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rTMS: Hope for treatment-resistant depression

September 19, 2019 | UCI Health
woman happy after tms treatment for depression

More than 17 million American adults experienced at least one major episode of depression in 2017 alone, according to the National Institute of Mental Health.

Untreated, depression is a crippling disease that can severely impair a person’s ability to conduct basic activities of life. It can lead to substance abuse, difficulties in work and personal relationships. It also increases a person’s risk of suicide.

But standard depression treatment doesn’t fully work for as many as 45% of patients. For those with treatment-resistant depression, brain stimulation may be the key.  

“We treat depression through talk therapy, chemicals or electricity,” says UCI Health psychiatrist Dr. Rimal Bera. “When psychotherapy and antidepressants fail, electrical stimulation can often provide relief in up to 65% of patients.”

What is rTMS therapy?

One treatment, called repetitive transcranial magnetic stimulation (rTMS), holds promise for people with treatment resistant depression.

First patented in 1903, magnetic stimulation fell out of use due to a lack of understanding about brain circuitry. The idea was revived in the 1980s as more powerful magnetic technology came into use for applications such as magnetic resonance imaging (MRI).

Studies in the mid-1990s began to show positive results when magnetic stimulation was directed at the prefrontal cortex, the part of the brain involved with mood regulation.

In 2008, the U.S. Food and Drug Administration approved rTMS as a treatment for mild treatment-resistant depression. The procedure has proven to be more effective than vagus nerve stimulation (VNS) and to have fewer side effects than electroconvulsive therapy (ECT).

First patented in 1903 and approved by the FDA in 2008, rTMS is an outpatient treatment that has been shown to be more effective than vagus nerve stimulation (VNS) and to have fewer side effects than electroconvulsive therapy (ECT).

Benefits of rTMS

Bera says rTMS treatment has produced remarkable turnarounds in some of his patients:

  • An airline pilot who suffered for years with depression was able to stop crying and resume normal activities with a total remission of symptoms after rTMS treatment.
  • A teacher recovered his joy for life.
  • Another patient who’d previously spent 22 hours a day in bed, recently experienced the simple pleasure of going to the store to buy groceries after a course of rTMS.

“It’s satisfying to see people who came in here barely talking transformed through this therapy,” says Bera, who also is a professor of psychiatry at the UCI School of Medicine. “They become different people who are laughing and talking.”

Magnetic current

The treatment involves delivering a magnetic current to areas of the prefrontal cortex identified through clinical tests as most likely to produce results. Alternating magnetic fields induce an electrical current in underlying tissue to help normalize brain activity.

During each outpatient treatment — which can last from three to 30 minutes — a magnetic coil is placed over the head. Through a cone placed at a 45-degree angle to the head and about 2 ½ inches from the front of the head to deliver the FDA-approved treatment protocol to a specific point in the brain. Patients may feel a light tapping sensation or sound, Bera says.

Unlike electroconvulsive therapy, rTMSis a noninvasive procedure that doesn’t require anesthesia or implanting of electrodes. Patients are awake throughout the process. They also are able to drive themselves to and from treatment sessions.

Patients sit reclined in a chair and are encouraged to relax and read or perform another intellectual activity to help prime the brain during treatment. They wear earplugs to shield their hearing from the noise of the device.

Many are depression-free at one year

Patients usually receive treatments five days a week for up to six weeks. Some patients may need more sessions depending on how quickly they respond. Bera typically sees results after 10 to 20 treatments. 

He says that 60% of patients with moderate to severe depression respond to rTMS, And of those, 60% are still depression-free after one year. Research indicates the results hold true for both men and women and that there are no age limitations for in its use.

To be eligible for rTMS, patients with moderate to severe depression should have experienced failures with medications and other therapies, Bera says.

TMS side effects are minimal

Although ECT may be more effective in some patients, rTMS doesn’t require anesthesia or cause memory impairment. It does carry a small risk of seizure, about 1 in 30,000 treatments.

Other minimal side effects may include:

  • Mild headaches
  • Lightheadedness
  • Scalp irritation where the magnetic pulses were directed
  • Tingling in the face, scalp or jaw
  • Temporary hearing problems resulting from the magnet noise

Bera says over-the-counter pain medications may alleviate most of those side-effects.

Therapy is not for everyone

Because of the magnetic coil, rTMS may be dangerous for some people who might otherwise benefit from the treatment. Anyone with metal implanted in their head or neck area should avoid rTMS. These include:

  • Aneurysm clips or coils
  • Stents in the brain or neck
  • Bullet fragments or shrapnel embedded in or near the head
  • Pacemakers or defibrillators
  • Metal implants in the ears or eyes

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