Why All the Fuss About TMS Lately?
Understanding how the SAINT Study is Changing Delivery of TMS
This morning while attending a personal medical appointment, the nurse asked me what type of work I do. "I'm a Psychiatrist", I answered proudly. As often happens when I tell people this, she struggled a little with how to respond. I wondered if she would reply as some people do, "oh, that must be so hard" or "so have you been analyzing me?" It took her a moment to reply and I shifted my attention back to my laptop where I was wrapping up a long stack of notes I had been neglecting. When I looked back at her she said, "that must be rewarding . . . some days." It was a well balanced answer I thought as it kept all the possibilities on the table. I smiled at her and said, "It is very rewarding, pretty much every day."
When I first started treating patients with TMS in late 2019, I was taught the standard protocol that was FDA approved in 2008. Transcranial Magnetic Stimulation (TMS), a form of neuromodulation, is provided for 1 treatment per day, 5 days per week, for 6 weeks. After the first 30 treatments are completed, the patient receives another 6 treatments which are spread out over 3 weeks as a taper off of TMS. Each treatment is approximately 19 minutes long. This was about to change.
One year prior to starting my practice, a group of Canadian researchers in Toronto had published an article that shook the TMS world. They found intermittent Theta Burst Stimulation (iTBS), to be of equivalent efficacy to TMS (1). Why was this so important? Because iTBS takes 3 minutes per treatment versus 19 minutes for TMS.
What sorts of new doors could open if we could shave that much time off of the treatment? There had previously been studies looking at the efficacy and safety of multiple TMS treatments per day that showed promise for faster relief from depression. With iTBS, the options for an accelerated treatment of depression seemed more possible.
In 2019, a group of researchers at Stanford undertook a study in which they offered 9 minutes of iTBS (triple the usual dose), 10 times per day, for five straight days (2). They utilized fMRI guidance and treated 21 participants. Their results were astonishing. 90.5% of their participants experienced a complete remission from depression! Comparatively, with standard TMS we might expect to see 1/3rd of participants achieve remission.
When their results were published in April 2020, there was a great deal of excitement in the TMS community. Not only did we now have a highly effective treatment for people with depression that hasn't responded to medications and psychotherapy, but we also had a tool that could work faster than the usual 3-4 weeks that it takes for antidepressants to kick in. Although this study was the equivalent of earth shaking in the TMS community, the timing of the publication was over shadowed by the beginning of the pandemic.
The Stanford group went on to reproduce their results in a follow up study published in October 2021 (3). This time, the media picked up on the excitement as well and now multiple news outlets were also talking about accelerated TMS.
While Stanford continues to refine the fMRI guidance and make it more available to the larger community, many patients are already receiving accelerated TMS around the country. At Camden Interventional Psychiatry, we have used accelerated protocols to help patients respond faster and for patients with depression that didn't respond to the standard protocol.
Having the option to offer accelerated TMS has been a game changer for many of my patients and their families. It is one of the reasons I feel deeply fortunate to be practicing Psychiatry at this point in time.
When people ask me what I do, the more honest answer is that I'm an Interventional Psychiatrist. Not only is the work deeply rewarding, there is simply nothing else that I would rather be doing.
