Antidepressants Compared to TMSAB: How quickly do you see results from TMS (on average)? Is this quicker than the results you see from antidepressants?
KS: Understandably, to avoid side effects, psychiatrists have been trained to start antidepressant medications at low doses and then gradually increase doses every month until a therapeutic level is achieved. Unfortunately for many patients, this means that full therapeutic trials of one or more antidepressant medications can take up to several months, if the medications are tolerated.
In comparison, we generally find that to receive a full treatment course of TMS, patients usually need 4 to 6 weeks of 40 minute TMS sessions, 5 days per week. While some patients may even start to respond after only 2 weeks, others (usually those with severe, long-standing depression) may need longer than 6 weeks.
AB: What is the standard response rate of TMS? How does that compare with antidepressants? How many patients will go into remission?
KS: When TMS is used alone without medications, research has shown that 1 in 2 patients who were unresponsive to one prior medication experience a significant improvement in their depressive symptoms, while 1 in 3 completely remit - a rate of success comparable to a first trial of antidepressant medication. Keep in mind that second, third and fourth antidepressant medication trials each have significantly lower chances of achieving remission (21%, 16%, and 7% respectively) than TMS monotherapy.
TMS can also be used as an add-on to medications that patients have partially responded to, which in practice seems to further increase the response rate. Since a patient has a better chance of completely responding to TMS than to a second trial of medication, it makes sense to provide TMS as a treatment option early on in a patient's struggle with depression.
I can't emphasize enough that the longer a patient suffers from depression, the more resistant the depression becomes, so it is very important to offer patients treatment options that can provide relief as soon as possible.
AB: Do you continue to use antidepressants when a patient is both undergoing TMS and after stabilized with TMS?
KS: For chronic and resistant cases of depression, particularly cases in which I believe that the medication has been partially helpful in reducing some of the depressive symptoms, I often prefer to add TMS to the medication, rather than risk losing the gain achieved from the drugs by removing them. We generally recommend continuing medication once TMS has brought them out of the depression in order to help maintain the response.
AB: I understand that West Coast TMS Institute in Los Angeles has a higher success rate than in research studies. Why do you think that is?
KS: Yes, interestingly, in our program we are achieving a much higher response rate than the 50% rate seen in studies of TMS monotherapy. This could be in part due to our willingness to use TMS with medication. Patients also likely benefit from our holistic treatment approach. We recognize that seeing a patient five times weekly is an opportunity to help them develop hope and skills to achieve remission and maintain recovery.
My staff and I actively encourage a more comprehensive program beyond TMS that integrates dietary changes, exercise, meditation, psychotherapy and even bright light therapy. Furthermore, optimization of TMS treatment is based on the latest research, clinical experience, and a careful risk-benefit analysis.
AB: What happens when a patient does not respond at all to TMS treatments?
KS: If there is no response to standard TMS by 6 to 8 weeks, depending on the patient's condition, I might suggest other treatment alternatives or adjust the TMS treatment, depending on the specific circumstances.
AB: What do you do when someone only starts to respond to TMS late in their treatment?
KS: Clearly, both experience and research shows that a minority of patients need as many as twelve weeks of treatment to benefit from TMS. In situations where a patient's condition is showing a progressive response to TMS, but one that is very slow - for example, extremely gradual improvement seen beyond the tenth or twelfth week of treatment - the issue arises as to whether or not the benefit of TMS is sufficient and rapid enough to warrant continuation.
If it is clear that slow progress - however optimistic the trajectory - puts the patient at risk of suicide or rapid decline due to lack of self care, I am likely to recommend that TMS be discontinued and electroconvulsive therapy (ECT) be offered as an alternative.
However, if a patient is clearly benefiting from prolonged TMS treatment, demonstrating a rapid-enough benefit that outweighs the risks of the depression, then - after much reflection and consultation - I may proceed with TMS treatment. As with any medical treatment, if the patient's response rate is too slow or if the risks of proceeding outweigh the benefits, other options need to be examined.
AB: What are the typical side effects of TMS? Is it fair to say that the side effects are less extensive than those associated with antidepressants drugs?
KS: The most common side effects of TMS are transient scalp/facial irritation and headache. On the other hand, medication treatment can involve ongoing side effects such as sexual dysfunction, weight gain, dry mouth and eyes, constipation, diarrhea, sweating and nervousness or sedation. The safety and tolerability of TMS is proven, with research showing a low discontinuation rate of about 4%, compared to a 23% drop-out rate of a second medication trial, and even a 8% drop-out rate of a first antidepressant medication trial.
AB: Is seizure a potential complication of TMS? What about medications?
KS: The seizure risk of TMS is low (0.003% per treatment or 0.1% per TMS patient) and is comparable or better than the risk of seizure associated with some antidepressant medications, such as fluoxetine (0.1%); buproprion SR (0.1%); or tricyclic antidepressants (0.4% - 2%). Keep in mind that a rare TMS-induced seizure would occur only during a staff-monitored TMS treatment session, whereas medication-related seizures could occur at any time.
Dr. Kira Stein is a board certified psychiatrist and clinical instructor at the UCLA Geffen School of Medicine. She is the founder of the West Coast TMS Institute in Los Angeles. Interviewer Andy Behrman is the author of Electroboy: A Memoir of Mania.
NOTE: Dr. Stein's interview responses are for general information purposes only and are not intended to be professional medical, psychological, or legal advice for any specific situation or individual. This information is intended for individuals and their families to use in consultation with a qualified healthcare professional. Dr. Stein does not warrant or make any representations, and disclaims any and all liability, concerning any treatment or action by any individual who has made decisions based on information from this interview.