Treatment for Major Depressive Disorder (MDD)

Patients who develop clinical depression now have several options to choose for treatment. Some patients see their primary care physician and are started on an antidepressant medication. When these medications are effective the depression resolves in a few weeks and the patient gets his functioning and wellness back. However for many patients this first intervention does not result in complete resolution of their symptoms and they need to try something else

Treatment options

Medication

Medications are often effective as they work on different neurotransmitters in the brain that regulate mood and sleep. If one antidepressant is not effective often switching to another or finding a combination can be effective. Managing side effects and monitoring medication effectiveness Is important.

Psychotherapy/Counseling

Talk therapy or counseling is another method of treating depression. This involves talking about your ways of thinking and viewing yourself and your problems . Often a person with depression has unhealthy thought patterns and get stuck in a negative chain of thinking that can be challenged and reframed when seeing a therapist. Proven approaches to therapy include cognitive behavioral therapy and interpersonal therapy.

TMS Therapy

TMS is a non-invasive therapy that involves no medication and has very few side effects. It was FDA cleared in 2008 and patients have been treated for major depression with TMS since the mid-1990s. It is our experience that TMS is effective in over 60% of patients which means it is much more effective than antidepressant medications.

TMS uses MRI strength magnetic pulses that are delivered several times per second into the front part of the head. A small area of the surface of the brain just under the skull is activated by the pulsing magnetic fields. Brain cells that are stimulated there set up a domino effect activating other brain regions. A circuit of nerve connections is created and stimulated 3000 times in a single 19 minute treatment.

TMS is administered while patients are awake and alert watching TV or interacting with staff. No anesthesia or pre-medication is required and there are no memory problems after the treatment. Patients can drive themselves home or to work immediately afterwards.

Patients may begin to notice changes in mood within 2 to 4 weeks. Continued stimulation creates new neural pathways and brain connections over time that lead to changes in energy, motivation and mood.

Unlike medication, TMS Therapy is not associated with weight gain, sexual side effects or slowed thinking. Generally there are very few side effects except for some scalp tenderness usually resolving after the second or third treatment. Our team has not had any patients discontinue TMS Therapy due to treatment discomfort

The use of TMS therapy may not always eliminate the need to continue antidepressant medicine although many patients can reduce the dosage or the number of medicines they are taking. In our practice we have had some patients get off all medications and depend only on TMS therapy to maintain their response. Many patients will benefit from continued “booster” treatments delivered every few weeks.

ECT – electroconvulsive therapy

ECT is an effective  therapy that has been used for decades to treat depression and some psychotic illnesses. During a treatment an electrical impulse induces a seizure in the brain causing nerve cells to fire in several areas throughout the brain. This treatment is performed using general anesthesia and often in a hospital setting. Improvements in ways of delivering the single electrical pulse has resulted in less severe memory problems after the treatments. TMS Therapy should not be confused with ECT as TMS appears to work on different brain circuits and never involves inducing a seizure.

What To Expect With Treatment

Consultation

The first step in the TMS treatment process is determining whether or not TMS is an appropriate treatment for you. This is done in a consultation with Dr. Hayden, who will review your symptoms, treatment history, and possible treatment options. Cindy Duvall RN, our TMS Coordinator, is also available for a prescreening, prior to seeing Dr Hayden. When you contact the office, our staff will
schedule this evaluation, which will last about an hour.

Your first treatment session

If TMS is right for you, an initial treatment session will be scheduled. At this first visit, which may last over an hour, Dr. Hayden will determine the appropriate placement and energy settings. Placement of the treatment coil and the strength of the magnetic field are important factors in successful TMS treatment. In order to do this, a test is done to determine what is called the motor threshold. A magnetic pulse will be repeatedly given to find the strength that is just enough to result in a finger twitch. From there, the coil is moved forward to a specific area over the left front of the head, and the energy levels are increased. Staff will continually monitor you during the treatment.

Procedure

The actual treatment session lasts about 20 minutes. As you sit reclined, awake and alert, the TMS System delivers 40 rapid MRI strength magnetic pulses over 4 seconds. The pulses make a loud clicking sound, and ear protection or ear plugs are provided. The pulses feel like a tapping on the scalp but without the sensation of anything touching the skin. The same 4 second sequence is repeated 75 times every 11 seconds. During the session you can watch television, listen to music, or simply sit back and relax.

After the procedure

After the treatment, you can drive and resume your normal day. TMS is non-invasive, meaning it does not involve surgery, and also non-systemic, meaning no drugs are used, and therefore no drug side effects. Typical TMS side effects are irritation or discomfort at the treatment site, or headache, and are usually mild.

Treatment sessions are then repeated by our trained TMS staff each day using the settings initially determined by Dr. Hayden. A usual course of treatment involves sessions 5 days a week for 4 to 6 weeks, although this can vary depending on a patient’s response to treatment. A tapering set of treatments is frequently offered over the final 3 weeks. As you progress through your therapy, Dr. Hayden, and the TMS staff will regularly assess your progress and determine the eventual number of treatments that optimize your response.

Frequently Asked Questions

 

What is TMS Therapy?

TMS stands for Transcranial Magnetic Stimulation. It is used to treat depression by stimulating the brain non-invasively using electromagnetic fields, similar to those produced by an MRI machine. During TMS Therapy, a magnetic field is administered in very short pulses to the part of your brain that research has demonstrated to be associated with depression. The initial course of treatment is typically 20-30 minutes daily for about 6 weeks.

How does TMS Therapy work?

The TMS Therapy system creates short pulses of magnetic fields to stimulate the area of the brain called the prefrontal cortex. The nerve cells about an inch under the magnet “fire” and stimulate connecting nerve cells deeper in the brain. A circuit is created and patients receive 3000 stimulations of this circuit in about 19 minutes. Changes occur over time with new neural connections in areas of the brain that have been underfunctioning.

Is TMS Therapy a good alternative for patients who cannot tolerate the side effects associated with antidepressant medications?

TMS Therapy is non-systemic- treatment is targeted at only a small part of the brain. It is a good alternative for people who are fearful or intolerant of med side effects and are otherwise appropriate for treatment. With any treatment option, including TMS, patients and clinicians should work together to find the most appropriate treatment approach for each patient.

Is TMS Therapy like other alternative therapies which use magnets to treat some illnesses?

No, TMS Therapy involves a unique method of using strong pulsed magnetic fields for potential therapeutic benefit. The intensity of the magnetic field is similar to that of the magnetic fields used in magnetic resonance imaging, or MRI. These techniques differ radically from the popular use of low intensity, static ( non moving) magnetic fields. These products deliver weak and undirected static fields that are not capable of activating brain cells.

Is TMS Therapy like electroconvulsive therapy (ECT)?

No, the two procedures are very different. While both are effective in the treatment of depression, there are many differences in safety and tolerability. During the TMS Therapy procedure, patients sit in a chair and are awake and alert throughout the entire procedure – no sedation is used with TMS Therapy. Patients can transport themselves to and from treatment.  TMS Therapy was also shown to have no negative effects on memory function in several studies. In contrast, electroconvulsive therapy (ECT), invoves inducing a seizure. Patients receiving ECT must be sedated with general anesthesia Recovery from an ECT treatment session occurs slowly, and patients are usually closely monitored for minutes or a few hours after a treatment. Short-term confusion and memory loss can occur, but newer methods utilizing less intense stimulation to initiate the seizure have reduced side effects. Because of the side effects associated with an ECT treatment, a significant amount of caregiver support is required when ECT is provided as an outpatient.

What is a typical course of treatment with TMS Therapy?

In clinical trials, patients received TMS Therapy 5 times per week for 20-30 minutes sessions over 6 weeks. Patients treated with TMS Therapy should receive treatment for a minimum of four weeks with additional treatments based on clinical judgment.

Does TMS Therapy cause brain tumors?

There is no evidence that TMS therapy causes any tumors. TMS Therapy uses the similar strength of magnetic fields as MRIs (magnetic resonance imaging), which have been used in tens of millions of patients around the world and have not been shown to cause tumors. The magnetic energy used in a full course of TMS Therapy is a small fraction of just one brain scan with an MRI although the TMS Therapy uses a more focal pulse.

Does TMS Therapy cause memory loss?

No, TMS Therapy was systematically evaluated for its effects on memory. Clinical trials demonstrated that TMS Therapy does not result in any negative effects on memory or concentration.

There is evidence that TMS can improve memory when applied to certain brain regions. TMS is used to treat dementia in Europe

Does TMS Therapy hurt?

The most common side effect related to treatment was scalp discomfort during treatment sessions. This side effect was generally mild to moderate, and occurred less frequently after the first week of treatment. Some patients choose to treat  this discomfort with an over-the-counter analgesic. If these side effects persist, your technician under the guidance of Dr. Hayden can reduce the strength of the magnetic field pulses being administered in order to make treatment more comfortable.

How long does the antidepressant effect last? Will I need any therapy beyond the first 4-6 weeks?

In many patients the benefits will last for many months. Studies show that TMS Therapy is very durable, and it continues to be effective over time. Many patients will benefit from “boosters” or continuation treatment ( for example receiving one treatment a month ) in order to maintain the results from the first series of treatments.

Can I also take antidepressant(s) if I am receiving TMS Therapy?

Yes, in clinical trials, TMS Therapy was safely administered with and without other antidepressant medications. The use of TMS therapy may not eliminate the need to continue antidepressant medicine although many patients can reduce the dosage or the number of medicines they are taking. In our practice we have had some patients get off all medications and depend only on TMS therapy to maintain their response.

Where can I talk to someone about my questions?

Please call TMS Huntsville and schedule a free consultation and tour of the TMS suite withCindy Duvall RN, Phone 256-722-1999. Cindy has been involved in delivery of TMS Therapy since 2011 and has extensive patient experience. She has a passion for seeing patients through from start of treatment to treatment response.

 

How much does TMS Therapy Cost?

TMS Therapy is covered by most insurance companies. We have staff available to help you find out about your insurance’s specific policy
coverage for TMS Therapy. We can help with the sometimes complex process of preparing pre- authorization forms to get approved. When insurance is denied or not available we strive to help patients find a way to get the treatment they need. Specific staff are designated to address insurance issues at TMS Huntsville.