. There was no sense of pain. It was like tapping against my head. This may just be my own imagination, but I could swear I felt it going through my skull. I know the brain has no pain receptors, so maybe that’s impossible.

During the sessions I didn’t really experience any kind of change in thought processes or perception. I also didn’t experience any emotional effects. Initially there were headaches and a sense of really deep fatigue. That lasted the first two weeks. After that the immediate effects were a little brightening. My mood improved a little bit each time. It wasn’t a long-term thing; I felt better for a little while, and as the day wanes, my mood dropped back down. For me, it was all about the cumulative effect.

Side effects

After 4 treatments I had some interesting effects occur. One night, after cooking an elaborate dinner, I was sitting on the couch and, suddenly, it felt like I could smell everything. It felt like my sense of smell had been dampened that whole time and, suddenly, it had come into focus. It was like until the TMS treatment, I was smelling things at about 25 percent of what they were. The super smell lasted for about an hour each time, and then things went back to baseline. They say a lot of your senses get dampened with depression. I now know that’s real.

Another thing that happened during treatment: I started experiencing these perception switches. I would go from one state of mind to another. The switches occurred every 15 to 30 minutes. The only way I can describe what it felt like was to compare it to when I did acid a few times and ate mushrooms as a kid. The perception shift you get when you’re under the influence of those chemicals—that’s what it felt like for me.

Later in the treatment cycle I started to get very irritable and very angry. I’d have these mini bouts of rage that would last for 30 seconds or so each time. That was disturbing. Everybody in the house was jumpy and avoiding me. The cats were like, “We’re out of here!” I was told by the lead TMS tech that that was a good sign, that my brain was creating new neural connections and that’s what was causing the irritation. Most people experience a depressive episode in the first three weeks, but some people experience anger. That was difficult to deal with.

The suicidal ideation faded in the first week and a half. It faded out quickly. I don’t know if that was what was happening in my brain—something the machine was doing—or if it was the fact that I was getting help and I was actively doing something to improve things. I was looking at living and improving my health and having hope instead of thinking about ending things. That alone was worth everything.

Charting progress

Over the course of my treatment, there were several markers I used to evaluate how it was going.

The first were the markers from the doctor’s notes. Every Friday I did one of the DSM questionnaires about depression and anxiety. The doctor kept those scores. Over the duration of the treatment, the doctor said my scores decreased depression-wise by about half and anxiety-wise by about a little more than half. The reduction in anxiety was the biggest thing I noticed. The other thing is that I found myself to be more motivated, more hopeful and a little more energized. The reduction in anxiety has been fantastic. Suicidal ideation disappearing has been fantastic. Depression has decreased, for sure. They said I would start sleeping better, but I didn’t. I’m a lifelong insomniac.

I have mixed emotions about this progress. I was hoping for more. At the same time, I know my expectations were unrealistically high and the whole time I fought to bring my expectations back to reality. I had to come to terms with the fact that this is something that will improve things so that I can further improve on my own. It’s like the treatment gave me a toehold so I could get moving in the right direction.

My doctor said things would continue to improve for about two months after the last treatment finished. I’ve also read that each TMS treatment cycle lasts about a year, and that after the year it really varies wildly. About a month later I’m still seeing improvement.

I also recognize that I’m lucky to have insurance. This treatment runs anywhere from $12,000 to $16,000. With my copay it was $980. This is what my specific insurance company and specific insurance plan required before approving TMS. I’m sure requirements are different from company to company, and even plan to plan within the same company.

After dealing with depression for most of my life, this feels like having a future. A lot of possibilities are now open that weren’t open before. My husband and I have been planning trips. We’re talking about going to Iceland and Finland. We talked about doing a bunch of different things. I feel much more excited and motivated to do that. I feel more excited to live.

Spreading the word

I kept a journal about my experiences. Once a week, I shared these journal entries with my friend list on Facebook. The entries were straightforward. Here’s what’s going on with me. Here’s what’s happening. Here’s what it’s been like. People were really interested. After my journal entries, I have been contacted by phone and through Facebook by people who are either interested in TMS for themselves or for loved ones.

I would recommend TMS. Even if TMS doesn’t work for someone at all, I encourage people to try something. Depression is not a way to live well, and it can end in your demise. For me, TMS felt like going to the moon, doing something totally unknown and super frightening.  At first, I felt like I was being a coward, but now I see the opposite is true. I can recognize it as being brave. The stigma around mental health is decreasing, which means more people are talking to each other about depression. Hopefully that means more and more people will start talking about TMS to help.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.