From the Desk of Dr. Kent
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Transcranial Magnetic Stimulation or TMS uses electromagnetic pulses to stimulate areas of the brain thought to be associated with depression. Electroconvulsive therapy or ECT use electricity to induce a generalized seizure which is thought to be therapeutic. The placement of the ECT pads is relatively strategic to areas of the brain associated with depression, but is not as precisely determined as with TMS.
The seizure induced by ECT lasts between 60-90 seconds typically and is stopped pharmacologically if it goes longer. ECT is performed under general anesthesia with an anesthesiologist or nurse anesthetist present as well as the psychiatrist performing the procedure. The patient is also given a muscle blocking agent so as to minimize the muscle contractions of the seizure. The patient is also given a brief acting drug to induce full anesthesia during the procedure. The patient is generally asleep for 15-20 minutes and has a period of recovery. The patient needs someone to bring them to the ECT treatment and take them home. ECT is considered a safe procedure, but can be associated with short term memory loss which generally resolves over time. The patient assumes also the risks of general anesthesia. ECT is considered to be a very effective treatment for refractory major depression and is the go to in severe cases that have failed multiple medication and psychotherapy trails. ECT can also be used to reduce symptoms of severe mania unresponsive to medications. Most patients receive 8-12 treatments (3 per week) to get good results. Some will need more than that and sometimes maintenance ECT is indicated. The procedure is generally covered by insurance but by the shear nature of the procedure it is expensive. It is considered life saving in severe cases. ECT is still in use today, but it isn’t always available in every community and travel sometimes is necessary to receive treatment. Following ECT treatment it is recommended that patients be on some type of anti depressant to prevent relapse.
TMS varies from ECT is several key ways. First there is no anesthesia involved and patients can drive themselves to and from their treatments. The treatments last from 20 minutes (Brainsway deep TMS) or up to 50 minutes (standard or rTMS). Patients have no memory loss complaints and do not have the risks associated with general anesthesia. The overall cost is less as well. It does take longer overall in general to complete treatments with TMS. TMS treatments will go 6-7 weeks at 5 days a week, then some type of taper may be recommended. Sometimes maintenance TMS treatments are indicated. TMS has no systemic or lasting side effects and should be considered the safest treatment for depression on the market. Most insurances cover TMS, but a few are still evaluating TMS for coverage.
TMS vs ECT, which choice should one consider? It really depends on many factors some of which are complex. If someone is acutely suicidal and failed many medications, ECT is faster acting and can sometimes be done while a patient is in the safe environment of a hospital. If patients do not have an emergency situation, TMS is a safer alternative and less invasive. In fact their has been a study that has shown a favorable response to TMS after failed ECT treatment (1). ECT should be considered the big stick and TMS a gentler approach. One strategy would be to go through a course of TMS first and only if that failed consider ECT. This is what most patients lean towards as there is still hesitation about undergoing general anesthesia and the lingering stigma of electroconvulsive therapy perpetuated by the media.
I personally have administered both types of treatment and performed ECT in the 1990s for 7 years and TMS since 12/2015 with good results. I’m currently using a 2nd generation device called Brainsway Deep TMS or dTMS.
For further information on deep TMS, review my website and blogs at www.tvtms.com
1. Response to Deep TMS in Depressive Patients with Previous Electroconvulsive Treatment Rosenberg O, Zangen A, Stryjer R, Kotler M, Dannon PN. Brain Stimulation, 3:211-7 (2010)