Transcranial Magnetic Stimulation (TMS)Columbia, SC

TMS Patient Experience

“I was in an emergency situation and that staff was amazing! They understood and was so caring! Feeling a little more at ease know my I will be in good hands.

UPDATE: ONE year later and I have never been so mentally happy. I did TMS treatments and the staff was so amazing and with me the whole way! Lilly's, Sarah and Doc are truly gifts from God!”

Google Review

- Amanda T.

The TMS Procedure

How TMS Works

During a TMS session, the patient is seated comfortably, and the device (magnetic coil) is placed near the head. The device generates focused magnetic pulses that stimulate the prefrontal cortex. More specifically, the treatment targets the left dorsolateral prefrontal cortex. It is thought that this region of the brain communicates with deeper structures in the brain that control mood. It is known that patients with depression have diminished cortical activity in the region of the left prefrontal cortex and other areas superficially in the cortex of the brain. However, during a depressive State deeper regions in the brain that control the mood such as the limbic system caudate nuclei, and nucleus accumbens tend to have increased activity during a depressive state. Typically, we use chemical Messengers activated by antidepressants to reach these deeper regions of the brain to treat depression. However, this does not always work. Oftentimes medications lead to intolerable side effects. With TMS, we indirectly get these mood regions to fire more normally and decrease their activity due to the reciprocal relationships between the left Prefrontal cortex and these deep regions of the brain.

Another way of stating this is that when people are depressed, the left prefrontal cortex (LPC) is very inactive. The Deep regions of the brain that control the mood tend to be more active than normal. These two regions counterbalance each other. When the left prefrontal cortex is stimulated repetitively over time, the LPC becomes more active and inversely the mood centers become less active. This profile is more congruent with a normal mood.

The TMS treatment is divided into several steps.

1) Medical clearance.
Medical clearance is necessary to gather and confirm the patient's physical and mental health history and to screen the patient for any contraindications for treatment. The objective is to verify that the patient is safe to move forward with the treatment. The visit also verifies that the patient meets the criteria for treatment to ensure that the treatment is covered by their insurance. This visit is used to educate the patient about the procedure and to address any questions the patient may have before starting.

2) Motor threshold visit.
The motor threshold visit is the first treatment session where the physician or authorized representative determines the prescription of the machine for the patient. The prescription includes the dose, the location, and the protocol entered into the TMS machine. This is determined by stimulating the motor strip on the brain to identify the right thumb. The right thumb on the motor strip correlates with where the left prefrontal cortex is. Locating this area is also necessary for determining the dose of stimulation. An adequate dose creates an action potential that will typically cause a finger twitch indicating that the dose was adequate to generate an action potential (nerve cell firing). After the prescription is determined the patient receives their first treatment on day one.

3) Daily treatments
The treatment course of TMS is 36 total treatments. The first treatment is the motor threshold visit, the subsequent 35 visits are considered daily treatments. The patient will return to the office 5 days a week for 6 weeks and then for the final three weeks they will be tapered down in a 3-2-1 fashion. Three treatments on week 7, two treatments on week 8, and one treatment on week 9. The TMS treater is responsible for greeting the patient, placing them in the TMS chair, positioning the treatment call to the location found at the motor threshold visit, and then rendering the treatment as prescribed by the physician. Typical treatment lasts 17 to 35 minutes depending on the patient and the protocol. Patients do not require anesthesia and they do not lose consciousness. The most common side effect of the treatment is discomfort at the treatment site.

4) Post-assessment
The post-assessment visit is used to evaluate the patient's results from the procedure. It is typically 3 to 4 weeks after completion of the series of treatments. The purpose is to evaluate the results and to make further recommendations based on the results or lack thereof in some cases. Many of these patients who reach remission likely won't need additional treatment from TMS but should be encouraged to continue their medication regimen until they have at least one year of stability. Patients who are partial responders may want to consider another treatment option such as IV Ketamine or Spravato to see if they can reach remission. For the patients who are non-responders, no further TMS is recommended but they may be appropriate for ketamine or Spravato. If all of those things have failed, typically we refer to ECT.

5) Optionally there is a mid-treatment reevaluation. Insurance allows for one redetermination of the motor threshold if the patient is not making progress at the halfway point. This is a billable service and reimburses nearly as much as the motor threshold initial session. Some clinics always do this Appointment however it is not always necessary for patients.

6) Maintenance treatments are not FDA-approved at this time and are a fee-for-service visits. Maintenance TMS treatments, also known as continuation TMS or cTMS, are designed to prevent relapse and maintain improvements in depressive symptoms over the longer term.

Research and Clinical Evidence:

Sustained Effects

Several studies have shown that the antidepressant effects of TMS can be sustained over time with maintenance sessions. These sessions may be scheduled weekly, monthly, or at other intervals based on individual patient needs and responses.

Randomized Controlled Trials:

Some randomized controlled trials have investigated the effectiveness of maintenance TMS treatments. These studies generally indicate that periodic TMS sessions can help patients maintain the benefits achieved from their initial treatment course.

Guidelines and Recommendations:

While specific guidelines for maintenance TMS treatments are still evolving, some professional organizations and clinical research support the practice. The decision to implement maintenance TMS is often based on clinical judgment, patient history of relapse, and individual response to the initial treatment.

Personalization of Treatment:

The frequency and duration of maintenance TMS sessions are highly individualized. Factors such as the severity of symptoms, duration of the initial response, and patient preference play significant roles in determining the maintenance regimen.

Clinical Outcomes:

Studies report varied outcomes, with many patients experiencing sustained remission or significant reduction in depressive symptoms. Maintenance TMS is particularly beneficial for patients with a history of recurrent depression or those who have shown a robust response to acute TMS treatment.

Conclusion:

Maintenance TMS treatments represent a promising approach for extending the benefits of TMS therapy and preventing relapse in patients with depression. While the evidence base is growing, further research is needed to optimize maintenance protocols, including the ideal frequency and duration of treatments. Clinicians should consider individual patient factors and clinical judgment when recommending maintenance TMS.

Equipment Used

Apollo TMS is a state-of-the-art device used in administering TMS therapy. It is designed for patient comfort and precision in delivering magnetic pulses.

Apollo TMS is a product of Neurocare. The Apollo device is ergonomically superior and utilizes a unique coil stabilization unit called HANS. The HANS (Head-And-Neck-Support) positioning system ensures that reproducibly stimulating the correct treatment spot by following head movement. Apollo s FDA-cleared for rTMS.

Apollo uses a unique coating cooling system to cool the coil between sessions. This makes the coil very quiet. Apollo has the shortest pulse width of any TMS device. The narrower the pulse width, the more potentiating it can be from the neurobiology standpoint.

Patient Eligibility for TMS

All individuals who have tried and failed two antidepressants at a maximum dose and a duration of at least 6 weeks are often eligible through their insurance. Alternatively if you've tried two antidepressants and had to stop due to the side effects you also may be eligible. Some insurances will require an augmentation strategy i.e. a trial of an antipsychotic and therapy before it becomes a covered service. If you think you've met these criteria please contact us for a consultation.