After reading 3,000 Pulses Later in 48 hours, two questions pounded in my head. How does a psychiatrist determine whether TMS (transcranial magnetic stimulation) or ECT (electroconvulsive therapy) is the right treatment for a depressed patient? And, as an informed consumer of medical care, when is the right time for patients to lobby their doctors for either TMS or ECT? Martha Rhode's new memoir regarding her positive experience with Transcranial Magnetic Stimulation (TMS) made me wonder if some of my information about these two procedures was out of date. If her experience with TMS is the norm, I wondered if TMS would be a good alternative for me if I ever became seriously depressed again.
I consulted Dr. Shawn McClintock, Associate Professor of Psychiatry and Behavioral Sciences, Duke University School of Medicine for information on this article. In addition he was a consultant in 2011 for Shire Development, LLC, regarding neurocognitive function information. He's currently on the teaching faculty for the ISEN (International Society of ECT and Nuerostimulation) TMS Course, and the Duke ECT Fellowship Program.
Dr. Shawn McClintock on a panel in Dallas, TX
Dr. McClintock studied both ECT and TMS when he was at UT Southwestern Medical Center and has continued his research at Duke. Considering he does not administer ECT or TMS, but rather assists clinical teams
and clients regarding the choice of ECT or TMS, I thought he might have a more objective opinion on when each should be used. My conversation with him showed that although TMS is a viable procedure, it fails to come close to the effectiveness rates of ECT. There are significantly fewer side effects with TMS, however, so TMS might be a good alternative for some.
First, a layperson’s explanation of each therapy might help. TMS uses magnetic coils to create electrical currents that stimulate the brain. A TMS patient will usually have 20-30 treatments. In the first treatment, the patient has a slightly longer session (1.5 hours approximately) followed by 5 days a week for 45 minutes per session. Dr. Oz did an episode on TMS.
ECT uses an electrical current to create a theraputic seizure, which causes a dramatic reset of the brain. Psychiatrists often cringe when I use this analogy, but think of restarting a computer that is frozen from too many applications running simultaneously. Typically a course of ECT involves approximately10 sessions. ECT requires anesthesia and muscle relaxants, and often providers prefer the first three sessions to be provided on an inpatient setting, with the remaining performed on an outpatient basis (although this varies by provider). Sessions are typically administered MWF, and the fequency of sessions may vary during the acute course. Dr. Oz did an episode that actually shows the ECT treatment.
Both ECT and TMS are typically used after an attempt to treat depression with medication produces unsatisfactory results. Occasionally, TMS is used as a first level treatment. In certain professions, some psychiatric medications are prohibited (e.g., pilots) so TMS might be considered as a first round alternative. Determining whether to use ECT or TMS is really a matter of weighing the risk level of the depression, convenience, cost and potential side effects.
Risk level of the depression
According to Dr. McClintock, ECT has a 75-83% success rate in battling depression (however without continued treatment such as medication or Maintenance ECT, many patients may relapse). TMS seems to work better with patients who’ve had no success with one round of psychiatric medication, having response rates as high as 30%, about the same effectiveness as antidepressants. The more rounds of antidepressants a patient has tried without success, the less likely TMS may work. Many patients turn to TMS in situations when medication is ineffective or the side effects of medication are intolerable. However, as seen on the Dr. Oz video, some patients try multiple rounds of medication with no success, and find relief with TMS.
It’s always possible to try TMS first and then escalate to ECT if TMS does not work. The main consideration in trying TMS is whether or not the patient can withstand the time it takes to try TMS. If someone is actively suicidal, waiting six weeks while trying TMS involves more risk for suicide. Beyond that, if the patient has tried numerous medications with no success, chances are TMS will not be successful.
TMS has clear advantages over ECT in this area. TMS is minimally invasive. No anesthesia or hospital stay is required. A TMS patient can drive herself to and from treatments and plan the TMS session as a break from work. ECT does require anesthesia and often a hospital stay the first week of treatment. The patient will have to arrange transportation to and from ECT sessions.
In terms of length of time in treatment, ECT (with ten sessions) takes about four weeks with fewer sessions per week than TMS. Although administration ECT takes minutes, by the time a patient receives anesthesia, recovers and is reoriented again, most people will require about two to three hours for an ECT treatment. TMS takes less time and is less disorienting per treatment, but a complete round of treatments lasts about six weeks with sessions five days a week.
On a sheer treatment basis, TMS is clearly less expensive than ECT. These prices vary by provider, but TMS is typically in the range of $400-500 per session for a total cost of about $15,000. ECT around $2,500 per session, $25,000 for ten sessions, plus the cost of one week hospital stay in some cases.
Most insurance companies will cover ECT, and a growing number are covering TMS. If a patient is doing this out of pocket, TMS is cheaper. However, if the treatment does not work and the patient has to escalate to ECT, the patient has added an additional $15K to the already expensive ECT.
Potential Side Effects
The most common side effects of TMS are scalp irritation or headaches, but these usually subside within the first week. With ECT, headaches and muscle aches often occur. Some complain of cognition issues up to one month after the last treatment. Typically short-term memory is impacted during this month period, but most patients feel functioning is back to normal within six weeks. Some patients complain of long-term loss of some autobiographical information, but these are in the minority. In my travels talking about my book, I have found people who claim their memory has improved with ECT.
The appropriate treatment is best determined on a case by base basis with a psychiatrist. I’m not a psychiatrist, but if a friend or loved one approaches me about how to deal with his or her depression, this is the information I convey based upon my own experience and research. If the person is actively suicidal, I would not meander on steps 1-3. Of course, I always advise people to seek professional medical help.
- Maintain sleep, exercise, nutrition and stress management techniques (e.g., cognitive behavior therapy and meditation). All of these things will help no matter what therapy is chosen, and may be enough to thwart depression.
- If the above don’t work, try medication first with a good psychiatrist. Shop around, ask friends and family for recommendations. As with any type of doctor, not all psychiatrists are created equal. Medication does seem simpler than either TMS or ECT if it works.
- If medication does not work or the side effects from medication are intolerable, TMS seems a viable option. Ask your psychiatrist about this treatment. Check to make sure your insurance covers the procedure.
- If TMS does not work, or you have tried a long list of medications without success, or if you are actively suicidal, ask your psychiatrist about ECT.
As someone who tried ECT with great success in both 2001 and 2007, I can personally attest that the procedure works and can be life saving. In 2001, with what was likely bilateral ECT, my short term memory issues were bad enough that I stopped after 5 treatments. At the time I had ECT, I didn't realize there were different methods of ECT. By the time I researched the method used ten years later, I was unable to locate hospital records detailing the method of ECT used. My psychiatrist and I discussed this, and considering the form of ECT used at the time, and my memory issues, it is very likely I had bilateral. I detail my 2001 memory issues in my book Struck by Living, but also am quick to say the procedure saved my life. There are pockets of memory lost from the two weeks before, during and two weeks after ECT during that time. By pockets, I mean an hour here or there, not whole days. Considering I was suicidal and miserable during that time, I don't miss these hours. I have not noticed any autobiographical information lost from prior to the period right around ECT treatment in 2001. Although my memory isn't perfect, I have no lapse I would attribute to ECT. In fact, because I am more happy, engaged and challenging my brain on a daily basis, I feel like my memory is better today than it was 15 years ago.
In 2007, I had unilateral ECT. ECT worked in 2007 again, not as quickly or dramatically, but with far fewer memory issues. I completed 7 treatments during that time. According to Dr. McClintock, typically today treaments involve a lower pulse of electricity delivered over a longer period of time. When I had ECT, patients more typically had 6-12 treatments, and the Mayo Clinic still lists this as the typical number of treatments on their website. Dr. McClintock indicated that today, that 10 is a more typical range of treatment.
I’ve continued to function well on a very low dosage of an antidepressant. After my 2001 treatment, I did well until I discontinued medication in 2005, against the advice of my psychiatrist. I relapsed in 2007. Since 2007 I've taken a low dosage of antidepressant religiously with very positive results. I do have down days, but nothing like the devasting depression I experienced in 2001 or 2007. However, we should all realize that any medication or therapy is not the complete answer to mental health.
As I say in every talk I give, we all need to establish our own mental health plan that includes sleep, exercise, nutrition, stress management and social support. How we manage stress will change over our lifetime as we gain experience. Here is a stay well list I developed for college students, but I encourage you to develop your own. Medication, ECT or TMS alone is not the answer to mental health. They are tools to help jump start and maintain the brain. Please consult a psychiatrist to find the right ones to help you or the person in you life that is suffering with mental illness.
Many thanks to Martha Rhodes for the publication of 3,000 Pulses Later. This is an excellent read of a courageous woman’s experience with TMS.
More information on Julie K. Hersh can be found on her website: www. struckbyliving.com