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Transcranial magnetic stimulation (TMS) can be administered using different methods to patients diagnosed with depression. What’s the difference between these methods, and how do they work? Read on to learn more.
When you read about TMS therapy in NYC, you most likely come across the following terms: TMS, rTMS, and dTMS. What’s the difference between these terms? And what do they mean for depression treatment?
Transcranial magnetic stimulation (TMS) therapy is a medication free, noninvasive technique for relieving depression symptoms. Today, there are two types of TMS therapy that are FDA-approved for use in a clinical setting to treat patients with depression: rTMS (repetitive TMS), often referred to as standard TMS, and dTMS (deep TMS). rTMS is typically performed using the Neurostar® system, and dTMS is performed using the Brainsway system. If you’re not sure which type of TMS your clinic performs, ask which system they use.
In this article, we’ll explore the similarities and differences between these two types of TMS treatment.
Both rTMS and dTMS are Clinically Proven to Successfully Relieve Depression Symptoms
TMS treatment delivered by both rTMS and dTMS are clinically proven to help patients achieve full remission from depression symptoms by targeting a region in the brain called the dorsolateral prefrontal cortex (close to the forehead).
Two major studies illustrate the efficacy of TMS therapy using rTMS compared to sham (placebo) treatment. One study published in 2007 reported that, after six weeks of active rTMS treatment, the number of patients that achieved remission were twofold compared to the number of patients who achieved remission after sham (placebo) treatment.(1) Another study, published in 2010, observed the effects of daily weekday rTMS sessions on depression symptoms in patients after three weeks of treatment. Patients who were given active rTMS treatment were 4.2 times more likely to achieve remission, compared to patients who were given sham (placebo) treatment.(2)
The efficacy of dTMS is supported by the results of a major study published in 2015. In this study, the percentage of patients who achieved remission after receiving active dTMS treatment for five weeks was more than double, precisely 32.6 percent, compared to 14.6 percent of patients who received sham (placebo) dTMS treatment.(3)
How Does TMS Treatment Relieve Depression Symptoms?
Transcranial magnetic stimulation (both rTMS and dTMS) uses repeated magnetic pulses to stimulate the brain in a noninvasive way. Magnetic pulses directed to a region in the brain associated with mood, called the dorsolateral prefrontal cortex, stimulate an electrical response in the neurons (brain cells) in this brain region. When electrically stimulated, neurons release more neurotransmitters (chemicals released by neurons that allow neurons to communicate with each other), improving communication along pathways of connected neurons.(4,5) This activity can also improve how neurons in the dorsolateral prefrontal cortex communicate with neurons in other brain regions, having a much wider effect.
A TMS treatment course typically lasts a total of nine weeks. The first six weeks are considered the treatment period, where patients receive five treatments (one session a day) per week. The last three weeks (weeks seven through nine of the treatment course) make up the taper period. Patients receive three TMS sessions during week seven, two sessions in week eight, then one final session in the ninth and final week of the treatment course. Both rTMS and dTMS treatment sessions last an average of 20 minutes.(6,7)
If both rTMS and dTMS successfully reduce and eliminate depressive symptoms in the same amount of time, then how do these two types of TMS differ? The differences between rTMS and dTMS can be found in the type of magnetic coil they use and therefore how deeply they stimulate the brain.
rTMS (Repetitive TMS) Gained FDA Approval in 2008 and Uses a Figure-8 Coil
The rTMS device was granted FDA-approved in 2008 for the treatment of treatment-resistant major depression disorder (MDD) and in 2020 for the treatment of bipolar depression.(8,9) rTMS delivers magnetic pulses using a figure-8 coil that stimulates the brain up to 1.5cm below the surface of the skull.(10)During an rTMS treatment session, the coil is carefully positioned over the patient’s head.
dTMS (Deep TMS) Gained FDA Approval in 2013 and Uses an H1 Coil
The dTMS device was FDA approved in 2013 for patients with treatment-resistant depression, 2018 for OCD, and in 2020 for smoking cessation in adults.(11,12,13)
Deep TMS gets its name because it stimulates the brain more deeply than rTMS. The dTMS H1 coil is able to stimulate the brain as deep as 3.2cm below the surface of the skull.(14) During a dTMS treatment session, magnetic pulses are delivered through the H1 coil located inside of a helmet, that is carefully fit to the patient’s head.
At My Practice in Manhattan, New York I Use Repetitive TMS Technology. Here’s Why.
I am one of numerous providers who offer repetitive TMS therapy in NYC. As a licensed psychologist who has been in private practice since 2002, and providing TMS therapy to my patients since 2017, I treat my patients with rTMS figure-8 coil technology. As the first FDA-approved TMS device, rTMS has been studied much more than dTMS.
The main reason that I choose to use repetitive TMS as opposed to deep TMS is due to the potential side effects, more specifically the potentially elevated risk of seizure to the patient with dTMS. The most commonly reported side effects of TMS are mild headache and discomfort of the scalp. These side effects typically subside within a few hours following treatment. One of the major risks of TMS, although very rare, is the risk of seizure.
Because dTMS stimulates deeper regions of the brain, the risk of seizure is higher than with rTMS. According to results from a major study that observed the efficacy and safety of rTMS, the risk of seizure associated with rTMS is estimated to be three out of 1000 patients per treatment, or less than a one percent overall risk.(15) In a controlled study that compared dTMS to sham (placebo) treatment, one out of 101 patients per treatment session had a seizure.(3)
According to data presented by the Clinical Standards Committee of the CTMSS at the Clinical TMS Society Conference held in February 2019, the seizure rate associated with rTMS is one seizure in 268,000 treatments sessions, while the seizure rate associated with dTMS is estimated to be one in 4,800 treatment sessions.(16,17,18)
Resources:
1. O’Reardon JP, Solvason HB, Janicak PG, Sampson S, Isenberg KE, Nahas Z, McDonald WM, Avery D, Fitzgerald PB, Loo C, Demitrack MA, George MS, and Sackeim HA. Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: A multisite randomized controlled trial. Biological Psychiatry. 2007; 62(11): 1208-1216. https://pubmed.ncbi.nlm.nih.gov/17573044/. Accessed January 07, 2020.
2. George MS, Lisanby SH, Avery D, McDonald WM, Durkalski V, Pavlicova M, Anderson B, Nahas Z, Bulow P, Zarkowski P, Holtzheimer PE 3rd, Schwartz T, and Sackeim HA. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: A sham-controlled randomized trial. Archives of General Psychiatry. 2010; 67(5): 507-516. https://pubmed.ncbi.nlm.nih.gov/20439832/. Accessed January 07, 2021.
3. Levkovitz Y, Isserles M, Padberg F, Lisanby SH, Bystritsky A, Xia G, Tendler A, Daskalakis ZJ, Winston JL, Dannon P, Hafez HM, Reti IM, Morales OG, Schlaepfer TE, Hollander E, Berman JA, Husain MM, Sofer U, Stein A, Adler S, Deutsch L, Deutsch F, Roth, Mark S, George Y, and Zangen A. Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial. World Psychiatry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329899/2015; 14(1): 64–73. . Accessed January 07, 2021.
4. Kozyrev V, Staadt R, Eysel UT, and Jancke D. TMS-induced neuronal plasticity enables targeted remodeling of visual cortical maps. June 2018;115(25):6476-6481. Proceedings of the National Academy of Sciences. https://www.pnas.org/content/115/25/6476. Accessed January 09, 2021.
5. Ruhr-University Bochum. What effect does transcranial magnetic stimulation have on the brain? Published June 5, 2018. https://www.sciencedaily.com/releases/2018/06/180605103511.htm. Accessed January 09, 2021.
6. Neurostar. NeuroStar® Advanced Therapy – Precision Treatment Delivered in Less Than 19 Minutes per Session. https://neurostar.com/hcp/neurostar-the-precise-choice/coil-design/. Accessed January, 09 2021.
7. Brainsway. How does BrainsWay Deep TMS treatment work? https://www.brainsway.com/professionals-faqs/how-does-brainsway-deep-tms-treatment-work. Accessed January 09, 2021.
8. Horvath JC, Mathews J, Demitrack MA, Pascual-Leone A. The NeuroStar TMS device: conducting the FDA approved protocol for treatment of depression. The Journal of Visualized Experiments. 2010;12(45):2345. https://pubmed.ncbi.nlm.nih.gov/21189465/. Accessed January 08, 2021.
9. Tropsha Y and Gramigna Joe. FDA grants breakthrough designation to transcranial magnetic stimulation device for bipolar depression. Healio. Published March 18, 2020. https://www.healio.com/news/psychiatry/20200318/fda-grants-breakthrough-designation-to-transcranial-magnetic-stimulation-device-for-bipolar-depressi. Accessed January 08, 2021.
10. Roth Y, Amir A, Levkovitz Y, and Zangen A. Three-dimensional distribution of the electric field induced in the brain by transcranial magnetic stimulation using figure-8 and deep H-coils. J Clin Neurophysiol. 2007;24(1):31-38. https://www.researchgate.net/publication/6526365_Three-Dimensional_Distribution_of_the_Electric_Field_Induced_in_the_Brain_by_Transcranial_Magnetic_Stimulation_Using_Figure-8_and_Deep_H-Coils. Accessed January 10, 2021.
11. Brainsway gets FDA approval for anti-depression device. Published January 09, 2013. https://www.reuters.com/article/brainsway-fda/brainsway-gets-fda-approval-for-anti-depression-device-idUSL5E9C99OU20130109. Accessed January 08, 2021.
12. US Food & Drug Administration. FDA permits marketing of transcranial magnetic stimulation for treatment of obsessive compulsive disorder. Published August 17, 2018. https://www.fda.gov/news-events/press-announcements/fda-permits-marketing-transcranial-magnetic-stimulation-treatment-obsessive-compulsive-disorder. Accessed January 08, 2020.
13. Global News Wire. BrainsWay Receives FDA Clearance for Smoking Addiction in Adults. Published August 24, 2020. https://www.globenewswire.com/news-release/2020/08/24/2082476/0/en/BrainsWay-Receives-FDA-Clearance-for-Smoking-Addiction-in-Adults.html. Accessed January 08, 2021.
14. Ginou A, Yiftach Roth Y, and Zangen A. Comparison of superficial TMS and deep TMS for major
depression. Brain Stimulation. 2014:7(5):e19. https://www.brainsway.com/wp-content/uploads/2018/12/Ginou_Brain_Stimulation_2014_H1_Fig8_vs_MDD.pdf. Accessed January 08, 2021.
15. Carpenter LL, Janicak PG, Aaronson ST, Boyadjis T, Brock DG, Cook IA, Dunner DL, Lanocha K, Solvason HB, and Demitrack MA. Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depression and Anxiety. July 2012;29(7):587-96. https://www.ncbi.nlm.nih.gov/pubmed/22689344. Accessed January 09, 2021.
16. Press D. Motor Threshold and Seizure Risk: Towards Quality Care. The 7th Annual Clinical TMS Society Meeting. Vancouver, British Columbia, CA; 2019. https://www.clinicaltmssociety.org/newsletter/article/letter-editor-8. Accessed January 09, 2021.
17. Tendler A, Roth Y, Zangen A. Rate of inadvertently induced seizures with deep repetitive transcranial magnetic stimulation. Brain Stimul. 2018;11(6):1410-4. https://pubmed.ncbi.nlm.nih.gov/30245161/. Accessed January 09, 2021.
18. Sheth M, Rabin S, and Cornejo BJ. Letter to the Editor: Safely Delivering Deep Transcranial Magnetic Stimulation: Lessons from the Clinic. Clinical TMS Society. Publication Date Unavailable. https://www.clinicaltmssociety.org/newsletter/article/letter-editor-8#:~:text=Out%20of%20268%2C000%20treatments%20reported,1%3A4800%20per%20individual%20treatment. Accessed 09, 2021.
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