For Providers

TMS FAQs for mental health service providers

Introduction

Since the introduction of electroconvulsive therapy (ECT) in 1938, stimulation treatments have been shown to be very effective in treatment for major depression. ECT became the gold standard of treatment resistant depression in the following decades and also proved effective in the treatment of acute mania and, to a limited extent, chronic schizophrenia. But ECT still remains one of the most controversial modalities of treatment in the entire field of medicine. Its proponents swear by it, while its opponents hate it. The movie “One Flew over Cuckoo’s Nest,” like many other movies before and after, portrayed ECT as a very crude and cruel method of treatment, which is sometimes abused as a form of punishment for behavior control. There has been a steady decline in use of ECT in clinical psychiatry settings, and it remains one of the most underutilized treatments. Less than eight percent of American psychiatrists use ECT.

The introduction of transcranial magnetic stimulation (TMS) and vagal nerve stimulation (VNS) and other such treatments (like DBS) in the last two decades has rekindled interest in the use of brain stimulation methods for the treatment of psychiatric disorders. TMS in particular enables the clinician to focally stimulate specific areas of the brain noninvasively and painlessly. The efficacy of TMS in the treatment of depression and OCD has been extensively studied with numerous trials showing sustained benefits. TMS has also been shown to have some beneficial effects in other conditions and is being studied for additional indications such as Migraine headaches, posttraumatic stress disorder (PTSD) and substance abuse conditions.

A TMS like device was introduced in 1985 by Anthony Baker at the University of Sheffield in England. It was initially designed to be a neurodiagnostic tool used to produce an evoked potential in muscle tissue by activating neurons in the motor cortex and later considered for other applications. TMS is based on two basic principles in physics: Ampere’s law and Faraday’s principle of electromagnetic induction.

Ampere’s law states that the magnetic field in the space around an electric current is proportional to the electric current. According to Faraday’s principle of electromagnetic induction, a voltage would be generated across a length of wire if that wire was exposed to a perpendicular magnetic field flux of changing intensity.

The stimulation coil of the TMS instrument consists of multiple wire loops encased in an insulated material. This is connected to powerful capacitors capable of passing a large electrical current through the coil. If a pulse of current is passed through this coil and placed over a person’s head, it produces rapidly changing magnetic pulses that penetrate the scalp and skull and reach the brain with minimal attenuation. When these pulses alternate rapidly enough, a secondary electric current is induced that alters the local electric field in the nerve tissue. This leads to depolarization of the underlying superficial neurons. High-intensity current is rapidly turned on and off in the electromagnetic coil using discharges from powerful capacitors. TMS thus produces brief but very powerful magnetic fields that lead to induction of electric currents in the brain. TMS pulses can be administered repetitively and rhythmically, and this process is called repetitive TMS (rTMS). This can be further classified as high frequency rTMS if the frequency is greater than 1Hz, whereas if the speed of stimulation is equal or less than 1Hz it is called low frequency rTMS.

At the CFFP in Saline, MI, we chose to bring in MagVenture Cool B-70 equipment for TMS Therapy. The “cool” term implies an internal cooling function inside the coil with coolant fluid moving through it to keep it from heating excessively. The magnetic pulse and indirect electro-therapy doses from this equipment have been shown to be highly effective, safe and very well tolerated by the patients worldwide. Below you will find a video demonstration of an actual treatment procedure as recommended by MagVenture. Please feel free to reach out to the CFFP staff and providers including Dr. Kirbat with any additional questions or concerns.

This video is a step-by-step guide demonstrating in detail how to use the MagVenture TMS Therapy system for treatment of major depressive disorder based on the use of transcranial magnetic stimulation. You may choose to watch the whole video, but if you are only interested in specific topics, we have listed them below; including their time codes. Just click on the time code to get to the chapter most interesting for you. System description: 0:23 Getting Started: 3:12 Defining Motor Threshold: 4:08 Getting Ready for Treatment: 8:18 Place the Treatment Coil: 9:29 Set and Start the Treatment Protocol: 10:17 Set or Recall Protocol: 11:43 End of the Protocol: 14:05 Second and Subsequent Treatment Sessions: 14:45 MagVenture TMS Therapy was formerly known as MagVita TMS. Since this video was made, MagVenture has received FDA clearance of a theta burst protocol which has now cut down treatment sessions to just 3 minutes instead of the standard 37 minutes mentioned in this video. Check out our YouTube channel for videos about the theta burst treatment which we call Express TMS. MagVenture TMS Therapy® is FDA cleared for: “Treatment of Major Depressive Disorder in adult patients who have failed to receive satisfactory improvement from prior antidepressant medication in the current episode.” MagVenture TMS Therapy® is CE approved for: “Treatment of Major Depressive Disorder in adult patients who have failed to achieve satisfactory improvement from two prior antidepressant medications, at or above the minimal effective dose and duration in the current episode” Caution: US Federal law restricts this device to sale by or on the order of a physician. The results and treatment details expressed in this presentation may vary. The views and opinions in this presentation do not necessarily reflect the official policy or position of Center For Family Psychiatry, MagVenture or any of its affiliates.