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Clinical Briefing: Transcranial Magnetic Stimulation (TMS) for Treatment-Resistant Depression

September/October 2008

At the Penn Comprehensive Depression Center, an office-based investigational procedure has shown significant promise for the treatment of major depression in patients for whom psychotherapy and antidepressant medications have not been effective.

Called transcranial magnetic stimulation, or TMS, the treatment involves placing an insulated coil on the scalp surface that issues brief electromagnetic pulses to stimulate neurons in the cerebral cortex. TMS treatments are administered in an outpatient setting under the supervision of a licensed MD, usually a psychiatrist. A full course of treatments can range from 15 to 30 sessions, with sessions typically conducted five days per week over a three – four week period. When an acute course of TMS has been effective, long term maintenance treatment sessions are usually administered about twice per month.¹

Although the mechanism of action of TMS in depression has yet to be fully elucidated, reports emanating from Penn and other research centers support its use as a therapeutic intervention in mood and anxiety disorders.² In a recent, large, multicenter clinical trial of TMS in major depression, patients treated with TMS therapy had an almost twofold higher remission rate at six weeks compared to patients in the control group.³

The side effects of TMS are mild and transitory, and may include mild headache or scalp discomfort at the site of stimulation.⁴ In contrast to electroconvulsive therapy (ECT), the standard treatment for refractory depression, no significant cognitive adverse effects (including memory impairments) are associated with TMS. Moreover, because TMS is a non-systemic device treatment, it avoids problems like weight gain, sedation and sexual dysfunction that can be problematic with medications.

Case Study
Mrs. K, a 43-year-old woman, came to Penn's Comprehensive Depression Center for a second opinion when her psychiatrist recommended consideration of electroconvulsive therapy for the treatment of her severe depression. At presentation, Mrs. K reported low mood, anhedonia, hopelessness, insomnia, weight loss and low energy, as well as significant impairment in her daily functioning. Mrs. K, a full-time teacher and mother of two young children, was finding it extremely difficult to keep up with her work and home responsibilities.

This was the third episode of major depression in her lifetime and adequate trials of antidepressants and a course of psychotherapy had failed to relieve her depression on this occasion. Following a careful weighing of her options, Mrs. K elected to pursue TMS as an off-label treatment for her depression at Penn.

After 20 sessions of TMS over four weeks, her depression responded. TMS was well tolerated with the only side effect being mild scalp discomfort during the first week of treatment. TMS was tapered to a session frequency of twice per month, which was continued as maintenance treatment for the next 6 months. Mrs. K made a successful return to work and was gratified to find that her cognitive functioning was as sharp as before. She now takes an antidepressant as prophylaxis against recurrence and is reassured by the knowledge that TMS is available to her as an option should she need further treatments in the future.

Our Team of Faculty
Comprised of psychiatrists, psychologists and dedicated support personnel, Penn Psychiatry's Comprehensive Depression Center specializes in the study of the causes of depression and anxiety, and treatments for these conditions.

The TMS Treatment Team

John P. O'Reardon, MD
Associate Professor of Psychiatry

Michael E. Thase, MD
Professor of Psychiatry

Deborah Kim, MD
Assistant Professor of Psychiatry

Pilar Cristancho, MD
Instructor, Fellow in Mood Disorders and Neuromodulation

For further information about transcranial magnetic stimulation, visit www.med.upenn.edu/tms.

Access

Department of Psychiatry
Penn Behavioral Health

3535 Market Street
Philadelphia, PA 19104
1.866.301.4PBH (4724)

To refer a patient and/or consult with a doctor about TMS, call 215.573.8582 or visit www.med.upenn.edu/tms/contact.

References

1. O'Reardon JP, Blumner KH, Peshek A, et al. Long-term maintenance therapy for major depression with left prefrontal repetitive transcranial magnetic stimulation (rTMS).
   J Clin Psychiat. 2005;66:1524-1528.
2. O'Reardon JP, Solvason HB, Janicak PG, et al. Efficacy and safety of Transcranial Magnetic Stimulation in the acute treatment of major depression: a multi-site randomized controlled trial. Biol Psychiat. 2007;62:1208-16.
3. Janicak PG, O'Reardon JP, Sampson SM, et al. Transcranial Magnetic Stimulation (TMS) in the treatment of major depression: A comprehensive summary of safety experience from acute exposure, extended exposure and during reintroduction treatment. J Clin Psychiat. 2008;69:222-232.
4. Lisanby, SH, Kinnunen LH, Crupain MJ. Applications of TMS to therapy in psychiatry. J Clin Neurophysiol. 2002;19:344-60.

	Referring Physicians: To speak with a Penn physician or refer a patient, contact PennHealth through the secure online referral form or by calling 1-800-789-PENN (7366).