Bipolar 2 From Inside and Out

Posts tagged ‘TMS’

Is TMS Right for You?

On Tuesday, when I went to my psychiatrist’s office, I noticed a large display of brochures for Transcranial Magnetic Stimulation (TMS). My husband, who was with me, asked about it, so I told him what little I knew about what it is and what it’s supposed to do. But I realized that I’ve never investigated it thoroughly. When I was considering ECT, TMS was rather new and not an option offered to me. Then a change in medication alleviated my treatment-resistant depression at last. When we got home from my appointment, I thought I’d look into TMS further.

What Is TMS?

TMS, sometimes called rTMS (for repetitive TMS), is a non-invasive treatment for long-term depression (and perhaps a few other conditions such as OCD, PTSD, migraines, epilepsy, and even nicotine addiction). It differs from vagus nerve stimulation and deep brain stimulation because it doesn’t require surgery or cutting the skin.

TMS involves placing electromagnetic coils on the patient’s scalp and moving them around until they have the desired effect. The procedure targets areas of the brain that show decreased activity in patients with depression and is thought to activate those areas.

Calibrating the magnetic coils and determining their placement happens at the initial appointment. For subsequent appointments, the coils are simply placed at the effective points already determined. TMS only affects areas of the brain that are close to the surface. Sessions are required five days per week for several weeks. Each session lasts approximately 20 minutes or sometimes less.

TMS doesn’t require anesthesia and can be performed as an outpatient procedure in a provider’s office or a clinic. You don’t have to have someone to drive you home afterward, though you may want to for your first session until you know how TMS will affect you. Symptom relief can occur after several weeks of treatment.

TMS is FDA-approved, and most insurance plans cover it if you meet certain criteria, like having no effect from several antidepressant medications. Many also cover repeated treatments if the effects wear off. Deep TMS, in which the electromagnetic pulse reaches deeper into the brain, is FDA-approved for OCD and nicotine addiction when standard treatments have failed, but is off-label for other conditions.

Outcomes

Approximately one-third of people who undergo TMS experience full remission of their depression. Fifty to sixty percent report improvement of their symptoms. Most patients, however, experience remission lasting for months after the treatment, with positive outcomes averaging somewhat more than a year. But the results are not permanent; there is a high rate of recurrence. Patients can engage in multiple rounds of treatment after the effects wear off. For patients who don’t respond to TMS, ECT is often considered.

Side Effects

One of the first things I learned about TMS was that I wouldn’t have been a good candidate for it. My illness is bipolar disorder, which has a mania component, and one of the possible side effects of TMS is mania. And I might not qualify for it now, as I have metal implants in my body, which is sometimes a contraindication. Although TMS is sometimes recommended for bipolar depression, I’m not sure I would like to risk it. I would have talked it over with my psychiatrist.

TMS has other potential side effects as well, though not the memory loss that can accompany ECT. In addition to possible mania, TMS carries the risk of seizures, as well as hearing loss if the ears aren’t properly protected. More common side effects include headaches, scalp pain, lightheadedness, and twitching facial muscles.

Pros and Cons

The relatively high success rate is certainly a selling point. Even better outcomes are expected for TMS guided by fMRI for more precise placement of the magnetic coils. Although seizures can occur, the rate is approximately 1 in 10,000 sessions. In addition to alleviating depression, TMS may also reduce suicidal ideation. If you’re taking medications for depression, they will not interact negatively with TMS. Many clinics offer the procedure.

On the other hand, TMS is not for everyone. The treatments can be time-consuming. And some practitioners don’t treat patients under the age of 18 or over 65. If you’re not insured, the procedure can cost $6,000 to $15,000. Advanced equipment and the costs of added therapies can boost the total to $30,000.

Only you and your doctor can determine whether TMS is worth trying. But if you have longstanding, treatment-resistant depression, you may want to explore the possibility.

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mental health

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When Depression Doesn’t Go Away

Back in the day, I suffered from treatment-resistant depression. (This was likely due to the fact that what I had was actually bipolar 2, but never mind that for now.) My psychiatrist prescribed me medication after medication, but none of them worked, or at least not for long. We got into a seemingly endless spiral of trying one drug, adding another, weaning me off one drug and ramping up another, then another and another.

Some of them just plain didn’t work. Others had intolerable side effects, from vivid horrible nightmares to making me feel like I was about to jump out of my skin.

All this went on for certainly months – maybe years. (Memory problems were one of the many intolerable side effects.)

Eventually, my doctor reached the correct diagnosis, and then there were months of trying medications that were targeted for bipolar disorder instead of plain depression with anxiety. Again, nothing worked, or didn’t work adequately.

Nowadays, there are non-pharmaceutical methods of coping with treatment-resistant depression, including ECT (better known as electroshock), TMS (transcranial magnetic stimulation), and ketamine treatment.

I never had any of these treatments, since my psychiatrist and I finally worked out a drug combo that brought me back to balance, with only minor tweaks in dosage over the years. Nonetheless, I’ve become interested in the alternate means of dealing with treatment-resistant depression, and here’s what I now know. (If you want a patient’s own experience with ECT, TMS, and ketamine treatment, look up Kitty Dukakis or read some of the Bloggess’s posts.)

ECT, or electroconvulsive therapy, is what used to be known as shock treatment. For a long time it went the way of prefrontal lobotomy, stigmatized as a cruel and harmful procedure. The portrayal of ECT in Ken Kesey’s novel One Flew Over the Cuckoo’s Nest and then the movie of the same name were major influences in terrifying the general public, leading to a nearly complete disavowal of its use.

It’s making a comeback, though. The theory behind it is that electric stimulation of the brain will shock the brain back into normal functioning. The American Psychiatric Association notes that it is now performed under anesthesia, with medical personnel attending the procedure. They report improvement in 80% of patients.

(ECT is the alternative treatment that I was ready to try when none of the drugs prescribed for me proved effective. Then my doctor wanted to try one last drug, and that was the one that did the trick.)

TMS, or transcranial magnetic simulation, is described by the Mayo Clinic as “a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression.” It’s also called rTMS, or Repetitive Transcranial Magnetic Stimulation, because more than one treatment is generally needed. The theory is that the magnetic pulses stimulate areas of the brain involved with mood control and depression. It doesn’t cause seizures or require anesthesia. The exact mechanism of how it works isn’t really understood, but that’s true of many other treatments for depression, including medications.

Harvard’s Health Blog reports that rTMS helps about 50% to 60% of people who did not respond to drug treatment “experience a clinically meaningful response.” They do note that treatments, “while encouraging, are not permanent,” which is true of many other forms of treatment.

Ketamine is the newest of the treatments for treatment-resistant depression. Ketamine was once known as a “party drug” called “Special K,” described by the DEA as “a short-acting anesthetic with hallucinogenic effects.” As a treatment for depression, however, it is thought to “enable brain connections to regrow,” according to scientists at Yale. The American Association of Nurse Anesthetists notes that ketamine “is not a first-line therapy for psychiatric disorders,” but then, neither are ECT and TMS.

Ketamine can be administered via nasal spray, but for psychiatric purposes (including to treat bipolar disorder and PTSD) it is often given as a series of infusions. An article in The Lancet says that “Ketamine is thought to act by blocking … receptors in the brain.” Another article by doctors at the National Institutes of Health comments that ketamine “has a robust and rapid effect on depression, which was seen immediately after the administration of ketamine and sustained at the end of 1 month.” Repeated treatments are generally necessary.

I don’t know about other patients and doctors, but after years of drug therapy not working, I was ready to give almost anything a try. ECT was next on the list, and the only likely alternative, as TMS and ketamine were not available at that time. I’m just glad that now patients and their doctors have more options when depression resists drug treatment and “talk therapy.” And I hope that even more alternatives become available for people with depression who are desperate to find a treatment that works for them.

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