At Human Health Clinics, our commitment lies in leading the charge in mental health treatment, particularly for persistent major depression. Grounded in the latest research, we offer pioneering solutions aimed at alleviating the burden of this debilitating condition, backed by the latest research available. With a steadfast dedication to advancing the frontier of mental health care, we strive to expedite the journey to recovery for individuals battling persistent major depression, fostering hope and healing along the way.

What is the research on TMS saying?

An alternative to anti-depressants

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), major depressive disorder manifests as persistent feelings of sadness, reduced pleasure, changes in appetite or sleep patterns, agitation or lethargy, fatigue, low self-esteem, difficulty concentrating, and suicidal thoughts (Nierenberg, Petersen, & Alpert). While traditional treatments like psychotherapy and medication can be effective for some, others find relief in alternative therapies such as TMS.

Repetitive transcranial magnetic stimulation (rTMS) has emerged as an effective therapy for treatment-resistant major depressive disorder. Standard rTMS protocols involve 20–30 sessions over 4–6 weeks, but accelerated delivery, with multiple sessions per day, shortens treatment duration.

The precise mechanisms through which TMS alleviates depression remain unclear, but it likely involves modulation of neuronal excitability in brain regions associated with mood regulation. High-frequency stimulation enhances excitability, while low-frequency stimulation decreases it. In depression treatment, TMS often targets the dorsolateral prefrontal cortex, implicated in cognitive and emotional regulation, aiming to induce lasting positive changes in brain function.

The lasting effects of TMS

A recent study was conducted by Bailey, et al which synthesized two decades of research; in general, their research indicates that accelerated rTMS protocols are generally safe and do not typically cause severe side effects. Based on current findings, treatment plans with higher pulse doses and multiple daily sessions offer potential for enhanced efficacy (Bailey, et al.).

What we know about depression

Longevity

Clinical depression, once thought of as acute and short-term has been widely studied over the past few decades. What we know now is that depression is often a chronic disorder an individual may face throughout their entire life, especially if left untreated; it is categorized by periods of relapse and recurrences (Nierenberg, et al.).

Studies have shown that major depression is both common and long-lasting, with 30-60% of people who experience one episode of depression experiencing further episodes throughout life (Pridmore, et al.). These episodes often increase in severity, if left untreated.

Resistance

Depression is an adaptive disorder, meaning that some patients who may experience benefits of treatment may over time become more resistant to said treatment, resulting in relapse. Each subsequent episode of major depression relapse increases the chance of chronicity, increasing from 30-50% after the first use of psychopharmacological treatments (d’Andrea, et al.). After two failures to achieve remission through these treatments, the depression may be classified as Treatment-Resistant Depression (TRD). TRD poses incredible risk of increased negative symptoms, including a seven-times higher risk of suicide and double the prevalence of hospitalization (Gaynes).

Human Health Clinics - Brain Health

Benefits of maintenance TMS sessions

Emerging research and FDA approval

Transcranial magnetic stimulation (TMS), also known as repetitive transcranial magnetic stimulation (rTMS), is a noninvasive method employed in addressing various mental health concerns, including migraine pain, obsessive-compulsive disorder, and notably, depression (and specifically, Major Depressive Disorder). TMS is often recommended when conventional antidepressants prove ineffective or intolerable due to side effects. Key features of TMS Therapy include its safety and effectiveness with minimal side effects, non-invasiveness, outpatient nature without the need for anesthesia, and wide acceptance by most insurance providers, including Medicare.

rTMS has been shown to be an effective treatment option for major depressive symptoms – one upside of TMS as a psychopharmacological alternative is it is seen as safe and free from most harmful side effects (O’Reardon, et al.).

What we know about maintenance TMS

Although the research on long-term or maintenance TMS treatment is limited at this time due to it being a newer treatment option, early studies have shown that TMS can be used as an intermittent treatment option to prevent depression symptoms relapse (Janicak, et al.). Should maintenance rTMS prove effective in preventing relapse/recurrence of depression, it could broaden treatment avenues for patients struggling to maintain remission with antidepressants and/or psychotherapy. Given the evolving nature of rTMS technology, there’s no assurance that the current stimulation protocol is optimal for treating MDD patients. Thus, ongoing research should explore optimal maintenance therapy protocols for rTMS and adapt to incorporate advancements in stimulation methods, which are continually improving (Yamazaki, et al.).

Neuronavigational TMS

TMS, a non-invasive treatment option which activates the cerebral cortex, first began being used over forty years ago. Since its induction, different technologies have been used to change the activity of neurons within different regions of the cortical region (Cocchi, et al.). TMS has been administered using wire coils which are applied to the scalp via elastic caps, creating a magnetic field; this has been the standard and sole practice until the recent introduction of neuronavigation equipment and processes.

Neuronavigation research is beginning to emerge, highlighting potential benefits of the new methods and limitations of the cap-based targeting that has been standard practice for decades. Although there is limited research so far on the benefits of neuronavigation, early studies indicate less target variability for the patient receiving TMS treatment. Target variability in coil placement can lead to significantly less stimulation reaching the intended target, whereas neuronavigation results in cortical stimulation reaching its intended targets (Caulfield, et al).

Localized targeting for portions of the cerebral cortex has been a challenge since TMS’ emergence as a treatment option. This is in part because there are slight differences in brain anatomy across participants (Lioumis & Rosanova). Because of the variability, targeting a consistent cortical area across participants requires the localization of the primary motor cortex and then repositioning thereafter. Differences in cortical and skull anatomy can result in differences up to 20mm. To account for this variability across individuals, neuronavigation systems used in conjunction with TMS have emerged as a promising tool to boost reliability and repeatability of treatment sessions.

Appendix

  • Caulfield, K. A., Fleischmann, H. H., Cox, C. E., Wolf, J. P., George, M. S., & McTeague, L. M. (2022). Neuronavigation maximizes accuracy and precision in TMS positioning: Evidence from 11,230 distance, angle, and electric field modeling measurements. Brain Stimulation, 15(5), 1192-1205. https://doi.org/10.1016/j.brs.2022.08.013
  • Cocchi, L., Zalesky, A., Nott, Z., Whybird, G., Fitzgerald, P. B., & Breakspear, M. (2018). Transcranial magnetic stimulation in obsessive-compulsive disorder: A focus on network mechanisms and state dependence. Brain Stimulation, 11(5), 1103-1114. https://doi.org/10.1016/j.brs.2018.05.013
  • d’Andrea G, Mancusi G, Santovito MC, Marrangone C, Martino F, Santorelli M, Miuli A, Di Carlo F, Signorelli MS, Clerici M, Pettorruso M, Martinotti G. Investigating the Role of Maintenance TMS Protocols for Major Depression: Systematic Review and Future Perspectives for Personalized Interventions. J Pers Med. 2023 Apr 21;13(4):697. doi: 10.3390/jpm13040697. PMID: 37109083; PMCID: PMC10141590.
  • Gaynes B. Assessing the risk factors for difficult-to-treat depression and treatment-resistant depression. J. Clin. Psychiatry. 2016;77((Suppl. S1)):4–8. doi: 10.4088/JCP.14077su1c.01. 
  • Janicak, P. G., Nahas, Z., Lisanby, S. H., Solvason, H. B., Sampson, S. M., McDonald, W. M., … Schatzberg, A. F. (2010). Durability of clinical benefit with transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistant major depression: assessment of relapse during a 6-month, multisite, open-label study. Brain Stimulation, 3(4), 262-268. https://doi.org/10.1016/j.brs.2010.07.001
  • Lioumis, P., & Rosanova, M. (2022). The role of neuronavigation in TMS–EEG studies: Current applications and future perspectives. Brain Stimulation, 15(5), 1206-1217. https://doi.org/10.1016/j.brs.2022.07.016
  • Nierenberg AA, Petersen TJ, Alpert JE. Prevention of relapse and recurrence in depression: The role of long-term pharmacotherapy and psychotherapy. J Clin Psychiatry. 2003;64(Suppl 15):13–7.
  • O’Reardon, J. P., Solvason, H. B., Janicak, P. G., Sampson, S., Isenberg, K. E., Nahas, Z., … Sackeim, H. A. (2007). Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: A multisite randomized controlled trial. Biological Psychiatry, 62(11), 1208-1216. https://doi.org/10.1016/j.biopsych.2007.01.018
  • Pridmore, S., Saxby, E., et al. (2018). Early relapse (ER) transcranial magnetic stimulation (TMS) in treatment-resistant major depression. Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation, 11(5), 1098-1102.
  • Yamazaki, R., Matsuda, Y., Oba, M. et al. Maintenance repetitive transcranial magnetic stimulation (rTMS) therapy for treatment-resistant depression: a study protocol of a multisite, prospective, non-randomized longitudinal study. BMC Psychiatry 23, 437 (2023). https://doi.org/10.1186/s12888-023-04944-0

 

 

BOOK INFORMATION SESSION