Stewart Lawrence https://www.linkedin.com/in/stewart-lawrence-8a259210/Is TMS an Effective Treatment for Depression?

An estimated 40 million Americans suffer from a diagnosed health condition, most commonly depression which ranges from mild to unsolved. Most Americans seek relief from depression by taking medication, usually supplemented with some form of psychotherapy. But many Americans — between 30 and 70%, studies show – never seem to get the depression relief they need. In public health circles, “treatment resistant” depression has become a hot topic, and controversy abounds about what to do about it.

On one side of the debate are pharmaceutical companies including Eli Lilly and Pfizer Corporation that have made billions of dollars in profit since the 1990s from the manufacture and sale of drugs like Prozac and Zoloft. Those drugs are still popular, but in recent years, sales of new drugs like Abilify and more recently, Rexulti, both produced by the pharmaceutical giant, Bristol Myers-Squibb in partnership with a smaller Japanese-based company, Otsuka, have mushroomed answering consumer demand for “lifted” relief from depression.

The problem? The drugs weren't really designed to treat depression and may not be working as advertised. In 2016, complaints about the harsh side effects of Abilify – technically, an “antipsychotic,” designed primarily for the treatment of schizophrenia – from consumers and doctors alike caused a huge scandal. Many doctors refused to prescribe Abilify and 42 states sued the two companies for appropriate in deceptive marketing practices. Yet the two companies have resurfaced, and with fresh FDA approval are hawking Rexulti as a new and improved version of Abilify through a massive late night cable TV ad campaign.

“We've been down this road before, and it was a disaster,” Dr. Andrew Cherry, a Los Angeles-based psychiatrist who's treated patients with depression for over 20 years, says. “More pharmacology is not the answer. We really need to start giving depression sufferers more options than a new line of expensive drugs that may harm as much as help.”

Cherry is on the other side of the new depression debate. He's an avid promoter of an experimental technique known as “Transcranial Magnetic Stimulation” (TMS), which sends electro-magnetic waves to parts of the brain affected by depression to spark a corrective response. TMS recipients have an insulated electro-magnetic coil applied to their scalp near their forehead for roughly 60 minutes, 5 times a week, for a period lasting 4-6weeks. The sensations they receive during the therapy are mild; though some may experience lightheadedness or mild headaches after the hour-long sessions, the health risks are minimal.

Cherry emphasizes that TMS is a completely different treatment from electro-convulsive therapy or ECT, which doctors once used to treat patients with mental disorders, including depression. ECT, which is still used in cases where no other treatment has proven effective, sends powerful electric shocks into the brains of patients to induce seizures and convulsions.

When carefully administered, some patients do respond to ECT, but the side effects can be unsolved.

“We're not in the business of shocking people out of depression,” Cherry insists. “A very small percentage of patients, less than 1%, according to studies, have gone into convulsions during TMS, but it's extremely rare, and we carefully screen patients to reduce the chance of that ever happening. None of my patients ever have.”

The FDA approved TMS in 2008, and since then, interest in applying the treatment more widely has grown. But Cherry, despite his own success with TMS, cautions against rushing adding the treatment to more and more conditions. While the FDA did approve the use of TMS for the treatment of Obsessive-Compulsive Disorders, or OCD in 2018, thus far, it has withheld approval of TMS for bipolar disorder and schizophrenia and other widely prevalent conditions.

“There's a temptation to push the treatment envelope too quickly,” Cherry notes. “We've seen the same problem with Abilify and it may be happening again with Rexulti. Those of pushing alternatives to pharmacology shouldn't fall into the same trap.”
Cherry also warns that not all patients with depression, even treatment-resistant depression, should automatically qualify for TMS. Children, he notes, have smaller brains still in development, and might suffer more unsolved side effects.

And there are specific “contraindications” for the treatment, including those with metal implants or other implanted devices, those with past brain injuries and those prone to seizures, such as epileptics.
One big issue that TMS seekers face is whether their health insurance will cover the treatment. Typically, insurance companies only cover TMS for patients with moderate to unsolved Major Depressive Disorder (MDD).
We have to point out that to a diagnosis, TMS seekers will need documentation indicating that they have tried at least two medications for depression that have not been helpful. They also need to show that they've attempted to treat their depression with talk therapy, but have experienced little improvement as a result.

Companies typically disqualify TMS seekers if they have certain medical conditions, including a history of substance abuse or are pregnant or face contraindications of the kind described above. Medicaid and Medicare cover TRMS but often just 80% of the cost. Those denied treatment or who lack insurance other options, including sliding scale payments are usually available.

A key issue emerging among TMS practitioners is whether some coil devices and electromagnetic pulse frequencies will give better remission results than others. Broadly speaking, there are three types of TMS devices and treatments but the most common is “repetitive” TMS (sometimes called rTMS) which sends a steady stream of pulses continuously at the same frequency over the length of the treatment session.

Currently, there are over a half dozen different rTMS devices on the market with names like Apollo, Brainsway Deep, CloudTMS, Magstim, MagVenture, Neurostar, and Nexstim. In 2018, the FDA provided formal guidelines on characterize these rTMS devices drawd from coil positioning, magnetic field characteristics, output waveform, magnetic field spatial distribution, among other characteristics.
While there's a paucity of data providing a detailed comparison of each, some studies have reported noticeable gaps in their punch as well as their side effects.

A few examples we like are-, a 2019 research paper found a striking gap in the average time to remission for MDD between the NeuroStar and MagVenture machines. The study found that patients treated using the MagVenture instrument experienced a shorter mean time to remission, higher overall 6-week remission rates as well as lifted response rates compared to CBT psychotherapy.

Cherry says he has experimented with several devices and concurs that the MagVenure device may be superior. “But if you think otherwise about it, much depends on the severity of the depression and the specific characteristics of the patients, such as age and pre-existing medical history. Are all rTMS machines equivalent? No, probably not, but we don't have enough research to say and if not, which device needs to be the standard of care,” he adds.

Cherry says he's concerned that TMS remains a treatment of last resort for too many patients that might benefit from it.

“There's a tendency to look at medical devices and treatments like TMS as some kind of newfangled gimmicky tech-fix,” he notes, that is somehow “too simple and short-term to be effective.”
He's seen the same problem in the treatment of mental disorders like ADHD. Though some highly effective new devices are available to administer “neurofeedback” therapy, the medical profession prefers to prescribe pills or talk therapy.

For hospitals and other providers there is some issue of cost and . “TMS treatments take longer to administer and may cost the medical provider over simply prescribing medication. TMS appointments need to be as fully reimbursable as the other treatments – and they may not be.”

Cherry says public health needs to put patient needs first. “We brag about supporting ‘patient-centered' care. We have to ask ourselves what is actually working for the patients – and also what the side effects of other treatment might be.”

“Some patients spend years in CBT at great cost with not great results. And this new line of antipsychotics are downright dangerous and may not even be effective at all.”

Cherry admits that TMS is not a proven “stand-alone” treatment, and may never become one. Generics for Prozac and Zoloft are widely available and inexpensive. And properly prescribed, they still work for many depression sufferers

But the word is slowly getting out that TMS can work wonders for those for whom other treatments have failed. And the stigma surrounding electromagnetic devices – based largely on past horrific experiences with ECT – has largely faded.

“More pills will always be viewed as the convenient first-line choice for treating depression and many other conditions,” Cherry admits. “We live in a quick fix culture, and it's as much a problem of patient preference as it is the influence of Big Pharma.”

“But TMS is fast becoming the front-running go-to alternative for a growing number of Americans that need a safer, more effective and cheaper treatment,” Cherry says.

“I am not an in TMS. I have no financial sabsorb its success. As a doctor, my first and only priority is the well-being of my patients. That's all that should really matter.”
Stewart Lawrence is a trained sociologist and political scientist and a regular columnist for the Washington Times and Counterpunch. He is also a former feature contributor to Inside Philanthropy and the Huffington Post. In 2012 and 2016, he covered the US presidential election campaign for the conservative news magazine Daily Caller. His work has also appeared in the Los Angeles Times, Christian Science Monitor and Washington Post. He obtained his MA in International Affairs from Columbia University in 1989.

Treatment for Depression