Introducing TMS: A New Service Option for Treatment-Resistant Depression and OCD

Approximately 19.4 million adults in the U.S. have been diagnosed with major depressive disorder, also known as major depression. An additional 2–3 million adults live with obsessive-compulsive disorder. Together, that’s 9% of the total adult population whose daily lives are affected by these common disorders.

Many of these individuals can find relief from their symptoms with the use of psychotherapy, medication, or a combination of both. With a little help from medical professionals, most people can learn to manage their disorders and live full, enriching lives in spite of their mental health challenges.

However, about 33% of people with major depression and 40–50% of people with OCD do not see improvement in their condition even after undergoing the normal treatments. In these cases, their disorder is known as “treatment resistant.” Treatment-resistant disorders can severely impact a person’s daily functioning and destroy any hope that their condition will ever improve.

Finding new ways to manage treatment-resistant disorders is an ongoing challenge in the mental health field, but breakthroughs do happen. One notable development is transcranial magnetic stimulation, or TMS, which has been found effective at helping individuals with treatment-resistant depression and OCD. Although results vary from person to person, research has shown that 73% of participants with depression and 58% of participants with OCD see a noticeable reduction in their symptoms after a full course of TMS treatment.

Cummins has recently received a Federal grant that will allow us to provide TMS treatment for our consumers at our Avon office. We’re very excited for this opportunity to better serve our community, and we want to answer any questions you might have about this new treatment!

In this blog post, Cummins’ Medical Director Dr. Steven Fekete explains who will be eligible for this treatment, how it is different from other forms of treatment, and what you could expect if you were to begin a course of TMS treatment at Cummins.

(Steven Fekete, M.D., Medical Director at Cummins Behavioral Health)

What Is TMS?

Transcranial magnetic stimulation is a form of treatment that uses electrical impulses and magnetic fields to affect the functioning of the brain. These impulses are created by a series of powerful magnets, which are placed around the patient’s head and controlled by a special machine.

Dr. Fekete explains, “The machine creates these little magnetic fields over different parts of the brain, and those magnetic fields then induce the brain cells to depolarize or become active, therefore regulating brain activity and helping that individual address the symptoms that they’re experiencing from their disorder.”

The electrical impulses are administered in waves over a period of several minutes, so this treatment is technically called repetitive transcranial magnetic stimulation (rTMS). The latest equipment is also capable of sending these impulses deeper into the brain than earlier machines could, which makes this specific form of rTMS deep repetitive transcranial magnetic stimulation (drTMS).

As we said above, drTMS is targeted toward individuals who suffer from treatment-resistant depression or OCD. “Treatment resistant means a person has used at least two antidepressants at maximally tolerated doses for six weeks, and received a course of evidence-based therapy, and they just did not get the response that they had hoped to,” Dr. Fekete explains. “Unfortunately, in the psychiatric field, the response rates of antidepressants are not where we’d like them to be. So there are a lot of individuals who experience this.”

At Cummins, we are especially interested in making drTMS available for individuals who get their health insurance through Medicaid, as this population has had poor access to TMS treatment in the past. “Treatment for depression is reimbursable through Medicaid, but there are a lot of individuals who we specifically want to target because Medicaid doesn’t pay for it. For example, we’re using the grant to help pay for individuals with OCD,” Dr. Fekete says.

How TMS Treatment Works

As we’ve mentioned, drTMS works entirely through the use of electromagnetism.

“An individual comes into the office, and they sit in a chair under this thing that kind of looks like an old hair dryer,” Dr. Fekete explains. “And they wear a cushioned helmet underneath this more rigid helmet.”

When the machine is turned on, the exterior helmet passes electric currents through a series of electromagnetic coils. The person wearing the apparatus can hear this as a repeated tapping or clicking sound. The coils inside the helmet create an electromagnetic field that reaches about 1 to 2 inches into the wearer’s brain, which stimulates neural activity in specific areas of their brain. For example, for patients suffering from depression, the apparatus is configured to stimulate the dorsolateral prefrontal cortex.

The magnetic field is similar in intensity to an MRI scan, and it is safe for the majority of people. However, side effects of drTMS treatment can include headaches, pain or discomfort at the treatment site, and jaw pain. No individual who has metal on or inside their head (which may include plates, medial devices, shrapnel, or metallic tattoos) is eligible for drTMS treatment, as the magnetic fields can be dangerous for these persons. Other possible contraindications include suicidal ideation, psychosis, substance use, and pregnancy or lactation.

Other pros and cons of drTMS include:

Pros

• The treatment is non-invasive and is performed in an outpatient setting
• Most patients can drive themselves to and from their appointments
• No memory loss or cognitive impairments
• Any medications may be continued during treatment

Cons

• Risk of minor side effects (headaches, site pain, jaw pain, muscle twitches)
• Very low risk of seizure, mania activation, and hearing loss
• Large time commitment (20-minute sessions for 30–36 days over a span of 6–12 weeks)

Dr. Fekete sums up the pros and cons of drTMS: “To me, the biggest advantage is you can drive to the appointment and drive away. The biggest downside is it’s very time consuming. I think about people who work, or who have responsibilities for children, or maybe responsibilities for an older adult or somebody else in their life. That may be very difficult to get around. They may have to arrange for somebody to take care of things at home while they’re gone. But once they’re done, they’re not impaired from the treatment to do whatever they need to the rest of the day.”

(Example of what the drTMS machine looks like when in use.)

A Typical TMS Treatment Session at Cummins

If you or a loved one are eligible for drTMS treatment and choose to receive it through Cummins, it begins with a conversation with our Central Access Office.

Dr. Fekete explains, “An individual would reach out to our Central Access saying they’re interested in getting TMS. We would also take a referral from a provider who might call us and say, ‘I have such and such, would they be eligible for getting TMS?’ “

Depending on the person’s eligibility and insurance coverage, the next step would be an initial consultation about drTMS services. “We would set up an appointment for that individual where we would come in and interview them,” Dr. Fekete says. “This psychiatric evaluation takes about an hour. We would go over the process with them and then determine if they are still interested in in it after reviewing the risks and benefits, side effects, etc. We would also take them over and show them the treatment room as long as there wasn’t anyone in there.”

Next would come the first drTMS appointment, which involves taking neurological measurements of the patient’s brain. “We map their activity in their motor cortex, and a percentage of that is utilized to adjust the magnetic impulses that will be used in their treatment,” Dr. Fekete explains. “It takes about an hour. Either myself or the other physician would be there the majority of the time, because we’re doing that mapping with the assistance of a technician.”

After this mapping session, the patient can begin attending treatment sessions based on the schedule determined with their provider. “It’s usually 30 treatments that are 20 minutes each,” Dr. Fekete says. “After the first appointment, you would not necessarily interface with the prescriber, you would interface with the person who is going to be setting up the machine. You would come in for your 20 minutes, and then you would leave. And that’s it.”

As you progressed through treatment, you would also continue your normal therapy or psychiatry appointments, if you were receiving these services. Dr. Fekete explains, “The TMS is freestanding, yet part of a larger approach to managing some of these more significant treatment-resistant illnesses that we face. The nice thing is that the TMS is one item in an armamentarium we can use to help people manage their illness. So it fits in with medication, it fits in with therapy, skills training, self-help groups, mutual help groups, and meditation.”

According to Dr. Fekete, the most important aspect of drTMS treatment at Cummins is that we are able to bring a new standard of care to people who did not previously have access to it. He says, “I only know of one other place in Indiana that currently provides TMS for the Medicaid-based population. This has been around for 13 years, it’s FDA approved, it’s Medicaid payable, but it’s not being offering to these people. This gives people access to care that they should have had since 2008.”

If you are interested in exploring the possibility of drTMS treatment for yourself or someone under your care, we encourage you to speak with your psychiatrist, therapist, or care provider. If you would like, you can also call us at (888) 714-1927 to speak with someone about drTMS services.

Suffering from a treatment-resistant mental illness can be extraordinarily difficult and discouraging, but with the help of new treatment technologies like drTMS, recovery is possible!