podcasts

Behind the Magnet: Understanding the Mechanisms of TMS Therapy – Podcast

By Jason Clayden on January 18, 2024

Join us as we explore the world of transcranial magnetic stimulation (TMS) with experts Dr. Barry Jones and Dr. Shristi Shrestha. Discover how TMS, a non-invasive treatment, uses magnetic pulses to activate specific brain neurons, targeting conditions like major depressive disorder, anxiety, and obsessive-compulsive disorder.

Learn about the effectiveness of TMS compared to other therapies, the criteria for TMS treatment, and its potential side effects. Dr. Jones provides insights into the history of TMS, insurance coverage, and its role in addressing treatment-resistant depression. The episode also touches on alternative treatments like ketamine and electroconvulsive therapy (ECT).

Learn more about TMS Therapy

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Nicholette Leanza:

Welcome to Convos from the Couch by LifeStance Health, where each episode covers the many facets of mental health and wellbeing. Hello, everyone. I’m Nicholette Leanza, and on this episode, I’m excited to be talking with Dr. Barry Jones and Dr. Shristi Shrestha

They will be telling us about transcranial magnetic stimulation, or otherwise known as TMS. Welcome to both of you. Thank you for being on.

Dr. Barry Jones:

Thank you for having us.

Nicholette Leanza:

Research shows that TMS is an effective treatment for several common mental health conditions, but many people still don’t know what it is and how it works. I’m excited to learn more about TMS from the both of you today. Thank you. What is transcranial magnetic stimulation, or TMS, and how does it work?

Dr. Barry Jones:

Transcranial magnetic stimulation is TMS, and that simply means going through the skin and through the skull into the brain tissue about a centimeter or a centimeter and a half, not very deep at all. We use magnetic pulsing. TM is magnetic, and S is stimulation, and it goes in a very rapid sequence of magnetic pulses that go into the brain tissue, and activate those neurons that are in that outer part of this, call them front part of your brain, that we think are underactive to some degree in people who are depressed.

What we’re doing, if you can remember in school, or if you can remember with one of your kids, if you take a nail and you wrap a wire around it, and you hook it up to a battery, you make a magnet. That’s basically what we do. We have a coil that has wire in it, the electricity runs through the coil, not into your brain at all, and we turn it on and off very rapidly, and each time it turns on and off, it shoots out a little pulse of magnetic energy that goes through your skin, and into your skull, and into your brain tissue.

If you do that repetitively for 15 to 18 minutes, depending on the treatment, some a little bit longer, 20 minutes, you actually begin to activate those neurons. Over a period of time, which means three, four weeks, just like with a medication, you can actually begin to see a change in your mood. That’s what TMS is, and that’s how it works.

Nicholette Leanza:

Thank you. Very wonderfully put. Anything you wanted to add to that? Dr. Jones did great job covering that.

Dr. Barry Jones:

Good.

Dr. Shristi Shrestha:

You pretty much explained it really well. It’s like a big magnet that’s creating a field and stimulating the brain cells. Pretty much just exactly what he said.

Nicholette Leanza:

I think what’s so wonderful in what you guys are clarifying is that I think sometimes, some of the misnomer of what TMS is is that it’s electricity going right into the brain, but this is magnet.

Dr. Barry Jones:

Nope.

Nicholette Leanza:

I think that’s a great clarification.

Dr. Barry Jones:

Magnetic energy.

Nicholette Leanza:

Very helpful to know that. Which mental health conditions does TMS treat best?

Dr. Shristi Shrestha:

TMS has been FDA approved for treatment resistant major depressive disorder, like depression that’s been there, trials of medications have been tried, and along with psychotherapy and it didn’t work as well. TMS has been shown to be very effective. In certain anxiety disorders, it helps with certain anxiety issues. That’s also FDA approved, and along with that, obsessive compulsive disorder, but that’s more the deep TMS than the superficial one, which is the more common one. Nevertheless, it does help with that as well.

Dr. Barry Jones:

If I can add just a little bit to that, she made a very good point. When I was talking about treating depression, major depressive disorder, I talked about it being in this area of the brain that we’re activating, and it’s relatively superficial, which means that we go into the brain tissue with the magnetic energy about a centimeter, which is about three quarters of an inch. It’s not very deep. With OCD, the researchers have shown that we use a different location.

It’s actually right in the middle of the brain, and it’s about three centimeters deep, which is about an inch and a half. We have magnets that are specifically made to focus the magnetic energy into a deeper location. This area out here, we call the left dorsolateral prefrontal cortex, it’s just a location. That’s for depression. The same area, but on the right side is the right dorsolateral prefrontal cortex, and that’s where you treat anxiety.

In the middle but deeper, the dorsomedial, medial meaning in the middle of the brain, prefrontal cortex, but about three centimeters deep, that’s where we would treat OCD. There are some other less commonly treated things that we don’t normally think of as specifically mental health related, but there is a treatment for migraine, there is a treatment for tinnitus.

What we found with magnetic stimulation, depending on the area of the brain and the rapidity with which we’re giving the pulsing sequence, we can activate that area or slow down that area, which is what we will do with anxiety, to help treat the symptoms that the person has.

Nicholette Leanza:

Thank you. Dr. Jones.

Dr. Barry Jones:

Sure.

Nicholette Leanza:

Thank you for sharing a little bit more detail with that.

Dr. Barry Jones:

Yeah.

Nicholette Leanza:

Now, how does TMS compare to other brain stimulation therapies, like ECT and deep brain stimulation?

Dr. Barry Jones:

There is a real dramatic difference between TMS and ECT, or electroshock therapy. You clarified a little bit earlier that some people want to be reassured that there’s no electricity involved with TMS, but that is exactly what happens with people who have ECT, electroshock therapy. It’s a very effective therapy, ECT. However, you have to have anesthesia, you have to be usually in a hospital setting or an outpatient setting.

You’re not necessarily hospitalized, but you go into an outpatient setting, like an outpatient surgery center, in order to get your treatments. They actually cause a discharge of the brain cells in a very organized kind of way, although it’s very controlled because of the anesthesia. The effectiveness of that is about 50% for people who have major depressive disorder who have not responded to medications. The effectiveness of TMS is actually a little better than ECT.

We have about 70, 65 to 70% of people who get TMS will tell us that they are at least 50% better on rating scales, and actually, a half of that 70% will tell us that their depression is in complete remission. Number one, TMS is a much, much less invasive treatment. You just drive up to the office, you walk into the office, you sit in a chair that’s like a dental chair, we put this magnet over your head, and we turn it on, and it gives these rapid pulses for a period of time. You get up out of the chair, you get in your car, and you drive off.

Nicholette Leanza:

Are you able just to drive home? You don’t need to have someone with you? I think with ECT, you can’t just drive. You need to have someone.

Dr. Barry Jones:

You absolutely do. It’d be like a surgery center. You’d have to have someone come with you to the treatment, and they have to be there to drive you home. Both are very safe. I’m not saying one’s not more safe than the other, it’s just that one is less invasive in the sense of all the additional support and the things that you need to provide the treatment.

Nicholette Leanza:

How is it determined whether TMS is a good fit for someone?

Dr. Shristi Shrestha:

Well, anyone looking for, like Dr. Jones said earlier, more non-invasive treatment, and anyone who’s tried meds, who’s been through therapy, and felt like depression is not going away, those people can be good treatment, like anyone who’s tried the traditional methods, I’d say no.

Nicholette Leanza:

Yeah. Dr. Jones, anything you’d like to add to that?

Dr. Barry Jones:

Yeah, she’s absolutely right. The criteria for TMS is actually an insurance-driven criteria, which is not saying very much, other than the fact that if a person has tried, this is for all insurance companies. Some have, I’ll clarify, but the absolute max is you have to have tried four different antidepressants, you have to have taken them for at least six weeks, and you had to have taken at least 50% of the maximum dosage for that six weeks period, or if you had a side effect to the medication and couldn’t tolerate it, that counts as one of four trials.

The second thing is medications, we have what we call classes of medications. Most people don’t really understand what that means, but it’s how they work. It would be similar to a person who we have different classes of antibiotics. There’s penicillin, and there’s the mycin drugs and so forth, [inaudible 00:10:48]. If you don’t respond to penicillin, you wouldn’t take another cillin drug. They would try a different class. The same thing is true when we’re treating people who have treatment-resistant depression, it has to have been in at least two different classes, some of the medications.

If a person has had those trials with medication and has also tried talk therapy, then they’re a candidate, as far as the insurance company is concerned, for TMS. If you’ve had those trials, most people have, who are thinking about TMS, have already met those criteria. It’s interesting, at least in my experience, and I’ve been doing it for about 10 years now, that medications really can help people with a depressed mood. By that, I mean they’re very depressed, they have no energy, they have no motivation, they have no joy, they’re tired all the time.

Medications can really help with those symptoms. One of the groups of symptoms that medications usually don’t do too much for is what we like to call the welfare emotions: joy, fun, interest, pleasure, laughter, those kinds of things. For some reason, which I don’t think we quite understand, TMS frequently will improve those symptoms also. A medication can get a person up out of bed, get them to work, get them being functionally productive, but the quality of their life may not be so great.

TMS, when it does work, and it works about 70% of the time, 65% depending on the location, will, they’ll tell you, not only is their mood improved, their energy has improved, that kind of thing, but they have more interest in things again. They feel like doing things. One of the examples that stands out in my mind a couple of years ago was a mother who had three children, five, seven, and nine.

The family always went to the beach during the summer breaks, and the mother was telling me how she just dreaded going to the beach. What she dreaded was the children wanting her to come down to the beach and play with them while they were in the water. It was just labor for her to get up and pull the tables down, pull the chair down, get the umbrella, and to be down there with the kids. She didn’t look forward to it at all.

After TMS, when she got to the beach and the kids said, “I’d like to go to the beach,” she really wanted to go to the beach. She got up and got the umbrella, got the chairs, went down and played with the kids for the first time in years. That’s one of the differences, at least a lot of the times, that TMS works. It does something in addition to the other traditional symptoms of depression for that quality of depression. ECT and medications don’t seem to do much for either, for that kind of zone of depression.

When you have someone, as Dr. Shrestha said, who meets these insurance criteria, and they don’t have much quality of life in their thing, that’s another reason, I think, to think of TMS. It’s not invasive and it’s easy to do.

Nicholette Leanza:

Thank you.

Dr. Barry Jones:

Yeah.

Nicholette Leanza:

What does a typical course of treatment look like?

Dr. Shristi Shrestha:

Oh. Okay. There will be assessments about if someone is qualified for it or not, and that requires an interview with a provider mostly. After that is done, patients, they just are called in for what we call as a mapping day. We just know which kind of area of the brain that is to be stimulated. We need to know where the motor threshold is. It’s just a day where a provider sits with them, and goes through the mapping system in the brain, and localizes it.

Then that’s where typical magnetic stimulation is sent daily. The course, it looks like someone driving in at certain time. I set up in a chair, the TMS chair, and the magnets are placed over the head. It can go anywhere from 15 to 20 minutes of time.

Nicholette Leanza:

That’s not very long at all. It doesn’t take very long.

Dr. Shristi Shrestha:

It’s very short. That’s five days a week. Mostly people don’t do on Saturday, Sundays, and mostly 36 days of treatment course. That’s it. They go home, [inaudible 00:16:00]. They can drive back, they can carry on their normal routine.

Nicholette Leanza:

That’s where the non-invasive comes in, right? They can continue-

Dr. Barry Jones:

That’s correct.

Nicholette Leanza:

Right. My gosh, that’s great.

Dr. Barry Jones:

Just to elaborate, on the first day that people come in, we use a series of measurements to locate this area of the brain, and we’re trying to activate a space that’s about the size of a nickel to maybe a quarter. We’d like the coil, the center of the coil, which is where the magnetic energy comes out, to be right in the middle of that space. We can use a series of measurements that will put us into that area very accurately and in a consistently repetitive way.

Depending on the system, some systems will use laser guidance to put the coil right back into the same location. Some systems actually have a series of measurements that the chair of the person is sitting in, they would use that. They put their head into an area, it’s not clamped in or anything like that, it’s comfortably sitting, but they use measurements that are part of the system to know how to put the coil right back into the same location when they come in each day. They don’t have to do a re-measurement of that each time they come.

Once they put the coil there, then as Dr. Shrestha was saying, we actually will use, there’s not anything in this front area that we can visually use to know that we’re getting enough energy, magnetic energy, to be effective. What we do is we will back up to this part of the brain just right above the ear, and that’s called the motor cortex. Those are just the neurons that move our muscles.

We can, again, with measurements, know exactly what part that moves our hand, and so we’ll put the coil over that, and then we’ll give a pulse, and we ought to see the hand wiggle. We want to get it to where we just barely get a twitch of the thumb. It’s a little bit more complicated than that, but not much. You get the idea that we just use measurements the first time that they come in, and once we get that location, we can reproduce it very easily, and we use just enough to be effective.

We know we can stimulate the neurons in the motor part of the brain. We’ve got the same distance that we use in this area that we want to treat for the depression, so we just move the coil forward, or if it was for anxiety, we put the coil on the other side. It’s a different thing when we have that middle one that’s deeper. We have to use a different way of getting to that three centimeter depth.

Interestingly, what we use is the toe, and you go right down in the middle of the brain, and the toe is about three centimeters deep. We get the toe to wiggle, we’re doing the same thing we’re doing with the thumb.

Nicholette Leanza:

That’s interesting. It’s very interesting.

Dr. Barry Jones:

Yeah, very interesting.

Nicholette Leanza:

Are there specific side effects to TMS?

Dr. Shristi Shrestha:

Yes, there can be some side effects, although the side effects are pretty rare. Some patients do complain of headaches. Sometimes they might have some neck pain, a little bit sight discomfort, like pain or irritation. Sometimes some people, very rare, might have seizure, and that’s where the pre-assessment comes in. Certain meds have to be avoided. Certain situations we have to completely say no to before starting the course, but these are extremely rare side effects.

Dr. Barry Jones:

What you actually hear when you ask a person what it feels like, they always describe it as, it feels like a woodpecker tapping on your head. Nobody’s ever had a woodpecker tapping on their head, but it’s a very fast, rapid tap. It feels not sharp, it doesn’t feel like a ice pick or anything like that. It feels like the eraser end of a pencil. It’s just tapping on your head 10 times a second.

Nicholette Leanza:

Oh, wow. That’s a lot.

Dr. Barry Jones:

Very rapid for four seconds. Sounds something like this. That’s one sequence. Then it waits eight seconds, and it does it again. That’s another 40 pulses, and those add up to 3,000 pulses per treatment.

Nicholette Leanza:

Wow.

Dr. Barry Jones:

That takes about 15 to 18 minutes.

Nicholette Leanza:

Oh, well, thank you for describing that. That’s helpful.

Dr. Barry Jones:

Yeah.

Dr. Shristi Shrestha:

Can TMS-

Nicholette Leanza:

Do you, oh no, go ahead, Dr. Shrestha.

Dr. Barry Jones:

Yeah.

Dr. Shristi Shrestha:

Just to say, that’s a very good visual demonstration.

Nicholette Leanza:

Yes, it was. Yes it was, and sound effects.

Dr. Barry Jones:

The audio wasn’t too bad, was it?

Nicholette Leanza:

No, it was good. It was good.

Dr. Barry Jones:

Let me see, wait a minute. There was another thought that I had about that, though. I’ll come back to it.

Nicholette Leanza:

All right, if it pops back in, just throw it out there.

Dr. Barry Jones:

Yeah, I will. I’ll pad it.

Nicholette Leanza:

Can TMS be used with other treatments?

Dr. Shristi Shrestha:

Okay. Yeah, we do not encourage that, if you could. If you’re meeting more, whatever meds they’re on currently, along with talk therapy, yes, we do that. We recommend to continue it along with the TMS, but if you are talking about ketamine, or someone might even go for ECT at the moment, and on the other days, they’re wanting to do TMS, we do not recommend that. We’re already stimulating the brain with TMS and-

Nicholette Leanza:

Good point.

Dr. Shristi Shrestha:

… [inaudible 00:21:42]. We do not want over stimulation, and just recommend to continue with the medications and the talk therapy along with the TMS sessions.

Nicholette Leanza:

Good to know that. Very important to know that. What are the costs for TMS? Is it covered by insurance?

Dr. Barry Jones:

Yes, it’s covered by insurance. Again, just to get a little bit of the history, TMS was actually approved by the FDA in 2008, so it’s been around a good long time. Most people don’t know about TMS, and one of the primary reasons is it did not begin to be covered by insurance until 2016, ’17 and ’18. It started off with coverage by Medicare, and then the Blue Cross groups for the most part, and then Cigna, and Aetna, and all of the major insurance companies now cover TMS, but it’s only been in the last five, six years that most of the insurance companies have begun to cover the cost.

Now, like any other procedure, the cost to a person will depend on their insurance policy. It’ll depend on their out-of-pocket copays that they have to pay, and it will depend on their deductible that have to pay. For most people, just to give you a round figure, it’s about a thousand dollars out of pocket for a course of TMS, and that includes 36 treatments, one daily as Dr. Shrestha said, five days a week for six weeks, and then three the seventh week, two the eighth week, and one the ninth week. A total of 36.

The reason we taper that at the end, when it was originally approved, they approved 28 treatments. People really did get a response with that, but they found that the maintenance of the depression, in other words, that continued to be improved, begin to taper off. They added these extra eight treatments to extend the period of time that the effectiveness would last. Again, you’ve asked, how do people make decisions about which one to do next? I’ve already said that ECT is about 50% effective. TMS is 65% effective.

ECT, even if it works, 50% of people will begin to have recurrent symptoms within six months. Now, ECT frequently, people will get what’s called maintenance ECT, which means they come back once a month and get a treatment, just one treatment. They do that every month. That significantly extends the benefit of ECT. With TMS, we have not been approved yet for any kind of maintenance protocol. We know it helps, and some practices are able to offer maintenance treatments once a week, once a month like ECT, and people can pay for that out of pocket.

What we do know, which is a real benefit, since they added those extra eight treatments, TMS, if you are a responder, you have an 85% chance of still doing well two years from now. If it works, it seems to continue to work. That’s another difference, I think, when you’re thinking about which decision to make.

Nicholette Leanza:

Thank you. Any other takeaways you guys would like to add? I think we covered a lot here. Anything else to share?

Dr. Barry Jones:

Yeah, I’ve got a couple of things. One-

Nicholette Leanza:

Yeah, please.

Dr. Barry Jones:

… As Dr. Shrestha said, it’s a treatment for major depressive disorder, treatment resistant. That means just at least some insurance companies, Cigna and Aetna, now are only requiring two treatments with, and the reason for that is there was a large study done some years back, trying to show what was the percentage of response rate from antidepressants for people with major depressive disorder over time.

It’s called the STAR-D program, you can look it up. They started off with 4,000 patients. They ended up with 2,500, which is one of the largest consumer type research projects with mental health. It was done by the National Institute rather than by an insurance company or a drug manufacturing company. It didn’t have those kinds of biases. What they found is that with your first antidepressant, you have about a 40, 50% chance of going into remission, and that’s important.

Remission means you essentially describe no residual depressive symptoms. It didn’t mean response, which means you’re at least 50% better, but in remission. If you did not respond to the first antidepressant and they tried a second one, your response rate dropped down, your remission rate dropped down to about 30%. Still, that’s not terrible, but it’s not real good. The real kicker is, your third antidepressant, you’re down to 16%, and your fourth antidepressant trial, you’re down to 5% chance of response. That’s pretty miserable.

Now, we have TMS, and we’re telling you, even after four trials, you have a 65% chance of response. That’s pretty impressive. You have a 35% chance, even after four trials of antidepressants and counseling, of going into remission. It’s something you really should consider if you’re not responding to the traditional treatments of antidepressants and/or counseling. It’s not invasive. It’s in the office and it’s covered by most insurance companies if you meet those criteria.

Interestingly, some of the younger generation, the only two trials, they really like that, because they’re looking for more innovative ways to help with their symptoms. Some of the folks that are in my category, the older folks, we’re okay with just continuing to try another medication for a time or two. The young folks, they want the response, and they want it quick. They don’t want to mess around for a year with four trials of medicines and all of those kinds of things. It works. That’s the real important thing. I think I thought of what the other thing I wanted to say back-

Nicholette Leanza:

Oh, yeah. Please. Sure.

Dr. Barry Jones:

I want to go back to that. We’re talking about predominantly treatment of treatment resistant depression, because that’s its biggest section, and that’s what it’s really most well known for. It has also been approved for anxiety. We know that people with depression, about 50% of people who have depression also tell us that they have anxiety. They worry, they’re anxious about things, even though they’re depressed. My point is, we can treat both at the same time, which you cannot do that with ECT. You can’t do that with Spravato.

You can actually treat the depression, move the coil to the other side, change the pulsing sequence, and treat the anxiety all at the same treatment. Do you see? You do that, but it extends the time from 18 to 20 minutes to 22 to 24 minutes. It adds a few more minutes to it. You heard me say how rapid the pulsing was with depression. We’re trying to activate these brain cells.

The other side, we’re actually trying to tone it down. It’s a very slow pulse, 600 pulses or a thousand, depending on the particular practice that you see. Again, those are differences that affect your chance or your choice, particularly if you have an anxiety component, you have at least a chance of that symptom being also improved with TMS.

Nicholette Leanza:

Wow. Thank you, Dr. Jones. Dr. Shrestha, any other takeaways you’d like to share?

Dr. Shristi Shrestha:

No, Doctor, I learned from him.

Nicholette Leanza:

We’re both learning from him. Yeah.

Dr. Shristi Shrestha:

Very well.

Nicholette Leanza:

He covered it very well.

Dr. Barry Jones:

One more last thing, we didn’t actually talk about it, but when you’re talking about what are your options after you’ve tried medications and counseling, the next option, this is how I think of it, would be TMS versus ketamine, or its provider. That again is a relatively non-invasive treatment that’s done in the office, it’s the ketamine treatments. It does require a person having someone with them, because it requires them sitting in the office for an hour getting an IV drip of ketamine.

They can’t just do that by themselves, unless they want to wait a couple of hours after the treatment in order for them to have cleared up completely to be able to drive. Unless something’s happened fairly recently, the insurance companies still are not paying for the IV ketamine, is that your understanding, Dr. Shrestha, or do they pay for it?

Dr. Shristi Shrestha:

State dependent. In Tennessee, it’s not. It’s totally not covered by insurance as a medicinal.

Dr. Barry Jones:

Yeah, so it’s not a covered treatment in Georgia either, not the IV part.

Dr. Shristi Shrestha:

Okay.

Dr. Barry Jones:

The insurance company has begun approving what’s called Spravato, which is a nasal spray-

Dr. Shristi Shrestha:

Nasal.

Dr. Barry Jones:

It’s really mostly for maintenance. It’s really not strong enough to be the first line of treatment, but if they want to pay out of pocket to get the ketamine treatments, which usually are eight to 10 treatments, and depending on the practice are 250 to $350 a piece, if you’re talking about cost. If they got a response, then they would use the nasal spray to help maintain that, just like we talked about maintenance ECT, and we’ve talked about maintenance TMS.

Those are your sequences. You try your medications, you try the counseling, that doesn’t work. In my opinion, TMS is your next recommendation. If that doesn’t work, then ketamine, because ketamine and TMS use the same circuitry. People ask, “Why don’t you do both at the same time?” As Dr. Shrestha said, you don’t want to overload the system. There’s some risk involved with that also. You use one if one doesn’t work, then you have the other one as an option, and then as a much more invasive treatment, you have the ECT.

Now, I want to say one last thing. I’m not against ECT. I’m telling you how a person should think about making their decisions. ECT works, and ECT is effective, and ECT is the treatment of choice for what we call psychotic depression. That’s a person who’s depressed, but also may be hearing voices in their head, or paranoid, or other things, which again is why we need a clinical assessment before we even recommend TMS. When that is the case, then ECT is without any question, the next decision to make. All right?

Nicholette Leanza:

Thank you. Thank you, Dr. Shrestha. Thank you, Dr. Jones for-

Dr. Barry Jones:

Yes, our pleasure.

Nicholette Leanza:

… Doing a comprehensive overview of TMS.

Dr. Barry Jones:

Yes.

Nicholette Leanza:

I know our listeners are going to take a lot from this, and as you just described, I think they’ll really be able to come armed with understanding if this would be the best treatment approach for them. I thank you both for sharing all your information and knowledge about this. Thank you.

Dr. Barry Jones:

All right, thanks. Enjoyed it. See you later.

Nicholette Leanza:

I’d like to thank the team behind the podcast, Jason Clayden, Juliana Whidden, and Chris Kelman, with a special thanks to Jason Clayden who edits our episodes. Thank you for listening to Convos from the Couch. Take care, everyone.