By Dr. David Woo - January 23, 2020
Deep TMS therapy, also called dTMS, is a type of transcranial magnetic stimulation (TMS) therapy that is FDA-approved to treat patients diagnosed with major depressive disorder (MDD), major depressive disorder with anxiety, and obsessive-compulsive disorder (OCD).
Additionally, a more recent development in Deep TMS, called theta burst stimulation, that delivers TMS at a lower level of intensity and within a shorter time, has been FDA-approved for the treatment of depression.
During dTMS treatments, a doctor or nurse fits a helmet that contains a metal coil over the patient’s head. The coil emits magnetic pulses that noninvasively stimulate brain cells located in specific regions of the brain associated with mood.(1)
Is dTMS Depression Treatment Effective?
Yes. Deep TMS has been clinically proven to relieve depressive symptoms, even in patients diagnosed with treatment-resistant depression. A randomized clinical study found that patients who receive dTMS are twice as likely to achieve remission compared to patients who were given sham or placebo treatment.(2)
Deep TMS is a type of repetitive TMS (rTMS). rTMS methods involve a series of magnetic pulses delivered to the brain, as opposed to single-pulse TMS, which is used in research settings for diagnostic purposes.(3) Both dTMS and rTMS are used in clinics to successfully treat depressive symptoms.
High-Frequency dTMS and Theta Burst dTMS
At Madison Avenue TMS & Psychiatry, we offer two kinds of Deep TMS treatments:
- High-frequency dTMS delivers pulses at a rate of 5 Hz or higher. These frequencies generally increase excitability in the brain, stimulating nerve activity in underactive regions of the brain.(4)
- Theta burst stimulation is a more recently developed method that has produced similar, if not greater, effects on brain activity when compared to traditional rTMS in clinical studies. Theta burst stimulation uses a more complex TMS signal that produces increased nerve activity with theta waves. Theta waves have been shown to activate parts of the mood circuit in the brain and facilitate the formation of new communication pathways. Theta burst dTMS has been shown to treat depression effectively, at a lower level of intensity, and in a shorter amount of time (three to ten minutes, compared to 20 minutes with traditional rTMS).(5)
Both high-frequency TMS and theta burst TMS are FDA-approved for treatment-resistant depression.
How Does dTMS Therapy Compare to rTMS Therapy?
Both dTMS and rTMS are FDA approved to relieve depressive symptoms in patients diagnosed with treatment-resistant MDD. So, what’s different between the two?
- The device used: Deep TMS is administered using the BrainsWay device, while rTMS is administered using the Neurostar® device.
- The shape of the magnetic coil: Deep TMS uses an H-coil, while rTMS uses an infinity coil (shaped like the infinity symbol).
- Stimulation depth: Deep TMS can stimulate the brain four to six centimeters below the surface of the brain, while rTMS can only stimulate one to two centimeters below the surface of the brain.(3,4)
- FDA-approved indications: Deep TMS was approved by the FDA for depression treatment in 2013, while rTMS was approved much earlier, in 2008. However, only dTMS has been FDA approved to treat anxious depression and OCD. (3,5,6) This doesn’t mean that rTMS can’t successfully be used to treat conditions other than depression – there are a number of studies that suggest that rTMS can be used successfully to treat other conditions off-label.
dTMS OCD Treatment
Both dTMS and rTMS can be used to safely treat symptoms of OCD, though only dTMS is FDA-approved for OCD treatment (and neither is approved yet for other non-depression conditions). FDA approval benefits patients because insurance companies will cover more of the treatment costs, but it is not the only indicator that a treatment option is safe and effective. A study published in The New England Journal of Medicine shows that repetitive TMS is safe and effective in reducing symptoms of OCD.(10)
The 2018 FDA approval of Deep TMS for the treatment of OCD is a big step in the right direction toward making TMS more accessible to patients with conditions like PTSD, anxiety, or traumatic brain injury.
TMS Treatment Safety
At Madison Avenue TMS & Psychiatry, our patients’ safety is our number one priority. TMS treatments are considered to be low-risk procedures that have mild side effects, such as scalp discomfort and headache, both of which can be treated with over-the-counter pain medication. TMS is associated with a rare, but serious, side effect – seizure.
The risk of seizure for the Neurostar® rTMS infinity coil is one out of 30,000 sessions.(11) The risk of seizure for BrainsWay’s H-coil is approximately one point five out of 10,000 sessions.(12)
The reason I use the BrainsWay device at Madison Avenue TMS & Psychiatry is that I think it is more effective than the Neurostar device. One big reason for this is that the BrainsWay process does not have the risk of error of missing the dorsolateral prefrontal cortex (DLPFC), the area we are targeting for the relief of depression. You achieve treatment of that brain center each and every time you give a treatment due to the wideness and deepness of the magnetic waves being administered.
With Neurostar, as with all of the other infinity coils on the market (Magstim, Magventure, and Nexstim), the mapping has built into its calculations an inherent error of not stimulating the area that we are interested in, the DLPFC.
1. What is Deep TMS and How Does It Work? BrainsWay. https://www.brainsway.com/patients-faqs/what-is-deep-tms-and-how-does-it-work. Publication Date Unavailable. Accessed December 05, 2019.
2. Levkovitz Y, Isserles M, Padberg F, Lisanby SH, Bystritsky A, Xia G, Tendler A, Daskalakis ZJ, Winston JL, Dannon P, Hafez HM, Reti IM, Morales OG, Schlaepfer TE, Hollander E, Berman JA, Husain MM, Sofer U, Stein A, Adler S, Deutsch L, Deutsch F, Roth Y, George MS, and Zangen A. Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial. World Psychiatry. February 2015;14(1):64–73. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329899/. Accessed December 05, 2019.
3. Klomjai W, Katz R, Lackmy-Vallée A. Basic principles of transcranial magnetic stimulation (TMS) and repetitive TMS (rTMS). Ann Phys Rehabil Med. 2015;58(4):208-213. https://www.sciencedirect.com/science/article/pii/S1877065715000792. Accessed June 28, 2022.
4. Wang J, Deng XP, Wu YY, Li XL, Feng ZJ, Wang HX, Jing Y, Zhao N, Zang YF, Zhang J. High-Frequency rTMS of the Motor Cortex Modulates Cerebellar and Widespread Activity as Revealed by SVM. Front Neurosci. March 19 2020;14:186. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7096733/. Accessed June 28, 2022.
5. Chung SW, Hoy KE, Fitzgerald PB. Theta-burst stimulation: a new form of TMS treatment for depression?. Depress Anxiety. 2015;32(3):182-192. https://pubmed.ncbi.nlm.nih.gov/25450537/. Accessed June 28, 2022.
6. Baeken C, Brem AK, Arns M, Brunoni AR, Filipčić I, Ganho-Ávila A, Langguth B, Padberg F, Poulet E, Rachid F, Sack AT, Vanderhasselt MA, and Bennabir D. Repetitive transcranial magnetic stimulation treatment for depressive disorders: current knowledge and future directions. Current Opinion in Psychiatry. September 2019;32(5):409–415. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6688778/. Accessed December 05, 2019.
7. McClintock SM, Reti IM, Carpenter LL, McDonald WM, Dubin M, Taylor SF, Cook IA, O’Reardon J, Husain MM, Wall C, Krystal AD, Sampson SM, Morales O, Nelson BG, Latoussakis V, George MS, MD, and Lisanby SH. Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression. Journal of Clinical Psychiatry. Jan-Feb 2018;79(1):16cs10905. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5846193/. Accessed December 05, 2019.
8. Horvath JC, Mathews J, Demitrack MA, and Pascual-Leone A. The NeuroStar TMS device: conducting the FDA approved protocol for treatment of depression. Journal of Visualized Experiments. November 12, 2010;(45). https://www.ncbi.nlm.nih.gov/pubmed/21189465. Accessed December 05, 2019.
9. FDA permits marketing of transcranial magnetic stimulation for treatment of obsessive compulsive disorder. US Food and Drug Administration. Published August 17, 2018. https://www.fda.gov/news-events/press-announcements/fda-permits-marketing-transcranial-magnetic-stimulation-treatment-obsessive-compulsive-disorder. Accessed December 05, 2019.
10. Zhou DD, Wang W, Wang GM, Li DQ, and Kuang L. An updated meta-analysis: Short-term therapeutic effects of repeated transcranial magnetic stimulation in treating obsessive-compulsive disorder. Journal of Affective Disorders. June 2017;215:187-196. https://www.ncbi.nlm.nih.gov/pubmed/28340445. Accessed December 05, 2019.
11. Janicak P, Heart K, McGugan B. 166 Post Market Rate of Seizures During TMS Treatment with NeuroStar® System Appears to Be Lower than Previously Estimated. CNS Spectrums. 2020;25(2):306-306. https://www.cambridge.org/core/journals/cns-spectrums/article/166-post-market-rate-of-seizures-during-tms-treatment-with-neurostar-system-appears-to-be-lower-than-previously-estimated/C0461158D1489FB42340F839488F08FE. Accessed June 28, 2022.
12. Tendler A, Harmelech T, Gersner R, Roth Y. Seizures provoked by H-coils from 2010 to 2020. Brain Stimul. 2021;14(1):66-68. https://pubmed.ncbi.nlm.nih.gov/33197655/. https://www.brainstimjrnl.com/article/S1935-861X(21)00118-2/fulltext. Accessed June 28, 2022.