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Dr. Philip Janicak administers transcranial magnetic stimulation treatments using the NeuroStar TMS Therapy device at Rush University Medical Center.

Magnetic stimulation therapy for depression seems effective, safe so far

by Helen Adamopoulos
June 02, 2011

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Alice, now in her early 60s, suffered from depression for about 13 years. She said she tried medication, but she still found herself considering suicide.

“I was willing to try anything because these thoughts of suicide scared me,” she said.

At that point, Alice (name changed for privacy) decided to try transcranial magnetic stimulation, or TMS, a depression remedy that uses magnetic pulses to increase brain activity. The South Loop resident said she started treatment in April 2010 at the private practice TMS Chicago. Within two weeks, she said there was a huge change. About a year after completing her 30 treatment sessions, she is still depression free.

“I’m enjoying things again. I just feel good,” she said. “For the first time in 13 years, I’m back to my normal self.”

Transcranial magnetic stimulation is a relatively new treatment option for patients with major depression, particularly those who have not responded to medication, according to the National Alliance on Mental Illness.

The therapy involves using an electromagnetic coil to deliver magnetic pulses to the left prefrontal cortex, an area of the brain that helps modulate emotions and which typically shows decreased activity in depressed patients. The amount of magnetic exposure a patient receives during a treatment is similar to that received from a brain MRI, according to NAMI. The theory behind the treatment is that the pulses stimulate the brain’s nerve cells and ultimately activate neurotransmitters such as serotonin, norepinephrine and dopamine.

In October 2008, the U.S. Food and Drug Administration approved NeuroStar TMS Therapy as the first magnetic stimulation device for treating individuals with major depression. According to the website for Neuronetics Inc., the Malvern, Pa.-based manufacturer of the device, about 20 health care providers in Illinois offer treatments using the device.

Rush University Medical Center in Chicago is one of those providers. The center has offered clinical treatments since June 2009, according to Dr. Philip Janicak, medical director of the Rush Psychiatric Clinical Research Center. He said the center has been studying magnetic stimulation therapy since 2004, and evidence from clinical trials so far doesn’t indicate that the treatment poses any long-term medical risks.

More invasive brain stimulation methods such as electroconvulsive therapy can cause memory loss as a long-term side effect, according to Dr. Peter Nierman, medical director of the psychiatric facility Chicago Lakeshore Hospital. Although studies don’t indicate any complications associated with TMS yet, he said it’s too soon to tell for certain what the lasting effects are.

“That’s something that research is still going to have to unearth for us,” he said. “The longer-term implications will require large numbers of patients.”

Janicak said he has observed that patients typically adapt well to minor side effects, such as pain at the stimulation site during treatments.

“The vast majority of people tolerate it pretty well,” he said. “They don’t stop the treatment.”

Alice said she experienced an extreme amount of pain during her treatments. She said it felt like someone was pounding on her head the whole time. Still, she went back because she thought the discomfort was worth the results.

“It was working,” she said. “I still finished it because I knew it was changing me.”

Roughly 5 percent of patients discontinue treatment due to adverse effects, NAMI reports. A typical treatment session takes 40 minutes, and patients usually come in every weekday for a session over the course of four to six weeks. About 54 percent of people who receive TMS treatments experience significant improvement in their symptoms, according to NAMI.

A team of researchers from the Medical University of South Carolina, Columbia University and other U.S. medical programs reported in the May 2010 issue of the Archives of General Psychiatry that magnetic stimulation does have an effect on depressed patients who are resistant to other treatments. The study, funded by the National Institute of Mental Health, found that active repetitive TMS treatments caused remissions in 14 percent of anti-depressant resistant patients. The placebo substitute produced remissions in 5 percent of patients.

Janicak said there is a “slight risk” of the treatment triggering seizures. Most of these incidents probably involve patients who are taking medications that lower the threshold of stimulation that will cause them to seize, he said. Certain antidepressants such as Wellbutrin (bupropion) can increase the risk of seizures.

According to the Mayo Clinic, common side effects from the treatment include headache, scalp discomfort where the magnetic stimulation is applied, and lightheadedness. More rarely, patients may experience seizures, mania or hearing loss.

Dr. Carl Wahlstrom, who treats patients for depression at TMS Chicago, said that magnetic stimulation seems very effective in treating depression so far, based on the 33 patients who have received magnetic stimulation at his practice. About two-thirds of them have experienced significant relief from their depression symptoms, according to follow-up reports, he said.

He noted that his practice treats patients who simultaneously use psychiatric medication.

“I think that’s probably the key ingredient to how we’re doing better than the studies show,” he said. “One is augmenting the other.”

Both Janicak and Wahlstrom said monetary issues might pose a road block for some patients. A round of treatment costs $7,000 to $12,000 on average, and most insurance companies don’t cover it. Janicak and Wahlstrom said they work with patients to appeal for coverage on a case-by-case basis.

Still, some patients don’t mind paying out of pocket. Alice said her insurance company wouldn’t cover her TMS treatment on the grounds that it’s experimental, but she was happy to pay the $13,000.

“The pain and the money were worth the results,” she said.

The treatment parameters for the therapy involve delivering 10 magnetic pulses per second at 120 percent of the patient’s motor threshold, according to Janicak. He said medical providers define the motor threshold as the least amount of power needed to get regular contractions in the patient’s right thumb. Patients receive the pulses in “stimulation trains” that involve 4 seconds of pulses and then 26 seconds when no pulses are administered. Janicak said a patient receives a total of about 3,000 pulses in one session.

Although TMS seems to help depression when administered with these specifications, Janicak said altering the parameters could potentially provide more effective depression treatment, or even a remedy for other conditions. He said preliminary trials have shown that TMS could potentially help people with schizophrenia, bipolar disorder, substance abuse issues and other psychiatric problems.

In a review of treatments for bipolar disorder published in the Journal of Affective Disorders last year, researchers from hospitals in Australia and the Alpert Medical School of Brown University in Providence, R.I., found that TMS treatments improved mania by at least 50 percent for the majority of patients in two studies that stimulated patients’ right prefrontal cortexes. The studies examined the treatment as a supplement to mood stabilizing medications such as lithium. Although the review authors caution that research regarding TMS and bipolar disorder is still in its preliminary stages, they write that the results so far are promising.

Janicak said other studies indicate that the treatment improves schizophrenia symptoms such as auditory hallucinations. It is also being considered as a remedy for anxiety disorders such as Post-Traumatic Stress Disorder. However, he said there is not enough research to start offering clinical magnetic stimulation treatments for conditions other than depression yet.

Wahlstrom said he has seen some “unexpected results” since he started offering TMS treatments in early 2009 that support the idea of magnetic stimulation as helpful for other conditions.

One woman found that the treatments reduced the recurrence of her migraines, he said. Another found that it significantly relieved her back pain.

“I think that we’re just at the very beginning,” Wahlstrom said. “I think it will be used for a wide variety of conditions.”