Integrative Psychiatry

TMS: It’s not just for TRD anymore by Earle Shugerman, MD

By April 17, 2021No Comments

Check out this awesome video as Dr. Earle Shugerman talks about the significance and risks of TMS.

I want to highlight some of the reasons I think TMS is of interest to integrative psychiatry. Very significant efficacy with difficult mood disorders. It’s compatible with almost any treatment that one can imagine. Medications, supplements, other therapies, very few problems with interactions or complications involved with other treatments.

Off label application for TMS
● Depression during pregnancy
● Postpartum depression
● Bipolar depression
● Substance dependence disorders

And then in off label applications of TMS, we’ll talk about several of these – depression during pregnancy, postpartum depression, maintenance treatment for chronic depressive disorders, which is a very important area. Bipolar depression, depressive disorders that are non-treatment resistant, most of the FDA approval has focused on patients who had failed to respond to an adequate course of antidepressant therapies. And that’s still mostly how TMS is used.

Acute phase: Procedure and outcome
At the end of the acute treatment phase, this four to six weeks of acute TMS, the average PHQ-9 had dropped from 18 to 8.8. And we’re going to see what happened, following those patients then out for about a year.

These are people who had improved significantly, their depression inventory had dropped by about 50% or more. And they maintain that response over the course of 12 months, essentially, fully. And this has been our experience in our clinic as well, that many people who get a good acute response to TMS will maintain that response for months or years after their acute treatment.

Risks for TMS
● Mild headache is most common
● Seizures
● Treatment emergent hypomania or mania
● Hearing loss, if used without at least 30 dB hearing protection
● Exposure risk for COVID 19

The risks of TMS are very low. Mild headache is the most common side effect. Usually, this is something that’s noted in the first week of treatment and tends to diminish over the course of the first couple of weeks. Some patients will take Tylenol or Ibuprofen before they’ll come in for treatment. But usually by the second or third week, they’re no longer needing to do that. TMS has to be done with hearing protection. The coil makes a fairly loud clicking noise during the treatment. So, patients are given ear protection to wear, ear plugs that they wear during their treatment.

How will TMS evolve and improve?
One thing that would be very valuable is if we could identify better likely non-responders. Even when TMS is well covered by insurance coverage, if somebody spent six weeks coming into our clinic daily for an hour, they’ve invested a lot of time, many times they’ve invested a lot of money in copays and if they’re in the one-third non-responder group, that’s painful. And so, if we could use some kind of functional imaging to better advise patients on their likelihood of response and there’s some research going on on this with some promising early results, but nothing that has been useful outside of a research setting quite yet.