Examining the Benefits of TMS - Psychiatric Times

Repetitive transcranial magnetic stimulation (TMS) is a useful clinical tool that is effective in patients with treatment-resistant ... CONTINUETOSITEORWAITnullSECSSpotlightSeeAll>PsychedelicsADHDAPAConferenceInsiderCaseDiscussionwithDr.Moukaddam:BipolarDisorderMajorDepressiveDisorderCommentarySeeAll>CouchInCrisisEarlyCareerPsychiatryHistoryofPsychiatryResidentsCornerCulturalCornerSeeAll>FilmandBookReviewsPoetryWritersContestPsychiatricPracticeSeeAll>BurnoutCareersCodingGuidelinesRiskManagementTelepsychiatrySeriesSeeAll>ClimateChangeCriticalConversationsinPsychiatryPortraitsPsychiatricViewsontheDailyNewsTalesFromtheClinic:TheArtofPsychiatryTalesfromtheNewAsylumContactUsEditorialTermsandConditionsPrivacyPolicyDoNotSellMyPersonalInformation©2022MJHLifeSciences™andPsychiatricTimes.Allrightsreserved.ExaminingtheBenefitsofTMSAugust11,2021AbhijitRamanujam,MDAclinicalreviewofaneffectiveapproachfortreatment-resistantdepression.Repetitivetranscranialmagneticstimulation(TMS)isausefulclinicaltoolthatiseffectiveinpatientswithtreatment-resistantdepression.Thisnoninvasivetreatmentisanoptionforpatientswithdepressionwhohavenotfoundrelieffromothertreatments,suchaspsychotherapyandantidepressants.TMStechnologywasdevelopedin1985andhasbeengainingclinicalinterestsincethen.Two-thirdsofTMSpatientsexperiencedeitherfullremissionoftheirdepressionsymptomsornoticeableimprovements.1Anout-patientprocedure,TMSdoesnothaveserioussideeffects.MechanismofActionApprovedbytheUSFoodandDrugAdministrationin2008,TMSusesanalternatingcurrentpassedthroughametalcoilplacedagainstthescalptogeneraterapidlyalternatingmagneticfields.Thesepassthroughtheskullnearlyunimpededandinduceelectriccurrentsthatdepolarizeneuronsinafocalareaofthesurfacecortex.ThemagneticfieldgeneratedbyTMSiscomparabletothatofastandardmagneticresonanceimagingdevice(MRI),measuredatapproximately1.5to3Teslas.However,theTMSfieldisfocal(beneaththecoil),whereastheMRIfieldislargeandfillstheroomhousingtheMRIdevice.OnehypothesisonhowTMSworksisthatthestimulationofdiscretecorticalregionsalterspathologicactivitywithinanetworkofgraymatterbrainregions,specificallythoseinvolvedinmoodregulationandconnectedtothetargetedcorticalsites.2FunctionalimagingstudiessupportthishypothesisbyshowingTMScanchangeactivityinbrainregionsremotefromthesiteofstimulation.3,4TMShasmanymoleculareffectscomparabletoelectroconvulsivetherapy(ECT),includingincreasedmonoamineturnoverandnormalizationofthehypothalamicpituitaryaxis.5Additionally,inoneneuroimagingstudyofdepressedpatients,aprefrontalserotonindeficiencyatbaselinenormalizedaftertreatmentwithTMS.High-frequencystimulationisthoughttoexcitethetargetedneuronsandistypicallyusedtoactivatetheleftprefrontalcortex.Low-frequencystimulationappearstoinhibitcorticalactivityandisusuallydirectedattherightprefrontalcortex.Consistentwiththishypothesis,areviewexamined66studiesindepressedpatientswhoweretreatedwithTMStargetingthedorsolateralprefrontalcortex.Itfoundthathigh-frequencyTMSgenerallyincreasedregionalcerebralbloodflow,whereaslow-frequencyTMSgenerallydecreasedregionalcerebralbloodflow,whichisreducedinadepressedbrain.6IndicationsTMSisindicatedforpatientswithunipolarmajordepressionwhohavefailedatleast1antidepressantmedication.Inaddition,TMSisindicatedforpatientswhorespondedtoapriorcourseofTMS.7UseofTMSfortreatment-resistantorrefractorydepressionisconsistentwithtreatmentguidelinesfromtheAmericanPsychiatricAssociation,CanadianNetworkforMoodandAnxietyTreatments,andtheRoyalAustralianandNewZealandCollegeofPsychiatrists.PatientAssessmentWhenconductingapatientassessmentforTMS,thepurposeoftheevaluationistoconfirmtheprimarydiagnosisoftreatment-resistantdepressionanddeterminewhethertheTMSinterventioncanbeusedsafely.Theassessmentincludesexaminationsofpsychiatrichistory,generalmedicalhistory,physicalhealth,andmentalstatuswithemphasisupondepressivesymptoms.Thisshouldemphasizeriskfactorsforseizuresandpreexistingneurologicdisease,suchasepilepsy,intracranialmasses,andvascularabnormalities.ContraindicationsTMSiscontraindicatedinpatientswith:increasedrisksforseizures,implantedmetallichardware(aneurysmclips,bulletfragments,etc),cochlearimplants, implantedelectricaldevices(pacemakers,intracardiaclines,medicationpumps,etc),andunstablegeneralmedicaldisorders.SeetheSidebarfora12-itemquestionnaireforTMScandidates.Sidebar.ScreeningQuestionnaireforTMSCandidates1.Doyouhaveepilepsyorhaveyoueverhadaconvulsionorseizure?2.Haveyoueverhadafaintingspellorsyncope?3.Haveyoueverhadaheadtraumathatwasdiagnosedasaconcussionorwasassociatedwithlossofconsciousness?4.Doyouhaveanyhearingproblemsorringinginyourears?Smalleustachiantubes,someringing?5.Doyouhavecochlearimplants?6.Areyoupregnantoristhereanychancethatyoumightbe?7.Doyouhavemetalinthebrain,skull,orelsewhereinyourbody(forexample,splinters,fragments,clips,etc)?Ifso,specifythetypeofmetal.8.Doyouhaveacardiacpacemakerorintracardiaclines?9.Doyouhaveamedicationinfusiondevice?10.Areyoutakinganymedications?Pleaselistthem.11.DidyoueverundergoTMSinthepast?Ifso,werethereanyproblems?12.DidyoueverundergoanMRIinthepast?Ifso,werethereanyproblems?24EfficacyMultiplereviewshavefoundconsistentevidencethatTMSprovidesaclinicallyrelevantbenefittopatientswithtreatment-resistantdepression.Inpatientswithacutemajordepressionwhohavenotrespondedtoatleast1antidepressantmedication,numerousmeta-analysesofrandomizedtrialshavefoundthatTMSissuperiortoplacebotreatment.8-11ItisnotknownifmaintenancetreatmentwithTMSforunipolarmajordepressionisbeneficial. Ameta-analysisof34randomizedtrialscomparedTMSwithplacebotreatmentin1383patientswithtreatment-resistantmajordepression.Itfoundthatimprovementwasgreaterwithactivetreatment.12Add-ontreatmentwithTMSwasefficaciousinpatientswhohadnotrespondedtoanadequateantidepressanttherapy.Response(forexample,thereductionofbaselinesymptoms≥50%)occurredinmorepatientswhoreceivedactive(47%)versusplacebo(22%)TMS.12TMSislesseffectivethanECT;however,TMSdoesnotrequiregeneralanesthesia,anditcanbedoneinanoutpatientsetting.UnlikewithECT,patientswithmajordepressiondonotexperienceimpairedcognitionwithTMS.PredictorsofResponseNoconsistentpredictorshavebeenidentifiedinmeta-analyses.A1-year,prospectiveobservationalstudyof120patientswhorespondedorremittedwithacuteTMSfoundthatthedurabilityofresponsetoTMSwasnotassociatedwithage,sex,severityofdepressivesymptomspriortoTMS,northenumberoffailedantidepressanttrialspriortoTMS.13Fortreatmentofmajordepression,TMSislessefficaciousthanECT.Follow-upstudiesofpatientswithmajordepressionwhoweretreatedacutelywithTMSinrandomizedtrialsindicatethattheshort-termbenefitsofTMSarestable.14Withregardtolonger-termbenefitsofTMS,prospective,observationalstudieslastingatleast6monthssuggestthatinpatientswithmajordepressionwhoimprovewithacuteTMS,relapseoccursinabout35%.15ForpatientswithunipolarmajordepressionwhoimprovewithacourseofTMSandsubsequentlydeteriorateorrelapse,reintroductionofTMSusingthesamestimulationparametersmaybehelpful.16ItisnotknownifmaintenancetreatmentwithTMSforunipolarmajordepressionisbeneficial,asfewrandomizedtrialsusingstandardprotocolshavebeenconducted.However,inseveralsmall,observationalstudiesofpatients,theresultssuggestthatmaintenanceTMSmay,perhaps,bebeneficial.7SafetyandAdverseEffectsTMSisgenerallysafeandwell-tolerated.Asanexample,arandomizedtrialof301patientsfoundthatstudydiscontinuationduetoadverseeffectswascomparableforactiveandplaceboTMS(5%and3%,respectively).17ThemostseriousadverseeffectofTMSisageneralizedtonic-clonicseizure.However,theriskofseizureappearstobecomparabletothatforantidepressantmedications. Seizuresprobablyoccurinlessthan0.1to0.5%ofpatientswhensafetyguidelinesarefollowedregardingpatientselectionandstimulationparameters.Seizuresthathaveoccurredwereself-limited,requirednomedications,anddidnotrecur.18FactorsthatincreasetheriskofseizurescanbefoundintheTable.Othersideeffectsincludehypomaniaandmania,describedinrandomizedtrials,17aswellascasereportsofpatientswithmajordepression(bothunipolarandbipolar)whoweretreatedwithTMS.19,20However,theclinicalsignificanceisnotknown,becausepatientswithbipolarmajordepressioncanswitchtomood-elevatedstatesintheabsenceofanantidepressanttreatment.TreatmentofunipolarmajordepressionwithTMSdoesnotappeartoincreasesuicidalideationorbehavior.21CommonSideEffectsofTMSHeadacheandscalppain:Areviewofrandomizedtrialsinpatientswithmajordepressionfoundthattheincidenceofheadachewithactivetreatmentandplacebotreatmentwas28%and16%,respectively.Theincidenceofscalppainwithactiveandplacebotreatmentwas39%and15%,respectively.Nomigraineheadacheshavebeenreported.Headacheandscalppainmaybemorepronouncedwhenhigherstimulationfrequenciesandintensitiesareused.Topicallidocainemayreducescalppain.Reducingstimulationintensitycandecreasescalpdiscomfort,butthiscanalsoreduceefficacyoftreatment.Forsensitivepatients,thedoseofTMScanbetitratedupduringthefirstweek.Headacheandscalppaingenerallyresolveoverthefirst2weeks,althoughsomepatientsmayrequireananalgesic,suchasacetaminophenoribuprofen.22Transient(