Questions You May Ask

What is TMS Therapy?

Transcranial Magnetic Stimulation is a mouthful to say, but if you break it down, it accurately describes what TMS actually does. It’s an MRI-strength magnetic pulse that is applied to the outside of the cranium (skull bone) and passes through it to stimulate the brain’s left prefrontal cortex. This is the area of the brain that is responsible for connecting to a variety of important functions, but it’s particularly integral to our emotional responses.

Our brain health depends on adequate levels of neuro-transmitters. (Dopamine and serotonin are the most common ones, but there are others.) These are organic chemicals that interface with the brain’s neural pathways. In essence, they enable the brain to communicate with itself and perform a multitude of functions. Some of these are directly related to our emotions (happy and sad); making decisions; drive and motivation; mental alertness; and our ability to deal with stress. The absence or lack of neurotransmitters indicates a communication breakdown within the brain. In other words, the brain isn’t doing its job of producing neurotransmitters to maintain a person’s balanced mood and behavior.

TMS delivers a magnetic pulse, not an electrical current as electroconvulsive therapy (ECT) does. However, the magnetic pulse does produce electrical stimuli once it penetrates the cranium and rouses the neurons so they’ll do their job. The stimulation starts at the outer part of the prefrontal cortex’s neural pathways and, in turn, they start to connect with deeper parts of the brain. Over a period of time with consistent stimulation, the brain’s chemistry is rebalanced. This is why TMS therapy requires the commitment of several weeks with consecutive sessions.

A psychiatrist must prescribe TMS therapy and must base his or her recommendation for TMS with the following FDA guideline in mind:

“NeuroStar TMS Therapy® is indicated for the treatment of adult patients with Major Depressive Disorder (MDD) who have failed to receive satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode.”

The Neurostar TMS Therapy system was the only FDA-cleared TMS device at the time I received transcranial magnetic stimulation. Therefore, it is important that I convey this fact and ensure that you, the reader, have understanding of its medical indications. 

Are there any side effects with TMS?

I didn’t experience any side effects from TMS at any time whatsoever. I didn’t feel dizzy, headache, nauseous, or tired after my treatments. The only challenge I had to deal with during the first week was the intense tapping that required some getting used to. It felt like a small woodpecker tapping on the left side of my head in the front above the temple. The tapping was very quick for four seconds and then it was off for twenty-six seconds and then on again for four seconds. This sequence lasted for the thirty-seven minute session. It “smarted” only for those four seconds. I was a bit of a wimp about it, and because I was so fragile and depressed, it made me feel even more pitiful. But it’s like anything else, you get used to it—sort of like buying a pair of shoes you absolutely adore but they hurt your feet for the first week or so until you break them in. Then you feel like you could walk a mile and back in them. The same thing happened with getting through the adjustment to the tapping. Eventually I hardly noticed it.

I also took an over-the-counter analgesic and asked my TMS coordinator to adjust the coil position slightly to make me more comfortable. This helped quite a bit.

Is TMS just another form of ECT?

Although TMS and ECT may seem as if they are the same, there’s a big difference between them. TMS is based on magnetic pulses that penetrate a specific, quarter-sized area of the skull. The magnetic stimulation to the brain creates a gentle electric impulse that awakens the neural pathways only in the area of the brain that pertains to depression.

On the other hand, electroconvulsive therapy is precisely that—electricity that is delivered to the entire brain and causes a controlled seizure. The seizure induces the brain to produce the deficient neurotransmitters, thus improving the neural activity. This process can be effective in severely depressed patients and people who suffer from psychosis. 

Studies have been done comparing the efficacy of both therapies and, so far, they seem to be on a par with each other. However, side effects and logistics are factors to consider.

ECT may result in mild confusion and short-term memory loss after treatment. Other than a remote risk of seizure, TMS has no reported side effects. However, there may be some discomfort at the site of the magnetic pulse coil on the scalp, but most patients find relief by taking an over-the-counter analgesic and/or having the TMS coordinator adjust the coil to a more comfortable position.

As for logistics, an ECT patient is required to have someone drive him or her to and from treatments because it requires general anesthesia in a hospital setting with a monitored recovery period. A TMS patient can drive to and from a TMS practice office for a treatment that lasts less than an hour. In my experience, it takes longer to get a manicure/pedicure than a TMS treatment.

If you desire an alternative to antidepressant medications, it’s up to you and your doctor as to which of these two therapies is best for you. Both are FDA-cleared and both have notable results. The American Medical Association (AMA) has assigned CPT insurance codes for both ECT and TMS and the American Psychiatric Association includes both therapies in its official Practice Guidelines.

Do insurance companies cover TMS?

In the United States TMS has only been FDA-cleared since October of 2008. Insurance companies’ unfamiliarity with it has caused them to deny coverage in many cases. Nevertheless, both government and commercial payers are now covering TMS on a case-by-case basis, including two Medicare regions (New England’s NHIC and CAHABA in Georgia, Tennessee and Alabama). Anthem, Health Net, Emblem Health Blue Shield of California are among the commercial payers who are covering TMS.

The good news is today there are approximately 57 million lives in the United Sates who have access to a policy that covers TMS.

More and more patients whose insurance companies don’t offer coverage are appealing their denials and are achieving partial to full benefits. The rate of pre-authorization and reimbursement for TMS is increasing every year—over 100 insurance companies nationwide have covered TMS upon appeal. 

Were you anxious about starting TMS?

I went for such a long time without any medications and fell into such depths of hopelessness that when I finally got the green light to start TMS treatments, I felt more excited than nervous. My greatest anxiety, however, was the fear that TMS wouldn’t work. I worried that since I had spent so much time researching it and challenging the insurance company, if I didn’t get a positive result I’d give up altogether on life. Since the medications weren’t working and I didn’t want to risk the side effects of ECT, I finally asked myself, “What have I got to lose, anyway?” 

How soon did you experience relief?

My doctor and TMS coordinator told me from the very first treatment that TMS isn’t a quick fix—and they were right. It took about two and a half to three weeks before I started to notice an improvement (session 19 or 20). At the 12th or 13th appointment I was actually feeling worse, and when I asked my doctor if any other patients had seen a dip in their mood, she said they hadn’t. The only report was that patients felt increased anxiety for a few days midway through the six weeks.

However, since that time there have been others who have reported this “dip” that lasts only a few days, and then they started to feel much better right after that, just as I had. Not everyone has this, however. In many cases this period requires more patience and trust. The main thing is to remember the original commitment to not give up on the six-week process.

When TMS does start to take effect, it is subtle but unmistakable. I woke up one morning to notice that something was just a little different. The disgusting “I wish I were dead” feeling had vanished. It was just a discreet awareness that the horrible dread feeling was gone. Slowly but surely I felt better from that day forward. I’ve also heard of patients who felt no improvement after their initial six weeks, but a week or two later they ultimately experienced the positive effect from TMS.

How many people have success with TMS?

A 2012 outcomes study in Depression and Anxiety, July 2012, Carpenter, et al; 29: 587-596) reports that fifty percent of patients responded to TMS (felt some relief), and thirty-three percent achieved remission (felt full relief) from depression. However, overall success rates vary by practitioner and a patient’s compliance to the therapy requirements.

Right now there are over 460 NeuroStar® TMS Therapy chairs installed in the United States and 11,000 patients have been treated with over 250,000 treatment sessions.

Does a patient stop medications prior to treatment or after?

Again, this all depends on your doctor’s assessment of how you’re doing, as well as your own feelings about it. Since the medications either didn’t work for me or made me feel absolutely awful due to their side effects, when I started my TMS therapy I had stopped taking them altogether. I’m aware of some patients who continued their meds while starting TMS and then got off them once they were into their six weeks of treatment, and others who have continued them after TMS, but at much lower doses. 

How long does TMS last and what did you do after the initial six weeks?

Each patient’s post-TMS treatment schedule is unique, so TMS maintenance is difficult to predict. It’s been three years since my initial six weeks of treatment and during the first year I had only two maintenance sessions, about six months apart. The second year I went for one maintenance session every other month. The third year it was about the same. At the end of the third year I had an extended period of intense stress resulting in a depression relapse and had to go for several treatments in a row. Now my doctor and I have decided that I’ll receive a minimum of one treatment per month, although I have a prescription for twice a month if we decide I need it. All of this is contingent on my commitment to following a healthy diet, good sleep habits, no alcohol or recreational drug consumption, exercise, and wise stress management. This strategy has allowed me to manage my depression without antidepressant medications.

Because I had more energy after TMS, I got busy doing things, volunteering, writing, and in general, focusing my attention in a new place outside of myself. I felt like giving more to others than stagnating in my own misery. It was liberating to say the least. I tell patients who ask me what my life has been like since I did TMS that putting my new energy to good use has been key to maintaining my remission from depression.

Do people stay in the room with you through the treatment?

A dear friend went with me the first time because we both thought it was going to be a big deal, and I didn’t know what to expect. When I finished that treatment I felt almost guilty I’d asked her to take a whole day to do something with me that I later realized I could have done on my own. (But I was still grateful she was willing to give up her day to be there for me!)

A friend or relative was allowed to stay in the room with me during my TMS treatment if I needed support, but most of the time my TMS Coordinator supervised the session while I sat in a comfortable spa chair and watched television or listened to relaxing music.

Every day for six weeks is a major time commitment. How did you get through it?

At first it seemed like making the ninety-minute drive every day would be nearly impossible. But I created a few tactics that made the distance and time go by so fast that I was surprised when it was over.

Keep in mind that a severely depressed person may not be able to do these things to begin with and shouldn’t feel discouraged. But as you go along, you might find some of these ideas can work for you. Just know that the more effort one makes during the process, the easier, more pleasant and faster it goes.

Here are a few strategies I used that may help you if you decide to use TMS to treat your depression:

  1. Remind yourself every day that TMS is not a quick fix—that it’s a cumulative process. As I mentioned before, the stimulation starts at the outer part of your pre-frontal cortex’s neural pathways and they, in turn, start to connect with deeper parts of the brain where the TMS will take effect. Once you start to feel better as I did, “The TMS Lift” is subtle but unmistakable and will give you a lighter, easier feeling.
  2. Ask the TMS Coordinator to give you the same time slot every day so you can create a routine. That way you can plan your mornings and/or afternoons from the smallest details (what time you get up, shower, eat breakfast/lunch) to the bigger issues of scheduling other necessary appointments and meet-ups with friends.
  3. Start paying attention to the little things in your life. It’s unlikely you’ll experience a sudden, dramatic “Aha” moment when you feel The Lift. It’s a subtle, quiet feeling, but if you are self-aware, you’ll notice a difference
          For example, observe how you’re responding to conversations with others, or if you’re feeling more inclined to engage others in chat. Notice if you’re more willing to do things that before seemed like too much of a chore (going to the movies, grocery shopping, or going out to dinner.)
          I realized things were getting better when I wanted to wear makeup again, and I started wearing more colorful clothing instead of grey or black. I also surprised myself when I became more attentive to what my husband was saying to me, whereas before TMS I basically ignored him. My ability to deal with frustration improved so I wasn’t flying off the handle during annoying situations. Overall, life just felt more manageable. That’s when I knew TMS was working.
    I couldn’t listen to music in the car when I first started my drives back and forth because it made me reminisce about the past and feel melancholy. Once I began to feel my TMS Lift, I listened to more upbeat CDs like show tunes and jazz. I laughed out loud the day I caught myself singing “Hello Dolly” as if I were on a Broadway stage. I began to go out and do errands with my husband instead of hanging around the house and returned friends’ long overdue phone calls. It’s little things like these that will tell you you’re starting to improve and that TMS is working for you. Don’t discount their value.
          The biggest indication that I felt better was the absence of that disgusting UGGGGHHH feeling I experienced every morning when I’d wake up and realize I was still alive and had to face another day. Keep in mind it wasn’t a transformation where I jumped out of bed shouting, “Hallelujah!” It was just an inner knowing that I could handle the day and that everything would be okay.
          Ask those close to you if they’ve noticed any little changes, and if they offer you a compliment, like “Hey, you’re looking better!” or, “You really seem happier today!” Believe them. I’ve heard from other patients who have said their loved ones noticed small improvements even before the patient herself did. When you’ve been in a depression for a long time, it’s almost impossible to know when things are getting better. A 1960s novel title by Richard Farina describes the feeling in a nutshell: Been Down So Long It Looks Like Up to Me.
  4. Keep a simple, short journal every day. Before or after your TMS appointment, record (either in writing, voice recorder or video) even your smallest thoughts. It doesn’t have to be a long, time-consuming thing. Even if you write one sentence-or one word-expressing your feelings or what you’re thinking at that moment, in the long run it will help you and your doctor see your progress. When you’re feeling better, you’ll be able to see how far you’ve come and thank yourself for making the effort.
  5. Keep your doctor and TMS coordinator informed of how you’re doing every day. If you need to have a conversation with either of them, do not hesitate to request more time to discuss your concerns. They want you to be comfortable and at ease with the TMS therapy process and are committed to your success as much as you are. They will coach you, validate your feelings, answer your ongoing questions, and offer you appropriate support every step of the way.
  6. Try to create a context for your six-week treatment. You might try to set up your six weeks as if you’ve just started a part-time job and have to be there, on time, to get the work done. Get up and dress for the part: nice outfit, hair and makeup—those depressing, worn out sweat pants and baggy tee shirt won’t do. Make a snack for the road and pack a lunch if you’re going to need it with a coffee/tea-to-go cup and a bottle of water for the car ride. You get to be both the employee and the boss in your new job as you commute to work on your way to a healthy brain.
  7. Make a game of it, especially if you have a long drive and you start to get weary because of the monotony. Plan side trips around your route to and from your sessions. Make a date with someone who lives nearby or find out if there’s a place you’d like to shop or a museum or something that puts more than a TMS session on your calendar.
  8. Entertain yourself with some new tunes for your car’s music system if you like music as a travel companion or listen to audio books that are inspirational or entertaining. If you feel like keeping up a conversation, ask a friend or loved one to come with you. I invited my sister to join me on a couple of occasions and it provided her a clearer understanding of what TMS meant to me that she shared with the rest of our family.
  9. Try to do one thing every day that is positive. This can be as simple as saying positive affirmations aloud, or making a list of basic things you’re grateful for that day-even if it’s only one thing. It could be sitting and consciously breathing in fresh air for just ten minutes or treating yourself to a manicure/pedicure.
  10. Mind your Zzzz’s as well as your diet and stress factors. It’s counterproductive to your TMS therapy to ignore the importance of getting enough sleep, maintaining a well-balanced diet, consuming no alcohol or recreational drugs, getting some level of exercise even if it’s a short walk around the block, and doing whatever works for you to stay out of stressful situations. When we go on a diet we tell everyone, “No dessert for me, thank you.” Well then, put yourself on a “No stress for me, thank you!” TMS diet.

The following quote delivered at a neuroscience symposium I attended at Yale University sums up my expectations for overcoming depression and describes the reality of living with this chronic illness:

“The opposite of depression is not happiness, it is vitality of life.” (Andrew Solomon, author, The Noonday Demon: An Atlas of Depression and Far From the Tree: Parents, Children and the Search for Identity).

My goal for treating depression isn’t necessarily to achieve happiness, because life’s circumstances will present days that are anything but happy. My endgame is to reclaim my spirit for living, an appreciation for life that this illness has robbed from me in the past and will continue to steal if I don’t take care of myself.

The decision to try an alternative treatment for depression such as TMS takes courage and commitment. In the beginning adopting all of these suggestions may seem like climbing a mountain, but allow yourself the luxury of envisioning the possibility of a hopeful future, even if you’re not able to believe it at first. Entertaining just the possibility that you may feel better can get you to the hope. And it’s the hopefulness that will become your trusted ally in living a life filled with vitality. 

The events described in this memoir are true. Some names have been replaced by pseudonyms in order to protect privacy, particularly those of medical personnel. This book is intended to reflect the life experiences of the author and in no way should it be considered to be medical advice, recommendations for treatment, or a replacement for medical care given by physicians or trained medical personnel. The author refers to and thereby endorses NeuroStar TMS Therapy® in this book because it was the only FDA-cleared transcranial magnetic therapy device available at the time of treatment and is an integral part of her story. This is by no means a promotional or advertising vehicle for NeuroStar TMS Therapy® nor does the author have any financial ties to Neuronetics, Inc.