Transcranial Magnetic Stimulation

Philip Hickey, PhD
25
5664

TMS is a psychiatric treatment that uses a rapidly alternating magnetic field to induce electric currents in the brain.  These currents stimulate neurons, causing them to “fire.” When used repetitively, TMS is said to alter the excitability of the brain area that has been stimulated.  In the psychiatric field, TMS is being used increasingly as a treatment for depression, particularly with so-called treatment-resistant clients.  I Googled the string “TMS + depression” and got 1.35 million hits.  So the idea is attracting attention.

One of the abstracts presented at the May 2013 APA annual conference in San Francisco was called A Multisite, Longitudinal, Naturalistic Observational Study of Transcranial Magnetic Stimulation (TMS) For Major Depression in Clinical Practice, by Mark Demitrack, MD, et al.

The abstract was a study of the efficacy of TMS involving 307 depressed participants who had failed to benefit from prior antidepressant treatment.  The authors’ conclusions were:

“These data support the view that TMS demonstrates a statistically and clinically meaningful durability of acute response over 52 weeks of follow up.  Maintenance of benefit was observed under a pragmatic regimen of continuation antidepressant medication and access to TMS reintroduction for symptom recurrence.”

The abstract also indicated that the study had been “supported by a grant from Neuronetics, Inc.”

The presentation generated some enthusiasm.  Medscape ran an article by Caroline Cassels on May 24, 2013, under the headline TMS for Resistant Depression: Long-Term Results Are In.  In this article Mark George, MD, a long-term advocate of TMS, is quoted:

“This is great news for our field and for the millions of patients who suffer from depression and do not respond well to medications…”

With regards to formal publication, the study is divided into three parts.

1.  L. Carpenter et al, 2012, focused on the effect of TMS on depressive symptoms.
2.  P. Janicak et al, 2013, focused on the effect of TMS on quality of life measures.
3.  Analysis of the 52-week follow-up, submitted for publication but not yet published.  Some of the data from the follow-up, however, was presented in the APA conference abstract.

The authors of the 2012 and 2013 articles are identical except for one person – Dafna Bonneh-Barkay, PhD – whose name appears on the 2013 article only.  Dr. Demitrack, listed as lead author on the APA conference abstract, is shown as an author on both the 2012 and 2013 papers.

The study, which started with 339 participants, was conducted on 42 sites which used TMS.  There was considerable participant attrition during the study.  By baseline the number was down to 307, and only 265 actually completed the acute treatment phase.  Reasons for drop-out were:

REASON FOR DROP-OUT NUMBER
No post-baseline evaluation 17
Non-standard treatment protocol used 7
Did not meet diagnostic criteria 4
Prior TMS treatment 4
Failed to return 18
Unsatisfactory response efficacy 7
Satisfactory response efficiency 2
Adverse event (seizure) 1
Patient request 1
Other reason 13
TOTAL 74

 

Of the 265 individuals who completed the acute treatment phase, 257 entered the 12-month follow-up phase, and of those only 204 participants provided data across the entire study period.  Presumably the reasons for these follow-up phase attritions will be listed in the formal write-up, but at present this information is not available.

The 2012 paper begins by stating that

“…20-40% of patients do not benefit from, or cannot tolerate, adequate trials of antidepressant medications even after repeated attempts.”

The authors go on to describe TMS, and state that

“When used as an antidepressant, TMS produces clinical benefit without the systemic adverse effects associated with medications, and has no adverse cognitive effects.”

The authors state that although the efficacy of TMS has been established, there have been no multisite studies of its utility and effectiveness in routine clinical practice.  Their goal in the present study was

“…to summarize outcomes experienced by a large population of depressed patients treated with TMS therapy in various clinical settings.”

Participant Eligibility

Clients were eligible for participation if

1.  Their primary “diagnosis” was a major depressive episode without psychotic features, using DSM-IV criteria
2.  They had no medical condition that precluded the use of TMS
3.  They had not received TMS previously
4.  They were pharmacoresistant as determined by the Antidepressant Treatment Record (ATR).  The ATR is a screening instrument developed by Neuronetics
5.  Their attending psychiatrists had determined that TMS was the most appropriate clinical option.

Treatment

All treatments used the NeuroStar TMS system – a Neuronetics product.  The intensity of the magnetic field was set at 120% of motor threshold, which in turn was determined on an individual basis with the help of a computerized mathematical algorithm called MT Assist, which is also a Neuronetics product.  Each treatment session involved about 3,000 pulses (average 3,216), usually over the left dorsolateral prefrontal cortex.  The motor threshold, incidentally, is the minimum amount of power output that will cause the client’s thumb to twitch.  The actual treatment is administered at a point 5cm in front of the motor threshold determination point.

Participants who were taking antidepressant drugs at the time of enrollment were permitted to continue taking these at the discretion of the treating psychiatrist.  At study baseline, 300 of the 307 participants were taking one or more psychotropic drugs.

The average number of TMS treatments administered was 28.3 (range 2-94) across an average duration of 42 days (range 2-130).  The normal protocol was about five sessions per week.

Outcomes

Outcome measures of depressive “symptoms” were reported in the 2012 paper, (Carpenter et al, 2012).  The primary outcome measures were the changes from baseline to the end of the acute phase of treatment on:

  • the Clinical Global Impression – Severity Scale (CGI-S)
  • the Inventory of Depressive Symptoms, Self-Report version (IDS-SR)
  • the 9-Item Patient Health Questionnaire (PHR-9).   

The CGI-S is completed by the treating clinician; the other two scales are completed by the client.

The mean scores on all three scales declined (i.e., improved) during the treatment period.    Remission rates (as defined by a score of 2 or 1 on CGI-S, a score of less than 5 on the PHQ-9, or a 50% or greater drop in score on the IDS-SR) were 37.10%, 28.70%, and 26.50% respectively.

The actual duration of acute-phase treatment was determined by the treating psychiatrist’s estimate of the “point of maximum benefit.”  The authors report that 22% of the participants were treated beyond the 6 weeks duration.  The maximum duration was 130 days, or a little over 4 months.

The 2013 study focused on quality of life outcome measures.  These were assessed by:

  • Medical Outcomes Study-36-Item Short Form Health Survey (SF-36)
  • EuroQol 5 – Dimensions (EQ-5D) 

Each participant was assessed on these self-administered measures at baseline and again at the end of acute treatment.  As with the depressive “symptoms,” mean scores on these quality of life measures improved during the acute treatment period.

Long-Term Outcome

As mentioned earlier, the formal write-up of this phase of the study is not yet available, but the APA abstract provided the following information:

CGI-S, PHQ-9, and IDS-SR scores were obtained at the 3, 6, 9, and 12-month marks.  The reduction in mean scores, noted at the end of acute treatment, was sustained throughout the 52-week follow-up

MEAN SCORES
End of Acute Treatment 52-weeks
CGI-S 3.2 3.0
PHQ-9 9.6 9.4
IDS-SR 27.4 27.3

 

Remission rates were also maintained.

REMISSION RATES
End of Acute Treatment 52-weeks
CGI-S 37.10% 40.40%
PHQ-9 28.70% 33.60%
IDS-SR 26.50% 26.10%

 

[Note there is an erroneous transposition of PHQ-9 and IDS-SR scores in either the 2012 article or the APA Conference abstract.  I believe that the way I’ve presented the figures above is correct, but, as the numbers are fairly close anyway, it makes little difference to the overall result.]

The APA Conference abstract provides no information on quality-of-life scores during the follow-up period.

Discussion

On the face of it, the two papers and the APA abstract suggest that TMS is an effective treatment for depression, and that its beneficial results are long-lasting.  But such an interpretation is misleading.

TMS is routinely presented as a safer alternative for the treatment of depression than ECT (e.g. TMS Center of Princeton).  It is well known that ECT provides, for some individuals at least, a temporary feeling of well-being, but that these effects are short-lived, and the treatment often needs to be repeated more or less indefinitely.  When Demitrack et al state (in the APA abstract) that TMS demonstrates

“…clinically meaningful durability of acute response over 52 weeks of follow up”

most people would, I suggest, interpret this to mean that the beneficial effects of the acute phase treatment lasted for 52 weeks.  In fact, both the TMS and the antidepressants were continued as needed to maintain therapeutic benefit for many of the participants for most of the year.  This is mentioned in the various documents.  For instance, in the APA Conference abstract it says:

“Maintenance of benefit was observed under a pragmatic regimen of continuation antidepressant medication and access to TMS reintroduction for symptom recurrence.” [Emphasis added]

In fact, 30.2% of participants required subsequent TMS after the 3 month assessment.

Earlier in the abstract, however, they had said that the participants who benefitted from “…acute TMS treatment were tapered from their TMS regimen, consented to long-term follow up over 52 weeks, and were evaluated for statistical analysis.”  [Emphasis added]

This, I suggest, implies that the TMS was discontinued after the acute treatment phase.  In my view, the fact that the TMS was reintroduced on an as-needed basis to combat “symptoms” might have been reported more prominently.

Further to this point, in Caroline Cassel’s Medscape article quoted earlier, there’s another quote from Mark George, MD:

“This is a very important and exciting study. Several prior studies have shown that prefrontal rTMS works to treat depression acutely. Until this study, we have had only limited information about how well these patients do a year after completing a course of TMS. Long-term data following remission produced by medications or electroconvulsive therapy [ECT] in these treatment-resistant patients have been disappointing, with only about 13% being still remitted a year later.”

“For example, over half of patients who remit with ECT are ill again 6 months later. Thus, having 45% in remission a full year later is very, very encouraging that rTMS is perhaps changing the underlying pathological circuitry associated with depression and producing a more stable remission than the other treatments.”

In this quote, Dr. George laments the fact that more than half the people who receive ECT are “ill” again 6 months later.

The transient nature of the ECT effect is a well-established fact, and these individuals are usually returned to the hospitals for further “treatment.”  By contrasting these individuals with the 45% still “in remission a full year…” after TMS , it appears that Dr. George is under the impression that these individuals did not receive further sessions.  Or at any rate, that is the impression he is giving, particularly with the phrase:  “…a more stable remission…”

Incidentally, I’m not sure where Dr. George got the 45% remission figure.  In the APA Conference  abstract, the highest remission rate was 40.4% (on CGI-S).  The others were 33.6% on PHQ-9 and 26.10% on IDS-SR.  Perhaps the 45% refers to individuals who remitted by any of the three measures – but there’s no mention of that in the paper.

Also incidentally, Dr. George is the director of the Brain Stimulation Lab in Charleston, South Carolina, which has received grant funding from Neuronetics.  (George et al, 2013, p 17).

After the conference PsychCongress ran an article highlighting the abstract.  Their headline read:  APA News:  Transcranial Magnetic Stimulation Shows Long-Term Benefit In Treating Depression, suggesting, here again, that the author of the article had been misled.

Conflicts of Interest

It is also of note that all of the authors of the 2012 and 2013 papers have significant conflicts of interest.

Scott Aaronson, MD:  speakers fee from Neuronetics.
Dafna Bonneh-Barkay, PhD:  Neuronetics, employee, with salary and stock options.
Terrence Boyadjis, MD:  Neuronetics research support contract.
David Brock, MD: Neuronetics employee, with salary and stock options.
Ian Cook, MD:  Neuronetics, speaker’s bureau, honoraria, research support, grant.
Linda Carpenter, MD: Neuronetics research support.
David Dunner, MD:  Neuronetics, grant support, research support, consultant fees.
Mark Demitrack, MD:  Neuronetics, employee (Chief Medical Officer) with salary and stock options.
Hugh Solvason, PhD, MD: Neuronetics research support.
Philip Janicak, MD:  Neuronetics, research support, advisor, consultant.
Karl Lanocha, MD:  Neuronetics, research support, speaker’s bureau.

Adverse Effects

On June 4, 2012, Shiv Gaglani posted an article on Medgadget.com.  The title was The Promise of TMS: Interview with Neuronetics Chief Medical Officer Mark Demitrack, M.DHere’s a quote:

“The makers of the NeuroStar TMS System, Neuronetics, contacted us to let us know about their new study released at the American Psychiatric Association meeting in May.” [Emphasis added]

This, incidentally, was not the same APA 2013 abstract mentioned earlier.  Dr. Demitrack had presented an earlier abstract – a preview of the Carpenter et al 2012 study – at the 2012 APA conference.  The Medgadget interview was based on the earlier abstract, and gave a brief summary of the study’s main findings, with quotes from an interview with Dr. Demitrack, but there is no mention of the concomitant use of the antidepressants, or of the continued use of TMS during the follow-up period.

An additional point of concern in this regard is Dr. Demitrack’s statement concerning safety.  Here’s the quote

Medgadget:  Were any side effects observed?”

Dr. Demitrack: The most common side effect directly related to the device is scalp pain or discomfort at the site of stimulation. Most patients find this to be mild to moderate in intensity, and it usually becomes unnoticeable after the first week.”

In fact, as the 2012 paper makes perfectly clear, one of the participants experienced a generalized tonic-clonic seizure (formerly known as grand mal seizure) during a TMS treatment session.

“There was one medical event considered probably or definitely related to the device and that was filed with the FDA as a Medical Device Report.  This event was a generalized tonic-clonic seizure that occurred in a female patient during her 10th TMS treatment session.  The patient had no prior history of seizure, however she had several clinical factors that may have contributed to altering her seizure threshold.  Specifically, the evening before her treatment she had completed a night shift of work, and was therefore sleep-deprived at the time of the TMS session.  In addition, she was also taking bupropion, sertraline, and dextroamphetamine/ levoamphetamine at the time of her TMS acute-phase participation.  The patient recovered fully from the event without neurological sequelae.

Seizure is a known, but rare, medical risk associated with TMS.  In the entire postmarketing experience with this system, there have been six reports of seizure filed as MDRs to the FDA.  Based on this experience, the estimated risk of seizure is approximately 0.003% per treatment exposure, and <0.1% per acute treatment course.”

It seems obvious to me that this should have been mentioned in the interview and included in Medgadget’s article.  This is particularly important in that Medgadget is a credible and sophisticated website operated by a team of MDs and biomed engineers.  They have 11,700 Twitter followers, they have their own YouTube channel, and they have a large following on their Facebook site.  In addition, the article was picked up and hyperlinked by at least three other sites:  Regator, AllVoices, and Organized Wisdom.

At the end of the Medgadget article there’s a link to a 20-minute Neuronetics promotional video.  At about 18:28 minutes, the spokesperson says:

“Over 10,000 active treatments were performed across all NeuroStar clinical trials, demonstrating its safety.  During trials, no seizures or systemic side effects were seen.”

However, as mentioned earlier, the Carpenter et al study states that six seizures had occurred in the post-marketing experience, and one during the Carpenter et al study itself.  On this basis, the video statement seems deceptive, or at least misleading.

The authors of the 2012 paper estimate the seizure risk at 0.003% per treatment session.  This is about 1 in 33,000, and on the face of it seems like a very small risk.  But a treatment course typically consists of about 30 sessions (5 per week for 6 weeks), which brings the risk per treatment course up to 0.09%, or 1 in 1,100.  But, further, some individuals receive considerably more than 30 sessions.  The maximum in the present study was 94.  The risk for a person receiving 94 sessions is 0.28%, or 1 in 357.  And when we remember that many people receive repeat treatments, it is clear that the risk for these individuals becomes increasingly significant.  It is also clear that these risk estimates are based on very limited actuarial experience, and may have to be revised (upwards or downwards) as TMS use increases.

TMS – Non-Invasive?

As mentioned earlier, TMS is getting a good deal of air-time in recent years.  In particular, it is being promoted as a “non-invasive” treatment.  I Googled the string “TMS + non-invasive” and got 317,000 hits, and the present authors use the term to describe the treatment (2012 paper, p 588).

This is misleading.  TMS involves sending multiple strong bursts of magnetic energy into the brain.  The pulses are increased in strength until they are actually causing neurons (brain cells) to fire, and are repeated at that intensity about 3,000 times in each session.  In the present study, the average number of sessions received by participants was 28.  Strictly speaking, a medical procedure is considered non-invasive if it doesn’t break the skin, but it seems a misnomer in the present context.  X-rays don’t break the skin, but would hardly be considered non-invasive.

Method of Action

George et al also note that “Mood regulating centers in the brain overlap significantly with the neural pathways involved in pain regulation…”  They also report that TMS, applied to the prefrontal cortex (the same general area that is used to treat depression), has an analgesic effect, from which they tentatively conclude that opiate receptors play a part in the effects of TMS.

The precise mechanism of action of TMS is not fully understood.  However, George et al suggest that depression results from neural “dysregulation” in the prefrontal and limbic regions.  They hypothesize that:

“…chronic, frequent, sub-convulsive stimulation of the prefrontal cortex might initiate a therapeutic cascade of events that rebalances and normalizes the dysregulated prefrontal and limbic circuitry.” [Emphasis added]

This sounds remarkably similar to the now discredited notion of antidepressants therapeutically correcting chemical imbalances.

Similarity to ECT

TMS is being routinely presented as a safer alternative to ECT for “treatment-resistant” clients.  In some instances (e.g. the quote from Dr. George, mentioned earlier), it is being promoted as more effective than ECT.  And based on present information, TMS does not seem to be as immediately traumatic to the brain as ECT.  However, there is a fundamental similarity between these two interventions:  they both interfere with the normal electrical activity of the brain.  We know that in the case of ECT, the long-term results are catastrophic, and that it is only a matter of time before this procedure will be banned. Though meanwhile psychiatry, to its shame, continues to tout it as safe and effective.

With TMS, the picture is less clear.  But as this technology becomes more widely used, and used more frequently for given individuals, we may see increasing evidence of cumulative neural damage, including even more pronounced anhedonia than the technology purports to address.  Certainly the already established risk of seizure suggests that TMS has more in common with ECT than its proponents might be willing to acknowledge.

There are already indications that TMS protocols may call for higher doses and more frequent treatments in the future, at least for some individuals.  Mark George, MD, et al wrote in January 2013:

“Another issue is determining the optimal dose over the optimal time period for alleviating depression.  Most studies have stimulated patients at or above motor threshold.  This is particularly important in elderly patients, in whom prefrontal atrophy may outpace motor cortex atrophy… There have never been dose-finding studies with rTMS.  Thus, some groups are studying whether higher doses of TMS might produce more rapid or more effective results …Also, there are a few case series suggesting that weekly or monthly rTMS can serve as maintenance therapy for acute responders…” [Emphases added]

Assessment Scales

A great deal of psychiatric research, including the present Neuronetics study, uses questionnaires and rating scale scores as outcome measures.  This is an inherent deficit in all research of this kind, in that there is inevitably some uncertainty as to whether positive responses on a questionnaire reflect positive changes in a person’s life.

An additional problem in this regard is that often the questionnaire items are ambiguous, or at the very least, difficult to unravel.

Psychiatry-Industry Links

It is clear from material presented above that there are already close links between the TMS industry and psychiatric researchers.  As has become glaringly obvious in the pharma sphere, these kinds of links do not generally foster research objectivity and integrity.

Treatment-Resistant Depression

The concept of “treatment-resistant depression” is an integral component of TMS promotion, and has become a hot topic in recent years (5.9 million hits on Google).  The idea is that there are some individuals whose feelings of depression are not alleviated by antidepressants to any appreciable degree despite multiple trials and high dosages.

Many of us on this side of the debate are of the opinion that this kind of chronic anhedonia is actually caused by long-term use of antidepressants, and this notion has been presented persuasively by Rif El-Mallakh et al, 2011.  Not surprisingly, this concept has garnered little support in psychiatric circles, where depression is assumed (groundlessly) to be an illness; antidepressants are promoted as the “cure;” and people for whom the cure is ineffective are labeled treatment-resistant.

Instead of recognizing and acknowledging the destructive effects of the drugs, psychiatry is salving its conscience by pretending that these individuals have some undefined (and hence unrefutable) quirk that prevents them from benefiting from psychiatric drugs, and is now busily developing and promoting TMS as a treatment for a problem that psychiatry very likely created in the first place.

The idea that people can find happiness or contentment or peace or mind by having their brains tweaked by chemicals or electromagnetism is a fundamentally dehumanizing and disempowering concept.  Feelings of loss and despondency are an integral part of the human condition, best resolved by dealing with the source of the problem, with the assistance and support of friends and loved ones.  The notion that we can banish these feelings with an effortless brain-altering intervention is precisely the same philosophy that underpins the marketing of street drugs.  It provides an increasingly short-lived sense of relief for some people, but always entails more problems than it solves.  Ask any member of Narcotics Anonymous.

25 COMMENTS

  1. I have called attention to the following paragraph from the above article:

    “This is misleading. TMS involves sending multiple strong bursts of magnetic energy into the brain. The pulses are increased in strength until they are actually causing neurons (brain cells) to fire, and are repeated at that intensity about 3,000 times in each session. In the present study, the average number of sessions received by participants was 28. Strictly speaking, a medical procedure is considered non-invasive if it doesn’t break the skin, but it seems a misnomer in the present context. X-rays don’t break the skin, but would hardly be considered non-invasive.”
    —————–
    Being a survivor of very traumatic ECT, I read this thoroughly. I would never, ever recommend this treatment!
    Dorothy

    • Dorothy, thank you for your input.

      I have in fact undergone TMS for BIPOLAR depression.

      Even to someone with knowledge of electromagnetic induction, as in a wireless toothbrush charger for example, it sounds like hope. “Maybe it will shake up those ions and jump start those pathways” I thought, as if spraying electric potential all over the entire prefrontal lobe could possible be a good idea, especially since neurologists seem utterly stupid about information technology from the eyes of a hobbyist senior software engineer who also has a background in electronics and RF… But it was that or more depression, so I took the TMS and crossed my fingers.

      I went to Island Counseling Center in Worcester, MA. My psychiatrist was Dr. Anthony Tabacco who likes to type all sorts of things into his computer when I visit him for 15 min (or less if someone “in need” is waiting). He never even allowed me to talk for more than 5 minutes, and I always felt rushed.

      He never would have suggested TMS, had I not, and kept telling me that if it wasn’t working that I should stop because it was “expensive” ??

      It seemed odd is that it was not covered by insurance, $50 per visit times 25 or so visits is a lot out of pocket. It costs a fortune (why?) and they told me that if I think positive thoughts that it will work better. Oh, you mean like a placebo, exactly! the tech explained to me.

      I looked at the thin 117 VAC wire plugged into the wall, and realized the cost had nothing to do with the power consumption, so it must be a royalty charge which indicates fowl play in my opinion, not an intent to provide help to people who are in crisis with life threatening depression. You know?

      It didn’t work. It didn’t do anything. I didn’t notice anything change at all.

      It was nice to get out of my house and have something to do though. I would stop at fresh city everyday and get a sandwhitch and smoothie. That was happy for me. There was a wacky guy named Dean, who was the son of Dr Och who ran the program. He was very nice to me and I enjoyed talking to him while my brain was being saved with 2 electromagnets.

      My parents said that it helped, but this makes me sad, because it was eating at fresh city and talking to dean about his poetry that lifted me up. I guess it was easier for my parents to believe a lie. Very sad, i cry and allow them to believe that their baby is getting better.

      So, to recap, the brain is a 3 dimensional object. How can you possibly target in X, Y, Z space with only two poles? You can’t. I’m not sure if a neuron even works that way, I mean maybe… but even it you could induce currents, what could you possibly hope to accomplish without gathering feedback from the brain in order to coordinate the “healing” process? Or prevent injury! Even if you did get feedback, which would require enormous precision and physical probes deep into the brain, you would have to run it through a parallel farm of quantum computers to process the data.

      It just goes to show that if you’re mentally ill, you’re on your own.

      Psychiatry is a crime against humanity because it destroys hope by obsessing with alchemy and witchcraft over many years until the patient looses all hope and wants to die, but can’t say for certain if that is the correct choice, to kill herself, so she lives on in fear and delusion, mixing alcohol with lorazepam and loosing the support of family as a result of alcoholism. I speak of my friend Gail, who is dying from alcoholism as a result of her depression.

    • It is amazing to me that people think that TMS is a lot like ECT. It is totally different from ECT and is nothing like it. If you think it is, you are ignorant of the facts. I know, I’ve had both. I repeat, TMS is nothing like ECT. Also, if you read the facts about TMS you will see that nothing is guaranteed and it does not work on everyone. I was lucky, it worked for me.

  2. Would never recommend this treatment. I had it and had to stop. Severe headaches and agitation. I was considered depressed and treatment-resistant after doctors failed to recognize adverse reactions to a short-term benzodiazepine – and the withdrawal syndrome. TMS harms the electromagnetic field of the client and of the operator. It is dangerous. Thank you for writing the article.

    • amnesia,

      Thanks for your comment. Psychiatry has hurt so many people with benzodiazepines and then diagnosed the withdrawal effect as evidence of another “mental illness.” All medical specialists make mistakes, but the real doctors recognize their errors and try not to repeat them. Psychiatry, however, has a built-in excuse for everything they do wrong – the “emergence” of a new illness. Of course there’s no evidence of the illness other than their say so. What a fraud.

  3. I can never understand why discussions of rTMS invariably fail to discuss cranial electrotherapy stimulation as a cheaper, safer, more convenient alternative. Yes, the FDA isn’t happy with CES, but if you look into their complaints, they hold CES research to a higher standard than they do pharmaceuticals.

  4. Philip,

    Thank you for putting another well-written piece together. I especially appreciate the obvious time and thought that goes into your work.

    I have read a little about TMS, but not much. Your article helped educate me a bit more, and I appreciate it…. I personally would have reservations about trying this treatment. When I was a young man, I found an osteopath who specialized in a non-invasive approach. It made a world of difference; helping me overcome trauma and depression:

    http://www.cranialacademy.org/benefit.html

    This might be worth looking into, for anyone considering TMS, as a safer alternative.

    My best,

    Duane

  5. This TMS study suffers from so many methodological problems that it cannot be used for anything.
    The most blatant error is that there is no control group and no placebo. TMS is a new fancy looking treatment with high tech equipment, the perfect treatment to elicit a good placebo response. And the results here, approximately 1/3 got remission, is a typical placebo effect of almost any kind of intervention.

    The problem with almost all ECT research is the lack of a control group getting a placebo/sham treatment and being exposed to the equivalent medical attention and optimism. now TMS research is repeating the same mistake.
    Without a control group we cannot say anything about neither effectiveness nor safety.
    When the researchers use the extremely subjective CGI as their primary measure and two of the researchers are employees of the device maker (and the others have serious conflicts of interest receiving money and grants from Neouronetics), this is close to a farce. That such research is taken seriously at all tells a lot about the field of psychiatry.

  6. I’m an ECT survivor. It took me years to recover my cognitive function after those treatments. Some never do, and those stories are rarely mentioned. People don’t get informed consent.

    After recovering from a traumatic brain injury, I realized just how similar the process was from recovery from ECT. I think that ECT works by giving you a brain injury to take your mind off the depression.

    I’m sure that a “little electricity” for a long time isn’t much better than a lot of electricity in the short term. These researchers oughta test this stuff on themselves if it’s so safe.

  7. From a page on TMS,

    ” The circuitry used to generate the magnetic field pulses is usually based on a capacitor discharge system (shown in its simplest form in figure 4) with typical peak coil currents in the range of several kiloamps and discharge voltages of up to a few kilo volts. The relatively high voltage is required to give the required rapid rise of current into the inductance of the stimulating coil.”

    http://www.scholarpedia.org/article/Transcranial_magnetic_stimulation

    “Several Kilo amps and discharge voltages of up to a few kilo volts” That’s big-time energy levels.

    Here on youtube you can see hobbiests playing with the ” inductance of the stimulating coil” crushing cans and destroying things.

    Capacitor Bank #64 – Can Crushing With Three Different Coils

    http://youtu.be/VQNDscsoygo

    http://www.youtube.com/results?search_query=crushing+cans+with+capacitors

    You don’t want to put your head in this thing no matter how “benign”, “safe” , “scientific” or “medical” the psychiatric industry will try and trick you into thinking it is.

    Capacitor Bank #26 – Clearing A Calculator With A Can Crushing coil

    http://youtu.be/kJqoYiPcP8k

    Do all the electrical math, call the device a can crusher or “transcranial magnetic stimulation” its the same thing.

  8. Before my TMS treatment, I was misdiagnosed with bipolar disorder and took psychiatric drugs for 15-20 years. I had a horrid childhood and come from a family that lacks emotional intelligence. I cannot yet bring myself to figure out yet exactly how many years I was medicated, the memories are so painful and I did not know what I was doing or not doing most of the time. What was really wrong with me are the following: I had both Scleroderma and Fibromyalgia, was menopausal and had also just relocated to what I must call a third world state – by myself. None of this is advisable. My doctors never told me to see a Rheumatologist re my two auto-immune conditions. After TMS, I left them as swiftly as I could. I am satisfied with my present medical care and I don’t ever want to lay eyes on a psychiatrist again.

    I must differ re TMS. My experience with Transcranial Magnetic Stimulation was excellent. I experienced no pain and had no problems. The treatment was enjoyable and amazing the entire time I had it. The provider was not my regular psychiatrist, but another in my city who does TMS. (He was not at all interested in my results, which truly shocked me. My medical insurance did not cover it and it cost me over $11K, upfront, of course. But, I feel it was worth it.) This treatment gave me my brain back and also rid me completely of the Fibromyalgia which I had for years; I knew that was a possibility and that’s one reason I did it. Right after I finished the treatment, I read Epitomy of an Epidemic which scared me to death, of course. So, in the following two years, I changed doctors, got a Rheumatologist, and got off of all the psychiatric medications with the help of another psychiatrist. That was a very difficult two years but at least I knew what I was doing. He saw no sign of bipolar disorder and neither did I. I am probably still recovering from being on those medications for so long, but I feel that I now have MYSELF back. I was not myself for a very long time. What a relief and what freedom I feel. I keep having astounding realizations about my life and I am beginning to understand it in much more depth now. I am seeing an excellent art therapist at present.

    All I can say is that I am baa-ak and delighted to be here! I think that anyone interested in TMS must research it themselves, learn all they can about it, talk to doctors and patients also if possible – and make up their own minds. A close friend in another state had TMS treatment at the same time I did and her experience was also good. I had ECT early in my life and I would never recommend that for anyone! I think it would have to be a last, desperate measure if nothing else would work.

    • Thank you so much for sharing your experience.
      That’s really great that you got your Real You back.
      Would you mind sharing who your psychiatrist was that helped you wean-off from the medication.
      By the way do you recon that TMS might have also contributed to the process of weaning-off your medications.
      Kind regards
      Fay

      • Dear Fay,

        I feel that any psychiatrist who is worth anything will help wean you off any medications you wish. All you have to do is ask for what you want. If he/she will not help you, find yourself one who will help you. I had no problem doing this.

        The TMS had nothing to do with my weaning off the medications. This was my highest desire and I did it on my own and it was difficult and scary and horrid. You have to research doing this and make up your mind to do it. It took me about two years. Some meds took longer than others to get off of. I did it; anything is possible!

        Since I went off of Alprazolam/Xanax, the last one to go off of, I have had panic attacks; I never, ever had a panic attack until I went off of this horrible medication. I am working on getting rid of this problem. I wish I could sue someone but I can’t.

        Remember that there are absolutely no guarantees with TMS. I feel that I was very fortunate.

        Best Regards

      • Dear Fay,

        To wean off the psych meds, it was not a big deal at all. I just went to a different psychiatrist who had an office at the local hospital. He retired and I kept going to the young psychiatrist that replaced him. I think that any psychiatrist would HAVE TO help you to wean off if you requested this. Honest! Just try one and if he/she doesn;t want to help you, try another one until you find one who will.

        I will tell you that when I told the young psychiatrist that I felt I had never had bipolar disorder, he said to me, “Oh, most patients just “burn out” when they get older.” BURN OUT? HEY, I WAS NEVER, EVER EVEN ON FIRE! Honestly, I never was bipolar. It is a shame what was done to me. I was so heavily sedated that I never questioned it. I am now almost 75 years old and I am in therapy for complex PTSD re my childhood of emotional neglect and emotional abuse. That’s what the problem was all along.

        Good Luck and Best Regards,
        Judith

  9. Much enjoyed reading this article. I am about to start seeing a psychiatrist for the first time in my life. He has a small website of which about 30% is taken up with TMS. Thought that looked concerning and I decided to do some research. I read the published articles and found it odd to only read positives, that didn’t seem reality. Am very happy to have found this article to bring matters in perspective.

    Am very happy for those the treatment works. For me, I find capitalism and medicine a scary concept. I am from the Netherlands and love living in the US for the past 15 years (I am a US citizen), but I worry about the medical system where it often seems that making money is the engine driving medicine. The fact that this treatment is extremely expensive clearly makes it much more interesting to a psychiatrist – especially compared to his normal office consultation.
    In addition, I would think that any insurance company would jump at a one time expense of $5000-$11000 compared to a lifetime of doctor consults and medication.
    The fact ‘maintenance’ is required makes me think it’s clearly the psychiatrist who feels happiest.
    I find it extremely scary to fire braincells, there’s no accurate method of true assessment on what exactly happens within the brain and what it’s long-term effects will be.
    I have been taking 3 anti-depressants for over a year and only feel worse. I am not even sure depression is the issue. And I am not sure if I should see a psychiatrist now…..

  10. Yes, you are right about the TMS psychiatrist being very happy about the $11K+ that I paid him up front. It seemed to me that the money is all he cared about. Blatantly. And I was told that “people come from all over the world to see him.” So the guy has big, fat income from all over the world. Whoop-dee-do for him!

    Unfortunately, my insurance carrier did not cover this. I live in the Southwest. If I had moved back East and gotten better insurance, it could have been covered, as it covered my friend in the East. At the time, only certain insurances covered it. You can research this. I was not about to move, had enough troubles. The TMS psych told me he’d”try to get them to pay for it” which was total B.S.

    I still don’t regret doing it. It worked for me and it changed my life for the better. I am just also poorer, of course.

    I will not ever take an antidepressant again because of the terrible side affects. They are worth trying if you need to because they work well for some people, just not for me and sometimes only VERY temporarily for most.

    EVERYTHING is a risk in psychiatry. It is all unproven “theory.” You might want to consider seeing a psychologist instead and delving into your childhood issues. Take them seriously. I feel that is mainly where it is at for most people.

  11. I was desperate enough 4 years ago to try TMS. This Doctors price was $12,000. I had suspicions of something not being legit about their services. I stopped going when left alone one day during the treatment. The finance company they signed me up with even withdrew.

    Now the Doctor is suing me for their payment. I need any helpful advice I can get to fight these people. I have no money for an attorney. I struggle just to maintain my independence.

    • Why in the world did you leave during treatment? You were committed to pay for this when you began treatment. Why didn’t you ask about your suspicions that it wasn’t legitimate?

      I am sorry but I cannot offer you any help re dealing with being sued except to perhaps see if your local Legal Aid office might help you. I can suggest that it might help you to see a psychologist and get help dealing with this problem emotionally and also help recovering from this experience. I mean a psychologist, definitely NOT a psychiatrist.

      • I left because I no longer trusted the individual to give the treatment. You don’t leave patients alone during this because of the risk of seizure . I don’t need help recovering from the. experience and unless you have helpful advice, please keep your opinion to yourself.

  12. I discontinued Brainsway deep tms treatment after approximately the 20th one. I wish now I had not not taken the treatments.
    I developed tinnitus just after the 3rd treatment and I was told it should fade out over time. By the 20th treatment, the high pitched static sound was so loud, so consistent and painful I could no longer tolerate the treatments. Plus there were migraines after each treatment.
    I was given and used hearing protection and honestly didn’t think the machine was horribly loud. My doctor and I agreed stopping treatment was the best option.

    Now, nearly 3 months after stopping the Deep TMS, I still have tinnitus accompanied by severe sound sensitivity. I’m now unemployed, have no insurance and live with this horrible sound that never stops. I simply cannot afford the $300 per visit to go back to the doctor. If anyone has any suggestions, they would be greatly appreciated. Please help. I’d rather go back to being depressed or be deaf than to hear this horrible screeching noise, not be able to tolerate a tv, and no longer enjoy the music I once loved. I’m back on Xanax to help me cope with the tinnitus and sound sensitivity. I’ve tried all the over the counter remedies available and wear earplugs like people wear ear rings.
    I’ve even tried listening to pink noise and brown noise.
    Has this happened to anyone else? Will it ever go away? Does Brainsway know this is a side effect?

  13. You’ve tried very hard to pick apart the results of rTMS, but the evidence for its stunning efficacy just keeps getting stronger. Direct brain stimulation is NOT the same thing as psychiatric medication, nor is it linked to it, and it is disingenuous and grossly irresponsible towards people suffering from mental disorders to suggest otherwise.

    This series of videos from the fall of 2014 discusses the remarkable results of over 1,000 rTMS client treatments at Toronto Western Hospital for depression, OCD and eating disorders:

    https://www.youtube.com/watch?v=-qSfVMDQtHw&t=2578s

    https://www.youtube.com/watch?v=x1D5OXCuQro&t=1211s