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Transcranial magnetic stimulation (TMS) is a safe, effecte, FDA-approved treatment for depression and OCD that can provide long-lasting relief without the side effects of medications. TMS can also help many other psychiatric conditions.
In studies, TMS helps about 60% of patients who have failed 2 or more antidepressants. When someone has not achieved remission with 2 or more antidepressant trials in the current episode of depression, they are diagnosed with “treatment-resistant depression,” or TRD. In comparison to TMS in people with TRD, another antidepressant medication trial only helps about 5-10% of the time.
TMS seems to improve OCD symptoms in almost half of all patients, regardless of whether they have responded to antidepressants or psychotherapy (talk therapy) for OCD.
No! TMS seems to be even more effective for severe OCD symptoms.
No. Unfortunately, there are no known cures for any psychiatric disorder, and it is possible for relapses to happen. However, TMS can provide relief lasting for years for some patients.
A typical TMS treatment course involves treatment 5 days per week for 4-6 weeks, followed by tapered treatment, for 44 total sessions. Each treatment is about 15 minutes. There are occasionally reasons for shorter or longer courses. Your provider will discuss an optimal treatment schedule with you.
TMS uses pulsing MRI-strength magnetic fields to activate nerve cells in the area of the brain responsible for mood, anxiety, OCD or other disorders. By doing this repeatedly over time, TMS can change the level of activity of these areas of the brain, and improve how different parts of the brain communicate.
Not typically. Most patients find the sensation of TMS to be mildly or moderately annoying, but not painful.
Yes! TMS is extremely safe. TMS is considered a minimal risk procedure, with no evidence of long-lasting adverse side effects.
Yes! Although there are fewer studies about children than adults, the studies that have been done show that TMS seems to be as safe and effective in children and adolescents as in adults. However, TMS is not FDA-cleared for use in children and adolescents, so insurance often declines to cover a treatment course. Some insurance companies will cover a course of TMS in adolescents ages 15 and older.
Risk of seizure with TMS is extremely rare, about 6 in 10,000 with the coils we use. Your provider will discuss this risk, screen for anything that may increase this risk, and will help adjust treatment to ensure it is as safe as possible. It is important to note that all TMS-induced seizures have occurred during active stimulation (while someone is receiving treatment). All TMS-induced seizures have stopped on their own, and no one has developed recurrent seizures (epilepsy) from TMS.
TMS has almost no side effects for most patients. 10-20% of patients have headaches, usually mild or moderate. TMS may cause mild scalp discomfort during treatment. Ear protection is necessary during TMS treatment. TMS does cause clenching down during stimulation, so some people have mild temporal-mandibular joint (TMJ) tenderness with treatment. We provide a mouthguard during treatment to help reduce TMJ tenderness. However, most patients have no side effects, and in studies, TMS is just as gentle as placebo TMS.
None at all! Patients can work, go to school, drive, and do anything else they like before or after TMS treatments.
Nearly all major insurances cover conventional TMS for depression for adults, although requirements vary. Insurances determine if they cover TMS based on:
Accelerated TMS protocols are not covered by and is an out-of-pocket treatment.
Absolutely! There is evidence that TMS is helpful for a variety of conditions, including:
Because the above conditions have not been studied enough to be approved by the FDA, they are considered “off-label.” These treatments may not be covered by insurance unless a patient is also receiving treatment for depression.
Some patients improve as soon as 1-2 weeks, though it is most common to start improving after 2-4 weeks of daily treatment. Some patients improve during (or after) the taper phase of treatment. In fact, over 70% of patients who do not appreciate improvement during the intensive phase (daily phase for 4 weeks) do go on to show a significant improvement during the twice weekly phase of treatment.
Some patients stay better for years after a successful course of TMS. However, some patients only stay better for months, and for some, maintenance treatments may be needed.
Intranasal esketamine (brand name Spravato®) is an FDA-approved nasal spray antidepressant. Intranasal esketamine is a derivative of ketamine, which has been shown to provide very rapid (within hours), profound relief of depression.
Ketamine is a medicine used in anesthesia. More recently, it has shown potential as a new antidepressant. Like many anesthetics, ketamine is abused by some people.
Intranasal esketamine works in about 50-70% of depressed patients who have failed 2 or more antidepressants.
FDA and U.S. Drug Enforcement Administration (DEA) regulations require that patients self-administer intranasal esketamine at a certified clinic, and then be monitored for 2 hours at the clinic for any side effects.
FDA regulations require that patients not drive home from an intranasal esketamine treatment, and recommend that they do not drive until the next day after a restful sleep. There are no restrictions on non-treatment days.
Intranasal esketamine involves an initial course of 2 treatments per week for 4 weeks (8 treatments). If patients are better at the end of 8 treatments, they have the option of transitioning into maintenance treatment, which is typically 1 treatment every 1-2 weeks.
The exact mechanism of ketamine and esketamine is not completely understood, but unlike other antidepressants that tend to target serotonin, dopamine or norepinephrine, esketamine affects the glutamate (information-processing) system.
Intranasal esketamine seems to be safe for use in the short- and medium-term, with current studies showing no significant lasting side effects out to 2 to 3 years. However, esketamine is a very new treatment, and longer-term safety data do not exist. While there is no evidence currently that esketamine or ketamine cause significant long-lasting problems, because it is a relatively new treatment, it is important to understand that there may be problems that we have not yet discovered. This risk must be considered when deciding whether to have esketamine or ketamine treatments.
Most patients find esketamine treatments to be very easily manageable and even pleasant. However, side effects during the 2 hours of monitoring may include: feeling mildly intoxicated, dissociation (feeling separate from one’s body), anxiety, nausea, increased heart rate and blood pressure. Most of these side effects go away by the time a patient leaves the clinic – some patients may feel tired or slow for the remainder of the day. Most patients do not have side effects between treatments.
Most insurances now cover esketamine, but specific details vary may by patient plan. Intrnasal esketamine is an expensive treatment when not covered by insurance, or if you have a high deductible plan. But there are savings programs (https://www.spravatohcp.com/patient-supportavailable) from the manufacturer to help reduce the cost. Our clinic helps patients to receive the most insurance coverage possible. Some costs are not covered by insurance.
Currently, esketamine is only well-studied and FDA-approved for treating unipolar depression. Like ketamine, esketamine may help pain conditions as well. There is not enough evidence to tell whether esketamine helps other psychiatric conditions.
Intranasal esketamine can provide rapid relief within the first 1-2 weeks, although some patients require the full 4-week course to see improvement.
Like all ketamine treatments, intranasal esketamine seems to require maintenance treatments to stay better. Most patients require at least 1 treatment every 2 weeks to stay better.
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