Q & A featuring Manish Sheth, M.D., Ph.D., board-certified specialist in psychiatry and addiction medicine and expert in neuromodulation
The human brain is, among many things, an electrochemical organ. Contemporary psychiatry treats mental illness by modulating brain function using chemical and electrical approaches. Until now, this neuromodulation approach to depression mainly included drugs and sometimes electroconvulsive therapy for medication-resistant depression, both of which involve the risk of significant adverse effects.
Transcranial magnetic stimulation (TMS) delivers painless high-frequency pulses that penetrate neurocircuitry on the molecular level deep within the neurocircuit of the brain that regulates mood. TMS treatment programs vary according to patient needs and protocols, but generally involve 25-minute sessions about five days a week for four to six weeks. Over time, these pulses increase blood flow, metabolism, and trans-synaptic activity with often dramatic results.
Developed and tested over the past decade, TMS has been shown in over 35 clinical trials to be beneficial for the treatment of acute major depression with very few adverse effects. As a result, TMS is now covered by many insurance providers. To get a more detailed sense about the science and practice of this new treatment, we asked Dr. Sheth a few questions about his experience with TMS.
Question: With two doctoral degrees, double-board certifications in psychiatry and addiction medicine, and an extensive educational, clinical, and research background, your incredible knowledge base and expert opinion is valued. There seems to be a lot of excitement in the mental health community over TMS as a promising treatment for the common, yet difficult-to-treat illness of depression. What is the reason for all of the excitement?
Dr. Manish Sheth: What Prozac did for depression and mental illness, TMS is the next frontier for neuropsychiatric disorders. It is the beginning of a new era. This is a really exciting time where we are getting into the neurobiology of mental health and neurological disorders. Think of TMS as a fancy navigation system where we can specifically locate the area of the brain we are trying to target and either stimulate the neurons or calm them down. It has numerous applications above and beyond depression and anxiety. TMS is a treatment for Parkinson’s disease, autism, which was aired on NPR, post-concussions and schizophrenia, just to name a few. It has also been seen to help with addiction, with results demonstrating decreased relapsed rates and remission.
Q: How does TMS work?
A magnetic coil, similar in strength to an MRI, is placed on the patient’s head. Magnetic pulses are sent across neural pathways to activate regions of the brain involved in mood regulation, such as the prefrontal cortex. This helps restore brain function for lasting change, with complete remission reported in some cases.
Q: What kinds of depression does TMS treat? Do patients with depression experience any additional beneficial effects from treatment?
TMS helps with all kinds of depression. Although it is FDA-approved for treatment-resistant depression, it is very quickly becoming a first-line treatment for depression for busy patients who want to get better faster. It improves all the neurovegetative symptoms of depression such as mood, anxiety, energy level, sleep, suicidal thoughts and motivation.
One of the first changes we see with TMS treatment is an improvement in sleep — quantitatively as well as qualitatively. We have often had to reduce the dosage of sleep medications for patients, as they sleep better and deeper and have a more restful sleep after treatment.
A very distinct improvement which is seen with TMS treatment other than improvement in mood is significant improvement in memory, cognition and processing skills. Patients have remarked that their thoughts are crisper, sharper and more focused. We have actually had a patient tell us that their scrabble and Sudoku scores have improved significantly.
Q: Can any other disorders be treated with TMS? If so, is the protocol different for various diagnoses?
TMS is FDA-approved in the U.S. for treatment-resistant depression, but it has CE approval in the U.K. for addictions, Alzheimer’s disease, autism, bipolar, smoking cessation and more.
At Achieve TMS Center, we have developed specific protocols for the treatment of attention-deficit hyperactivity disorder, movement disorders, post-concussion symptoms and anxiety. We have had patients come from as far as Australia, Canada and Mexico specifically for treatment of these conditions.
TMS also appeals as a type of treatment to a very distinct population of patients. For example, pilots who are not allowed to be on medications while working will choose TMS as their treatment method. This treatment also appeals to pregnant women because there is no radiation and will not cause any harm during their pregnancy.
Q: Which patients benefit the most from TMS?
All patients see some improvement with TMS treatment. One practical aspect to TMS is that it is a time commitment. We also want patients to continue taking medications as prescribed, going through therapy and making positive changes while their brain is “waking up” or recovering. We also encourage drinking lots of water and we provide a food list to inspire healthy eating that includes all of the nutrients that the brain requires to function normally.
Q: Are there any contraindications to TMS or can anyone try it?
There are no absolute contraindications to TMS. Psychotic symptoms and uncontrolled seizures need to be stabilized before starting TMS treatment. We do ask if there is any metal in or around the treatment area. We have had a patient with a titanium plate implantation, but after consulting with their neurologist, the patient was cleared for treatment. We have also treated a patient with a pacemaker. After consulting with the cardiologist who was present for the first couple of treatments to monitor the activity of the pacemaker, there was no change in rhythm of the heart during treatment and TMS did not affect the pacemaker function in any way.
Q: What are the risks of TMS? Are there any side effects?
There are minimal risks to TMS. There are no systemic side effects such as weight gain, sexual side effects, insomnia, etc., that may be caused by some medications. There is also an extremely low risk of seizures, less than the risk of Wellbutrin. Some patients have systemic, localized headaches, which can be controlled with nonprescription pain relievers.
Q: Is TMS like electroconvulsive therapy? Do people undergoing TMS have seizures?
TMS is nothing like electroconvulsive therapy. ECT is invasive, involves anesthesia, headaches and possible memory loss. Patients who undergo ECT treatment are at risk for aneurysms and must be cautious if they have a pacemaker. TMS is a noninvasive treatment with absolutely no systemic side effects. Patients are able to drive themselves to and from treatment. Many of our patients who are working or going to school will come in during their lunchtime for treatment before returning.
Q: What is the most important thing for people to know about TMS?
Medications help some patients get 30 percent better, but TMS helps patients get 70 percent better. It is not a magic bullet but it is definitely an exciting, cutting-edge treatment. I predict TMS will become the first line of treatment for depression and other conditions within the next few years.
This is a very exciting time in neuropsychiatry. There was also an NPR piece on a patient with autism who underwent TMS treatment. There have been so many advances in this treatment. It has also been seen to help with addiction. Depression and anxiety are often comorbid with addiction and patients often self-medicate. TMS will collectively help with the depression, anxiety and addiction.
About Manish Sheth, M.D., Ph.D.
Dr. Manish Sheth, M.D., Ph.D., is licensed and board certified in psychiatry and addiction medicine. He has experience working with patients who have various conditions, including depression, bipolar disorder, obsessive-compulsive disorder (OCD), anxiety, attention-deficit hyperactivity disorder (ADHD) and other mental disorders.
Dr. Sheth also applies his background as former clinical director of genomics and work with genetic technology to help create an individualized treatment regimen. In addition, he combines neuromodulation — the noninvasive electromagnetic stimulation of specific brain areas — and neuropharmacology to provide cutting-edge care to each of his patients. He keeps up with new advances in the field of psychiatry, including novel therapy techniques and medications, and is trained in the administration of TMS. Sheth strives to help his patients achieve their maximum potential in their social, educational and professional lives.
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