TMS And Treatment-Resistant Depression
The first options recommended to treat depression typically include some form of talk therapy, sometimes in combination with medication and lifestyle changes like regular exercise. However, for some individuals, these traditional treatments are not enough to reduce or resolve their symptoms.
For those experiencing treatment-resistant depression, a healthcare provider might look to other options to help them find symptom relief. One of these is transcranial magnetic stimulation (TMS), a procedure approved by the US Food and Drug Administration (FDA) to treat symptoms of depression. Learn more about this option below.
Treatment-resistant depression symptoms
Depression, also called unipolar depression or major depression, is a diagnosable mental illness that’s common but serious. Conditions that fall under this category of depressive mood disorders are thought to be caused by a combination of risk factors, including genetics, differences in levels of brain chemicals, exposure to trauma or stressful life events, and others. Symptoms of depression can range from mild to severe and typically include things like:
- Persistent low mood
- Trouble with emotional or mood control
- Feelings of guilt or worthlessness
- A feeling of emptiness
- A lack of interest in activities previously enjoyed
- Fatigue
- Difficulty concentrating
- Significant changes in appetite
- Significant changes in sleeping patterns
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Treating depression typically involves some form of interpersonal psychotherapy, such as cognitive behavioral therapy sessions (CBT), acceptance and commitment therapy, behavioral activation techniques, and dialectical behavioral therapy. Medication may be recommended in conjunction with therapy in some cases. Your therapist or psychiatrist may also suggest some healthy lifestyle changes to help reduce symptoms, such as exercising, meditating, and eating nutritious foods.
Treatment resistance is defined as the “failure of a disease or disorder to respond positively or significantly to treatment.” Treatment-resistant depression is when traditional treatments such as therapy, medication, and lifestyle changes don’t improve depression symptoms, or only help minimally or for a short time.
An individual with depression who is engaging in positive behaviors loses hope in many cases when they don’t see any results. So in cases like these, a doctor or psychiatrist may suggest alternative treatments such as TMS to help ease depression symptoms.
Transcranial Magnetic Stimulation (TMS)
A person may qualify for TMS rapid relief treatment based on their history with depression, how long their symptoms have persisted, and how they’ve responded to past treatments. This procedure is a clinical practice performed in a medical setting, often by a psychiatrist, neuropsychologist, or doctor.
TMS process
Repetitive transcranial magnetic stimulation for depression involves placing a device that looks somewhat like a helmet on the patient's head in order to send electromagnetic currents to the brain through the skull. The patient may receive impulses to the head for several minutes in timed intervals to get certain parts of the brain involved in stimulation.
An individual may be encouraged to attend sessions several days a week for four to six weeks as part of their treatment. TMS requires no sedation, surgery, or anesthesia. Side effects from treatment may include mild scalp discomfort or a headache after a session.
How effective is TMS?
The idea of using magnetic currents to stimulate parts of the brain comes from the theory that mental disorders like persistent depression result from certain parts of the brain being non-responsive to traditional treatments. Research suggests that TMS may be able to effectively stimulate these areas.
Consider a recent meta-analysis of several clinical trials that has associated TMS with symptom remission. In one study cited in the analysis, 20.7% of patients had remission and 34.5% had partial remission after this treatment. So while these results for TMS as a standalone treatment show promise, many mental health experts believe that several factors—including social, biological, and psychological influences—may contribute to depression. That’s why a person might see greater symptom improvement by using TMS in combination with other forms of treatment.
Possible challenges to seeking TMS
While TMS may be able to help individuals living with treatment-resistant depression, it’s not always readily available to them due to various barriers. For example, to qualify for TMS treatment, individuals must work with a professional to determine whether they meet the criteria, since certain health conditions or aspects of medical history may make some ineligible. In addition, qualified technicians must administer TMS with tools and equipment authorized by the FDA. Some locations may not have this option available due to a limited number of professionals providing the service.
Finances can be another barrier to receiving TMS. TMS therapy costs can be expensive, with some options priced as high as $10,000. That’s why most people must ensure that their insurance will provide coverage for the procedure, which could require a complex process of referrals, approvals, and/or appeals.
People experiencing depression for an extended period may have symptoms that are resistant to treatment. For some, making adjustments to traditional treatments helps temporarily or shows no results. These are the cases in which TMS may be considered as a way to provide some symptom relief to those who have been living with long-term depression. Even if TMS doesn’t help a given individual with persistent depression, there are other forms of experimental treatments available as well.
Since various studies indicate that it may be helpful for treatment-resistant depression, TMS is now also being used to treat other conditions that affect the brain, including forms of anxiety, post-traumatic stress disorder, bipolar disorder, chronic pain, substance use disorders, thyroid hormone issues, and diseases that affect mobility and cognitive behaviors.
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Why doesn’t TMS treat depression for everyone—and what then?
TMS may not be effective for everyone, and research is still being done to determine why this may be. So far, there are a few theories that primarily relate to variations in how the brain receives magnetic impulses.
Some clinical neuroscience experts believe there could be a lack of understanding of exactly how the currents penetrate the skull and brain, creating varied results in how the brain is stimulated. In addition, some researchers believe that one side of the brain is responsible for the development of depression and, therefore, should be targeted by TMS, while others say there isn't yet enough research to support this claim.
Electroconvulsive therapy options
If TMS doesn't work for you, there may be other options available—such as electroconvulsive therapy, or ECT treatments, which are done under anesthesia. Talk to your doctor about the best option for you.
Other forms of support for those living with depression
Living with treatment-resistant depression symptoms can be challenging. It can be frustrating to try different treatments and not experience symptom relief, and the process of working with health insurance companies and various specialists to try new treatments and get the cost covered can be stressful and frustrating. Working with a therapist throughout the process can be helpful.
A therapist can offer you a safe space to express your feelings, get support, and build healthy coping mechanisms for symptoms as you navigate the process of finding the right alternative treatment for you. If you don’t want to add another in-person appointment to your schedule, you might consider meeting with a therapist virtually for your convenience.
How online therapy can help
With a platform like BetterHelp, you can get matched with a licensed therapist and meet with them remotely via phone, video call, and/or in-app messaging. Research suggests that online therapy in general can offer similar effectiveness to in-person therapy for treating conditions like depression.
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Takeaway
Frequently asked questions (FAQs)
Read more below for answers to questions commonly asked about this topic.
TRD refers to depression that does not respond adequately to standard antidepressant medications or other conventional treatments. Managing a mental illness or mental health condition like TRD can be challenging, and the most effective approach may vary from person to person. Here are several strategies that may improve symptoms for individuals with TRD:
Medication adjustments:
- Switching medications: Trying a different class of oral antidepressant or a combination of medication strategies may be considered.
- Augmentation therapy: Adding another medication to enhance the effects of the current antidepressant, such as lithium, atypical antipsychotics, or thyroid hormones. Medications may help to balance brain chemistry and reduce symptoms.
Psychotherapy:
- Cognitive behavioral therapy (CBT): CBT has been shown to be effective in treating depression and mood disorders, including MDD, and it may be adapted for individuals with TRD.
- Dialectical behavioral therapy (DBT): DBT has been adapted and studied for its effectiveness in treating symptoms, particularly for individuals who struggle with chronic and recurrent depressive symptoms.
- Psychodynamic Therapy: This type of therapy explores unconscious thoughts and feelings and may be helpful for some individuals with TRD.
Electroconvulsive therapy (ECT):
ECT is a medical treatment that involves passing a small electrical current through the brain to induce a controlled seizure. It is a treatment that may be considered for severe, treatment-resistant cases.
Transcranial magnetic stimulation (TMS):
TMS involves using magnetic fields to stimulate nerve cells in the brain. It is a non-invasive procedure that is generally well-tolerated and may be considered for TRD.
Vagus nerve stimulation (VNS):
VNS involves implanting a device that stimulates the vagus nerve, which is connected to mood-managing brain areas. It is an option for some individuals with TRD.
Deep brain stimulation (DBS):
DBS involves implanting electrodes in the brain and connecting them to a stimulator device. It is an experimental treatment for severe TRD and is still being studied.
Lifestyle changes:
- Exercise: Regular physical activity has been shown to have positive effects on mood and may be beneficial for individuals experiencing these symptoms.
- Sleep Management: Ensuring adequate and quality sleep is essential for mental health.
What is the new treatment for TRD?
Treating TRD can be challenging, many medical professionals are implementing new treatments for TRD. Here are some emerging and relatively novel treatments that have been explored for TRD:
- Esketamine nasal spray (Spravato): Esketamine, a derivative of ketamine, is an FDA approved medication for the treatment of TRD. It is administered as a nasal spray in a healthcare setting and may reduce symptoms.
- Psilocybin and psychedelic-assisted therapy: Some studies are exploring the potential antidepressant effects of psilocybin, a psychedelic compound found in certain mushrooms, in combination with psychotherapy. However, the official classification of psychedelics varies, and their use is still under investigation.
- Transcranial magnetic stimulation (TMS): TMS is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain. It has been approved for the treatment of TRD and is considered when other treatments have not been effective.
- Deep brain stimulation (DBS): DBS involves implanting electrodes in specific areas of the brain and connecting them to a stimulator device. While still being studied, DBS has shown promise as a potential treatment for severe TRD.
- Vagus nerve stimulation (VNS): VNS involves implanting a device that stimulates the vagus nerve. It has been studied for some individuals with TRD.
What are 2 potential treatments?
Treatment for depression can vary based on the severity of symptoms, individual circumstances, and preferences. Here are two common treatments:
Psychotherapy (Counseling or Talk Therapy):
Cognitive behavioral therapy (CBT): CBT is a widely used form of psychotherapy that focuses on identifying and changing negative thought patterns and behaviors. It helps individuals develop coping strategies, problem-solving skills, and a more positive outlook. CBT has been shown to be effective in treating various forms.
Interpersonal therapy (IPT): IPT is another form of psychotherapy that focuses on improving interpersonal relationships and communication skills. It helps individuals address specific issues that may be contributing to their symptoms, such as conflicts in relationships or major life changes.
Psychodynamic therapy: Psychodynamic therapy explores unconscious thoughts and feelings, often looking at past experiences to gain insight into current emotional struggles. It can be a longer-term therapy that aims to understand how early life experiences influence current patterns of thinking and behavior.
Medication:
Antidepressant medications: There are several classes of antidepressant medications, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and others. These medications work by affecting the levels of neurotransmitters in the brain, such as serotonin and norepinephrine. It's essential to work closely with a healthcare provider to find the most suitable medication and dosage.
Esketamine: Esketamine, administered as a nasal spray, has shown rapid antidepressant effects in some individuals, especially those with TRD.
What is an effective treatment for most people?
The most effective treatment for these individuals can vary from person to person, and it often depends on factors such as the severity of symptoms, individual preferences, and the presence of any coexisting medical or psychological conditions. However, research consistently supports the idea that a combination of psychotherapy and medication tends to be particularly effective for many individuals with these symptoms.
The vast majority is treatable, and effective treatments are available for various forms of depressive disorders. However, the success of treatment can vary among individuals, and some cases may be more challenging to manage than others. Factors such as the severity of symptoms, the presence of co-occurring conditions, and individual differences in response to treatment can influence outcomes.
The term "treatment-resistant depression" is often used to describe cases where standard treatments, such as psychotherapy and antidepressant medications, have not been effective. It does not mean that the condition is entirely untreatable, but rather that additional or alternative interventions may be necessary.
What factors contribute to TRD?
TRD is a complex condition, and several factors can contribute to its development. Understanding these factors may be important for tailoring treatment approaches to individual needs. Here are some potential contributors to TRD:
Biological Factors:
- Genetics: Genetic factors can influence an individual's response to antidepressant medications and may contribute to the development of TRD.
- Neurotransmitter dysfunction: Alterations in the levels or functioning of neurotransmitters, such as serotonin, norepinephrine, and dopamine, may affect mood management and response to treatment.
Psychosocial Factors:
- Psychosocial stressors: Chronic stress, trauma, or ongoing life difficulties can contribute to the development of symptoms and may make it difficult to manage.
- Co-occurring Disorders: The presence of other mental health disorders or physical health conditions, such as anxiety or substance use disorders, can complicate treatment and contribute to treatment resistance.
Medical Factors:
- Underlying medical conditions: Certain medical conditions, such as chronic pain, hormonal imbalances, or autoimmune disorders, may contribute to symptoms and impact treatment response.
- Medication interactions: Interactions between antidepressant medications and other medications an individual is taking may affect treatment outcomes.
Treatment-related Factors:
- Adherence to treatment: Inconsistent adherence to prescribed medications or difficulties in attending psychotherapy sessions can impact treatment effectiveness and may worsen symptoms.
- Inadequate treatment duration or dosage: Some individuals may not receive an adequate dose or duration of treatment, affecting the likelihood of improvement.
Individual differences:
- Genetic variability in drug metabolism: Variability in the metabolism of medications can affect their effectiveness in different individuals.
- Personality factors: Individual differences in personality traits, coping styles, and cognitive patterns may influence treatment outcomes.
What is the remission rate for TRD?
The remission rates for TRD can vary based on several factors, including the specific treatments used, the severity of symptoms, and individual differences in response to interventions. Remission is generally defined as a significant reduction or complete elimination of depressive symptoms.Individuals with TRD should work closely with mental health professionals to explore appropriate treatment options tailored to their specific needs. The goal is not only symptom reduction but also sustained improvement in overall functioning and quality of life.
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