Research shows that many patients with severe Major Depressive Disorder fail to achieve effective resolution of their symptoms with antidepressant therapy alone. TMS of Westchester, located within The Therapy Center, offers a noninvasive treatment that yields remarkable improvement for a substantial number of these patients: Transcranial Magnetic Stimulation (TMS).
Nearly 7 percent of the U.S. population has at least one Major Depressive episode each year, according to the National Alliance on Mental Illness. Antidepressant therapy is the most common treatment, but not all patients respond to medication, and some are unable to take certain drugs because of side effects and other complications.
TMS can fill that gap. This nonsystemic therapy delivers highly focused, MRI-strength magnetic pulses to the left prefrontal cortex in order to stimulate areas of the brain that are underactive in people with Major Depressive Disorder.
A Direct Approach
Scientists’ understanding of Major Depressive Disorder is continually evolving. An imbalance of neurotransmitters, such as serotonin, was once thought to be the cause of depression. However, the development of advanced imaging tools, such as PET scans, has enhanced understanding of the roots of depression. A growing body of research suggests that neuron growth and the function of neural networks in certain areas of the brain are also involved in depression onset.
“PET scans documented hypoactivity in the left dorsolateral prefrontal cortex in people suffering from depression,” says Lorraine Innes, MD, Medical Director of TMS of Westchester and TTC Psychiatric. “Researchers began looking for a tool that could target that area and stimulate it directly. TMS is the result of that research.”
The magnetic pulses delivered during a TMS session allow an electrical stimulation to cross through the skull. The depth of stimulation is approximately 5 centimeters into the prefrontal cortex.
“Even though TMS stimulates only a quarter-size area in the brain, because the prefrontal cortex is part of a circuit, the entire prefrontal cortex, as well as the limbic system, is affected,” Dr. Innes explains. “By stimulating the prefrontal cortex, TMS stimulates the limbic system, including the amygdala, hippocampus and cingulate gyrus, which are also believed to be involved in depressive symptoms.”
Patient Candidacy for TMS
“Insurance coverage has made the treatment much more accessible, eliminating potential financial barriers,” Dr. Innes says. “Physicians should know that this is available locally to patients and is an effective alternative for people who aren’t doing well or are unable to tolerate their medications.”
Lorraine Innes, MD, Medical Director of TMS of Westchester and TTC Psychiatric, and Alexandra Meisner locating a patient’s motor threshold prior to commencing Transcranial Magnetic Stimulation (TMS) therapy
The magnetic coil is placed on the patient’s prefrontal cortex.
The FDA cleared TMS in 2008 for use in patients who failed at least one medication trial during the course of the current episode of depression. Although TMS is included as part of the American Psychiatric Association’s standard of care, insurance companies did not begin to provide coverage until 2014. With the exception of Medicare, all insurance companies require prior authorization. Their criterion is stricter and patients have to fail multiple trials of medication. However, as TMS of Westchester has provided TMS since 2010, they have become experts at obtaining authorization and coverage of TMS for their clients.
Dr. Innes recommends TMS to three categories of patients. The first includes those who take their medication regularly but achieve only moderate symptom relief, even with therapy, medication adjustment and complementary strategies such as yoga. Other candidates may include patients who are taking antidepressant medications that work well but cause significant side effects or other complications that require lowering the dosage and consequently reducing the benefit. Thirdly, TMS may be considered for patients who have not responded to antidepressant drugs.
The Typical TMS Course
The display monitor provides continuous information during TMS treatment.
Dr. Innes evaluates every patient who is referred or self-refers for TMS. Because TMS is not considered a first-line therapy for Major Depressive Disorder, these evaluations enable Dr. Innes to ensure patients are appropriate candidates and have completed adequate medication trials. Genetic testing may be performed to help make more informed decisions in regard to medication. Adjusting medications as needed can optimize TMS outcomes.
TMS of Westchester uses the NeuroStar TMS Therapy System, SenStar Treatment Link, a device that houses the coil and acts as a barrier between the coil and the patient. The SenStar Treatment Link helps ensure the coil is functioning and positioned correctly. This was the first TMS technology to receive FDA clearance.
The first TMS treatment session involves establishing the motor threshold, which dictates where the pulses will be delivered and the optimal level of pulse intensity for each individual patient.
The standard TMS protocol consists of 30 sessions, each lasting 37.5 minutes. At TMS of Westchester, patients receive treatments five days a week for five weeks. The remaining five sessions are tapered over a period of several weeks. Tapering treatment allows the TMS of Westchester team to ensure the patient’s responses are holding steady and helps initiate the separation process.
“While TMS is an intensive treatment option, many patients find that they enjoy their sessions, and the unique personal care they receive,” Dr. Innes says.
The TMS support team: Linda Kaye, LCSW, Alexandra Meisner and Bernardine Barry
At the beginning of the 30-session treatment course, patients most often establish goals with the help of the TMS team. Goals may range from improving basic activities of daily living to entering couples counseling to working on career changes. For many, discovering or rediscovering past interests or hobbies has become an invaluable part of the TMS process and experience. An adjunctive treatment, TMS is delivered typically in conjunction with antidepressant use. Participation in psychotherapy is also strongly advised for people undergoing TMS.
A Sense of Clarity
The outcomes observed following TMS meet and even exceed the outcomes achieved following antidepressant therapy alone. Results from the National Institute of Mental Health’s STAR*D study — the longest and largest study to date on depression treatment, which analyzed the effectiveness of antidepressants — revealed that 33 percent of people experienced remission and 10-15 percent experienced symptom resolution following an initial antidepressant trial. As the number of medication trials increased, however, the percentage of people who achieved remission decreased.
“In the research studies that resulted in FDA clearance, it was found that 30 percent of participants achieved complete remission and 50 percent had significant improvement in their symptoms,” Dr. Innes says. “However, we and most providers in private practice find that the success rates are much higher than those found in research trials. During the FDA trials, people were not on medication. In the real world, people who receive TMS are on medication and benefit from the daily, personalized care. We have observed 60 percent remission and 85 percent improvement, which is remarkable.”
While the mechanism by which brain stimulation resolves symptoms is not fully understood, most people who undergo TMS have a greater awareness of the issues in their life that contribute to their depression and are better equipped to address these issues, according to Dr. Innes.
“When we started administering TMS, we noticed what I refer to as an enhanced sense of clarity or level of insight,” she says. “I spoke with researchers, and they thought that meant patients’ response was better. That may be the case, but there seems to be a level of understanding that isn’t observed following medication use. This cognitive enhancement helps people not only feel better, but also perform deeper, meaningful work and address issues they didn’t understand or weren’t able to address before.”
Unlike antidepressant use, which is a systemic therapy that can lead to significant side effects and affect multiple parts of the body, TMS causes few side effects, the most common being mild scalp pain during treatment. The treatment is also safer than other forms of brain stimulation. Electroconvulsive Therapy, for example, requires anesthesia and carries a risk of memory loss and other cognitive impairments — concerns that are eliminated with TMS.
To learn more about TMS and the team of professionals at TMS of Westchester, visit www.tmsofwestchester.com.