Raul J. Rodriguez MD, DABPN


Treatment resistant depression is one of the most crippling and emotionally devastating conditions known to man. The loss of hope in ever recovering from a disease that does not respond to conventional treatment and has hopelessness as one of its symptoms can lead to a deadly downward spiral. Many good medications have been developed to treat Major Depression over the years, but sometimes the disease can be too severe and the medicine does not work. Some intensive treatments, such as ECT (Electroconvulsive Therapy), are very effective but have severe side effects. This leaves many patients seeking a better solution. This dire need for a better solution led to the development of TMS.

So what exactly is TMS? TMS is the acronym for Transcranial Magnetic Stimulation, which is a cutting edge treatment for depression that involves stimulation of brain tissue using electromagnetic pulses. This non-invasive procedure improves symptoms of depression by activating the parts of the brain associated with mood control and depression. TMS has grown in popularity due to the high degree of effectiveness while having very few side effects and absolutely no circulation of medication in the bloodstream. The process starts with the placement of an electromagnetic coil over the scalp near the forehead. The motor strip, the area of the brain responsible for movement of limbs and muscles, is then mapped out. This is necessary in order to subsequently determine the location of the lateral pre-frontal cortex. The actual procedure involves delivering a sequence of magnetic pulses to the left lateral pre-frontal cortex to induce stimulation. The magnetic pulses pass through the scalp and the skull to reach the target brain tissue. TMS activates the actual neurons by inducing an electrical current in the part of the brain cell called the axon. This current travels to the nerve cell body and then affects other connecting brain cells. This stimulation ultimately creates the powerful antidepressant effect. TMS is indicated when conventional treatments for Major Depression have not worked. TMS is also an option for individuals who suffer from Major Depression and do not wish to take medications. TMS was approved by the FDA for the indication of treatment resistant depression in 2008. Deep TMS, possible with the newer generation of TMS technology, was approved by the FDA for the indication of treatment resistant depression in 2013.

Deep TMS, also known as dTMS, refers to a more deeply penetrating form of TMS now possible, using the newer generation of TMS technology produced by the Brainsway Corporation. Brainsway has engineered the H1 dTMS coil that was approved by the FDA for the indication of Treatment Resistant Depression. The H1 coil produces a magnetic pulse that stimulates a larger area than a traditional figure 8 coil. The stimulation also penetrates deeper, reaching 1.7cm into the cortex. The benefits of this have to do with both a more complete stimulation of the target area, as well as some stimulation of the neighboring areas of the brain that interconnect with the target area. The risk of dramatically losing efficacy from deviating even just 1mm from the target area is greatly diminished using a Brainsway device, as compared to a traditional figure 8 coil, due to the larger and deeper area of stimulation. The treatment session consists of up to 2,500 pulses delivered over a time span of approximately 20 minutes. This all helps yield higher rates of both response and remission of Treatment Resistant Depression.

So we have seen what TMS can do as far as having very high response and remission rates in severe grades of depression. What is TMS like though? The very first step is proper screening and evaluation. TMS has an FDA indication for Treatment Resistant Depression, although many practitioners have reported even better results in the non-resistant grades of Major Depression. Individuals do have the option of receiving TMS for a non-resistant grade of Major Depression, as an off-label usage of this medical technology. Insurances will only cover the FDA indication for Treatment Resistant Depression though.

Treatment Resistant Depression is most commonly defined as a Major Depressive condition that has not responded to at least four different antidepressants, including medications from more than one antidepressant category. Appropriate candidates would also have not responded to one or more “augmentation” strategies, which is when a secondary medication is added to boost the effect of the primary medication. Appropriate candidates commonly also would have failed a course of psychotherapy. Some may have also even failed ECT. A medication “failure” is defined as not achieving an adequate response after reaching the maximum dose for at least 4 to 6
weeks, or not being able to tolerate the medication at any point in the dosing range. A “response” is most commonly defined as a 50% reduction in symptom intensity based on depression rating scales. Most people will appropriately determine a medication non-response by simply recalling that it did not make them feel much better. An antidepressant that once worked but at some point stopped working, would also constitute a failure. Others, again, simply could not tolerate a medication due to side effects. Some cannot tolerate a medication at all, at any dose. Some cannot tolerate a medication at the dose that it would take to get it to work. Either way, it is considered a medication failure. After a patient has been determined to have actual Treatment Resistant Depression, the next step is to make sure there are no medical conditions that are TMS exclusions.

Please read part 2 in the February 2018 issue of The Sober World.
Dr Rodriguez is the founder and Medical Director of the Delray
Center For Healing, the Delray Center for Brain Science, and
the Delray Center For Addiction Medicine. He is board certified
in both Adult Psychiatry and Addiction Medicine, with a clinical
focus on Treatment Resistant Depression, Bipolar Disorder,
Anxiety Disorders, Addiction and Eating Disorders. The Delray
Center is a comprehensive outpatient treatment center that
incorporates the most advanced psychotherapeutic and medical
modalities, such as Dialectical Behavioral Therapy (DBT) and
Transcranial Magnetic Stimulation (TMS), in the treatment of
complex and dual-diagnosis cases. www.delraycenter.com,