Is Transcranial Magnetic Stimulation (TMS) therapy effective?

Effectiveness of Transcranial Magnetic Stimulation (TMS) Therapy

TMS therapy is effective for treatment-resistant depression with moderate effect sizes comparable to antidepressant medications, but its efficacy varies by condition and treatment protocol. 1

Evidence for TMS in Major Depressive Disorder (MDD)

• TMS is recommended for patients with major depressive disorder who have shown partial or no response to two or more adequate pharmacologic treatment trials 1
• Response rates range from 29-48% with a number needed to treat of 3.4 to 9 patients for response and 5 to 7 patients for remission 1
• The aggregate literature suggests that the benefits of repetitive TMS (rTMS) for treatment-resistant depression in improving symptoms and facilitating remission outweigh the harms 1
• TMS is well-tolerated with minimal side effects, generally limited to transient scalp discomfort or pain 2

Limitations and Considerations

• One recent RCT in a veteran population with high rates of comorbid PTSD and substance use disorders found no significant differences between rTMS and sham treatment, suggesting placebo effects may play an important role 1
• Access to TMS treatment can be challenging as it requires frequent onsite visits (typically 5 sessions per week for 4-6 weeks) 1
• Predictors of better response include lower age, lower degrees of treatment resistance, and absence of comorbid anxiety or psychotic symptoms 3

TMS for Other Conditions

• TMS has received FDA approval for obsessive-compulsive disorder (OCD) 4
• For bipolar depression, a randomized controlled trial showed active deep TMS was superior to sham at endpoint with no treatment-emergent mania episodes 5
• There is insufficient evidence to make a recommendation for or against theta-burst stimulation (TBS), a variation of TMS that uses rapid, repetitive pulses 1
• Some evidence suggests TMS may have potential applications in substance use disorders by reducing craving and potentially improving cognitive control 1

Treatment Protocols and Optimization

• Standard protocols typically involve high-frequency (10 Hz) stimulation over the left dorsolateral prefrontal cortex 2
• Accelerated TMS protocols, with all treatments delivered over a few days rather than weeks, show promise with comparable efficacy to standard protocols 6
• Optimal stimulation parameters are still being investigated, with research exploring sequential bilateral stimulation and extended number of pulses per session 3

Combination Approaches

• TMS may be more effective when combined with behavioral interventions such as cognitive behavioral therapy (CBT) 1
• Some studies show promising results when TMS is combined with pharmacotherapy, such as nearly 50% of patients becoming abstinent from cigarettes when TMS is used with nicotine replacement therapy 1

Practical Considerations

• TMS is generally considered safe with a low dropout rate for adverse events (4.5% in one large trial) 2
• The most common side effects are mild and limited to transient scalp discomfort or pain 2
• TMS is cost-effective compared to existing treatments for treatment-resistant depression, including pharmacological interventions and electroconvulsive therapy 3

While TMS shows promise as an effective treatment option, particularly for treatment-resistant depression, ongoing research is needed to determine optimal stimulation parameters and expand its applications to other conditions.