1. What is TMS?
TMS stands for transcranial magnetic stimulation. It is an exciting, new, very effective, extremely safe, non-invasive, FDA approved, insurance covered treatment for Major Depression. Electromagnetic fields, similar to those produced by an MRI machine, are delivered in ultra short pulses to a part of the frontal lobe of the brain associated with mood and known to be underactive in depression. During a TMS treatment, thousands of these pulses are delivered in a treatment that takes about 30 minutes while the patient is awake and alert. Treatments are generally delivered five days a week over 6-9 weeks.
2. How does TMS work?
It has long been known that certain critical areas of the frontal lobe of the brain are underactive in Major Depression. TMS delivers a very fast but very strong pulse of electromagnetic energy (on the scale of an small MRI machine) that causes the neurons in the brain to fire as the pulse passes through them. This increased firing has been demonstrated to trigger the release Brain Derived Neurotrophic Growth Factor (BDNF) and increased activity in the areas stimulated, as well as the brain regions connected to the area stimulated. Research has shown increased blood flow to the stimulated areas as well as increased neuronal connections and cellular growth. It’s the equivalent of exercising this part of the brain, and just as a muscle responds to being exercised by getting bigger, so does the brain.
3. Is TMS a good option for those who cannot tolerate medication side effects?
TMS is non-systemic (does not circulate in the blood), so it does not have bodily side effects such as weigh gain, sexual dysfunction and nausea that are commonly seen with anti-depressant medication. The most common side effects reported during clinical trials were headache and scalp discomfort during the treatment – generally mild to moderate – occurring less frequently after the first week of treatment. This discomfort during treatment can be managed and reduced by a skilled TMS technician such as those at Southern California TMS Center. This discomfort almost always decreases over time.
4. Is TMS Therapy like other alternative therapies which use magnets to treat some illnesses?
No. TMS Therapy involves a unique method of using pulsed magnetic fields of extremely high strength from an electromagnet as opposed to the static magnetic field in a permanent magnet. The intensity of the magnetic field in TMS is similar to that of the magnetic fields used in an MRI machine, and is over 1000 times stronger than a typical refrigerator magnet. This differs radically from the popular use of low intensity, static magnetic fields. These products deliver weak and undirected static fields that are not capable of firing brain cells.
5. Is TMS Therapy like electroconvulsive therapy (ECT)?
Mostly no. The two procedures are very different, but there are some similarities. They both are forms of brain stimulation that are proven to be very effective in the treatment of Depression, yet there are vast differences in side effects and tolerability. During TMS Therapy, magnetic energy (as opposed to electricity) is used to stimulate a specific focal area of the brain without inducing a seizure. Patients sit in a chair and are awake and alert throughout the entire procedure, and no sedation is required. Patients can drive themselves to and from treatment and continue going to work without confusion and short term memory problems common with ECT. Studies have shown TMS to have no negative effects on memory in clinical trials.
In contrast, electroconvulsive therapy (ECT) or “shock therapy” uses electricity to intentionally trigger a controlled seizure which fires the whole brain. Patients receiving ECT must be sedated with general anesthesia and given muscle paralyzers. Recovery from an ECT treatment session occurs slowly, and patients are closely monitored for as much as an hour or more after a treatment. Short-term confusion and memory loss are common, and long-term disruptions in memory occur in some people. Because of the side effects associated with ECT, a significant amount of caregiver support is required.
6. Will TMS Therapy be covered by my insurance?
Transcranial Magnetic Stimulation is covered by most insurance companies around the country. Companies that are currently covering TMS include Anthem Blue Cross, Blue Shield, Aetna, Cigna, and Kaiser, along with many others. Southern California TMS Center is In-Network with all of these listed providers and will work with you to make the insurance process as easy as possible.
7. Is TMS Safe?
Many clinical trials and over 10 years of clinical experience post FDA approval have shown TMS to be extremely safe. The most common side effect is scalp discomfort during the treatment, which is experienced as a tapping sensation on the head. Mild headaches or fatigue can sometimes occur. Patients with Bipolar Disorder can see induction of mania, a risk also present with antidepressant medication. An uncommon increase in anxiety is easily managed with a change in the treatment pulse protocol. The most serious side effect is the rare incidence of seizure that can be induced during the treatment, which occurs at a rate of less than 1 in 30,000 treatments with the NeuroStar machines used at SoCal TMS.
8. Why choose Southern California TMS Center?
Southern California TMS Center is one of the world’s leading TMS providers and does more TMS treatment than anyone else in Southern California. Our focus is only on TMS, with dedicated technicians highly trained in the most advanced TMS treatment techniques. We use the state of the art equipment and have the best doctors and staff dedicated to the practice of TMS. Started in 2009, our vast experience helps us deliver the best treatment possible.
Our Medical Director Todd Hutton MD is an internationally recognized expert in the field and has been elected by his peers in the international TMS community as President of the Clinical TMS Society (www.clinicaltmssociety.org) for 2019-20. Dr. Hutton lectures world wide on TMS and teaches other physicians his treatment techniques.
We hire only excellent, caring staff. We make your treatment easy with convenient hours to accommodate your schedule whenever possible. Your wellness is our number one goal. See our Testimonials page to read what our patients say about us.
9. What is the difference between rTMS and dTMS?
TMS was initially used by scientists and doctors using only single magnetic pulses for research or diagnostic purposes. Using TMS as a treatment came later and when used therapeutically, thousands of repetitive pulses are used, hence rTMS. As the therapeutic use of TMS has become widespread, the “r” has been increasingly dropped from usage, but all TMS used in treatment uses repetitive pulses and could be called rTMS.
Deep TMS (dTMS) is a term created by Brainsway Ltd. of Israel to describe the TMS magnets that they sell. There is no accepted scientific definition of Deep TMS, and this term is only used by this company and its researchers.
10. Is Deep TMS better?
There is no research anywhere that shows that “Deep” TMS has any advantage over standard TMS in the treatment of Depression. When the FDA approved the Brainsway magnet used to treat depression (the Hesed-1 coil) in 2013, they did so by determining it to be equivalent to the NeuroStar TMS magnet. The FDA considers them to be in the same therapeutic category and makes no distinction between them. The area of the brain being treated in Depression is in the cortex or outer layer of the brain, and all TMS devices FDA approved for use in Depression are designed to reach this target. There is a documented higher seizure rate with Deep TMS devices however.
11. Why does SoCal TMS only use NeuroStar?
The NeuroStar TMS system offers the most advanced platform for doctors and technicians to deliver treatment compared to other TMS devices. It is the only system with contact sensors built into the magnet so that the technicians can know that the magnet is always in as close contact with the head as possible. It also has the most sophisticated magnet positioning system available to ensure reliable, repeatable positioning. TMS machines use a lot of energy, and can overheat with repeated use. The patented design of the iron core NeuroStar magnet and built-in air-cooling fan allow us to remain operational all day without interruption.
NeuroStar is the only TMS machine made in America and has the largest designated field service team to keep us up and running without interruption in treatment, preventing patient down time. Its cloud based software networks all our machines in all of our offices, allowing a patient to treat at any of our centers knowing all the treatment parameters will be the same. Even though NeuroStar is the most expensive TMS system to operate of all those on the market, it is still the most commonly used by hospitals and psychiatrists in the USA.
12. What is a typical course of treatment with TMS Therapy?
TMS treatments at SoCal TMS generally take 30-40 minutes and are done five days a week for the first four to six weeks with a tapering decrease in treatment frequency over subsequent weeks. The parameters, frequency, and number of treatments are individualized to the particular patients need by our doctors.
13. What are the potential risks of TMS Therapy?
TMS Therapy is well tolerated and has been proven to be safe in clinical trials. The most commonly reported side effect related to treatment was scalp discomfort during treatment sessions. This side effect is generally mild to moderate, and occurs less frequently after the first week of treatment. Less than 5% of patients treated with NeuroStar TMS Therapy discontinued treatment due to side effects.. However, there is a small risk of a seizure occurring during treatment which occurs in less than 1 in 30,000 treatments. This risk is actually less than what has been observed with most antidepressant medications. While TMS Therapy has been proven effective, not all patients will benefit from it. As in any treatment for depression, patients should be carefully monitored for worsening symptoms, signs or symptoms of suicidal behavior, and/or unusual behavior. Families and caregivers should also be aware of the need to observe patients and notify their treatment provider if symptoms worsen.
14. Does TMS Therapy cause brain tumors?
No, TMS Therapy uses the same type and 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.
15. Does TMS 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. In fact, cognition actually seems to improve with improvement in depression, as decreased cognitive function is a common symptom of depression.
16. Is TMS Therapy uncomfortable?
A little bit, and mostly just in the beginning. The most common side effect of TMS is scalp discomfort during treatment sessions. This side effect is generally mild to moderate, and goes down after the first week of treatment. In studies, less than 5% of patients treated with NeuroStar TMS Therapy discontinued treatment due to side effects. The technicians at SoCal TMS are highly skilled in reducing any discomfort and can make sure the treatment is easily tolerable for you.
17. Can I also take antidepressants if I am receiving TMS Therapy?
Yes. In clinical trials, TMS Therapy was safely administered with and without other antidepressant medications.
18. Will doing TMS mean I won’t have to take medication ever again?
Maybe, but mostly no, although it is common to take less medication after treatment. Depression is a terrible foe. TMS is a highly effective treatment, but not necessarily a cure. Depression can be episodic throughout one’s lifespan, and chronic as well for many people. Long-term success involves using multiple modalities such as TMS, medication, and psychotherapy, as well as lifestyle techniques such as exercise and stress management.
Since depression is a recurrent illness for many people, successful management requires a long-term strategy. Patients we treat at SoCal TMS are commonly those for whom medications were not effective. However, studies have shown that after a successful course of TMS, patients who take medications do better on average than those who don’t. While we have some patients who take no medication, most patients still take some but less.
19. How long does the antidepressant effect last? Will I need any therapy beyond the first 6 weeks?
In most patients, the clinical benefit of TMS Therapy was maintained through 6 months of follow-up study. For those who did see depression start to return, rescue or booster treatment works 85% of the time.
Depression is known to commonly recur. After one episode of depression, the chance of a second in your lifetime is 50%. (That’s good for half the people, but not for the other half.) After 2 episodes, the risk increases to 75%, and after three the risk is 90%. With multiple episodes or years, depression requires a long term treatment plan.
Studies have shown that after successful treatment with medication, staying on that medication reduces the risk of depression returning, and we keep people on their medications for maintenance purposes. With ECT, a highly effective treatment, the 6-month relapse rate is 40-50%, and maintenance treatment with ECT has become the standard of care.
We are strong advocates for maintenance treatment with TMS having had patients in successful maintenance since 2010, however, insurance does not cover TMS as a maintenance treatment currently. We hope that insurers will adopt this in the future as we believe it to be a cost effective win-win for both patients and insurers.
Talk to your doctor about your long-term treatment path as everyone’s prognosis is different.
20. Is TMS Therapy system cleared by the FDA?
Yes, the NeuroStar TMS Therapy system was the first TMS device to be cleared by the U.S. Food and Drug Administration (FDA) in late 2008 for the treatment of Major Depression. The NeuroStar TMS Therapy system is also the first TMS device to have been evaluated in a large, multicenter, randomized controlled clinical trial.
21. Is brain imaging necessary for TMS Therapy for depression?
No, but it’s an important question. The whole theory of TMS began with the observations from brain imaging decades ago that, on average, patients with depression showed certain specific decreased activity areas of the brain. While individual scans of brain activity are not diagnostic, if one averaged out the scans of patients with depression compared to those without, certain areas such as the Dorsal Lateral Pre-Frontal Cortex (DLPFC) were under active in depression. This brain region became the focus for research in TMS, and stimulating here led to measurable improvement in depression. Currently, all FDA approved treatment for depression targets this anatomic location. No other brain location has been definitively shown to treat depression.
However, not everyone gets better with stimulation at the DLPFC, and perhaps the location of treatment should be based on underactive regions of that particular patient’s brain scan. Recent research suggests that patients with depression can be categorized into one of four different patterns of brain activity. Maybe in the future, we would do a scan and decide treatment based on the areas of underactivity in that patient’s brain. This would allow our treatments to become individualized for each patient. This research has not been done yet, and such personalized treatment remains a goal for the future of psychiatry and TMS.
22. Do you do Theta Burst treatment?
Theta burst TMS is a pulse protocol that uses pulses within pulses to reduce the time of a TMS treatment session. So far, there is only one study out of Toronto that shows that theta burst treatment is as good as regular TMS treatment, just shorter. Based on this one study, the FDA approved theta burst protocols for depression treatment. SoCal TMS is following this closely and will offer theta burst treatment if further studies bear out its effectiveness.
23. Do you offer OCD treatment?
In October of 2018, the FDA approved TMS for the treatment of OCD using the Brainsway Hesed-7 coil. TMS treatment for OCD was used with symptom provocation during treatment and shown to be comparable to the effects seen with medication. OCD is a chronic condition often present since childhood, and we are evaluating the long term efficacy of this treatment before we offer it to patients. Insurance coverage is still pending as well.