Illustration by Angela Krieg
In our new column, Weighing the Options, we look at various mental health treatments and terminology to help you make more informed choices regarding your mental health care. Today, we take a look at Transcranial Magnetic Stimulation (TMS) and Electroconvulsive Therapy (ECT), two cranial therapies used to treat severe depression.
What is ECT?
Electroconvulsive Therapy (ECT) is one of the oldest psychiatric treatments around, first introduced roughly 80 years ago in Rome. ECT, historically referred to as “electroshock therapy” is a treatment in which small electric currents are passed through the brain, intentionally inducing a brief seizure. During and after the seizure, many chemical aspects of brain function are changed.
The negative stigma surrounding ECT negative comes from an admittedly complicated history—but the current treatment has little in common with a treatment administered by Nurse Ratched.
ECT can provide significant relief in a short period of time for severe or treatment-resistant depression, severe mania, catatonia, and agitation and aggression in people with dementia. In circumstances where a patient cannot take medications (if allergic or pregnant, for example), or for whom standard medications haven’t worked, ECT may be the best treatment option.
Side effects from ECT and anesthesia are minimal compared to earlier forms of the treatment. Short term side effects can include confusion, nausea, headaches, and jaw pain, while long term side effects can include memory loss, and retrograde amnesia. ECT is also risky for people with heart conditions, as blood pressure and heart rate increase during treatment.
ECT treatment is usually about 12 sessions over 3-4 weeks. Some people can resume normal activities a few hours after treatment, others may be advised to wait 24 hours or until they have finished the entire course of treatment. Driving is usually not recommended.
The stigma attached to the treatment is from decades-old psychiatric standards and images of 20th century Hollywood, for example, One Flew Over the Cuckoo’s Nest and Requiem for a Dream. At the time, ECT used a higher electrical current and without anesthesia, with severe side effects including memory loss and fractured bones. ECT is much safer today, during which the body simply tenses and relaxes. The side effects have not been eliminated completely and like anything other treatment that requires a patient to be put under, ECT is not to be undertaken lightly.
What is TMS?
Transcranial Magnetic Stimulation (TMS) uses magnetic waves to activate neural pathways causing new healthier synapses to form. (The neurons that fire together wire together!) TMS is an FDA-cleared treatment for Major Depressive Disorder (MDD) and Obsessive Compulsive Disorder (OCD), with other protocols currently CE cleared for European use, and hopefully gaining traction in the US in the coming years.
There are two types of TMS: rTMS (repetitive TMS) and dTMS (deep TMS). Both repetitive TMS and deep TMS are safe, noninvasive procedures that follow similar protocols and would be used in similar situations. They both are based around repetitive magnetic pulses delivered to specific areas of the brain. The main difference between the two is the shape of the magnetic coils themselves.
RTMS uses a figure-8 coil, while dTMS uses a more three-dimensional ‘H’ coil. The H coil can cover a larger surface area and stimulate deeper into the brain’s structure. This makes deep TMS more advanced, with a slightly higher level of efficacy; dTMS also is the only FDA-cleared TMS therapy for OCD. At Brooklyn Minds, we use dTMS.
Over time, these pulses help regulate neural activity in areas of the brain associated with certain mental illnesses. If the need for treatment is urgent, accelerated TMS (50 treatments spread out over 5 days) can have similarly rapid effects to ECT without the need for general anesthesia. The main issue here is that very few clinics offer accelerated TMS treatment.
Deep TMS treatment generally involves sitting in a comfortable chair with a helmet (similar to a bike helmet) placed on a specific part of the patient’s head. The magnetic coil within the helmet generates repetitive magnetic pulses – which feel like taps – at specific intervals for between 6 and 30 minutes, depending on the treatment protocol. Unlike ECT, deep TMS the patient remains awake for the duration of the treatment and does not induce a seizure. Side effects could include headaches, jaw soreness, and occasionally nausea, which tend to be mild and lessen in severity over the course of treatment. Insurance usually covers 36 treatments, spread out over the course of 4-6 weeks.
What do ECT and TMS have in common?
Both ECT and TMS fall under the category of “brain stimulation” therapies. While both treatments can help people struggling with mental illness, neither should be seen as a cure-all. Even for those who enter remission through either ECT or TMS treatment, symptoms need to be monitored and ongoing depression treatment may be required to prevent recurrences of symptoms– whether that be through occasional ECT or TMS “top-ups,” therapy, medication management, or some combination of all three.
The development of TMS for treatment-resistant depression owes its existence to ECT; an article in the American Journal of Psychiatry states that, when developing the treatment, “ECT had provided clear evidence that regional electromagnetic stimulation could treat the illness.”
Why choose one over the other?
One of the main advantages ECT has over TMS is that its results tend to be a bit more immediate so may be the best choice for someone suffering from acute suicidality, when a few hours can be a matter of life and death.
However, TMS may be the better option for more complex cases because of the various protocols and ways that very specific parts of the brain can be targeted with both magnetic pulses and, if appropriate, exposures (for OCD). It also may be a better choice for those with medical conditions that are contraindicated for anesthesia.
The more treatment options that are made available for people with treatment-resistant depression, the more people can find relief from this life-threatening illness. Deciding on the right course of treatment for you is ultimately a conversation to be had with your psychiatrist.
