The TMS Therapy Guide

Harness the Healing Potential of Ketamine Therapy for Lasting Relief

Tue, 17 Mar 2026 05:41:12 GMT

New Tampa TMS Clinic: Expert Transcranial Magnetic Stimulation Therapy for Depression and Anxiety

Tue, 17 Mar 2026 05:22:30 GMT

Westchase TMS Clinic: Expert Transcranial Magnetic Stimulation Therapy for Depression and Anxiety

Tue, 17 Mar 2026 05:18:14 GMT

Carrollwood TMS Clinic: Expert Local Services for Transcranial Magnetic Stimulation Therapy

Tue, 17 Mar 2026 05:13:48 GMT

TMS Therapy in Tampa at Florida TMS Clinic: Effective Depression and Anxiety Treatment Options

Tue, 17 Mar 2026 05:09:22 GMT

Brandon TMS Clinic: Expert Transcranial Magnetic Stimulation Therapy for Depression and Anxiety Treatment

Tue, 17 Mar 2026 05:05:58 GMT

TMS Therapy in Wesley Chapel: Expert Depression and Anxiety Treatment at Florida TMS Clinic

Mon, 16 Mar 2026 04:43:39 GMT

Land O' Lakes TMS Treatment: Effective Transcranial Magnetic Stimulation Therapy for Depression and Anxiety

Mon, 16 Mar 2026 04:37:56 GMT

Riverview TMS Clinic: Comprehensive Local Services for Transcranial Magnetic Stimulation Therapy

Mon, 16 Mar 2026 04:33:53 GMT

Lutz TMS Clinic: Expert Transcranial Magnetic Stimulation Therapy for Depression and Anxiety Treatment

Mon, 16 Mar 2026 04:28:52 GMT

Florida TMS Clinic Locations Guide: Expert TMS Therapy in Wesley Chapel & Tampa

Mon, 16 Mar 2026 04:15:30 GMT

How To Get Out Of Depression

Thu, 23 Oct 2025 00:38:11 GMT

Dr. Bowarshi advises on how to get rid of depression. FLORIDA TMS CLINIC provides the most advanced treatment options for depression in Tampa & Wesley Chapel FL

New Treatments for Depression

Thu, 09 Oct 2025 01:18:32 GMT

Discover 2025’s newest depression treatments — from rapid-acting options like Esketamine (Spravato®) to advanced TMS protocols such as SAINT and ONE-D. Florida TMS Clinic in Tampa & Wesley Chapel offers faster, personalized relief when medications haven’t worked.

TMS Devices | 2025 Review

admin@floridatmsclinic.com (Khaled Bowarshi) — Sun, 21 Sep 2025 03:36:08 GMT

TMS Devices Review

Updated Sep 2025

Before we dive into the different TMS Therapy machines, I have to make a few disclaimers:

FloridaTMSClinic has no financial affiliation with any of the TMS manufacturers. I (the author, Dr. Khaled Bowarshi ) don’t own any shares or stocks in any TMS company. These are my personal opinions based on my experience with these devices in my practice, testing at exhibits and live demos, and visiting some colleagues to check out devices.

This list is made in an order that I can explain the technology. There are a few criteria I use to evaluate a TMS device and the parent manufacturer:

Ease of use.
Quality of the product, technical support.
Research and innovation.
Transparency . Manufacturers who make false claims of superiority will lose points.
Affordability and business model. Manufacturers who adopt the “silent partner” approach by the pay-per-use model lose points.
History and experience in the field.

I added a rough estimate of the cost. Please note that pricing could change based on the market. Some manufacturers use the pay-per-use model. For those, I considered the cost of the machine upfront + treating 50 patients in year one before giving an overall cost rating.

NeuroStar

Neuronetics makes NeuroStar TMS. Neuronetics was created in 2003 and funded the pilot studies that came up with the conventional 10 Hz TMS therapy protocol as we know it today. Neuronetics sponsored the main pivotal trial published in Dec 2007 and got the first FDA clearance for TMS therapy in 2008. This makes NeuroStar the first FDA-cleared TMS in the USA market. Because of their original patent in the US, they were the only player in the US market for a while. This explains their penetration in the TMS market. Please note that Neuronetics didn’t invent TMS. TMS was developed in Europe, not in the US.

NeuroStar Advanced Therapy uses a figure-of- 8 coil. The NeuroStar system can do standard, 37.5 minutes per session; DASH, 19 minutes per session and TouchStar™ Theta Burst, which is simply iTBS protocol. NeuroStar came late to adopt Theta Burst Stimulation technology. NeuroStar resisted iTBS for a while before finally accepting reality. NeuroStar doesn’t have a navigation system to ensure the placement of the coil. Instead, NeuroStar has a "Contact Sensing" that will alert the treater if contact was lost. They have other fancy trademarks for gimmicks like D-Tect™ which helps the operator "detect" thumb/hand movement during MT determination. Neuronetics has a pay-per-use business model, meaning the TMS clinic has to pay a fee for every TMS session. This, in my opinion, is a poor business model that doesn't serve physicians and patients.

In addition depression treatment for adults, NeuroStar is FDA cleared for treating OCD and anxious depression . Also, most recently it got FDA-cleared for depression in adolescents. NeuroStar aligned their name with an advocacy that resulted in an inappropriate Medicare policy allowing nurse practitioners to manage TRD with TMS. A subspeciality outside the scope of practice for midlevel providers.

Pros:

Good market penetration.
Good support and training.

Cons:

The pay-per-use business model makes them a “silent partner” with the TMS practice.
The website directory favors some clinics over others.

BrainsWay

BrainsWay is based in Israel. BrainsWay TMS devices use Hesel coils. An H coil stimulates deeper in the brain but that comes at the expense of focality. This had been described as “Deep TMS”. The terminology dTMS is not restricted to Hesel coils. It also describes dTMS induced by double cone coils and Halo-circular assembly (HCA) coils. BrainsWay has a patent or a trademark on the terminology deep TMS, which is a descriptive terminology. Any coil can be large enough and powered enough to stimulate deeply. A better description of their product is: non-focal TMS or diffuse-TMS. For this reason, I am calling their H coil dTMS diffuse-TMS.

The main proposal for dTMS is stimulation larger area of the brain cortex. This could increase the chances of “hitting the correct target.” But also, It means delivering a diffuse magnetic field. Often this results in more discomfort during the treatment and, possibly (for the H1 coil), a higher risk of seizure compared to the focal TMS treatment with the figure-of-8 coil. BrainsWay is also FDA cleared for iTBS. H coils are incompatible with any navigation systems. For an obvious reason, there is no point in using navigation for targeted treatment when the coil is stimulating broadly.

BrainsWay H1 coil is FDA-cleared for Treatment Resistant Depression and for anxiety associated with depression. BrainsWay H7-coil FDA-cleared for OCD and MDD. BrainsWay H4 coil is FDA-cleared for smoking cessation. It is interesting how close the H7 and H4 coils are in design and function. Their FDA-clearance paperwork presented the H4 coil as substantially equivalent to the H7 coil. The H4 coil was a 510(k) clearance, not a de novo clearance. Feel free to read the FDA document here and make your own conclusions. In September 2025, Brainsway announced FDA clearance for accelerated TMS.

Pros:

Good support and training.
Indications for MDD + Anxiety, OCD, and Smoking Cessation.

Cons:

Expensive.
Superiority complex.
It might be less tolerable for some patients.

MagVenture

MagVenture is one of the two major pioneers of TMS in Europe (the other one being MagStim). They are based in Denmark. They are proud of the modularity of their system. They have many coils that serve the purpose of research. MagVita is FDA-cleared for rTMS and iTBS. They are the first ones to get the iTBS clearance in 2018. They offer a couple of neuronavigation systems: Atlas™ and Localite. Also, you can add your own neuronavigation system from Brainsight, Vizor2 or Soterix. MagVenture also collaborated with Axilum for a robotic arm. The most recent collaboration was with Magnus, but more on that later.

In 2020, the MagVenture Cool D-B80 coil received a 510(k) FDA clearance for adjunctive treatment of OCD. MagVenture Cool D-B80 coil is the coil equivalent of H7 from Brainsway. But then Neurostar said their F8 coil is similar to D-B80 and got FDA cleared for OCD, then MagVenture said their F8 coil is similar to the Neurostar F8 coil, and MagVenture got another FDA clearance for their F8 coil for OCD. Yes, you read that right, this is how ridiculous the FDA clearance game is. A copy of a copy of a copy going back in full circle, while science and technology can RIP.

MagVenture uses a liquid cooling system. This makes it fast to cool the coil, treating patients back-to-back throughout the day. It is also quieter than air-cooled systems. Liquid cooling and electrical components are not exactly the best combo. You have to be vigilant with maintenance.

Pros:

Reliable, versatile.
Good support.

Cons:

Aesthetically behind, cart-like design.
Warranties can be expensive upsells.

Apollo

Apollo TMS is a product of Mag & More. They are based in Germany. They make fashionable designs for the TMS machine and the TMS chair. They make a unique coil stabilization unit called HANS. The HANS (Head-And-Neck-Support) positioning system ensures that you are reproducibly stimulating the correct treatment spot by following head movement. HANS is good on paper, but not very practical in real life. That being said, they offer alternatives to how you can mount the coil. Apollo is FDA-cleared for both rTMS and iTBS . It is also cleared for OCD.

Apollo uses a unique coating cooling system to cool the coil between sessions. This makes the coil very quiet. This cooling method is not very practical for having multiple back-to-back sessions. Recently, they added an air cooling add-on function to their coil, which seems to cool it faster. Neurocare took over the distribution and support of the Apollo system. They improved support, fixed some apparent flaws, and added air cooling and a new, robust chair. These improvements came with an expense passed on to the consumer by increasing the system's list price and warranty. Apollo has the shortest pulse width of any TMS device. The narrower the pulse width, the more potentiating it can be from the neurobiology standpoint. That finding is not proven to be clinically relevant except in the patient's sense of pain or discomfort during treatment.

Pros:

Aesthetically pleasing modern design.
Quiet.

Cons:

Afterthought cooling system.

Ultimate rTMS

Ultimate rTMS is a product of Brain Ultimate. The device is manufactured in China by Yingchi TMS. Ultimate rTMS has FDA clearance for coils for MDD and OCD. For MDD, it uses an F8 coil that is liquid-cooled (water-cooled). Their clearance also has an air-cooled coil. So, they basically have two different F8 coils. Ultimate TMS is FDA-cleared for both rTMS and iTBS. The OCD coil is a legit double cone coil. The system is affordable and modular enough to be practical.

Pros:

Modular design.
Good value.

Cons:

Not the best aesthetic!

Blossom

Blossom TMS is a product of Sebers Medical. They are in the US as a branch of a parent company in Germany. The device is manufactured in South Korea. It looks aesthetically pleasing. It uses an F8 coil that is oil cooled, which means effective cooling and relatively quiet stimulation. The coil is permanently attached to the stimulator structure. This means less risk of leaks and potential low maintenance. On the other hand, it means you can’t add different coils for other indications. Blossom can do both rTMS and iTBS. But currently, Blossom is FDA cleared for 10 Hz rTMS only. I understand that they are working on another upgraded TMS system with more indications.

The chair is very promising. It has a massage function and a unique, comfortable “head nest” to stabilize the patient's head during TMS treatment. The unit is very portable—it plugs into a 110-volt outlet. The system is affordable and offers the best value for the money I have seen so far.

Pros:

Beautiful design.
Great value.
Quit.

Cons:

Only 10 Hz protocol has FDA clearance for MDD despite the device's capability of iTBS.
A new company, so reliability and support are to be seen.

NexStim

NexStim is based in Finland. SmartFocus by Nexstim was originally made to help Neurosurgeons with brain mapping before performing brain surgery. They brought their TMS system to the US market for depression therapy. NexStim TMS is capable of rTMS, iTBS, and neuronavigation TMS , which they call NBT Navigated Brain Therapy.

SmartFocus requires a specific structural brain MRI to enable the neuronavigation function. Getting an MRI is not a medical necessity. Therefore, insurance may not pay for the MRI portion of the treatment plan, so the patient will have to pay out of pocket, or the TMS clinic will have to eat the cost of such an MRI. Sadly, they don't have a clear business model for selling their system to doctors. They say it is not a pay-per-use model, but you have to buy the disposable head trackers from them for every TMS session you do. That is technically a pay-per-use model!

Pros:

Cutting-edge NeuroNavigation technology.
Well-made system.

Cons:

Needs an MRI. No option to upload an MNI Average Brain MRI.
The disposable head tracker fee is a walk-around the pay-per-use model.

MagStim

I use MagStim in my practice. MagStim is based in the UK. Dr. Anthony Parker pioneered the first TMS machine in the UK in 1985. In 1990, MagStim's parent company made TMS commercially available. Horizon Performance with Stim-Guide is FDA-cleared for rTMS, iTBS, and navigated TMS. Stim-Guide is their version of neuronavigation. StimGuide doesn’t require an MRI to guide the operator to the treatment location. Non-MRI-guided targeting is less accurate than structural MRI-guided targeting, and structural MRI-guided targeting is less accurate than functional connectivity MRI targeting. Read my detailed article about navigated TMS if you are interested in learning more about navigated TMS.

MagStim uses an air cooling system. This makes cooling the coil very fast. We never encountered downtime between patients to cool the system. The caveat to air cooling is that it makes the system loud because of the cooling fans.

H3 is their updated TMS system. It builds on the sound foundations of Horizon Performance with StimGuide but adds better user interface software. In addition to rTMS and iTBS FDA clearance for depression, it is also FDA cleared for anxious depression and OCD.

Pros:

Reliable, versatile, and reasonably priced.
Excellent technical support and warranty.
Navigation system.

Cons:

Unable to upload a patient’s MRI or an MNI Average Brain MRI to improve the navigation accuracy.
Loud cooling system.

Others:

Magnus Medical got an FDA clearance for the SAINT TMS protocol. In my opinion, apart from the functional connectivity MRI targeting, Accelerated Intermittent Theta Burst Stimulation is the future of TMS. As you are probably aware, SAINT coupled aiTBS with individualized fcMRI targeting the functional DLPFC (the most anticorrelated PFC to the sgACC). Magnus Medical is a new startup that licensed this intellectual property to bring the SAINT protocol to the market. Magnus Medical, as a company, is a huge disappointment. Magnus created a monopoly on accelerated TMS without actually producing the device. The fcMRI component of the SAINT is questionable clinically and might be serving the patent rather than the patient. If Magnus didn't exist, thousands of patients would have received aiTBS at an affordable cost, and dare I say, some lives would have been saved! Anyway, Magnus didn't make a new device; they are using MagVenture hardware and licensing the patent to certain clinics, bloating the cost of aiTBS to unreasonable figures, making it unreachable for most patients.

AMPA is a promising startup that made an almost portable TMS device with a couple of coils: L, which is equivalent to F8 coils, and M, which seems closer to H coils. Interestingly, the L coil is FDA cleared using the iTBS protocol, not the 10 Hz protocol. The company is hyper-focused on the ONE-D protocol , which is the next big thing in accelerated TMS. I like their camera-based navigation system. I am disappointed that they only offer a leasing model to get their device. That might be an issue for docs who want full control of their practices.

ExoMind , which is BTL-995-rTMS, a product of BTL Industries, is another new company that received FDA clearance for a TMS device for depression. They are trying to take a page from the aesthetic clinics and cool sculpting to present TMS as cool lifestyle health care. I don't know how I feel about that. Until I get over that, I will hold myself from reviewing the device.

NeuroQore is a new company that received FDA clearance for a TMS device. I haven't seen the actual device yet.

Cloud TMS is not on my recommended TMS devices list. Please don't contact me asking why I dropped Cloud TMS; contact Cloud TMS and ask them why!

TMS Machines Comparison Table

* The device is capable of iTBS but not approved for it.

Above, you can see a table of features compared side by side. Please note that devices compared are the top-tiered FDA cleared system from each manufacturer. This article gets updated annually.

SAINT TMS | FDA Cleared Accelerated TMS Protocol [2023 update]

admin@floridatmsclinic.com (Khaled Bowarshi) — Mon, 01 Sep 2025 13:56:30 GMT

Special Offer: ONE-D Accelerated TMS Therapy for Just $1800!

Take advantage of our limited-time offer for ONE-D TMS Therapy at FLORIDA TMS CLINIC. For only $1800, you can start your journey towards improved mental health. This innovative treatment is designed to help those struggling with depression. Don't miss out on this opportunity to invest in your well-being until the end of 2025.

Florida TMS Clinic offers ONE-D Accelerated TMS Therapy , which involves 20 iTBS treatment sessions in one day. We don't offer SAINT.

SAINT TMS Depression Treatment

Is 90% Too Good To Be True?

Khaled Bowarshi, M.D.

FLORIDA TMS CLINIC

Tampa, FL

SAINT stands for Stanford Intelligent Accelerated Neuromodulation Therapy. SAINT depression treatment protocol uses a rapid form of Transcranial Magnetic Stimulation called Intermittent Theta Burst Stimulation, delivering 1800 TBS pulses in less than 10 minutes, every hour, 10 times a day, for 5 days. In total, delivering 50 treatment sessions equivalent to 90,000 pulses in 5 days. SAINT uses a unique brain imaging method to determine the magnetic stimulation's target area. SAINT reported a success rate of 90% at the end of SAINT treatment and 60% in a month from the treatment. The already FDA-cleared protocol of Repetitive Transcranial Magnetic Stimulation [rTMS] also delivers a total of 90,000 pulses but in 30 sessions, each session delivering 3000 pulses, done daily, 5 days a week for 6 weeks. Conventional rTMS has a success rate that doesn’t match up to the reported success rate of SAINT. Based on the reported results, SAINT was nothing short of a breakthrough in the field of neuromodulation. SAINT promised that a more dense TMS protocol could be superior. SAINT depression treatment got FDA-clearance in September 2022. Naturally, SAINT was an astonishing surprise to the old establishment in the field of TMS, creating a state of confusion for both patients and doctors. Here, I clarify this confusion. If you are here for small bites, no worries, I've got you covered. Just read the key takeaway points below and the one-paragraph summary at the end.

KEY TAKEAWAYS

SAINT protocol is 1800 pulses of iTBS done every hour, 10 times a day, for 5 days.

SAINT uses a resting functional connectivity MRI to specify the treatment target.

SAINT reported an impressive success rate of 90% but dropped to 60% after a month.

SAINT is now FDA-cleared. It is available at about 10 locations in the US, but it is costly.

Accelerated TMS without fcMRI is not SAINT; a new one-day accelerated TMS protocol called ONE-D beats SAINT in practicality and cost. It doesn't require a complicated MRI and is more durable.

In this article, I will explain the history of accelerated TMS. The previously documented success of accelerated TMS. This will include accelerated left-sided high-frequency TMS, accelerated right-sided low-frequency TMS, and accelerated left-sided theta burst stimulation. I will touch on the concept of neuronavigation in the field of TMS. Finally, I will explain the SAINT protocol. I will summarize both SAINT, the open-label trial, and SNT, the randomized controlled trial. I will explain the flaws of some of the conclusions made in the headlines. I will then give my take on SAINT. I will divide this into three chapters:

Chapter 1: Accelerated TMS.

Chapter 2: Navigated TMS.

Chapter 3: Accelerated fcMRI NeuroNavigation TMS = SAINT.

Chapter 1: Accelerated TMS

Accelerated Transcranial Magnetic Stimulation | Terminology, History, and Importance.

Traditional daily TMS therapy has been used in clinical psychiatric practices since 2008 following its clearance by the FDA. Despite the alternative it provided, rTMS was challenged by the inconvenience of the duration of the treatments. A typical rTMS therapy session takes 37 minutes. The duration can be shortened to 18.5 minutes using the “Dash” protocol. The " Dash " protocol shortened the intra-train interval [ITI] from 26 to 11 seconds. Despite the time efficiency “Dash” protocol provided, accounting for the entire course being 30-36 sessions, it is still a lot of time on the treatment chair. It became obvious that we need more efficient and practical treatment. Hence comes accelerated TMS. Trying to accelerate TMS treatment is as old as TMS itself. Let me be clear here; accelerated TMS was proposed a decade before Stanford entertained the idea of accelerated TMS. It was even before Theta Burst Stimulation clearance by the FDA (read about accelerated iTBS below). In the medical literature, the term accelerated TMS is used to describe any TMS therapy protocol applying more than one TMS session a day. Accelerated TMS therapy is exciting because of many reasons. The main reasons are:

Accelerated TMS can be more effective than traditional daily TMS.
Accelerated TMS can be more practical for some patients who can’t commit to 6 weeks of treatments and prefer just a few days.
Accelerated TMS can improve access to patients who need it the most. Particularly those hospitalized with severe depression.

Evidence Supporting Accelerated TMS

We are going to discuss three main methods of delivering accelerated TMS. SAINT, as a category of accelerated TMS, falls under the third category.

Left-Sided High-Frequency Accelerated TMS
Right-Sided Low-Frequency Accelerated TMS
Accelerated Intermittent Theta Burst Stimulation

1. Left-Sided High-Frequency Accelerated TMS

Clinical research supports the efficacy of accelerated TMS therapy for depression treatment. The vast majority of the work is done outside of Stanford and is completely independent of it. Stanford's work was more like the icing on the cake. Let’s review some of the published evidence.

In 2010 , an open-label accelerated TMS (aTMS) trial was done at Emory. It consisted of 15 rTMS sessions administered over 2 days and treated 14 depressed patients. Accelerated TMS demonstrated an excellent safety profile with efficacy comparable to that achieved in daily rTMS in other trials. Here is the PubMed link to the trial .

In 2014 , a naturalistic trial result from Canada came out, 27 patients with moderate to severe chronic and treatment-resistant MDD were treated with twice-daily HF-rTMS (10 Hz) applied over the left dorsolateral prefrontal cortex for 2 consecutive weeks (60,000 pulses). Ten (37.0%) patients met the criteria for clinical remission, and 15 (55.6%) were classified as responders. This meant that an accelerated protocol involving twice-daily sessions of HF-rTMS over the left DLPFC for 2 weeks was effective in treatment-resistant MDD and had excellent acceptability. Here is the PubMed link .

In 2017 , a very well-respected Canadian research group, including Dr. Daniel M. Blumberger and Dr. Jonathan Downar. reported a retrospective chart review of 130 patients with MDD who went through either twice-daily rTMS or once-daily rTMS for 20-30 treatment sessions. They concluded that twice-daily rTMS appears feasible, tolerable, and capable of achieving comparable results to once-daily rTMS while also reducing course length approximately twofold. Therapeutic gains tracked the cumulative number of sessions, not pulses. Here is the link to the abstract .

Another group in Canada compared twice-a-day rTMS (17 patients) to once-a-day rTMS (19 patients). The majority of patients in both groups responded to treatment, and there was a trend toward a greater response rate in the twice-daily group (82.4%) compared to the once-daily group (52.6%). Patients in the twice-daily group experienced an improvement in symptoms faster than in the once-daily group due to the accelerated therapy period. The conclusion was made that the administration of two rTMS treatment sessions per day is tolerable for patients and does not seem to be inferior in efficacy to a once-daily protocol. Twice-daily administration has the benefit of producing symptom improvement over a shorter time span and requires fewer visits to the clinic. This was published in the Neuropsychiatric Disease and Treatment in 2018 . Here is the PubMed link .

Dr. Fitzgeral (a star in the field of TMS in Australia) and his group designed a study comparing accelerated TMS to traditional TMS. They devised an approach consisting of 3 weeks of decreasing treatment intensity. In week 1, patients were provided 3 treatments per day over 3 days. In week 2, 3 treatments over 2 days were provided, and in week 3, 3 treatments on a single day were provided. Each treatment day involved a total of 250 10 Hz trains, so the total dose of TMS provided across 6 days was equal to that provided in 20 days of treatment at 75 trains per day. 115 outpatients with MDD received either accelerated rTMS (n = 58) or standard rTMS (n = 57) following randomization. There was no significant difference in response rates or remission rates between the groups in any of the analyses. This was published in 2018 . PubMed link .

Another Canadian group did a retrospective data analysis of 73 patients with unipolar and bipolar depression who went through accelerated rTMS of 30 treatment sessions in 3 weeks (2 sessions a day). The overall outcome was positive but more notable for those over the age of 60. They concluded that the accelerated rTMS protocol is a safe and effective treatment for unipolar and bipolar depressed subjects, including older adults. This was published in the American Journal of geriatric psychiatry in 2019 . PubMed link .

In 2020 , my colleagues at WVU explored accelerated TMS on 6 post-stroke depression patients using High-frequency (20-Hz) rTMS at 110% resting motor threshold (RMT) was applied to the left dorsolateral prefrontal cortex (DLPFC) during five sessions per day over four consecutive days for a total of 20 sessions. All 6 patients remitted and maintained remission at 3-months follow-up. Here is a link to the paper .

2. Right-Sided Low-Frequency Accelerated TMS

It is already established that right-sided low-frequency TMS can also help with depression. Low-frequency TMS (1 Hz) is thought to carry a lower seizure risk than high-frequency TMS. If we were to give multiple TMS sessions in a day and we were concerned about safety, it would make a lot of sense to consider low-frequency TMS.

Some primary work was done in 2016 . An open-label accelerated rTMS pilot was done with 7 treatment-resistant patients (4 unipolar, 3 BP). Accelerated rTMS was given over the right dorsolateral prefrontal cortex at 120% of the resting motor threshold at 1 Hz, and 900 pulses were delivered per session. A single rTMS treatment was administered on the first day to test for tolerability, followed by 5 rTMS sessions a day for 2 days, then 7 days of daily rTMS sessions. The total course consisted of 16,200 pulses across 18 sessions given over 10 consecutive weekdays. Though the efficacy was mediocre, the authors found accelerated low-frequency right-sided rTMS was a safe and possibly efficacious treatment for treatment-resistant depression. Here is the link .

Recently in 2021 , Dr. Downar and his group in Canada did a feasibility study of a 5-day accelerated 1 Hz rTMS protocol. They conducted a prospective, single-arm, open-label feasibility study. Thirty (30) participants received a one-week (5 days) accelerated (8 sessions per day, 40 sessions total) course of 1 Hz rTMS (600 pulses per session, 50-minute intersession interval) over the right dorsolateral prefrontal cortex (R-DLPFC) using a figure-of-eight coil at 120% of the resting motor threshold (rMT). Response and remission rates 1 week after treatment were 33.3% and 13.3%, respectively, and increased to 43.3% and 30.0% at follow-up 4 weeks after treatment. This meant that 1 Hz rTMS administered 8 times daily for 5 days is safe and well-tolerated. Link to the study .

Then, in the same year 2021 , they published their proof of concept doing right-sided low-frequency accelerated TMS targeting the right DLPFC using F4 (no neuronavigation). Forty-eight (48) MDD participants received an initial accelerated rTMS course (arTMS) of 6 sessions/day over 5 days (30 total), followed by a tapering course of daily sessions (up to 25) to decrease the odds of relapse. Response and remission rates were 35.4% and 27.1%. This trial was of unique importance because it used the most cost-effective method of delivering accelerated TMS. Click here to read the paper .

3. Accelerated Intermittent Theta Burst Stimulation

As we saw above, there is adequate evidence supporting accelerated TMS using the older rTMS frequency of 10 Hz, which is the standard high-frequency protocol that was FDA-cleared in 2008. Fast forward 10 years to 2018, a breakthrough in TMS called iTBS got FDA-cleared. Intermittent Theta-Burst Stimulation (iTBS) is the “version 2.0” of rTMS. Just like rTMS, iTBS is a non-invasive brain stimulation treatment that is FDA-cleared for treatment-resistant depression (TRD). It uses a different magnetic pulse (in triplets) at a unique frequency, delivering the treatment in just 3 minutes and 12 seconds. iTBS was proven to be as effective as rTMS, with the obvious time saving of over 5-fold. This opened the door wide open to an even more aggressive accelerated treatment protocol.

A significant amount of research done exploring accelerated TBS started in Europe, particularly in Belgium. Based on a 2014 study, it was concluded that Accelerated TBS treatment in depressed, suicidal patients is safe and well-tolerated and may potentially decrease suicidal ideations. Here is the link . A couple of years later, in 2016 , they published in the Journal of Affective Disorders in 2016 that 20 sessions of iTBS given 5 sessions a day for only four days of accelerated iTBS treatment applied to the left DLPFC in TRD may lead to meaningful clinical responses within two weeks after stimulation. Here is the PubMed link . Then in 2018 , the group did a retrospective comparison between accelerated high-frequency rTMS (arTMS) with accelerated intermittent theta burst stimulation (aiTBS) in the refractory depressed state. The clinical efficacy was not significantly different between both protocols. This substantiates the potential of the accelerated stimulation to shorten the treatment duration from the depressed state to the response state. Any time gained from the depressed state to the recovered state is in the patient's interest. Here is a link to the publication.

In 2019 , Erine Bröcker and colleagues reported on accelerated theta-burst repetitive transcranial magnetic stimulation for depression in South Africa. In their report, 9 patients (7 with MDD and 2 bipolar depression) went through 20 iTBS sessions in 8 days spread over 2 weeks. 1782 pulses per session at 80% MT using an F8 coil without neuronavigation. Five of the nine participants were responders. This study was received in 2018 and published in 2019. See the link .

In 2020 , Dr. Muir Owens and his group at Brooklyn Minds published an analysis of collected data on accelerated and non-accelerated dTMS protocols. One hundred eight patients received dTMS treatment for depression. Stimulation with H1 coil was administered to the left prefrontal cortex (LPFC) at 80% MT intermittent theta burst (iTBS) 600 -1800 pulses with an intertreatment interval of fifty minutes. Patients received a range of treatments between 3 and 92 sessions (m = 42.94). Of those 107 patients, 21 received an accelerated protocol which consisted of, a range of 3 to 10, treatments in a day. The other 87 patients received a non-accelerated protocol. Results indicate that both accelerated and non-accelerated protocols of dTMS reduced depression symptoms in MDD patients. See the link to Brain Stimulation Journal.

In 2021 my group and I at FLORIDA TMS CLINIC reported retrospective data analysis of non-MRI-guided accelerated intermittent theta burst stimulation. Six patients with depression, five unipolar and one bipolar II, all had severe treatment resistant depression (> 4 antidepressant history), two with a previous history of receiving TMS therapy, received accelerated iTBS. Stimulation with F-8 coil was administered to the left dorsolateral prefrontal cortex (DL-PFC) determined using StimGuide, a non-MRI-navigation system. Stimulation was at 90% MT intermittent theta burst (iTBS) for 1800 pulses with an intertreatment interval of fifty minutes. Patients received ten sessions every day for five consecutive days for a total of fifty sessions. Five out of the six patients responded to accelerated iTBS. Results indicate that non-MRI-guided accelerated intermittent theta burst stimulation reduced depression symptoms in depressed patients with treatment resistance. See the link to Brain Stimulation Journal.

In 2021 , The Australian group with Dr. Fitzgerald in Australia published a RCT comparing rTMS with accelerated iTBS unilateral and bilateral. The overall treatment response rate was 43.7 %, and the remission rate was 28.2 %. There were no significant differences for response or remission across the three groups. Here is the PubMed link .

Chapter 2: Navigated TMS

How about the evidence for neuronavigation targeting? Is Neuronavigation targeting superior to scalp measures targeting? The multi-million dollar question!

I will divide this topic into three sections:

The case for neuronavigation.
The case against neuronavigation
fcMRI neuronavigation targeting

1. The case for Neuronavigation

MRI navigation might be better... At least on paper!

Dr. Fitzgerald and colleagues investigate whether repetitive transcranial magnetic stimulation (rTMS) targeted to a specific site in the dorsolateral prefrontal cortex (DLPFC), with a neuro-navigational method based on structural MRI, would be more effective than rTMS applied using the standard localization technique. Fifty-one patients with treatment-resistant depression were randomized to receive a 3-week course (with a potential 1-week extension) of high-frequency (10 Hz) left-sided rTMS. Thirty trains (5 s duration) were applied daily 5 days per week at 100% of the resting motor threshold. Treatment was targeted with either the standard 5 cm technique (n=27) or using a neuro-navigational approach (n=24). This involved localizing the scalp location that corresponds to a specific site at the junction of Brodmann areas 46 and 9 in the DLPFC based on each individual subject's MRI scan. There was an overall significant reduction in the Montgomery-Asberg Depression Rating Scale scores over the course of the trial, and a better outcome in the targeted group compared with the standard localization group at 4 weeks (p=0.02). Significant differences were also found on secondary outcome variables. The use of neuro-navigational methods to target a specific DLPFC site appears to enhance response to rTMS treatment in depression. Further research is required to confirm this in larger samples or to establish whether an alternate method based on surface anatomy, including measurement from the motor cortex, can be substituted for the standard 5 cm method. See link to paper.

2. The case against Neuronavigation

Navigation is not better… At least not clinically relevant.

The Canadian group behind THREE-D answered the question by quantifying the discrepancy in scalp site between BeamF3 versus MRI-guided neuronavigation for left DLPFC. Out of 100 subjects, they found that BeamF3-to-MRI-guided discrepancies were <0.65 cm in 50% of subjects, <0.99 cm in 75% of subjects, and <1.36 cm in 95% of subjects. This meant that the BeamF3 heuristic may provide a reasonable approximation to MRI-guided neuronavigation for locating left DLPFC in a majority of subjects. See this link . The group used these findings in their final recommendations from the THREE-D trial. Though three THREE-D trial used MRI navigation, they didn’t justify the added cost. Hence, the FDA approved iTBS based on the THREE-D trial without navigation. See this link .

A study in Taiwan published in 2019 , showed that the MRI-guided method of coil targeting is not better than the standard method. This group did prolonged intermittent theta-burst stimulation (piTBS) with triple doses of the standard protocol. The primary objective was to investigate the antidepressant efficacy of piTBS monotherapy. Efficacy between the standard 5-cm method and magnetic resonance imaging (MRI)-guided coil positioning to the left dorsolateral prefrontal cortex method was also compared. This was a double-blind, randomized, sham-controlled trial, 105 patients with recurrent depression who exhibited no responses to at least one adequate antidepressant treatment for the prevailing episode were assigned randomly to one of three groups: piTBS monotherapy (n = 35), repetitive transcranial magnetic stimulation monotherapy (n = 35), or sham stimulation (n = 35). The acute treatment period was 2 weeks. Half of the patients were randomized to MRI navigation in each group. The piTBS group exhibited significantly greater decreases in depression scores than the sham group at week 2 (-40.0% vs. -13.9%). The MRI navigation method (-32.4%) did not yield better antidepressant effects than the standard method (-40.6%). Read the paper here.

A more recent publication from Germany in 2021 also showed no superiority of MRI navigated TMS. This randomized controlled trial investigated whether a four-week course of neuronavigated intermittent theta burst stimulation (iTBS) of the left dorsolateral prefrontal cortex is superior to the non-neuronavigated F3-EEG method of positioning. 37 inpatients with at least moderate depressive episode were randomized to receive either neuronavigated or 10-20-EEG-system based F3 guided iTBS. Both groups received twenty daily sessions of iTBS while continuing to receive standard-of-care treatment by their ward physicians. The number of remitters was exactly the same for both groups. The investigators noticed a high antidepressive effect of add-on iTBS treatment to standard inpatient treatment but failed to demonstrate a clinical superiority of neuronavigated localization. The non-navigated, F3-guided iTBS treatment used as a control group may be sophisticated enough to dilute potential added benefits, and the difference between the localization approaches is either negligible or too small to justify the additional efforts of navigation. See this link .

3. Functional Connectivity MRI Targeting

How about functional connectivity MRI targeting? That must be better. Or is it?

Parallel to the work that was done exploring accelerated TMS and accelerated TBS. Others were exploring optimizing the treatment location. A group from Ghent University, Belgium, reported that the anti-correlation between the sgACC and parts of the left prefrontal cortex could be indicative of a beneficial outcome. This group was also investigating accelerated HF-rTMS treatment designs to have the potential to acutely adjust deregulated sgACC neuronal networks in TRD patients. This dates back to 2014 . Here is the link .

Dr. Michael D. Fox and his group at MGH reported that the antidepressant efficacy of different left DLPFC TMS sites is related to the anticorrelation of each site with the subgenual cingulate, potentially lending insight into the antidepressant mechanism of TMS and suggesting a role for intrinsically anticorrelated networks in depression. These results can be translated into a connectivity-based targeting strategy for focal brain stimulation that might be used to optimize clinical response. Here is the link .

Probably the best summary of the argument about the location of treatment was done by Dr. Fitzgerald. In his paper, he discusses all the data available up to 2021 . fMRI-connectivity-based approaches to targeting specific circuits in the DLPFC are intellectually attractive but it may not be possible to demonstrate differential effectiveness of these over the methods most commonly been used in clinical practice. He concludes There is emerging literature helping to improve our understanding of the optimal methods for targeting rTMS treatment for depression. However, we lack substantive prospective clinical trials demonstrating improved clinical outcomes with these techniques. See the link here.

The most recent publication on the topic of neuroimaging targeted TMS and TBS was published in March of 2023 . In this paper , analysis of about 300 patients from the THREE-D trial indicated that in a large representative sample of patients with major depressive disorder, individual differences in sgACC-StimFC explained only ∼3% of the variance in outcomes, which may limit the utility of existing sgACC-based targeting protocols. This again shows that functional neuroimaging targeting might not be as high yield as it sounds.

Chapter 3: SAINT

Functional Connectivity MRI Targeted High Dose Accelerated Theta Burst Stimulation

Now that we know what accelerated TMS and accelerated iTBS are. We already learned about the controversy surrounding the superiority of fcMRI navigation. Let’s couple the two together. aiTBS + fcMRI = SAINT.

What is SAINT Depression Treatment Protocol?

Today, the terminology accelerated TMS and accelerated TBS is commonly used to describe the TMS therapy protocol in which the patient gets 10 TMS therapy sessions a day for 5 days for a total of 50 TMS therapy sessions. This accelerated TMS therapy protocol shortens the duration of treatment from 6 weeks to just 5 days.

In the beginning, Dr. Nolan Williams examined the effects of multiple iTBS treatments per day in a small sample of patients who did not previously respond to a full course of rTMS and an acute course of ECT. The pilot study was published in 2018 in which accelerated TMS was used to treat 6 patients with highly refractory MDD patients using intermittent theta-burst stimulation (iTBS), 1800 pulses/session, 10 sessions per day over 5 days, and reported remission in 5 out of the 6 patients at day 5. All patients were back into depression 4 weeks after the treatment. See the link . This raised the question about the “fast on / fast off” phenomenon of accelerated TMS. Read more about it in this link . That pilot study paved the road for SAINT.

SAINT Depression Treatment is an accelerated TMS protocol that came from Stanford University and was published in the prestigious peer-reviewed American Journal of Psychiatry in April 2020 . See the PubMed link . Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression (SAINT-TRD) proved the efficacy and safety of accelerated TBS protocol for depression. In SAINT clinical trial, 21 participants with TRD received 50 iTBS sessions as 10 daily sessions over 5 consecutive days. Amazingly, 19 of 21 participants (90.48%) met the criteria for remission immediately after SAINT. In the intent-to-treat analysis, 19 of 22 participants (86.4%) met remission criteria. Neuropsychological testing demonstrated no negative cognitive side effects. This supported that accelerated iTBS was well tolerated and safe. Efficacy was surprisingly high.

Is SAINT too good to be true?

Let’s talk numbers.

SAINT response rate on day 5 was 85-90% (depending on the rating scale).

SAINT response rate at week 5 was 60-70% (depending on the rating scale).

If we agree that the meaningful outcome should not be at day 5 but rather at a point of time similar to the 4-6 weeks of traditional TMS treatment. A 60-70% response/remission rate should have been reported to avoid the “too good to be true” dilemma. But even with a 60-70% success rate, this is nothing short of a breakthrough!

What is SNT Depression Treatment Protocol?

SNT is Stanford Neuromodulation Therapy (previously referred to as Stanford Accelerated Intelligent Neuromodulation Therapy or SAINT). SAINT and SNT are exactly the same. It is more of a branding exercise. It seems like the main goal was to avoid the word “accelerated” because, as you read above, Stanford didn’t invent the idea of accelerated TMS therapy. Rather, optimized it. That being said, SAINT was more catchy than SNT. A quick Google trend check would show that patients are primarily looking up SAINT depression treatment, Stanford TMS protocol, or just accelerated TMS, ignoring the terminology SNT and ignoring the terminology Neuromodulation.

Besides branding, SNT was the name of the randomized controlled trial that applied the SAINT protocol. SNT results were revealed in late 2021 in the American Journal of Psychiatry. In the SNT trial, 32 participants with treatment-resistant depression were enrolled, and 29 participants who continued to meet inclusion criteria received either active (N=14) or sham (N=15) SNT. Just like SAINT (open-label trail), SNT (randomized controlled trial) coupled iTBS with individualized circuit-based neuronavigation and an accelerated treatment schedule. SNT found a 52.5% drop in depression scores with active SNT compared with an 11.1% drop with sham. From the research design aspect, this proves the effectiveness of accelerated TMS over sham (placebo device). This is a huge step forward for the FDA clearance. Here is a link to the paper .

In SNT (randomized controlled trial), the response rate immediately after the treatment (day 5) rate was 85.7% (12 out of 14) which dropped to 69.2% (9 out of 13) one month after (week 5). The remission rate immediately after the treatment (day 5) rate was 78.6% (11 out of 14) which dropped to 46.2% (6 out of 13) one month after (week 5).

Key differences in results reporting in SAINT vs. SNT

Unlike SAINT, participants with prior exposure to rTMS were excluded from enrolling in SNT. It seems that the authors picked on the pattern noted in SAINT with a delayed response and higher relapse in those with previous TMS treatment. They decided to exclude patients with a previous history of TMS in the RCT, increasing their chances of separation. Maybe they had to exclude patients previously treated with TMS for better blinding, but it is still worth noting.

SNT reported success as remission at any week during the next five weeks after SNT treatment. It is unusual to report remission and response for just one out of five follow-up points. The remission rate at week 5 was 46.2%, and the response rate at week 5 was 69.2%. Don’t take me wrong, these numbers are excellent. But less earthshattering than the 90% number picked up by the media and press releases.

What did SNT prove?

SNT as a blinded randomized controlled trial proved that accelerated TMS is effective. This eliminates any doubt about SAINT efficacy being a placebo effect. When it comes to the proof for fcMRI targeting, the picture becomes less clear. That’s because SNT/SAINT already used three components with a high probability of increasing the efficacy of treatment. SAINT added a fourth ingredient which is the fcMRI-targeting that we are not very sure about.

The three proven ingredients for SAINT/SNT success.

1. Dose per session:

The dose of iTBS is X3 folds the FDA-cleared iTBS dose. That’s 1800 pulses in SNT vs. 600 pulses in THREE-D.

2. Density:

The density of the treatment course was over X20 folds over the FDA-cleared course. The density of TMS is the frequency of treatments (frequency of treatments is the number of treatment sessions per day, not to be confused with pulse frequency which is number of TMS pulses per second and measured in Hz). SNT did 50 minutes between sessions instead of 24 hours between sessions in THREE-D.

3. Number of sessions:

SNT did a total of 50 sessions instead of 20-30 in THREE-D.

We already know that more pulse can lead to a better response. More treatment sessions can lead to a better response, and a more dense treatment course is better than a spread-out treatment course. Putting these three factors together. It makes a lot of sense that SNT was effective.

The one unproven ingredient for SAINT/SNT success:

fcMRI

SNT doesn’t prove the superiority of fcMRI-guided targeting. That is because SNT missed a golden opportunity to add a third arm doing accelerated with conventional targeting. Perhaps SNT investigators were aware that SNT and sham would separate very easily, and 60 participants would be more than enough to power the study for this separation. In reality, they didn’t even need 60 participants and stopped at 29 because of the obvious separation. On the other hand, fcMRI-SNT vs. non-MRI-SNT will need a couple of hundreds of study participants to stand any chance of separation. Unfortunately, this missed opportunity is going to cost us a lot of money on unnecessary imaging or a delay of a few years until the question of neuroimaging is answered once and for all.

On the topic of neuroimaging targeting, we need to understand that SNT used functional neuroimaging in addition to the structural MRI taking during such an fcMRI process, it wasn't just a structural neuroimaging. If you want to learn more, I wrote about the different types of navigated TMS. Resting functional neuroimaging requires sophisticated technology, a technician, a standardized protocol, and an experienced neuroradiologist. Many of these are readily available for mass production. Please remember that neither SAINT nor SNT was a multisite clinical trial. Replicating the same imaging standards in a multicenter clinical trial and then in real life to produce the same quality is going to be challenging, to say the least.

Cortical Depth Adjusted Intensity... Necessary or Gimmick?

SAINT and SNT added a unique intensity target of 90% MT depth adjusted up to 120%. So what was that about?

As you probably know from using your cell phone. The closer you are to the 4G or 5G tower, the stronger the signal is. The same principle applies to TMS. The closer the magnetic coil to the brain cortex, the stronger the stimulation. Based on that, SAINT research designers went fancy and decided to stimulate at 90% MT adjusted (up to 120%) based on the distance between the scalp and brain cortex. The larger the distance (depth), the more stimulation intensity but not to exceed 120% of resting Motor Threshold [rMT]. While it sounds smart, I think it ignores other aspects of simple physics. There are an unlimited number of other variants that need to be taken into consideration beyond depth. We can’t just pick one and ignore the others. Here are some examples:

Bone density
Skin type
Hair type
Body composition (subcutaneous fat)
Age
Gender
Race

As you can see, the list can go on and on. For the calculation of intelligent neuromodulation to be meaningful, we either have to take all of it into consideration. Or we can just standardize the treatment to 120% of resting MT, which was repeatedly deemed safe.

SAINT Durability: The "fast on / fast off" phenomenon of SAINT & SNT

Let’s make the observation that in both SAINT and SNT, about one-third of patients who responded/remitted with SAINT protocol lost the response/remission after a month. This was addressed in the section above when we discussed the pilot trial in which all responders relapsed. It is worth noticing that the less treatment-resistant the participants are, the better durability at the one-month follow-up. This can be observed in participants' selection from SAINT to SNT. SNT participants were less treatment-resistant compared to SAINT. In the pre-print copy of SAINT, which had 31 participants, 13 of them had failed a previous rTMS. These 13 failed-rTMS-participants responded less than "TMS-naïve" participants both immediately and 4 weeks after SAINT. The separation was much more obvious at week number 4. In other words, higher treatment resistance (previous failure to rTMS) is a negative predictive factor for response and a much more negative predictive factor for durability at week number 4 after SAINT. Interestingly, only 6 rTMS-failed-participants made the cut to be included in the published SAINT. Moreover, no rTMS-failed patients were recruited for the SNT trial. All of which helped massage the durability number in the final publication. I am sure there are valid reasons why these changes were made, but nevertheless, we need the durability question to be answered.

Summary:

In summary, SAINT/SNT might be the biggest breakthrough in neuromodulation to date. That being said, The 90% success rate thrown around in the media is too good to be true. A better report should be ~70% response rate and ~50% remission rate after a month. We are not yet sure we need individualized neuroimaging to get the efficacy of aiTBS. We are not completely confident about the long-term durability of SAINT, especially for those with previous failed TMS. And lastly, we can’t really give a blanket statement that SAINT is superior to conventional rTMS, but for sure, we can recognize that SAINT can be more practical solution for some patients.

SAINT is FDA-cleared now and is available at a few treatment centers certified by Magnus Medical. Please visit Magnus's website for a complete list of SAINT centers. Of note, the cost at some of these centers is $28,000, making access to SAINT more theoretical than practical.

The availability of the ONE-D accelerated TMS protocol , which doesn't require a complicated MRI and is more practical and durable, raises questions about SAINT adoption.

Conflict of Interest Disclosure:

FLORIDA TMS CLINIC and Dr. Khaled Bowarshi have no financial affiliation with Stanford or Magnus Medical. Florida TMS Clinic offers ONE-D Accelerated TMS Therapy , which involves 20 iTBS treatment sessions in one day. We don't offer SAINT.

TMS Therapy Near Me In Tampa [2024]

Mon, 05 Feb 2024 04:17:39 GMT

TMS THERAPY NEAR ME

A Step By Step Guide To Find The Best TMS Clinic

TMS Therapy Clinics Ranking Criteria

There are over 20 TMS clinics in the Tampa Bay area. Considering many of them have multiple locations. The total number of clinics is well over 35 TMS locations. Many of these locations have multiple treatment chairs. It is estimated that there are well over 60 TMS treatment chairs in the Tampa Bay area. This is excellent news for patients because it means you have plenty of options. Our advice is to pick a TMS clinic based on the following criteria:

1. TMS Doctor

Your TMS psychiatrist’s experience and knowledge of your case are essential.

2. TMS Device

While all TMS devices are cleared for the treatment of depression. Some are more accurate than others.

3. TMS Staff

Friendly and knowledgeable staff is a must. Training and supervision by the doctor is essential.

4. TMS Cost

In network with your insurance or affordable out of insurance fees.

How to find the best TMS therapy clinic near you?

We will discuss the main factors that make a TMS clinic good quality. Then, we will discuss finding and locating TMS clinics near you in Tampa, Florida. Lastly, I will list all TMS clinics and rank them to compare to each other.

The Five Pillars For The Ultimate TMS Center Of Excellence:

#1 TMS Doctor

We always advise our patients to know who their TMS doctor is. You should also know how involved the TMS doctor will be in providing your TMS therapy. In other words, you need a TMS doctor who is hands-on in managing, supervising, and adjusting your particular TMS treatment protocol.

#2 TMS Technology

Well, that's a self-explanatory one. Because a TMS machine delivers TMS treatment, you want to ensure that your treatment is delivered via a high-quality FDA-approved TMS device. Not all TMS devices are created equal. For example, Florida TMS Clinic uses one of the most advanced 3D Navigated TMS technology which helps us make sure that every single pulse is delivered precisely where it was planned. This Navigation TMS technology is not available anywhere else in the Tampa Bay area. That doesn't mean that other TMS machines are not effective. They are also effective; otherwise, they would not be cleared by the FDA. It just means that there is always a good option and a better option. Why would you settle for anything less than the best if you had the choice?

#3 TMS Staff

This is a big one. Your TMS treatment sessions are going to be delivered by your TMS therapist. You're going to see this person daily for six weeks. You want to make sure that you're comfortable and happy with this person. You also want to ensure that the TMS psychiatrist will train this TMS therapist to use that particular TMS device. Let me give you another example of what Florida TMS Clinic does. All of our TMS therapists are certified by the TMS device manufacturer. All of our TMS therapists are BLS certified. And despite their excellent experience in delivering TMS therapy, they are still always supervised by the physician who supervises their performance via the navigation system and video cameras. All staff undergoes a quarterly evaluation to demonstrate their knowledge of TMS therapy’s most up-to-date knowledge and advances.

#4 TMS Insurance Specialist

The TMS insurance specialist is the person who presents your case to your health insurance to get your TMS therapy prior-authorized or pre-approved. The TMS insurance specialist needs to be very knowledgeable and detail-oriented; otherwise, your insurance may deny your TMS prior-authorization. This could mean a significant delay in your TMS therapy. Florida TMS Clinic has a meager rate of denials from insurance. When insurance denies a TMS case, it's almost always for an illegitimate reason as we only request prior-authorization for fully qualifying patients. Our doctor always takes the case peer-to-peer. If a peer-to-peer review doesn't turn around the denial, the doctor will take it to the appeal level. The only time we will stop is when the patient does not want us to proceed further. Otherwise, we always fight for the patient to get their TMS approved.

#5 TMS Cost

The good news is that almost all insurances cover TMS therapy costs. But not everybody has insurance. We still have patients who pay out-of-pocket for their TMS treatment. The cost of TMS therapy could be prohibitive for some. For this reason, Florida TMS Clinic offers a reasonable rate to uninsured patients. Speaking of cost, you need to know about the cost of TMS “add-on” treatments. You see, the FDA-approved protocol targets the left side of the brain, which is used for depression. Often, patients will have depression and anxiety at the same time. These patients with co-occurring anxiety might need an “add-on” treatment protocol targeting the right brain. This means using an extra treatment session every day. Most TMS clinics charge extra for this extra time on the chair. Florida TMS Clinic doesn’t charge additional fees for “add-on” treatments. It is complimentary.

Now that you know how to evaluate TMS clinics in your area let’s list all the TMS clinics providing TMS Therapy in the Tampa Bay area.

Tampa TMS Therapy Clinics Directory

Find the best TMS clinic in your area

FLORIDA TMS CLINIC - Tampa TMS Therapy Center

#1 TMS Clinic in Tampa

2805 W Busch Blvd, STE 208

Tampa, FL 33618

‪Phone (813) 867-3646

FLORIDA TMS CLINIC - Wesley Chapel TMS Center

#1 TMS Clinic in Wesley Chapel

26843 Tanic Dr, STE 101

Wesley Chapel, FL 33544

Phone (813) 867-2378

Tampa Neuropsychiatry

Recommended TMS Clinic in St. Pete

625 6th Ave South, Suite 155

St. Petersburg, FL 33701

TMS Advantage

Recommended TMS Clinic in Clearwater

28465 US Hwy 19 N, Suite 202

Clearwater, FL 33761

Brandon TMS & Psychiatry

407 N. Parsons Ave, Suite 107A

Brandon, FL 33510

TMS of South Tampa

508 S. Habana Ave, Suite 320

Tampa, FL 33609

USF Health Department of Psychiatry

3515 East Fletcher Ave

Tampa, FL 33613

James A. Haley Veterans Hospital

13000 Bruce B. Downs Blvd

Tampa, FL 33612

Stedman Clinical Trials

14506 University Point Place

Tampa, FL 33613

TMS of Central Florida

1119 Nikki View Drive

Brandon, FL 33511

Florida Medical Clinic

6719 Gall Blvd, Suite 207

Zephyrhills, FL 33542

Neurobehavioral Medicine

613 W. MLK Dr. Blvd, #102

Tampa, FL 33603

South Tampa Psychiatry

2919 W Swann Ave, STE 104

Tampa, FL 33609

Embracing Life Wellness Center

6332 U.S. 301

Riverview, FL 33578

Florida Behavioral Medicine

1100 Clearwater Largo Rd N

Largo, FL 33770

Baycare Life Management

1106 Druid Road, Suite 201

Clearwater, FL 33756

Penn-Tampa Neurology and TMS Wellness

35111 US Hwy 19 North, Suite 207

Palm Harbor, FL 34684

TMS of Tampa

2909 W Bay to Bay Blvd, Suite 210

Tampa, FL 33629

Health and Psychiatry

3919 Tampa Rd

Oldsmar, FL 34677

Solace Behavioral Health

Multiple locations

Northwest Tampa Bay

Greenbrook TMS Neurohealth Centers

Multiple locations

Florida and other states

Esketamine Depression Treatment [2024]

Sun, 04 Feb 2024 20:15:38 GMT

Esketamine Depression Treatment

Depression affects over 300 million people worldwide. Around 16 million adults suffer from a major depressive disorder in the US alone. While some studies show that esketamine nasal spray can effectively treat treatment resisting depression, other studies suggest that it might not be as effective as previously thought. There are also concerns about its safety. The FDA has approved a study to evaluate the efficacy and safety of esketamine for treatment-resistant depression (TRD). The drug is a racemic mixture of the enantiomers esketamine, which is active in the brain, and esketamine hydrochloride, inactive. The dose of esketamine used in clinical trials was 0.5 milligrams per kilogram (mg/kg) of body weight. This amount is equivalent to about 100 mg of esketamine HCl. It is administered as an intranasal spray.

Esketamine nasal spray works by blocking N-methyl-D-aspartate (NMDA) receptors on neurons. These are glutamate receptors that help transmit signals between nerve cells. Blocking these receptors reduces activity in the brain responsible for mood regulation. In animal studies, esketamine reduced depressive symptoms when given alone and also prevented relapse after antidepressant drugs had been discontinued.

In humans, esketamine improved depression severity and quality of life more than placebo did. However, there were no statistically significant differences between esketamine and placebo at any time point during the study.

In addition, esketamine was associated with some side effects. People taking esketamine reported dizziness, nausea, vomiting, confusion, and hallucinations. There were two deaths among people who took esketamine. One person died from suicide and another from heart failure.

There have not yet been any controlled studies comparing esketamine to other antidepressants. However, one uncontrolled study found that people who responded well to a trial of esketamine continued to respond well to the medication after discontinuing it. Another uncontrolled study showed that people who didn't respond to esketamine could benefit from switching to another antidepressant.

What is esketamine?

The FDA has approved Esketamine nasal spray to treat severe depression. The drug was originally developed for military veterans who have posttraumatic stress disorder (PTSD). Can it also treat depression? Esketamine nasal spray is a ketamine derivative that acts on the brain's NMDA receptors. This receptor plays a key role in learning, memory, and mood regulation. Ketamine is a dissociative anesthetic that produces rapid antidepressant effects.

Ketamine is a potent NMDAR antagonist that activates α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPA) receptors. These receptors play a critical role in synaptic plasticity, essential for learning and memory. Ketamine also increases the release of dopamine and serotonin in the brain.

Esketamine reaction process

Although scientists don't fully understand how it works, they know that it affects the brain's neurotransmitters. These chemicals transmit messages between nerve cells. Neurotransmitters are like messengers that carry information from one cell to another. They include serotonin, dopamine, norepinephrine, and glutamate. Serotonin is associated with feelings of calmness and happiness. Dopamine helps regulate movement and attention. Norepinephrine controls heart rate and blood pressure. Glutamate plays a key role in learning and memory.

When you feel depressed, levels of certain neurotransmitters may drop. Researchers believe that esketamine increases the amount of serotonin and dopamine in the brain. NMDA receptors are important because they play a role in learning and memory. They are located on the surface of neurons. They send chemical messages across the cell membrane to neighboring neurons when activated.

When NMDA receptors are blocked, this prevents communication between neurons. Blocked NMDA receptors reduce the activity in the part of the brain responsible for mood regulation, leading to improvements in mood. It is unclear how long esketamine stays in the brain. Animal studies suggest that it may be eliminated within 24 hours. However, human data are limited.

Esketamine's safety

In clinical trials, researchers found that esketamine nasal spray significantly improved symptoms within hours. Patients reported feeling less anxious. It's important to note that esketamine nasal spray isn't new. It's already being used off-label to treat TRD. In clinical trials, people with severe depression were given either an injection of ketamine or a placebo. The results showed that those who got ketamine experienced significant improvement within hours. This is why some experts call esketamine "the next big thing" when it comes to treating depression. An esketamine nasal spray is a form of ketamine. Ketamine is a dissociative anesthetic. It works on the same receptors as PCP, but it doesn't produce the same side effects. Esketamine nasal spray contains a small amount of ketamine. It's designed to dissolve quickly to be absorbed into the bloodstream.

Ketamine can produce dissociative states characterized by altered perception, feelings of unreality, derealization, depersonalization, and emotional numbing. These changes may be accompanied by visual disturbances, auditory distortions, and other perceptual abnormalities. The drug also produces an increase in blood pressure and heart rate. It is important to adhere to the principles of the drug during medication.

Does esketamine treat anxiety disorders too?

Esketamine nasal spray is approved only for treatment-resistant major depressive disorder. However, preliminary evidence suggests that it may be useful for treating other types of anxiety disorders. A small number of patients with posttraumatic stress disorder (PTSD) have shown improvement while using esketamine. In one case report, a woman with PTSD experienced relief from her symptoms within minutes of receiving a single dose of esketamine. Another patient with PTSD received three doses of esketamine over four weeks. After each dose, she felt less anxious and depressed. She also slept better and had fewer nightmares. Two small studies suggest that esketamine might improve obsessive-compulsive disorder (OCD). OCD involves repetitive thoughts or behaviors that cause distress. A third study found that esketamine helped reduce OCD symptoms in people with Tourette syndrome.

Drug Interactions

Esketamine has the potential to interact with a variety of different drugs and supplements. These chemicals may affect the way your antidepressant works, or they may alter the effects of your antidepressant. Amphetamines, anti-anxiety drugs, monoamine oxidase inhibitors (MAOIs), opioid pain treatments, sedatives, seizure medications, sleeping aids, and tranquilizers are all known to interact with esketamine. Drowsiness, difficulties thinking, confusion, motor impairment, and dizziness may all be worsened if you drink alcohol while taking this medication.

You should always tell your doctor about any other prescription prescriptions, over-the-counter pharmaceuticals, vitamins, herbs, or other supplements you're taking or intend to take to reduce the risk of potentially hazardous interactions.

What should I know before taking esketamine?

Before you start taking esketamine nasal spray, tell your doctor if:

You have ever had suicidal thoughts or plans
You have bipolar disorder, schizophrenia, or mania
You have liver disease
You take any medicines called MAOIs, including certain antidepressants, diet pills, or herbal supplements
You have an allergy to ketamine or any of its ingredients
You have a history of seizures
You have a history or family history of stroke
You have kidney problems
You have low blood pressure
If you experience any new or worsening symptoms, call your healthcare provider immediately.

Is there any evidence that esketamine works better than a placebo?

There have been two randomized controlled trials comparing esketamine with placebo. In both studies, patients who did not respond to at least one antidepressant were randomly assigned to receive either esketamine or a placebo. Both studies showed significant improvement in depressive symptoms compared to placebo. One study found that the effect lasted up to four weeks, while the other study showed that the benefit persisted for up to 12 weeks. In addition to these two studies, there have also been several open-label studies showing that esketamine can help treat treatment-resistant depression.

Esketamine mechanism?

The exact mechanism by which esketamine acts on the brain is unknown. However, it appears that esketamine enters the brain through the nose and then crosses the blood-brain barrier into the hippocampus, amygdala, and prefrontal cortex. Once inside the brain, esketamine binds to NMDA receptors on neurons, blocking their activity. As a result, the release of neurotransmitters such as dopamine, serotonin, norepinephrine, and glutamate decreases. Esketamine is similar to ketamine, a powerful dissociative anesthetic that has been used for decades as an anesthetic during surgery. Ketamine is also known for its ability to produce rapid antidepressant effects. Ketamine is often administered intravenously or via injection into muscle tissue. This method can cause dangerous side-effects such as hallucinations, confusion, and even death. Esketamine nasal spray is different because it works through the nose. It is designed to deliver low doses of the drug directly to the brain. The goal is to avoid these potentially harmful side effects while still delivering the same benefits.

Conclusion

Esketamine nasal sprays are currently only approved for use in adults. Esketamine is a dissociative anesthetic similar to ketamine but without its psychotomimetic effects (i.e., hallucinations). It acts on the brain's glutamatergic system, specifically on N-methyl-D-aspartate (NMDA) receptors. This action reduces activity in the amygdala, a part of the brain involved in emotional processing. It's important to note that esketamine nasal spray is only intended to be used as part of a treatment plan involving psychotherapy or other types of therapy. The medication should never be taken alone. Also, there is a need for proper medical guidelines in using esketamine as a drug to prevent health damage.

If you live in the Tampa area and would like to learn more about Florida S Ketamine Clinic please click this link to take you to our Spravato page to learn more about our Esketamine treatment services in Tampa, Florida.

Maintenance TMS [2024]

admin@floridatmsclinic.com (Khaled Bowarshi) — Sun, 04 Feb 2024 19:24:44 GMT

Maintenance TMS

How Long Does TMS Last? Does Maintenance TMS Help?

It has been about 15 years since the FDA cleared Transcranial Magnetic Stimulation therapy (TMS) for treating depression, and the success rate has been very good. A frequently asked question that we often hear is, “is TMS therapy a permanent solution, and how long can patients expect the results to last?” Continue reading to find out. In this article, we will answer the following questions.

Is TMS Permanent?

Does Depression Come Back After TMS?

How Long Do TMS Benefits Last?

What To Do When Depression Relapses After TMS Therapy?

What Is Taper-Off TMS Therapy?

Does Taper TMS Help Prevent Or Delay Relapse?

What Is Maintenance TMS Therapy?

Does Maintenance TMS Therapy Prevent Relapse?

Is Maintenance TMS Therapy Covered By Insur ance?

The benefits of TMS therapy can last for a long time. Durability is the terminology we use for how long a certain treatment effect lasts. A couple of durability papers showed that two-thirds of patients kept the effect of TMS therapy for 6-12 months after the treatment. We don’t have good published data on the long-term durability of TMS beyond 12 months. But from anecdotal observation of our patients, those who make it beyond a year without recurrence of depression symptoms remain well for years and may never need TMS retreatment. Those who relapse early may need retreatment and a plan of maintenance and prevention of relapse. Please note that each case is unique, and our general answers might not apply to you and your specific circumstance. With that disclosure being said, let's be specific with the answer now.

Is TMS Permanent?

For many, it is not permanent. If we track patients over a long period of time, about one third will have depressive symptoms again.

Does Depression Come Back After TMS?

Yes. Depression can come back again after TMS therapy.

How Long Do TMS Benefits Last?

About two-thirds of patients will continue to enjoy the benefits of TMS therapy 6 to 12 months after the end of TMS therapy.

What To Do When Depression Relapses After TMS Therapy?

At Florida TMS Clinic , if depression relapses soon after TMS therapy is over (less than 2 months), then we move on to another treatment option ( Esktamine , ECT). If depression relapse later after TMS therapy (more than 2 months), then we recommend retreatment with a full course of TMS therapy again.

What Is Taper-Off TMS Therapy?

Taper-off TMS therapy is a sequence of 6 TMS therapy sessions tapered down in frequency over 3 weeks. Typically, 3 TMS sessions in the first week, then 2 in the second week, and then 1 in the last of the three weeks. Typically, it is performed after a successful course of daily TMS therapy for 30 sessions.

Does Taper TMS Help Prevent Or Delay Relapse?

Yes. Taper-off TMS can help push out relapse of depressive symptoms after a successful course of TMS therapy. Taper-off TMS is recommended only if the patient had positive results with the 30 sessions daily TMS course. There is no point in tapering off TMS if one didn’t respond to the acute course of TMS.

What Is Maintenance TMS Therapy?

Maintenance TMS is when we continue to do TMS on a regular basis beyond the acute phase and taper-off. Typically, maintenance TMS is done once a week TMS for a few months up to a year. Other names used to describe maintenance TMS are; preservation TMS, preventive TMS, and continuation TMS.

Does Maintenance TMS Therapy Prevent Relapse?

Maintenance TMS may prevent relapse of depressive symptoms after TMS. Or it may delay the onset of such a relapse. That being said, the clinical evidence is not conclusive.

Is Maintenance TMS Therapy Covered By Insurance?

No. Insurance doesn’t cover maintenance TMS.

FLORIDA TMS CLINIC Maintenance TMS Therapy Guidelines

Based on the fact that taper-off TMS may delay the onset of relapse. We always recommend taper-off TMS to patients showing response or remission in depression symptoms.

Based on the fact that TMS responders have a good chance of keeping the response after the first course of TMS, we don’t routinely recommend maintenance TMS after the first course of TMS therapy.

Based on the high likelihood of response again with TMS retreatment. We recommend TMS retreatment for patients whose depressive symptoms relapse 2 months or later after the end of the acute TMS therapy course.

We recommend maintenance-TMS therapy on weekly bases for 6 months after the second course of TMS therapy to delay further relapses.

As of now, and because of the lack of insuran ce coverage for maintenance TMS, FLORIDA TMS CLINIC offers maintenance TMS therapy free of charge to our patients who meet the above criteria.

References

Wilson S, Croarkin PE, Aaronson ST, Carpenter LL, Cochran M, Stultz DJ, Kozel FA. Systematic review of preservation TMS that includes continuation, maintenance, relapse-prevention, and rescue TMS. J Affect Disord. 2022.

Connolly KR, Helmer A, Cristancho MA, Cristancho P, O’Reardon JP. Effectiveness of transcranial magnetic stimulation in clinical practice post-FDA approval in the united states: results observed with the first 100 consecutive cases of depression at an Academic Medical Center. J Clin Psychiatry.

Richieri R, Guedj E, Michel P, et al. Maintenance transcranial magnetic stimulation reduces depression relapse: A propensity-adjusted analysis. J Affect Disord.

SENOVA S, COTOVIO G, PASCUAL-LEONE A, OLIVEIRA MAIA AJ. Durability of antidepressant response to repetitive transcranial magnetic stimulation: systematic review and meta-analysis. Brain Stimul. 2018.

Sackeim HA. Acute Continuation and Maintenance Treatment of Major Depressive Episodes with Transcranial Magnetic Stimulation. Brain Stimul. 2016.

Abraham G, O’Brien S. Repetitive transcranial magnetic stimulation is useful for maintenance treatment [3]. Can J Psychiatry. 2002.

O’Reardon JP, Blumner KH, Peshek AD, Pradilla RR, Pimiento PC. Long-term maintenance therapy for major depressive disorder with rTMS. J Clin Psychiatry. 2005.

Langguth B, Landgrebe M, Zowe M, Gerst M, Hajak G, Eichhammer P. Repetitive transcranial magnetic stimulation for maintenance treatment of depression: A case report. J Clin Psychiatry. 2006.

Demirtas-Tatlidede A, Mechanic-Hamilton D, Press DZ, et al. An open-label, prospective study of repetitive traescraeial magnetic stimulation (rTMS) in the long-term treatment of refractory depression: reproducibility and duration of the antidepressant effect in medication-free patients. J Clin Psychiatry. 2008.

Januel D, Benadhira R, Braha S, Gastal D, Zodi I. A Six-month TMS treatments in elderly resistant depressed patients. Ann Médico-Psuchologiques. 2010.

Janicak PG, Nahas Z, Lisanby SH, et al. Durability of clinical benefit with transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistant major depression: Assessment of relapse during a 6-month, multisite, open-label study. Brain Stimul. 2010.

Mantovani A, Pavlicova M, Avery D, et al. Long-term efficacy of repeated daily prefrontal transcranial magnetic stimulation (TMS) in treatmnt-resistant depression. Depress Anxiety. 2012.

Harel EV, Rabany L, Deutsch L, Bloch Y, Zangen A, Levkovitz Y. H-coil repetitive transcranial magnetic stimulation for treatment resistant major depressive disorder: An 18-week continuation safety and feasibility study. World J Biol Psychiatry. 2014.

Bersani FS, Girardi N, Sanna L, et al. Deep Transcranial Magnetic Stimulation for treatment-resistant bipolar depression: A case report of acute and maintenance efficacy. Neurocase. 2013.

Fitzgerald PB, Grace N, Hoy KE, Bailey M, Daskalakis ZJ. An open label trial of clustered maintenance rTMS for patients with refractory depression. Brain Stimul. 2013.

Ozten E, Sayar G, Karamustafalıoğlu K. Acute and maintenance transcranial magnetic stimulation in a pregnant woman with major depression: a case report. OA Case Reports. 2013.

R. R, E. G, P. M, A. L, P. A, C. L. Maintenance transcranial magnetic stimulation reduces depression relapse: A propensity-adjusted analysis. J Affect Disord. 2013.

Noda Y, Daskalakis ZJ, Ramos C, Blumberger DM. Repetitive transcranial magnetic stimulation to maintain treatment response to electroconvulsive therapy in depression: A case series. Front Psychiatry. 2013.

Dunner DL, Aaronson ST, Sackeim HA, et al. A multisite, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: Durability of benefit over a 1-year follow-up period. J Clin Psychiatry. 2014.

Burton C, Gill S, Clarke P, Galletly C. Maintaining remission of depression with repetitive transcranial magnetic stimulation during pregnancy: A case report. Arch Womens Ment Health. 2014.

Brock DG, Philip NS, Dunner DL, et al. A Randomized Pilot Study of Maintenance NeuroStar Transcranial Magnetic Stimulation (TMS) in Patients with Major Depression. Brain Stimul. 2015.

Nierengarten MB, Benadhira R. TMS Shows Promise in Preventing Relapse in Patients with Resistant Depression. MD Conf Express. 2015.

Rapinesi C, Bersani FS, Kotzalidis GD, et al. Maintenance deep transcranial magnetic stimulation sessions are associated with reduced depressive relapses in patients with unipolar or bipolar depression. Front Neurol. 2015.

H.-N. W, X.-X. W, R.-G. Z, et al. Clustered repetitive transcranial magnetic stimulation for the prevention of depressive relapse/recurrence: A randomized controlled trial. Transl Psychiatry. 2017.

Benadhira R, Thomas F, Bouaziz N, et al. A randomized, sham-controlled study of maintenance rTMS for treatment-resistant depression (TRD). Psychiatry Res. 2017.

Rybak M, Kelly E, Erger S, Pridmore S. A system of TMS maintenance for depressed mood. Brain Stimul. 2017.

Rachid F. Maintenance repetitive transcranial magnetic stimulation (rTMS) for relapse prevention in with depression: A review. Psychiatry Res. 2018

Haesebaert F, Moirand R, Schott-Pethelaz AM, Brunelin J, Poulet E. Usefulness of repetitive transcranial magnetic stimulation as a maintenance treatment in patients with major depression. World J Biol Psychiatry. 2018.

Pridmore S, May T. Relapse prevention (RP) TMS. Brain Stimul. 2018.

Pridmore S, Erger S, Rybak M, Kelly E, May T. Early relapse (ER) transcranial magnetic stimulation (TMS) in treatment resistant major depression. Brain Stimul. 2018.

Malik, S., Malik, A., Mercille D. 79 Failure to Do Maintenance Therapy After Completion of Transcranial Magnetic Stimulation Treatment Is a Causwe of Relapse of Depression in MDD patient. Cambridge Univ Press. 2019.

Fukuda, Tirrell, Gobin C. Repetitive Transcranial Magnetic Stimulation for depression relapse or recurrence: Naturalistic retreatment series outcomes. Brain Stimul. 2019.

Li X, Nahas Z, Anderson B, Kozel FA, George MS. Can left prefrontal rTMS be used as a maintenance treatment for bipolar depression? Depress Anxiety. 2004.

Thirthalli J, Bharadwaj B, Kulkarni S, Kharawala S, Andrade C, Gangadhar BN. Successful use of maintenance rTMS for 8 months in a patient with antipsychotic-refractory auditory hallucinations. Schizophr Res. 2008.

POULET E, BRUNELIN J, KALLEL L, D’AMATO T, SAOUD M. Maintenance Treatment With Transcranial Magnetic Stimulation in a Patient With Late-Onset Schizophrenia. Am J Psychiatry. 2008.

Kar SK, Dwivedi S, Agarwal V. Relevance of extended protocol and maintenance TMS in obsessive-compulsive disorder: A case report. Asian J Psychiatr. 2019.

Mhalla A, Baudic S, de Andrade DC, et al. Long-term maintenance of the analgesic effects of transcranial magnetic stimulation in fibromyalgia. Pain. 2011.

Langguth B, Landgrebe M, Hajak G, et al. Maintenance repetitive transcranial magnetic stimulation can inhibit the return of tinnitus. Laryngoscope. 2008.

Mennemeier M, Munn T, Allensworth M, et al. Laterality, frequency and replication of rTMS treatment for chronic tinnitus: pilot studies and a review of maintenance treatment. Hear Res. 2013.

Ketamine & Esketamine (Spravato) For Anxiety [2024]

admin@floridatmsclinic.com (Khaled Bowarshi) — Sun, 04 Feb 2024 16:37:52 GMT

Ketamine And Esketamine (Spravato) For Anxiety

What Is Generalized Anxiety Disorder (GAD)?

Generalized anxiety disorder (GAD) can be characterized by excessive anxiety and worry about real or imagined issues in everyday life. Anxiety can present on most days and is hard to control. Affected people commonly feel irritable and restless; their concentration is poor, and they are quickly tired; they may suffer aches and pains in muscles and frequent headaches, and they may have limited sleep. These symptoms impair activities and efficiency in everyday life. GAD is often present along with one or more other psychiatric disorders, most commonly depression or panic disorder. GAD affects about 2-5% of the population and is severe in 1%.

What Is Social anxiety disorder (SAD)?

Social anxiety disorder (SAD) can be characterized by an excessive fear of embarrassment or humiliation in small or large gatherings. Affected individuals may avoid parties, find it challenging to speak in groups, and underperform in social contexts. Such social situations almost always trigger anxiety. There is no anxiety or impairment when there is no social demand. The condition is also called social phobia. SAD affects about 7% of the population and is severe in about 2%.

Treatment Options For GAD and SAD

Most drugs used in the treatment of depression are also effective in the treatment of GAD. Examples include antidepressant drugs like Celexa, Prozac, Paxil, Zoloft, etc. Antianxiety drugs such as Buspar and Seroquel are less effective treatments, as are antihistaminics. Finally, different kinds of psychotherapy, relaxation therapies, biofeedback interventions, yoga, meditation, and even aerobic exercise can benefit patients with GAD. SAD can be treated with drugs belonging to the antidepressant class, like SSRIs; a benzodiazepine, like Xanax, can provide emergency relief in specific situations. Behavioral and psychotherapeutic interventions are also essential treatment strategies for SAD. TMS therapy for anxiety can be another effective treatment option for anxious depression and GAD.

A small percentage of patients with GAD may remain severely impaired by anxiety despite trials of different treatments. Many patients with SAD may require emergency relief for workplace or community events that demand social engagement and performance.

Ketamine And Esketamine (Spravato) For Anxiety

Ketamine has been better studied in anxiety associated with depression, called MDD with Anxious Distress. Ketamine also showed benefits for Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SAD or Social Phobia). Clinical research is inconclusive about Ketamine for Panic Disorder.

How Is Ketamine Given For Anxiety?

Ketamine can be given in many routes.

Intravenous (IV).

Intramuscular (IM).

Subcutaneous (SQ).

Sublingual (SL) - Lozenges or Troche.

Intranasal (IN) - Esketamine Spray or Spravato is today's only FDA-approved form of Ketamine product.

Oral (PO) - oral Ketamine is the least recommended route because of the poor bioavailability of the medication in the oral gastrointestinal route.

How Does Ketamine Or Esketamine (Sparavto) Work For Anxiety?

In anxiety disorders, there is substantial evidence of stress-induced brain cell damage. Ketamine antagonizes NMDA receptors, increasing Glutamate in the brain, impacting AMPA receptors, kainate receptors, and delta-opioid receptors. These receptors mediate excitatory signals and enhance plasticity between brain cells, which affects learning and memory. We call this process Neuroplasticity.

To simplify Neuroplasticity, think of it as two words. Neuro, which means brain, and plasticity, which means moldability. Plastic is called plastic because you can mold it into any shape. Plastic surgery is called plastic surgery because we are remolding the shape of the site of the surgical intervention. Neuroplasticity means remolding the brain, referring to the new molding of the connections between brain cells.

How Effective Is Ketamine Or Esketamine For Anxiety Disorders?

Though data on Ketamine for anxiety is less abundant than data on Ketamine for depression, generally speaking, and based on the current data, about two-thirds of patients can expect a 50% decrease in anxiety symptoms with Ketamine treatment.

Glue et al. (2017) studied subcutaneous ketamine in 12 patients with treatment-resistant Generalized Anxiety Disorder (GAD) and/or Social Anxiety Disorder (SAD). All 12 patients had a diagnosis of SAD, and 10 had a comorbid diagnosis of GAD. 10 out of 12 responded with reduced anxiety reported within 1 hour of drug administration. Eight of 12 patients (67%) had a >50% reduction in anxiety rating scales at 2 hours post-treatment.

The same authors examined the efficacy and safety of ketamine as maintenance therapy in treatment-refractory GAD and SAD. Twenty patients (15 with GAD and 18 with SAD, and some both) were given one or two weekly ketamine doses of 1 mg/kg subcutaneously. Anxiety rating scores decreased by ~50%. Clinician-Administered Dissociative States Scale (CADSS) mean scores dropped from 20 points at week 1 to 8.8 points at week 14. Eighteen patients reported improved social functioning and/or work-related functioning during maintenance treatment.

In an open-label study , oral ketamine was given to 14 hospice patients who also suffered from depression and anxiety symptoms. The Hospital Anxiety and Depression Scale (HADS), which is used to rate overall depression and anxiety symptoms, showed that all subjects who completed the trial had a reduction in both anxiety and depression symptoms when given ketamine treatment. The mean time to response for anxiety symptoms with ketamine was 8.6 days, while the mean time to response for depressive symptoms was 14.4 days. All subjects maintained this response to ketamine treatment through day 28.

In Lattie et al. (2021) paper , 24 patients received subcutaneous Ketamine had a decrease in anxiety symptoms reported on Fear Scale. The improvement was dose-dependent.

In a study by Lucchese et al. (2021) , subcutaneous Esketamine was given to 70 patients with depression and/or anxiety. The response rate was 50%.

Ketamine Vs. SSRIs For Anxiety

Current pharmacologic therapies for anxiety disorders primarily target the monoaminergic system, like SSRIs and SNRIs. Unfortunately, the use of SSRIs and SNRIs is limited by a delay in onset to action (6–8 weeks) and low remission rates (25–35%). Another treatment option for anxiety disorders is benzodiazepines. Benzodiazepines are well known to provide immediate relief of symptoms of anxiety. Still, these are associated with long-term concerns about dependence and tolerance, which makes benzodiazepines poor treatment options as long-term therapeutic because of the loss of efficacy, side effects, and addiction risk.

Ketamine may provide a unique alternative treatment option for both immediate relief and maintenance treatment.

Risks And Side Effects Of Ketamine and Esketamine (Sparavto)

We advise that you speak with your doctor about the safety of Ketamine before taking this approach to treatment. Ketamine is a dissociative anesthetic. So the main side effect is dissociation. Lightheadedness, which is a by-product of dissociation, could also occur. Ketamine may cause dependence, and patients with a high risk for addiction should be cautious. Ketamine may increase heart rate, and patients with cardiac arrhythmias should not be candidates for Ketamine. Ketamine may cause a transient increase in blood pressure and some cases, hypertensive urgency. Patients with medical conditions sensitive to increased blood pressure, like aneurysms, should not be treated with Ketamine. Ketamine has not been proven safe and should not be given during pregnancy. Minor side effects include sleepiness, nausea, and rarely vomiting. It is important to note that patients shouldn’t be driving or operating heavy machinery after their Ketamine or Esketamine treatment until a restful night's sleep.

Can Ketamine Be Done Safely At Home?

No. Ketamine and/or Esketamine are not recommended for home use. Ketamine and Esketamine should always be done under medical supervision in a medical setting (clinic or doctor’s office). Before leaving the clinic, the patient should be monitored for 2 hours after each of their Ketamine or Esketamine treatments. Someone other than the patient should drive the patient back home. The presence of a therapist or receiving psychotherapy during Ketamine treatment may be beneficial but not mandatory.

Take Home Message

If you have been suffering from anxiety that didn't improve with talk therapy and classical medications treatment. It might be a good idea to bring up Ketamine or Esketamine as a treatment option. This is particularly important if you also have comorbid depression. Esketamine is an FDA-approved treatment option for Treatment Resistant Depression, which means that your insurance will cover the treatment when indicated.

Learn More

If you or someone you love is suffering from Depression and/or Anxiety, we encourage you to reach out to Florida TMS Clinic to learn more about our innovative, effective, evidence-based Esketamine (Spravato) treatment.

Alternative Treatments For Depression [2024]

admin@floridatmsclinic.com (Khaled Bowarshi) — Sun, 04 Feb 2024 16:15:15 GMT

Alternative Treatments For Depression

Mental health care has been under the spotlight recently, and for all the good reasons we are already familiar with. The shortage of mental health care makes it challenging to get the mental health care needed in a timely manner. Depression tops the list of mental health disorders affecting the population in the US. Severe clinical depression can lead to several dysfunctions in all aspects of life, including but limited to personal, medical, family and career-wise. Clinical depression cases lead to death by suicide which should be taken with all seriousness. If you or your loved one needs immediate help, please call 911. The new 988 Suicide and Crisis Lifeline 988 can also be utilized as well.

Traditionally depression is treated with talk therapy and antidepressants. CBT, or Cognitive Behavioral Therapy, is the most commonly used form of talk therapy. SSRIs, or selective serotonin reuptake inhibitors, are the most widely used class of medications for depression. That being said, there are many other alternative treatments for depression that can be utilized in addition to traditional treatments. Some alternative treatments are available to everyone, and others require medical professionals. Please consult with your psychiatrist for personalized medical care.

Alternative Treatments for Mild to Moderate Depression.

Some of the alternative treatments for depression that don’t requi re taking any supplements include Meditation, Yoga, Acupuncture, Guided imagery, Chiropractic treatments, Hypnosis, Biofeedback, Aromatherapy, and Light Therapy.

Some of the alternative herbal treatments for depression include Curcumin, Saffron, St. John’s Wort, SAM-e, and Ginkgo biloba.

Though the above options could be helpful for patients suffering from mild to moderate depression, these might not be strong enough to combat severe depression. About one-third of patients with clinical depression have what is called Treatment-Resistant Depression. This is more of a stubborn depression that doesn’t respond to classical psychotherapy and antidepressants. Herbals (chemicals, after all) can sometimes help with mild cases of depression. Yoga, massage, and exercise are helpful for mild to moderate depression. A severely depressed patient will probably have severe anhedonia (lack of interest) that lowers their motivation to take such an approach.

Alternative Treatments for Severe Depression.

In the last decade, a few treatments emerged as alternatives to medications in the case of severe depression and particularly treatment resistant depression. Three of the most important examples are TMS, Esketamine, and VNS.

TMS

TMS is Transcranial Magnetic Stimulation . TMS is a non-invasive, non-drug, alternative treatment for depression that uses magnetic pulses to simulate areas of the brain involved in the cycle of depression. It requires daily treatments for a few weeks and has non of the side effects associated with medication antidepressants, like sexual side effects and weight gain. The FDA has cleared TMS since 2008, and it is available at many specialized clinics.

Esketamine

Esketamine is a dissociative anesthetic derived from Ketamine. When used in a small dose, it induces temporary mild dissociation. When repeated a couple of times a week over 1-2 months, it can heal depression via a process called neuroplasticity. This is a form of rejuvenating brain cell connections. Esketamine was approved by the FDA in 2019 and is available at a few specialized clinics.

VNS

VNS is Vagus Nerve Stimulator. It is a device that consists of a battery-driven stimulator that gets implanted in the upper chest wall with wires branching out of it to the neck connecting to the Vagus Nerve. Stimulating the latter helps with refractory cases of depression. This treatment is available at multidisciplinary treatment centers, requiring coordination with neurosurgeons to place the device.

Future Alternative Treatments for Depression.

Psilocybin and MDMA

Psilocybin and MDMA are being heavily studied for depression and PTSD. Safety and efficacy clinical trials are currently ongoing to give direction on how to use psychedelics for depression treatment.

Implantable Microchip

Implantable Microchip Technology for “machine-brain interface” is also being developed to solve some of the most stubborn neuropsychiatric disorders. Elon Musk invested billions of dollars in a startup under the name Neuralink.

SAINT TMS

Out of the future alternative treatment options for depression, the closest to mass market application will probably be accelerated TMS . This modified TMS protocol is much faster and possibly more effective than traditional TMS. It is now FDA cleared but the device is not wisely available yet.

As you can see, there are many treatment options for depression beyond talk therapy and medications. All of which can be used to decrease the suffering of those struggling with clinical depression. Florida TMS Clinic stands out as the best depression treatment center in the Tampa Bay Area providing many alternatives for depression treatment.

TMS Therapy For Insomnia & Sleep Disorders

admin@floridatmsclinic.com (Khaled Bowarshi) — Sat, 17 Jul 2021 20:55:26 GMT

TMS Therapy For Insomnia & Sleep Disorders

~ 5 MIN READ

This article will discuss the use of TMS therapy or Transcranial Magnetic Stimulation in treating insomnia and other sleep disorder. The neuromodulatory technique rTMS is a treatment method approved by the United States Food and Drug Administration for patients with major depressive disorder that has not responded to antidepressant medication. The device utilizes magnetic fields to generate localized electrical currents in neurons just a few centimeters below the scalp, creating depolarizing and normalizing effects. Localized brain stimulation impacts neural plasticity, activates compensatory processes, and influences cortical excitability. Additionally, rTMS has been used in various clinical trials to study and treat neurological and psychiatric disorders such as anxiety, post-traumatic stress disorder (PTSD), epilepsy. Several studies have found that Transcranial Magnetic Stimulation (rTMS) can benefit inefficiency and sleep quality.

Using magnetic fields to affect brain function is now being used to treat sleep disorders and multiple disorders associated with insomnia, such as Restless Leg Syndrome, Parkinson’s, Chronic Pain, or Anxiety. Many of our patients who are treatment-resistant depressed may have co-existing insomnia that may have preceded their depression or put them at risk of relapse. This symptom is often underappreciated and should be attended to improve outcomes., People who have insomnia may be at risk of developing depression and suicidal ideation, as reported by Suh et al. 2013. This is based on their 6-year follow-up study that documented two or more episodes of insomnia in 'nondepressed patients' increasing the risk of both depression and suicidal ideation. Studies have shown improvement in patients with primary insomnia when treated with TMS. Studies of both depression and insomnia scales may find that their findings can't be separated. However, they do document the need to be aware of both symptoms. There have been some conflicting findings of the effectiveness of treatment with TMS on insomnia.

Physicians and scientists have documented improvements in patients’ sleep with rTMS treatment. He et al. suggest that disturbed intracortical excitability is responsible for sleep disturbances such as insomnia, which causes a hyperarousal state of the cerebral cortex, affecting metabolism and hormones, enabling neurogenesis.

Clinical Evidence of TMS Efficacy for Insomnia

Sanchez-Escandon et. al. 2014 studied ten patients with idiopathic insomnia and EEG abnormalities who were given a series of treatment sessions using TMS over the left frontal and frontal central areas for ten days, leading to an improvement in total sleep time, sleep efficiency, sleep onset latency, total wake time, and wake time after sleep onset.

It was reported in Jiang et al. 2013 that rTMS improved both Slow Wave Sleep and REM sleep, compared to those who received CBT, or hypnotic agents. They reported that TMS had the lowest relapse rate and was a better option for insomnia than CBT. They studied 120 patients with chronic primary insomnia, assigning 40 people to receive rTMS, 40 people to take estazolam 2 mg, and 40 people cognitive-behavioral therapy focused on sleep health education and coping skills. The patients were treated with right dorsolateral prefrontal cortex transcranial magnetic stimulation (TMS) at 1 Hz for two weeks. Differences between the rTMS and other treatments were significant at three months after treatment, with improved stage three REM sleep and lab tests. This study shows that "rTMS treatment is better than medications and psychotherapy treatments in improving the sleep architecture." rTMS significantly decreased the body awakening level and provided a better long-term treatment effect.

Song et al. (2019) studied 20 patients with Primary Insomnia using 1 Hz rTMS for 14 days monitoring the Pittsburgh Sleep Quality Index, Insomnia Severity Index, and the Epworth Sleepiness Scale. They also conducted 20 minutes of TMS-EEG before and immediately after TMS. A PSQI, ISI, and ESS ratings showed significant improvements that were maintained for one month. The researchers found that targeting the right posterior parietal cortex through low-frequency rTMS for at least one month often reverses abnormal changes in the brain’s electroencephalogram and helps with Primary Insomnia.

Pellicciari et al. 2013 used ten daily bilateral rTMS treatments of 1 Hz over the right dorsolateral prefrontal cortex and subsequent 10 Hz TMS over the left dorsolateral prefrontal cortex in 10 patients with resistant depression. They used the Hamilton Depression Rating Scale and changes in sleep patterns with EEG changes during both NREM and REM sleep before and after rTMS. The topographical-specific decrease of the alpha activity during REM sleep over the left dorsolateral prefrontal cortex (L-DLPFC) was demonstrated. The study suggests that “rTMS, and specifically the high-frequency stimulation, can represent a relevant strategy in the modulation of hypoactivity syndromes, like in MDD. And they suggested that the left frontal alpha frequency of the REM sleep as a state-dependent marker for depression and its remission.”

Li et al. 2013 studied 30 patients with major depressive disorder and 30 patients with major depressive disorder associated with insomnia while following the Montgomery-Asberg Depression Scale and the Pittsburgh Sleep Quality Index; both groups improved after four weeks of treatment. People with insomnia saw improvements in their sleep quality, daytime functioning, and the amount of time they slept per day after treatment.

In a study by Khurshid and Holbert 2015, as early as day 2-the Insomnia Severity Index started to improve and significantly improved insomnia by session 5.

Tello et al. 2017 reported on 25 patients with chronic insomnia without depression who were given 20 sessions of 1 Hz rTMS at 110% MT for 1800 stimuli/day over the right dorsolateral prefrontal cortex and found 80% of them had a “significant decrease” in their Pittsburgh Sleep Quality Index with 32% relapse rate after six months.

Stultz et al. presented a poster in June 2019 at the SLEEP conference in San Antonio, Texas, on a 6-month study of insomnia, depression, and TMS. There was a significant improvement in their sleep in people with insomnia after they received dTMS delivered to the left dorsolateral prefrontal cortex at 120% MT for an average of 27 treatments. This benefit maintained itself for six months.

Theta Burst Stimulation for Insomnia

Mensen et al. 2014 calculated the effects of theta-burst stimulation on sleep and vigilance using both continuous and intermittent theta-burst protocols with inhibition or excitation of the left dorsolateral prefrontal cortex vs. the left dorsolateral associative visual cortex. Theta burst stimulation decreased the time it took to enter stage 2NREM sleep and increased sleep efficiency. It did not affect sleep drive or psychomotor vigilance of either form or location.

TMS & Insomnia & Comorbidities

Multiple reports of improvement in sleep while using repetitive transcranial magnetic stimulation to treat other disorders such as anxiety, restless leg syndrome, and chronic pain have been described.

TMS for Anxiety Plus Insomnia

With respect to anxiety, Osuna et al. 2018 studied 16 patients who underwent one session of excitatory rTMS to either the right DLPFC or left DLPFC. Results revealed that Right DLPFC rTMS treatment had the most improvement in sleep quality with an increase in an average time of sleep, decreased number of times eyes opened during sleep and improved sympathetic activity during sleep.

Huang et al. demonstrated the effect of 1Hz rTMS on a right-sided parietal cortex for patients with generalized anxiety and insomnia; their results showed improvement in the Hamilton Rating Scale for Anxiety and Pittsburgh Sleep Quality Index scores in 36 patients.

Diefenbach et al. 2019 measured the Insomnia Severity Index before and after Generalized Anxiety treatment with TMS over time. They used low-frequency (1 Hz, 90% MT, 900 pulses) to the right dorsolateral prefrontal cortex and documented elevated ISI scores pretreatment, subthreshold scores at posttreatment and non-clinical values at 3-month follow-up.

TMS for RLS Plus Insomnia

Restless Leg Syndrome can interfere with sleep because it is a significant source of insomnia, and treatment with TMS seems to improve sleep quality.

Altunrende et al. found that ten sessions of high-frequency rTMS over the supplementary motor area can help patients with restless leg syndrome improve their symptoms. a

Lin et al. 2015, using 15 Hz TMS at 100% MT to 14 patients with RLS over the leg representation motor cortex area of the frontal lobe, showed improvement in their IRLS-RS scores and the PSQI after only two weeks, followed by benefits lasting up to two months.

The research by Sanchez-Escandon et al. 2017 used left primary motor cortex TMS in a patient with periodic limb movements and restless legs syndrome, following IRLS-RS and PSG findings with 1 Hz/1000 pulses per day. They documented improvement in total sleep time from 342 minutes to 474 minutes, increased sleep efficiency from 70 to 80%, decreased periodic limb movements, and the patient reported subjective improvement in their sleep.

TMS for Chronic Pain Plus Insomnia

In a study conducted by Park et al., the improvement of insomnia severity from severe to sub-threshold increased in two women with lower back pain and chronic insomnia. The author used transcranial magnetic stimulation for three weeks, five days per week at 1Hz and1200 stimuli per session.

TMS for Parkinson Plus Insomnia

A growing number of studies suggest new ways to treat symptoms of Parkinson's Disease and help with sleep in those patients. Van Dijk et al. 2009 studied sleep with actigraphy and pressure data from a 5 Hz rTMS conducted over either the motor or parietal cortex in 13 patients with Parkinson’s disease. Research has found that rTMS over the parietal region but not over the motor cortex improved sleep efficiency and lessened episodes of nocturnal awakenings.

Antczak et al. studied 11 patients using 15 Hz rTMS bilaterally over both primary motor areas at 120% MT. They found that patients with Parkinson’s disease have an increase in NREM sleep spindles and decreased nocturnal arousal. Patients also report improvement by using this scale.

TMS for Substance Use Plus Insomnia

There has been much excitement about the treatment for substance abuse, and Lin et al. 2019 investigated sleep quality and mood in 105 male opioid addicts after an average of 6 months of abstinence. Forty patients were randomized to 10 Hz electroconvulsive therapy (ECT), and 40 were sham-treated. The other 25 participants did not receive treatment. The Pittsburgh Sleep Quality Index, Self-rating Anxiety Scale, and Self-rating Depression Scale found improved sleep quality, depression, and anxiety in dependent patients in early abstinence. This could have a beneficial impact on preventing future relapses.

TMS Plus Acupuncture for Insomnia

TMS has even been studied with acupuncture for chronic insomnia by Zhang et al. 2018. They studied 78 patients divided into two treatment groups of TMS and acupuncture vs. acupuncture with sham TMS. Both groups improved, but the control group improved more significantly.

Conclusion:

Multiple studies have shown that Transcranial Magnetic Stimulation (TMS) effectively treats insomnia but without a clear consensus on how to use it. There does seem to be great potential for growth in this area, and research is ongoing.

TMS for Insomnia at Florida TMS Clinic

Many of our patients with depression have comorbid insomnia. Based on what we know so far. We treat the underlying depression first with High Frequency Left DL-PFC TMS. We used the magnetic intensity of 120% MT for 3000 pulses. After ten sessions of treatment, we review the patient progress in depression, anxiety, and insomnia. If there is no improvement in anxiety and/or insomnia, we add Low-Frequency Right DL-PFC TMS to the treatment protocol. We usually magnetic intensity of 110% MT for 900 pulses and increase gradually to 1800 pulses if needed.

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Morin CM, Belleville G, Bélanger L, Ivers H. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011;34(5):601-608. http://www.ncbi.nlm.nih.gov/pubmed/21532953 .
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Chaudhuri KR, Pal S, DiMarco A, et al. The Parkinson’s disease sleep scale: A new instrument for assessing sleep and nocturnal disability in Parkinson’s disease. J Neurol Neurosurg Psychiatry. 2002;73(6):629-635. doi:10.1136/jnnp.73.6.629
Walters AS, LeBrocq C, Dhar A, et al. Validation of the International Restless Legs Syndrome Study Group rating scale for restless legs syndrome. Sleep Med. 2003;4(2):121-132. http://www.ncbi.nlm.nih.gov/pubmed/14592342 .
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He Y, Sun N, Wang Z, Zou W. Effect of repetitive transcranial magnetic stimulation (rTMS) for insomnia: a protocol for a systematic review. BMJ Open. 2019;9(7):e029206. doi:10.1136/bmjopen-2019-029206
Sánchez-Escandón O, Arana-Lechuga Y, Terán-Pérez G, et al. Transcraneal Magnetic Stimulation Improves Sleep Parameters in Patients Affected with Imsomnia Associated to Electroencephalographic Abnormalities. Neurosci Med. 2014;05(01):72-77. doi:10.4236/nm.2014.51010
Arana-Lechuga Y, Sanchez-Escandon, Callado C., Castillo M., Gonsalez R., Jimenez-Anguiano A et al. Neurosci Med. 2011;2:178-184.
Jiang C, Zhang T, Yue F, Yi M, Gao D. Efficacy of Repetitive Transcranial Magnetic Stimulation in the Treatment of Patients with Chronic Primary Insomnia. Cell Biochem Biophys. 2013;67(1):169-173. doi:10.1007/s12013-013-9529-4
Pellicciari MC, Cordone S, Marzano C, et al. Dorsolateral prefrontal transcranial magnetic stimulation in patients with major depression locally affects alpha power of REM sleep. Front Hum Neurosci. 2013;7:1-11. doi:10.3389/fnhum.2013.00433
HAMILTON M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62. doi:10.1136/jnnp.23.1.56
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Li T, Wang W, Hong L, Lin Y, Wang F. Repetitive transcranial magnetic stimulation enhances sleep quality of patients with comorbid major depressive disorder and insomnia. Sleep Med. 2013;14:e303-e304. doi:10.1016/j.sleep.2013.11.743
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Khurshid, K. and Holber R. A New Approach to Treatment of Insomnia With Transcranial Magnetic Stimulation (TMS). In: San Diego, CA; 2017.
Stultz DJ, Voltin R, Thistlewaite D, et al. 0401 Insomnia, Depression and Transcranial Magnetic Stimulation - A 6 Month Study. Sleep. 2019. doi:10.1093/sleep/zsz067.400
Stultz DJ, Voltin R, Thistlethwaite D, Osburn S, Walton R, Burns T. Evaluating depression, weight change and insomnia with transcranial magnetic stimulation. Brain Stimul. 2018;11(6):e13. doi:10.1016/j.brs.2018.07.016
Mensen A, Gorban C, Niklaus M, Kuske E, Khatami R. The effects of theta-burst stimulation on sleep and vigilance in humans. Front Hum Neurosci. 2014;8(JUNE). doi:10.3389/fnhum.2014.00420
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Lin S, Hsiao Y-Y, Wang M. Test Review: The Profile of Mood States 2nd Edition. J Psychoeduc Assess. 2014;32(3):273-277. doi:10.1177/0734282913505995
Huang Z, Li Y, Bianchi MT, et al. Repetitive transcranial magnetic stimulation of the right parietal cortex for comorbid generalized anxiety disorder and insomnia: A randomized, double-blind, sham-controlled pilot study. Brain Stimul. 2018;11(5):1103-1109. doi:10.1016/j.brs.2018.05.016
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Diefenbach GJ, Rabany L, Hallion LS, et al. Sleep improvements and associations with default mode network functional connectivity following rTMS for generalized anxiety disorder. Brain Stimul. 2019;12(1):184-186. doi:10.1016/j.brs.2018.09.004
Altunrende B, Yildiz S, Cevik A, Yildiz N. Repetitive transcranial magnetic stimulation in restless legs syndrome: preliminary results. Neurol Sci. 2014;35(7):1083-1088. doi:10.1007/s10072-014-1653-4
Lin YC, Feng Y, Zhan SQ, et al. Repetitive transcranial magnetic stimulation for the treatment of restless legs syndrome. Chin Med J (Engl). 2015;128(13):1728-1731. doi:10.4103/0366-6999.159344
Sanchez-Escandon OA-LYT-PGV-MJ. Transcranial magnetic stimulation in sleep medicine. JSM Schizophr. 2017;2(2):1010.
Park EJ, Lee SJ, Koh DY, Han YM. Repetitive transcranial magnetic stimulation to treat depression and insomnia with chronic low back pain. Korean J Pain. 2014;27(3):285-289. doi:10.3344/kjp.2014.27.3.285
van Dijk KD, Møst EIS, Van Someren EJW, Berendse HW, van der Werf YD. Beneficial effect of transcranial magnetic stimulation on sleep in Parkinson’s disease. Mov Disord. 2009;24(6):878-884. doi:10.1002/mds.22462
Antczak J, Rakowicz M, Banach M, et al. The Influence of Repetitive Transcranial Magnetic Stimulation on Sleep in Parkinson’s Disease. Biocybern Biomed Eng. 2011;31(3):35-46. doi:10.1016/S0208-5216(11)70017-1
Chaudhuri, K.R., Pal, S., DiMarco, A., Whately-Smith, C., Bridman, K., Mathew, R., Pezzela, F. R., Forbes, A., Hogl, B., Trenkwalder C. The Parkinson’s disease sleep scale: A new insturment for assessing sleep and nocturnal disability in Parkinson’s disease. J Neurol Neurosurg Psychiatry. 2002;73:629-635.
Zhang Y, Liao W, Xia W. Effect of Acupuncture Cooperated with Low-frequency Repetitive Transcranial Magnetic Stimulation on Chronic Insomnia: A Randomized Clinical Trial. Curr Med Sci. 2018;38(3):491-498. doi:10.1007/s11596-018-1905-2
Zung WWK. A Rating Instrument For Anxiety Disorders. Psychosomatics. 1971;12(6):371-379. doi:10.1016/S0033-3182(71)71479-0
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Rosenquist PB, Krystal A, Heart KL, Demitrack MA, Vaughn McCall W. Left dorsolateral prefrontal transcranial magnetic stimulation (TMS): Sleep factor changes during treatment in patients with pharmacoresistant major depressive disorder. Psychiatry Res. 2013;205(1-2):67-73. doi:10.1016/j.psychres.2012.09.011
Rush AJ, Trivedi MH, Ibrahim HM, et al. The 16-item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): A psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54(5):573-583. doi:10.1016/S0006-3223(02)01866-8
Rosenquist PB, McCall W V. Does rTMS treat insomnia? Brain Stimul. 2019;12(3):809. doi:10.1016/j.brs.2019.02.004
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Kaur M, Naismith SL, Lagopoulos J, et al. Sleep-wake, cognitive and clinical correlates of treatment outcome with repetitive transcranial magnetic stimulation for young adults with depression. Psychiatry Res. 2019;271:335-342. doi:10.1016/j.psychres.2018.12.002

TMS Therapy For Fibromyalgia

admin@floridatmsclinic.com (Khaled Bowarshi) — Sat, 17 Jul 2021 20:18:01 GMT

TMS Therapy For Fibromyalgia

~ 2 MIN READ

Fibromyalgia is a common chronic disorder that causes people with fibromyalgia to experience general discomfort in several areas of their body, including the joint cavities, muscles, ligaments, and tendons. Fibromyalgia has also been linked to fatigue, sleep problems, headaches, depression, and anxiety.

Fibromyalgia’s pain can significantly alter a person’s quality of life, and current treatment options for Fibromyalgia, including antidepressants, are not very effective and can cause side effects.

While the FDA approved TMS treatment of major depression , OCD, and smoking cessation, some studies have suggested that it can also be beneficial for other disorders or diseases such as fibromyalgia. There have been multiple attempts to test TMS to determine if it would help various illnesses, including chronic pain states such as, but not limited to, migraine and fibromyalgia.

Transcranial Magnetic Stimulation (TMS) For Fibromyalgia

Brain treatments using magnetic fields sound like something out of a sci-fi movie, but the brain is an electrical organ and uses tiny bits of electricity - to send signals. That's why using magnetic waves can create electric changes within the brain, can treat some conditions.

Transcranial Magnetic Stimulation

Transcranial magnetic stimulation (TMS or repetitive magnetic stimulation – rTMS) produces brief pulses of magnetic fields transmitted to the brain through a coil placed near your head. In the beginning, TMS was used for the treatment of depression and other central nervous system disorders. But over time, it’s been found to help treat more and more conditions.

TMS has been employed to reduce the symptoms of depression and fatigue in multiple sclerosis. A scientific study demonstrates how Transcranial Magnetic Stimulation (TMS) might help alleviate freezing in patients with Parkinson's.

Pain in Fibromyalgia

Research suggests that increased activity in the dorsolateral prefrontal cortex, orbitofrontal cortices, and anterior insula is associated with more pain. Given the brain's prefrontal cortex (the seat of executive functioning) is a higher-level brain region, it might seem strange that increasing activity in this area could be linked to more rather than less pain.

The brain's prefrontal cortex is a complex part of the brain, and it affects not only pain but also pain detection. Activity in the left frontal cortical area of the DLPFC has been associated with increased sensations of pain unpleasantness. More DLFPC activity has also been associated with allodynia, a common problem in FM.

Pain activation and pain inhibition are both regulated by the DLPFC. Activating one region of the DLPFC appears to result in improved pain control and reduced pain or overstimulation while activating another DLPFC region seems to lead to increased anxiety and catastrophizing.

TMS to Treat Pain in Fibromyalgia

Low or high frequency transcranial magnetic stimulation (TMS) can be used. While low-frequency TMS generally results in reduced brain activity, high-frequency TMS produces increased brain activity.

Fibromyalgia patients already have more active DLPFC than average, so to see results in other brain regions, this research used low-frequency Transcranial Magnetic Stimulation (TMS). The TMS was applied to the DLPFC, and scientists hoped it would calm down these particular parts of the brain.

In a particular clinical trial published in 2020, The researchers recruited 45 patients with fibromyalgia (FM) after four weeks of treatment every day for five consecutive days. The randomized study comparing active TMS and sham TMS involved 27 minutes of TMS delivered over the right DLPFC total in each session for up to 4 weeks per patient, beginning at five times per week. The patients were followed for six months to see if the effects lasted.

Using a magnet to calm the electrical signals in the DLPFC worked. The FM patients receiving the electrical signals in their brains gently rearranged with significant benefits, allowing them to use less morphine and get relief from pain.

According to the research, pain levels in those given TMS treatment appeared to remain low six months after the treatments had ended. The researchers also found that pain-related depression and anxiety were significantly reduced in those given the actual TMS treatments.

How does TMS work for Fibromyalgia?

This study used low-frequency TMS to calm down the right dorsolateral prefrontal cortex activity – an area of the brain associated with chronic pain.

It's unclear from the research how TMS works, but most experts believe that it probably decreases blood flows between regions of the brain involved in pain production.

More Clinical Evidence for TMS to Treat Fibromyalgia

Researchers have found that 7 out of 10 FM Trials show positive results. The meta-analysis in 2016 found significant improvements in quality of life and a trend to lessen pain for Fibromyalgia patients. It highlighted a key issue: the need to determine “optimal treatment protocols.”

A European Commission published "Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation." They concluded that there was Level B evidence (of probable efficacy) for using high-frequency rTMS on the left motor cortex in fibromyalgia.

A study on the Efficacy of Transcranial Direct Current Stimulation and Repetitive Transcranial Magnetic Stimulation for Treating Fibromyalgia Syndrome has concluded that TMS showed analogous pain reductions, as well as considerably fewer side effects compared to FDA approved Fibromyalgia pharmaceuticals.

Conclusion:

More studies and trials are needed to investigate just how beneficial TMS can be to treat and even cure Fibromyalgia. Still, for now, early results indicate TMS may be the necessary treatment to alleviate chronic pain. Florida TMS Clinic is devoted to keeping track of recent advances involving TMS therapy.

TMS Side Effects [Read Before Doing TMS]

admin@floridatmsclinic.com (Khaled Bowarshi) — Wed, 09 Jun 2021 21:10:18 GMT

TMS Side Effects

~ 2 Minute Read

By Mhd Khaled Bowarshi, M.D.

TMS Psychiatrist at Florida TMS Clinic

Before starting TMS Therapy , you must know the risks that could be associated with TMS. Obviously, just like anything in medicine, every treatment has its own benefits and risks. Knowing the pros and cons of TMS should help you make a better decision about choosing TMS over other depression treatment options. In this article, we will discuss the absolute contraindications of TMS, relative contraindications of TMS and then the side effects of TMS. You will notice that TMS is for the most part doesn't have systemic side effects. TMS side effects are local like local scalp discomfort at the site of the TMS coil placement.

What are the absolute contraindications for TMS?

The main absolute contraindication for TMS therapy is the presence of a movable ferromagnetic intracranially (inside the head). In other words, if someone has a brain stent, clip, or stimulator then this person should not be receiving TMS therapy. There are other relative contraindications for TMS that will require further evaluation with the doctor before TMS therapy.

What are the relative contraindications for TMS?

The list of contraindications includes a history of seizure, head injury, brain surgery, any metal in the head (outside of the skull) such as shrapnel, surgical clips, or fragments. Implanted devices such as pacemakers. The presence of any of the above warrants further investigation and discussion with the doctor to evaluate the benefits vs the risks of TMS therapy.

Is Transcranial Magnetic Stimulation safe?

For the right patient, the answer is; Yes. TMS is one of the safest treatments currently available for depression aside from talk therapy. TMS therapy has proven safety and efficacy in many clinical trials.

What are the negative side effects of TMS Therapy?

The most common side effect of TMS therapy is scalp irritation or discomfort. It is reported in about 5% of patients and it usually goes away after a few sessions. The other side effects of TMS is seizure, which is very rare.

Can TMS therapy cause seizures?

Yes. Though it is very rare, TMS therapy can induce a seizure. It is estimated to happen in 1/30,000 treatments. Considering that each patient is getting about 30 sessions. This is estimated to happen at a rate of 0.1%. That chance is one in a thousand. To put this in perspective, one of the antidepressants; Wellbutrin is estimated to cause seizures in 0.4% which is four in a thousand. In other words, some medications have more risk to induce seizures than TMS. That being said, every patient undergoing TMS therapy should have a full evaluation by a TMS psychiatrist to screen for medical issues and current medications that could alter the risk of seizures.

Is Transcranial Magnetic Stimulation painful? Does TMS hurt?

For most patients, the answer is; No. TMS doesn’t hurt for the vast majority of people. Pain is subjective. About 5% of patients treated with TMS report head discomfort in the first 4-5 sessions. It mostly goes away as they get used to the treatment. A very small minority of patients could experience a tension headache. This usually goes away in 30 minutes to 2 hours. In some cases, Tylenol or Ibuprofen can be helpful. It can be avoided by starting the magnetic stimulation intensity low and increasing gradually.

What does Transcranial Magnetic Stimulation feel like?

It simply feels like a woodpecker on the side of the head. As the patient is basically laying in a spa-like chair watching Netflix, most of the time this feeling disappears in the background after a few minutes.

Does TMS Therapy cause Migraine?

TMS could cause mild head discomfort in about 5% of patients. Rarely some patients could experience a headache. It is usually more of a tension-type of headache, not a migraine headache. Also, there is a single pulse TMS device that is actually FDA-cleared for migraine headache treatment. See the section for TMS Therapy Uses above.

Does TMS Therapy cause hearing loss?

Constant exposure to loud noise could cause some hearing damage. It is highly recommended that patients wear earplugs during their TMS sessions to avoid hearing loss. In fact, we ask all of our patients to do so. Earplugs decrease the level of noise by about 30 dB which puts it in the safe range.

Does TMS Therapy cause brain damage?

No. TMS doesn’t cause brain damage. This is assuming that all the screening measures are taken and there are no contraindications to the magnetic treatment (no ferromagnetic metals in the brain).

Does TMS Therapy cause memory loss?

There is no clinical evidence that TMS causes memory loss. On the other hand, there is clinical evidence to the contrary. TMS could actually enhance memory and cognition. Many researchers are looking into the use of TMS for cognitive enhancement and treatment of early dementia.

Does TMS Therapy cause insomnia?

Not directly. On the contrary, many patients report improvement in sleep after a few sessions. There are trials looking into using TMS for insomnia.

Does TMS Therapy cause lucid dreams?

Possibly. Some patients report lucid dreams especially in the first week of treatment. We don’t have reports of nightmares though.

Can TMS Therapy be done with dental implants?

Yes. For the vast majority of cases, TMS therapy can be performed with dental implants. Please share with your TMS doctor where and what dental implants you have to discuss more and monitor.

Can TMS Therapy be done with a heart pacemaker?

Possibly, but with extra care, TMS can be done with a cardiac pacemaker. It requires very detailed evaluation. Coordination with the cardiologist and electrophysiologist to make sure the pacer and battery interrogated recently. We also would need to contact the manufacturer (Medtronic for example), depending on the model, they might recommend and send us a "shield".

Can TMS Therapy be done with a brain stimulator?

No. TMS is contraindicated with a brain pacemaker (deep brain stimulator). Brain pacemakers are used for deep brain stimulation in some cases of refractory Parkinson’s disease and respiratory depression.

Can you have TMS Therapy if you have a Spinal Cord Stimulator?

Yes, one can have TMS with a spinal stimulator. Assuming the stimulator in the thoracic or lumbar spine.

References:

O'Reardon JP, Solvason HB, Janicak PG, Sampson S, Isenberg KE, Nahas Z, McDonald WM, Avery D, Fitzgerald PB, Loo C, Demitrack MA, George MS, Sackeim HA. Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biol Psychiatry. 2007 Dec 1;62(11):1208-16. doi: 10.1016/j.biopsych.2007.01.018. Epub 2007 Jun 14. PMID: 17573044.

Perera T, George MS, Grammer G, Janicak PG, Pascual-Leone A, Wirecki TS. The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder. Brain Stimul. 2016 May-Jun;9(3):336-346. doi: 10.1016/j.brs.2016.03.010. Epub 2016 Mar 16. PMID: 27090022; PMCID: PMC5612370.

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, Lisanby SH; National Network of Depression Centers rTMS Task Group; American Psychiatric Association Council on Research Task Force on Novel Biomarkers and Treatments. Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression. J Clin Psychiatry. 2018 Jan/Feb;79(1):16cs10905. doi: 10.4088/JCP.16cs10905. PMID: 28541649; PMCID: PMC5846193.

TMS Plus Therapy | Is The Combination Of TMS Plus CBT Better? | 2021

admin@floridatmsclinic.com (Khaled Bowarshi) — Mon, 01 Feb 2021 02:21:15 GMT

TMS Plus Therapy

3 Minute Read

By Dr. Bowarshi

Florida TMS Clinic

We already established that TMS therapy is an effective alternative for treating depression and other psychiatric disorders. We also know that psychotherapy is also useful in treating depression and other psychiatric disorders. How about combining both Transcranial Magnetic Stimulation plus Psychotherapy? Is it better than TMS alone or psychotherapy alone? In this blog post, you will learn the fact about combined TMS plus Psychotherapy.

TMS therapy was FDA cleared in 2008 to treat depression that doesn’t respond to psychotherapy and medications. Deep TMS therapy was FDA cleared for adjunct treatment of OCD in 2017. That “adjunct” was added because of the design of the trial that granted the approval. In that trial, the patient will go through the provocation of obsessions before starting the TMS treatment session. It seems that getting the “state of mind” to a certain level of activation in specific brain pathways was necessary to induce the therapeutic effect of TMS.

That same phenomenon of prepping the state of activity of the brain was necessary to show the efficacy of deep TMS as an adjunct treatment for smoking cessation. Which also got FDA clearance in 2020. Both of the above examples hint that the active brain is more responsive to stimulation than a non-active one. This forms the basis of why TMS Therapy + Psychotherapy Can be superior to either one alone.

Let’s examine the evidence!

Combining transcranial magnetic stimulation with psychotherapy

In combination with psychotherapy, response and remission rates may have the potential to increase further and sustain long-lasting effects. In a large study, Dr. Donse and colleagues reported that TMS and psychotherapy’s simultaneous application resulted in a 66% response and a 56% remission rate at the end of treatment with 60% sustained remission at a 6-month follow-up.

Click here to learn how TMS works.

Behavioral activation therapy during transcranial magnetic stimulation

Behavioral Activation (BA) Therapy and Transcranial Magnetic Stimulation (TMS) have each been shown to be effective in the treatment of adult outpatients with major depressive disorder (MDD). Combining both treatments may produce synergistic antidepressant outcomes. A group of researchers at Brown University reported their data on this methodology in 2018. They concluded that incorporating a modified version of BA therapy into a standard acute course of TMS therapy is feasible, well-tolerated, and holds the potential for augmenting the efficacy of TMS treatment for patients with depression .

TMS to augment cognitive processing therapy in veterans with PTSD

Dr. Kozel and colleagues at the University of South Florida combined efforts with James A. Haley Veterans' Hospital and Clinics, Tampa, FL, to study TMS plus therapy’s efficacy. They aimed to test whether repetitive Transcranial Magnetic Stimulation (rTMS) just before Cognitive Processing Therapy (CPT) would improve the clinical outcome compared to CPT alone. They did this randomized clinical trial in veterans with PTSD. The study was done on 62 participants split into two groups. The group reported that the TMS+CPT group showed more significant symptom reductions from baseline compared to CPT alone.

Conclusion

It is apparent so far that the combination of TMS plus Psychotherapy can augment the antidepressant effect of both .

At Florida TMS Clinic , we have a strong network of psychotherapists in our area that we refer our patients to. We want our patients to maximize their chance of recovery from depression. If you are a licensed therapist in the Tampa Bay area and interested in learning more about the TMS program for your patients or are interested in helping our patients with CBT while going through TMS therapy, please contact us.

Success Rate of TMS? Click find out today.

References

Donse L, Padberg F, Sack AT, Rush AJ, Arns M. Simultaneous rTMS and psychotherapy in major depressive disorder: Clinical outcomes and predictors from a large naturalistic study. Brain Stimul. 2018 Mar-Apr;11(2):337-345. doi: 10.1016/j.brs.2017.11.004. Epub 2017 Nov 11. PMID: 29174304.

Kozel FA, Motes MA, Didehbani N, DeLaRosa B, Bass C, Schraufnagel CD, Jones P, Morgan CR, Spence JS, Kraut MA, Hart J Jr. Repetitive TMS to augment cognitive processing therapy in combat veterans of recent conflicts with PTSD: A randomized clinical trial. J Affect Disord. 2018 Mar 15;229:506-514. doi: 10.1016/j.jad.2017.12.046. Epub 2017 Dec 28. PMID: 29351885.

Russo GB, Tirrell E, Busch A, Carpenter LL. Behavioral activation therapy during transcranial magnetic stimulation for major depressive disorder. J Affect Disord. 2018 Aug 15;236:101-104. doi: 10.1016/j.jad.2018.04.108. Epub 2018 Apr 25. PMID: 29723763.

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, Bennabi D. Repetitive transcranial magnetic stimulation treatment for depressive disorders: current knowledge and future directions. Curr Opin Psychiatry. 2019 Sep;32(5):409-415. doi: 10.1097/YCO.0000000000000533. PMID: 31145145; PMCID: PMC6688778.

TMS Therapy Side Effects | Full List Of 7 Side Effects | Facts Vs Myths [2022]

admin@floridatmsclinic.com (Khaled Bowarshi) — Sat, 30 Jan 2021 04:51:26 GMT

TMS Therapy Side Effects

~ 4 Minute Read

By Dr. Khaled Bowarshi

TMS Psychiatrist in Tampa, FL

TMS therapy or Transcranial Magnetic Stimulation offers an alternative treatment option for patients suffering from depression who don’t respond to the classical treatment approach of psychotherapy and antidepressants. Unlike medications, TMS therapy has a much shorter list of side effects. TMS therapy side effects are also less common. Nevertheless, TMS therapy could still carry some risk of side effects.

Many TMS psychiatrists tell patients that TMS is free of side effects! This is not entirely true. To be more specific, TMS therapy has meager chances of significant side effects. But that doesn’t make TMS therapy utterly free of any side effects. In this article, you will have access to complete scientific evidence of most of the possible side effects resulting from TMS therapy. Please note that TMS therapy is an FDA-cleared treatment that is prescribed for severe depression. All other treatment options prescribed for severe major depressive episodes do have side effects. This article aims to make you more informed, not to deter you from seeking a badly needed treatment option.

Before we start, let’s distinguish the difference between contraindications and side effects. A contraindication is a pre-existing condition that excludes a patient from being a right candidate for TMS therapy. There are contraindications for TMS therapy, like the presence of ferromagnetic or magnetic sensitive metal objects implanted in the head or neck areas close to the TMS coil magnetic fields (e.g., metal plates, clips, electrodes, chips, pumps, stimulators, cochlear implants). On the other hand, a side effect is an undesired outcome that is caused by TMS therapy. In this article I aim to explain the potential side effects of TMS therapy. I will break it down into common side effects, uncommon side effects and a list of debunked myths of TMS side effects.

Click here to learn more about the pro's & con's of TMS

Common Side Effects Of TMS Therapy

#1 Scalp Discomfort

The most common side effects of TMS during treatment are transient head or scalp discomfort at or around the location where TMS pulses are applied.

#2 Facial Twitching

Sometimes patients may experience twitching or movement of the eyelid or jaw during stimulation due to the excitation of superficial nerve branches and superficial muscle groups’ contraction.

#3 Headache

Headache is sometimes reported after TMS treatment , particularly early in the course of the treatment when there has been no accommodation to the tapping sensation created by the stimulus. TMS headache typically decrease due to habituation or direct local analgesic effect of TMS. For those who may experience moderate headache we may recommend Tylenol or Ibuprofen 30 minutes before the treatment. We sometimes adjust the treatment intensity to avoid such a headache. We rarely see patents experiencing severe headache that requires quitting the treatment.

Uncommon Side Effects Of TMS Therapy

#4 Manic or Hypomanic Symptoms

An uncommon side effect of TMS is the induction of mania or hypomania. As patients are common daily for treatment we closely watch for manic/hypomanic symptoms (e.g., agitation, irritability) as early signs of mania. In such a case, we stop TMS therapy and follow up closely until symptoms resolved and they usually do.

#5 Decreased Hearing

Exposure to loud noise could result in decreased auditory acuity. If ear protection is worn that protects at minimum up to 30 dB, hearing will not be affected by TMS. Thus, ear protection for the patient, TMS device operator, and others in the treatment room during active stimulation is warranted to minimize possible hearing loss. Foam ear-plugs are given to each patient at the beginning of every single session. At Florida TMS Clinic we don’t make an exception to this rule. Every patient wears earplugs during treatment. We have no incidence of any hearing issues.

#6 Syncope

Vasovagal response, particularly in the context of heightened anxiety, hypoglycemia, hyperventilation, or dehydration, can result in syncope during or following TMS. Also the positioning and tilting of the treatment chair could contribute to orthostasis (lightheadedness upon setting up or standing up). The change of position could cause vertigo for those with Benign Paroxysmal Positional Vertigo (BPPV).

#7 Seizure

Inducing a seizure is an extremely rare event during TMS, The risk of tonic-clonic seizure is related to the motor cortex’s direct stimulation or stimulation of adjacent brain areas with the spread of neuronal excitation to the motor cortex. We often watch out the right hand for signs of twitching or movement during stimulation. This helps us ensure that stimulation does not spread from the prefrontal to the primary motor cortex, which can lead to generalized seizure induction with a tonic-clonic movement pattern.

The risk of TMS-induced seizures under ordinary clinical use with the figure-of-eight coil is estimated to be 1 in 30,000 treatments (0.003%). Newer data from real life practices found the risk of seizure is even lower than what was previously reported. It is now believed that the risk of risk of TMS induced seizure is 0.001%, or approximately 1 in 89,000 TMS treatments. A published summary of reported seizures related to TMS found that most TMS-related seizure events occurred in patients with preexisting risk for seizure or when stimulation parameters exceeded recommended safety ranges. Concurrent use of medications that lower the seizure threshold (e.g., imipramine, bupropion, clozapine) may increase the risk of TMS-induced seizure during or after treatment.

Most TMS induced seizures have been relatively brief (usually less than a minute and no longer than 5 minutes), with no associated long-term medical complications.

What's the success rate of TMS? Click here to find out more.

TMS Side Effects Myths Debunked

Again, just like anything in medicine, you will find people spreading unscientific rumors about side effects of TMS therapy not supported by clinical evidence. I picked the top three TMS side effects myths to discuss and present the evidence to fact check them.

#1 Effects On Cognition: TMS Doesn’t Cause Memory Loss

There were no adverse cognition effects of TMS; in fact, studies demonstrated a better performance trend on measures such as delayed story recall. Several additional safety studies have not reported adverse long-term effects or sustained cognitive function changes in subjects receiving TMS . In several studies, performance on standard neuropsychological tests was not adversely affected by TMS sessions; instead, verbal memory tended to improve, and motor reaction times tended to decrease.

#2 Brain Damage: TMS Doesn’t Cause Brain Damage

There is no evidence of pathological change in brain tissue resulting from TMS treatment delivered within the safety ranges. Published data show exposure to “accelerated” dosing (an increased number of total daily pulses) generally appears safe as well. Studies in animals, as well as studies of subsequently resected anterior temporal lobes of humans subjected to direct cortical stimulation or TMS, have failed to demonstrate evidence of histotoxicity (brain damage). The maximal field strength generated by commercially available stimulators is in the 2 Tesla range. The field is induced for a brief period only and the field’s strength falls off rapidly with distance from the coil. There is no evidence of adverse effects from magnetic field exposure during TMS.

Learn about TMS patient reviews

#3 Migraine: TMS May Cause Transient Headache But Not Migraine Headaches

In clinical practice, TMS does not increase migraine headache risk in healthy participants or those with a history of migraine. In fact, the FDA cleared a single-pulse device (eNeura) for the treatment of acute migraine headache.

References:

Rossi S, Antal A, Bestmann S, Bikson M, Brewer C, Brockmöller J, Carpenter LL, Cincotta M, Chen R, Daskalakis JD, Di Lazzaro V, Fox MD, George MS, Gilbert D, Kimiskidis VK, Koch G, Ilmoniemi RJ, Pascal Lefaucheur J, Leocani L, Lisanby SH, Miniussi C, Padberg F, Pascual-Leone A, Paulus W, Peterchev AV, Quartarone A, Rotenberg A, Rothwell J, Rossini PM, Santarnecchi E, Shafi MM, Siebner HR, Ugawa Y, Wassermann EM, Zangen A, Ziemann U, Hallett M; basis of this article began with a Consensus Statement from the IFCN Workshop on "Present, Future of TMS: Safety, Ethical Guidelines", Siena, October 17-20, 2018, updating through April 2020. Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clin Neurophysiol. 2021 Jan;132(1):269-306. doi: 10.1016/j.clinph.2020.10.003. Epub 2020 Oct 24. PMID: 33243615.

Taylor R, Galvez V, Loo C. Transcranial magnetic stimulation (TMS) safety: a practical guide for psychiatrists. Australas Psychiatry. 2018 Apr;26(2):189-192. doi: 10.1177/1039856217748249. Epub 2018 Jan 17. PMID: 29338288.

Stultz DJ, Osburn S, Burns T, Pawlowska-Wajswol S, Walton R. Transcranial Magnetic Stimulation (TMS) Safety with Respect to Seizures: A Literature Review. Neuropsychiatr Dis Treat. 2020 Dec 7;16:2989-3000. doi: 10.2147/NDT.S276635. PMID: 33324060; PMCID: PMC7732158.

Post Marketing Rate of Seizures During Transcranial Magnetic Stimulation (TMS) Treatment with NeuroStar Advanced Therapy Is Lower Than Previously Estimated

Bridget A. McGugan, Karen L. Heart, David G. Brock, Philip G. Janicak

https://www.brainstimjrnl.com/article/S1935-861X(20)30145-5/fulltext

Lan L, Zhang X, Li X, Rong X, Peng Y. The efficacy of transcranial magnetic stimulation on migraine: a meta-analysis of randomized controlled trails. J Headache Pain. 2017 Aug 22;18(1):86. doi: 10.1186/s10194-017-0792-4. PMID: 28831756; PMCID: PMC5567575.

Barker AT, Shields K. Transcranial Magnetic Stimulation: Basic Principles and Clinical Applications in Migraine. Headache. 2017 Mar;57(3):517-524. doi: 10.1111/head.13002. Epub 2016 Dec 28. PMID: 28028801.

5 TMS Therapy Secrets Your Doctor Might Not Have Told You

admin@floridatmsclinic.com (Khaled Bowarshi) — Fri, 15 Jan 2021 19:30:48 GMT

Why Your Doctor Did Not Tell You About TMS?

~ 4 Minute Read

Dr. Khaled Bowarshi

TMS Psychiatrist

Have you ever wondered why you never heard of T MS Therapy before? How is it possible not to hear about it despite being an approved and safe treatment since 2008? In this article, I will explain the impact of depression on our society, the cost we are facing, and the solutions we have. Lastly, I will put my thoughts into why the most effective solution of them all is left in the dark.

One in five Americans is affected by mental illness every year. The majority being depression, anxiety , or the combination of both. Depression affects individuals early in life. This means that the lifetime morbidity and cost of depression could reach astronomical numbers. Depression is a chronic disorder by its nature. It is a relapsing-remitting disease (it comes, and it goes). It causes significant disability during severe episodes. The World Health Organization lists depression as a leading cause of disability worldwide. Approximately 6-7% of full-time U.S. workers experienced major depression (MDD) within the past year. The total economic burden of MDD is now estimated to be $210.5 billion per year. To put it in perspective, this is more money lost for depression than the total GDP of New Zealand! For every dollar spent on MDD direct costs in 2010, an additional $1.90 was spent on MDD-related indirect costs.

Teens’ depression on the rise, thanks to social media, screen time, and other factors. We can only expect the problem to get worse over time. Depression is headed to be a major epidemic facing humanity in the next few years. Despite all we know, we are still struggling to provide the appropriate treatment options to patients battling depression. The lack of awareness of Transcranial Magnetic Stimulation (TMS) as an effective treatment option for Treatment Resistant Depression (TRD) is a screaming example of this failure. If you are battling depression and the possibility of TMS was never brought up to your attention, then you are not alone. The vast majority of primary care providers, psych nurse practitioners, therapists, psychologists, and even psychiatrists, never bring up the option of Transcranial Magnetic Stimulation (TMS). That’s even though TMS is effective, safe with no systemic side effects compared to medications. I put together the top 5 reasons why your doctor is not telling you about TMS.

How does TMS work? Click here to learn more

#1. Your psychiatrist doesn’t know about TMS.

Many psychiatrists don’t know much about Transcranial Magnetic Stimulation . However, it was approved by the FDA in 2008 and included as a treatment option in the American Psychiatric Association practice guidelines in 2010. Still, many psychiatrists don’t have this option in their treatment options algorithm. Recent takers of the American Board of Psychiatry and Neurology (ABPN) would agree that the topic of transcranial magnetic stimulation is not tested on the board exam. We know that 60% of psychiatrists in the US are over 55, making psychiatrists one of the oldest of all medical specialties. This means that these psychiatrists have no hands-on experience with TMS during their psychiatry training.

#2. Your psychiatrist doesn’t have a TMS system available in the clinic or doesn’t know one who does.

This is called availability bias. It is more like “if you are a hammer, then all you see are nails.” If your psychiatrist doesn’t have a TMS system, then the chances of her/him bringing it up as a treatment option will be less. TMS systems are costly. Depending on the technology it uses, the cost is between $100K to $200K. Compare that to a few cents cost for a prescription pad!

#3. Your family doctor doesn’t know about TMS.

Now let’s face it. There is a massive shortage of psychiatrists in the U.S. Family physicians are doing most of the heavy lifting. This means that family physicians are faced with being first-line providers to treat depression . Contrary to what one could think, psychiatrists are not the most prescribing specialists of antidepressants. Primary care physicians are the number one prescribing specialty of antidepressants in the U.S. Most primary care physicians don’t know about TMS. As explained in #1, many psychiatrists don’t know about TMS. It’s no wonder why family physicians don’t know either.

#4. Pharmaceutical companies don’t want you to know about TMS.

Pharmaceutical companies will continue to run commercials about their newest antidepressants whenever they get the chance to do so. Pharmaceutical companies are thrilled to give doctors samples of their latest medication to try their patients on. They know that the chances of response are very slim in some cases. They are in the business of making chemicals, after all. Why would they ever mention other treatment options in their ads?

#5. Insurances makes it very difficult for your doctor to advocate for your TMS Therapy .

We all know that commercial insurances make money when they don’t spend it on their members. Insurers try to find any possible reason to avoid paying for your TMS. All commercial insurances require prior authorization to pay for TMS therapy . The criteria they put in place are ridiculous at times. For example, before considering a patient for TMS, the patient should have done the following: Tried four different antidepressants, continue each one for the full duration of treatment at the maximum dose. These medications should be from at least two different pharmacological classes of antidepressants . At least two of these medications should have been augmented by another. The patient should have tried a full course of cognitive-behavioral therapy. All the above to be done during the current acute depressive episode. In other words, your insurance wants you to suffer depression for almost a year before approving your TMS. These criteria were inspired by depression treatment guidelines based on a study published in 2006 called STAR*D. But wait, TMS was approved in 2008. TMS was not included in the STAR*D trial in 2006! How is this even acceptable logically. How could you go back in time! Insurances want us to treat patients in 2021 based on old science presented 15 years ago. That is the kind of hypocrisy that is standing between breakthrough medical treatments and delivering such therapies to the patients. In summary, some doctors might just not bring up TMS because of the headache involved in obtaining approval from some insurers.

Florida TMS Clinic was founded to tear-down all the above barriers. We are committed to delivering patient awareness directly. We offer free consolation to any patient interested in learning about TMS. If you have insurance, we will advocate for you to get your treatment approved and paid for by your insurer. If you don’t have insurance or your insurance denied your case, then we can help too. We offer the most advanced TMS therapy technology at the most affordable cost in the U.S.

References:

Key Facts About Depression World Health Organization https://www.who.int/news-room/fact-sheets/detail/depression

Workplace Mental Health http://www.workplacementalhealth.org/Mental-Health-Topics/Depression/Quantifying-the-Cost-of-Depression

Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, Niederehe G, Thase ME, Lavori PW, Lebowitz BD, McGrath PJ, Rosenbaum JF, Sackeim HA, Kupfer DJ, Luther J, Fava M. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006 Nov;163(11):1905-17. doi: 10.1176/ajp.2006.163.11.1905. PMID: 17074942.

Pigott HE. The STAR*D Trial: It Is Time to Reexamine the Clinical Beliefs That Guide the Treatment of Major Depression. Can J Psychiatry. 2015 Jan;60(1):9-13. doi: 10.1177/070674371506000104. PMID: 25886544; PMCID: PMC4314062.

Gelenberg AJ. A review of the current guidelines for depression treatment. J Clin Psychiatry. 2010 Jul;71(7):e15. doi: 10.4088/JCP.9078tx1c. PMID: 20667285.

Alternative Treatments For Depression

admin@floridatmsclinic.com (Khaled Bowarshi) — Sun, 10 Jan 2021 17:51:56 GMT

Alternative Treatments For Depression

~ 3 Minute Read

By Mhd Khaled Bowarshi, M.D.

TMS Psychiatrist at Florida TMS Clinic

Depression is a widely prevalent chronic illness, with over 15 million Americans suffering from depression. Traditional treatment for depression includes psychotherapy like cognitive behavioral therapy and antidepressants like SSRIs. Many patients experience side effects to medications and look for an alternative treatment for depression that is medication-free and has no side effects .

What are the alternative treatments for depression?

Some of the alternative treatments for depression include:

Meditation
Yoga
Acupuncture
Guided imagery
Chiropractic treatments
Hypnosis
Biofeedback
Aromatherapy

What are the alternative herbal treatments for depression?

Some of the alternative herbal treatments for depression include:

Curcumin
Saffron
St. John’s Wort
SAM-e
Ginkgo biloba

TMS Therapy As An Alternative Treatment For Depression

Though the above could be helpful for patients suffering from mild to moderate depression. It lacks providing a real drug-free alternative for severe depression treatment .

You see, about one-third of patients with clinical depression have what is called Treatment-Resistant Depression. This is more of a stubborn depression that doesn’t respond to classical psychotherapy and antidepressants. Herbals (chemicals after all) can sometimes help with mild cases of depression. Yoga, massage, exercise are helpful for mild to moderate depression. A severely depressed patient will probably have severe anhedonia (lack of interest) that lowers their motivation to take such an approach.

So what is the real alternative for depression treatment? The answer is Transcranial Magnetic Stimulation [TMS] . TMS was invented in 1985, approved in the USA in 2008, and is widely implemented in clinical practice since 2019. TMS is a real drug-free, effective, approved alternative treatment for severe depression.

TMS works by magnetically stimulating an area of the brain that connects to circuits responsible for depression. It is mostly painless therapy done in an outpatient doctor’s office setting. Most patients spend a very comfortable and relaxing time while the treatment takes place. It takes about 19 minutes per treatment. Typically each patient will need 30-36 treatments session over 6 to 9 weeks. Here is the good news, it is beneficial. It has none of the side effects associated with medications (or supplements, for that matter).

Learn more about How TMS Works

TMS Therapy Alternatives

To be completely informed, you need to know about all the alternatives out there for TMS therapy. In this section, I am not going to talk about classical antidepressants and talk therapy as these are for depression that is not resistant. We will only discuss the treatment options available for TRD or Treatment Resistant Depression.

Click Here Learn more about Success rate of TMS

What are the alternatives to TMS therapy?

There are three treatment options that are FDA-approved for treatment resistant depression:

ECT , which is electroconvulsive therapy. AKA Shock Therapy.
TMS, which is Transcranial Magnetic Stimulation
S-Ketamine or Spravato.
VNS, which is Vagus nerve stimulation.

Is Transcranial Magnetic Stimulation Shock Therapy?

The answer is absolutely not. There is a big confusion out there thinking that TMS is the same as shock therapy. TMS is NOT shock-therapy. There is no shock at all in TMS. Shock therapy is ECT or Electroconvulsive Therapy. In ECT, an electrical shock is delivered to the brain to induce a therapeutic brain seizure. This is done in hospital settings and under sedation. This is not how TMS works . TMS basically uses what we know with Faraday's law of induction. We know that a magnetic field can induce a micro-electrical current. With a focused magnetic field, we can activate the brain cells by inducing these micro-electrical currents. So basically TMS gives us most of the end results we want from ECT without the side effects that come from ECT.

Click here to learn more about TMS vs ECT

How does TMS compare to ECT?

For starters, TMS is not shock-therapy. So TMS doesn’t involve inducing a therapeutic seizure. Therefore TMS doesn’t require that we put the patient to sleep. So no sedation or anesthesia of any kind. TMS is done in an outpatient doctor’s office setting. No need for a hospital visit like ECT. Patients can drive into the clinic for TMS therapy and drive themselves back. While with ECT and because of the sedation, patients will need someone to drive them back. Memory loss is a common side effect with ECT. TMS doesn’t cause any memory loss or any cognitive decline. On the contrary, there is evidence that TMS can improve memory and cognition. There is a growing interest in the preventive and therapeutic use of TMS for early dementia.

Click here to learn about the conditions treated with TMS

Which one is better: ECT or TMS?

It depends on what we are treating. For depression without psychosis, both TMS and ECT are effective. But for depression with psychotic features then ECT is better.

What are the main side effects of ECT?

Memory loss, cognitive decline, side effects related to anesthesia, and seizure.

Pro's & Con's of TMS? Click here to learn more

What is Ketamine or S-ketamine?

Ketamine is a dissociative anesthetic that is used in anesthesia for humans (rarely nowadays and animals (veterinary medicine). It was a popular party drug in the 70s and 80s. It causes dissociation like feeling “K-Hole”. It primarily blocks NMDA receptors. IV ketamine had been used to treat TRD. Recently Esketamine (Spravato) received FDA approval for treatment-resistant depression TRD.

How is Esketamine given?

Spravato or Esketamine is an intranasal spray administered under medical supervision. Patients need to be monitored in the medical office for 2 hours after the administration of Esketamine. It is given twice a week for 4 weeks then weekly thereafter.

What are the side effects of Ketamine and Esketamine?

Dissociation, nausea, and vomiting. Rare but high-risk side effects are cardiovascular, like hypertension and tachycardia.

Which one is better: TMS or Esketamine?

There is no head to head trials comparing TMS to Esketamine. But my answer will almost always be TMS first. Basically, because it is more effective and much safer. Also, TMS is more convenient as patients spend about 20 minutes per session while Spravato requires 2 hours hold in the medical office after the dose is given.

References:

G onzález-Valero G, Zurita-Ortega F, Ubago-Jiménez JL, Puertas-Molero P. Use of Meditation and Cognitive Behavioral Therapies for the Treatment of Stress, Depression and Anxiety in Students. A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2019 Nov 10;16(22):4394. doi: 10.3390/ijerph16224394. PMID: 31717682; PMCID: PMC6888319.

Cramer H, Lauche R, Langhorst J, Dobos G. Yoga for depression: a systematic review and meta-analysis. Depress Anxiety. 2013 Nov;30(11):1068-83. doi: 10.1002/da.22166. Epub 2013 Aug 6. PMID: 23922209.

Smith CA, Armour M, Lee MS, Wang LQ, Hay PJ. Acupuncture for depression. Cochrane Database Syst Rev. 2018 Mar 4;3(3):CD004046. doi: 10.1002/14651858.CD004046.pub4. PMID: 29502347; PMCID: PMC6494180.

Holmes EA, Blackwell SE, Burnett Heyes S, Renner F, Raes F. Mental Imagery in Depression: Phenomenology, Potential Mechanisms, and Treatment Implications. Annu Rev Clin Psychol. 2016;12:249-80. doi: 10.1146/annurev-clinpsy-021815-092925. Epub 2016 Jan 15. PMID: 26772205.

Banerjee S, Argáez C. Neurofeedback and Biofeedback for Mood and Anxiety Disorders: A Review of Clinical Effectiveness and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2017 Nov 13. PMID: 30299634.

Sánchez-Vidaña DI, Ngai SP, He W, Chow JK, Lau BW, Tsang HW. The Effectiveness of Aromatherapy for Depressive Symptoms: A Systematic Review. Evid Based Complement Alternat Med. 2017;2017:5869315. doi: 10.1155/2017/5869315. Epub 2017 Jan 4. PMID: 28133489; PMCID: PMC5241490.

Kocaadam B, Şanlier N. Curcumin, an active component of turmeric (Curcuma longa), and its effects on health. Crit Rev Food Sci Nutr. 2017 Sep 2;57(13):2889-2895. doi: 10.1080/10408398.2015.1077195. PMID: 26528921.

Haller H, Anheyer D, Cramer H, Dobos G. Complementary therapies for clinical depression: an overview of systematic reviews. BMJ Open. 2019 Aug 5;9(8):e028527. doi: 10.1136/bmjopen-2018-028527. PMID: 31383703; PMCID: PMC6686993.

Shafiee M, Arekhi S, Omranzadeh A, Sahebkar A. Saffron in the treatment of depression, anxiety and other mental disorders: Current evidence and potential mechanisms of action. J Affect Disord. 2018 Feb;227:330-337. doi: 10.1016/j.jad.2017.11.020. Epub 2017 Nov 7. PMID: 29136602.

Ng QX, Venkatanarayanan N, Ho CY. Clinical use of Hypericum perforatum (St John's wort) in depression: A meta-analysis. J Affect Disord. 2017 Mar 1;210:211-221. doi: 10.1016/j.jad.2016.12.048. Epub 2017 Jan 3. PMID: 28064110.

Wilson A. S-Adenosyl Methionine (SAMe) for Depression in Adults. Issues Ment Health Nurs. 2019 Aug;40(8):725-726. doi: 10.1080/01612840.2017.1392161. Epub 2019 Jan 11. PMID: 30633610.

Chen P , Hei M , Kong L , Liu Y , Yang Y , Mu H , Zhang X , Zhao S , Duan J . One water-soluble polysaccharide from Ginkgo biloba leaves with antidepressant activities via modulation of the gut microbiome. Food Funct. 2019 Dec 11;10(12):8161-8171. doi: 10.1039/c9fo01178a. PMID: 31742291.

Hermida AP, Glass OM, Shafi H, McDonald WM. Electroconvulsive Therapy in Depression: Current Practice and Future Direction. Psychiatr Clin North Am. 2018 Sep;41(3):341-353. doi: 10.1016/j.psc.2018.04.001. Epub 2018 Jun 15. PMID: 30098649.

Taiminen T. Ketamine as treatment for depression. Duodecim. 2017;133(1):52-60. PMID: 29199810.

Bottomley JM, LeReun C, Diamantopoulos A, Mitchell S, Gaynes BN. Vagus nerve stimulation (VNS) therapy in patients with treatment resistant depression: A systematic review and meta-analysis. Compr Psychiatry. 2019 Dec 12;98:152156. doi: 10.1016/j.comppsych.2019.152156. Epub ahead of print. PMID: 31978785.

TMS Success Rate

admin@floridatmsclinic.com (Khaled Bowarshi) — Sun, 10 Jan 2021 00:56:59 GMT

What Is The Success Rate Of TMS?

~ 2 Minute Read

By Dr. Bowarshi

Florida TMS Clinic

The success rate of TMS therapy is between 58% to 67%. The success rate is better at some TMS clinic like Florida TMS Clinic. This is attributed mostly to the ability to use navigated TMS for more accurate treatments. Also, the ability to perform newer TMS protocols like theta burst stimulation and accelerated TMS. In this article, I will explain the rate of success of TMS therapy and compare it to others.

The Effectiveness Of TMS Therapy

The success rate of TMS therapy is an important topic for anyone looking into TMS therapy for depression treatment. This is particularly true when we look at the high success rate reported in real-life clinical practices. Please remember that TMS is a medical treatment. As you might have already guessed, there is nothing 100% in medicine. When you read that 58% of patients receiving TMS show a response, your mind might jump to ask about the 42% who did respond to the treatment. I would like you to keep the following points in your mind:

These numbers are our of randomized controlled trials to eliminate the effect of placebo. Meaning the patients receiving the treatment wouldn’t know whether they are receiving actual magnetic stimulation or just a machine that makes noise to make it sound as if they are receiving magnetic stimulation. This inherently will show a lower response rate when compared to open-label (actual real-life clinical practice).
Patients recruited in clinical trials usually have severe resistant depression. This means that the number of medication trials they had before is significantly high. Some are in the 20+ medication trials. That by itself tells you how severe and stubborn their depression is.
58% is a great response rate when compared to antidepressants . To put it in perspective, The chances of improving with the first trial of a medication antidepressant is 27%. By the fourth trial of antidepressants, the chance of response plummets down to 6.9% only.
TMS therapy technology in evolving and improving. The reported success rate of 58% in 2007 and 67% in 2010 can be lower than what we have nowadays especially with navigated accelerated TMS success rate. The later is 90% in 2019.

Is Transcranial Magnetic Stimulation effective?

The short answer is, Yes. It is effective for the treatment of certain psychiatric disorders. Currently, the evidence is most obvious in Depression, Anxiety, OCD , and smoking cessation.

Click here to learn more about the conditions treated with TMS

How effective is Transcranial Magnetic Stimulation?

All TMS therapy studies had shown a good success rate. The main pivotal randomized controlled trial that was submitted for FDA approval in 2007 showed that 58% of patients showed a response and 37% of patients had a remission after 30 treatment sessions of TMS. An NIH sponsored trial in 2010 showed a similar outcome. Many other randomized controlled trials replicated the same outcome. Nowadays, it is a given that TMS is effective for depression.

How does TMS work? Click here to learn more.

What is the success rate of TMS Therapy?

TMS research had shown great results. Especially when compared with the low success we have with medications. In randomized controlled trials the success rate ranges from ⅔ to ½ of patients receiving TMS. In open-label trials, when people know for a fact that they are actually receiving the TMS therapy, the response rate is higher. It is worth mentioning that accelerated TMS therapy showed a 90% response rate in SAINT-TRD trial. We at Florida TMS Clinic have achieved this high success rate with accelerated TMS .

Is Transcranial Magnetic Stimulation FDA-approved?

Currently, TMS therapy is FDA-cleared for two psychiatric disorders:

TMS therapy is indicated for the treatment of Major Depressive Disorder in adult patients who have failed to receive satisfactory improvement from prior antidepressant medication in the current episode. Also recently
TMS therapy is also FDA-cleared for the treatment of OCD in adult patients who have failed to receive satisfactory improvement from prior treatments.
Most recently dTMS therapy got FDA-clearance for short-term smoking cessation in adults.

If TMS treatment is so effective, why isn't it tried before medication?

Usually, we would reserve a more expensive treatment option to be second-line treatment. That's why the initial trials for TMS (2007) included patients who failed one or more antidepressants. For this reason, the FDA approved it for treatment-resistant depression based on the data they had. This doesn't mean it won't work as a first-line treatment.

Want a free consultation? Visit Florida TMS Clinic today.

References:

George MS, Lisanby SH, Avery D, McDonald WM, Durkalski V, Pavlicova M, Anderson B, Nahas Z, Bulow P, Zarkowski P, Holtzheimer PE 3rd, Schwartz T, Sackeim HA. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Arch Gen Psychiatry. 2010 May;67(5):507-16. doi: 10.1001/archgenpsychiatry.2010.46. PMID: 20439832.

Cole EJ, Stimpson KH, Bentzley BS, Gulser M, Cherian K, Tischler C, Nejad R, Pankow H, Choi E, Aaron H, Espil FM, Pannu J, Xiao X, Duvio D, Solvason HB, Hawkins J, Guerra A, Jo B, Raj KS, Phillips AL, Barmak F, Bishop JH, Coetzee JP, DeBattista C, Keller J, Schatzberg AF, Sudheimer KD, Williams NR. Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression. Am J Psychiatry. 2020 Aug 1;177(8):716-726. doi: 10.1176/appi.ajp.2019.19070720. Epub 2020 Apr 7. PMID: 32252538.

Treatment Resistant Depression

admin@floridatmsclinic.com (Khaled Bowarshi) — Sun, 03 Jan 2021 22:21:16 GMT

Treatment Resistant Depression (TRD)

In this article, we cover the fundamentals of TMS for Treatment-Resistant Depression. First, you’ll learn more about clinical depression. Then we discuss a more stubborn form of depression called TRD. Finally, you’ll learn about current treatment options and why TMS therapy provides hope for those suffering from treatment-resistant depression.

What is Clinical Depression?

Depression is one of the most challenging disorders one can face. It cannot be diagnosed with a lab test or brain scan, making the condition especially isolating. According to the DSM-5, a major depressive episode is diagnosed when an individual experiences five or more symptoms during the same 2-week period, with at least one of them being either depressed mood or loss of interest/pleasure.

Symptoms of Major Depressive Disorder:

Depressed mood most of the day, nearly every day
Diminished interest or pleasure in almost all activities
Significant weight loss or gain, or appetite changes
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or guilt
Diminished ability to think or concentrate
Recurrent thoughts of death or suicide

Can Depression and Anxiety Happen Together?

Yes. Depression is often associated with anxiety, which is why the DSM-5 includes the specifier “Major Depressive Disorder with Anxious Distress Features.”

Severity of Depression

Depression severity is classified as mild, moderate, or severe depending on the symptoms and functional impairment in relationships, work, or daily life.

How Serious is Depression?

Depression has a significant global impact. According to the World Health Organization:

Over 264 million people worldwide suffer from depression
Close to 800,000 people die due to suicide every year
Suicide is the second leading cause of death among 15–29-year-olds

Depression is not only a leading cause of disability but also worsens outcomes for conditions like cardiovascular disease, diabetes, stroke, and hypertension.

Is There a Depression Test?

Common tests include the PHQ-9, MADRS, and HAM-D. These are used for both screening and monitoring progress. Such assessments also help determine eligibility for TMS therapy.

Are Women More Likely to Get Depression?

Yes. Women are more likely to experience major depression and attempt suicide, while men are more likely to die from suicide.

Treatment Options for Depression

Mild depression is often treated with psychotherapy such as:

Cognitive Behavioral Therapy (CBT)
Interpersonal Therapy (IPT)
Mindfulness-Based Cognitive Therapy (MBCT)
Acceptance and Commitment Therapy (ACT-D)

Moderate to severe depression typically requires a combination of psychotherapy and antidepressant medication. Common medications include:

SSRIs: Celexa, Lexapro, Paxil, Prozac, Zoloft
SNRIs: Effexor, Pristiq, Cymbalta
Other options: Wellbutrin, Remeron, Buspar
Augmentation strategies: Seroquel, Abilify

Side Effects of Antidepressants

Common side effects include:

Stomach issues, diarrhea
Dry mouth, headache, dizziness
Weight gain
Sexual side effects
Emotional numbness (“feeling like a zombie”)

Weight gain and sexual side effects are among the most common reasons patients discontinue medication.

How Successful Are Antidepressants?

The success rate of antidepressants is modest. About one in three patients responds to the first medication. Combining therapy and medication raises the response rate to around 50%.

What Happens if Antidepressants Don’t Work?

Each subsequent trial of antidepressants lowers the chance of success:

First attempt: ~27%
Second attempt: ~21%
Third attempt: ~16%
Fourth attempt: ~7%

Roughly one-third of patients do not respond at all. This is called Treatment Resistant Depression (TRD).

What is Treatment Resistant Depression (TRD)?

TRD is typically defined as the failure to achieve remission after two or more adequate treatment attempts. Definitions vary:

Clinical trials: failure after one antidepressant
CMS criteria: failure after two or more antidepressants
Some insurance companies: outdated definitions requiring failure of four medications

How to Treat TRD?

Four major treatments are currently available for TRD:

TMS (Transcranial Magnetic Stimulation) – safest and non-invasive option
ECT (Electroconvulsive Therapy) – also known as “shock therapy”
Esketamine (S-ketamine) – a ketamine derivative, FDA-approved for TRD
VNS (Vagus Nerve Stimulation)

�� TMS stands out as the safest, most effective, and non-invasive treatment for patients with TRD.

TMS Plus Ketamine For Depression [Recommended Read]

admin@floridatmsclinic.com (Khaled Bowarshi) — Sun, 06 Dec 2020 08:27:44 GMT

TMS Plus Ketamine For Depression

~ 2 MIN READ

Both TMS therapy and Ketamine enhances neuroplasticity in the brain. Helping depression sufferers beat depression and live a better life. It is not surprising that all eyes are on TMS plus Ketamine or TMS plus Esketamine together for Treatment Resistant Depression.

TMS Therapy

Transcranial Magnetic Stimulation or TMS therapy is an effective, safe, FDA-approved treatment option for Treatment Resistant Depression or TRD. It had been approved in the USA since late 2008. The American Psychiatric Association (APA) determined TMS Therapy was a treatment option when someone does not respond to an antidepressant, which is consistent with the FDA indication. We have an abundance of research supporting its safety and efficacy. It is uniquely positioned as a nonpharmacological treatment for depression, making it a unicorn in an overwhelming sea of antidepressants.

TMS therapy uses a magnetic pulse to target depression at the root source. The in-office procedure is non-invasive, and the patient is awake and aware during the session. A TMS session typically lasts 19 minutes, and a recommended full course of treatment includes five days a week for six weeks for 30 sessions. Immediately following the TMS treatment, the patient can return to their typical day, drive, and there are no adverse side effects like those associated with antidepressants. In some cases, patients may experience mild scalp discomfort.

Generally speaking, about a third of patients will have relief of depressive symptoms with TMS therapy, another third will have some improvement, and the last third wouldn’t respond to TMS. TMS antidepressant effect lasts for a relatively long term, with more than 60% of patients doing as well or better a year after the acute treatment.

How does TMS work? Click here to learn more.

Ketamine and Esketamine

More commonly known as a party drug, “special K” and causing the ‘K-hole” experience, the anesthetic ketamine was of particular interest in psychiatry because of its potent antidepressant effect in a matter of hours. Esketamine is the S-enantiomer of ketamine, which is more potent at the N-methyl-D-aspartate (NMDA) glutamate receptor than its mirror image, R-ketamine. Ketamine (or Esketamine) works through the NMDA receptor to lead to the growth of new nerve connections (synapses). This phenomenon is often referred to as neuroplasticity.

This means that Ketamine and Esketamine work differently than existing antidepressants . Rather than affecting one of the “monoamine” neurotransmitters (serotonin, norepinephrine, and dopamine), as antidepressants do, it acts on glutamate, the most common chemical messenger in the brain. Glutamate plays a vital role in the changes synapses undergo in response to experiences that underlie learning and memory. That is why researchers suspected such “neuroplasticity” would lie at the heart of ketamine’s antidepressant effects.

Why is Ketamine important for treating depression?

Mainly because of its ultra-fast antidepressant effect. Other treatments for suicidal thoughts and depression often take weeks or even months to take effect. This applied to CBT, ECT , or TMS. In the clinical studies leading up to esketamine’s FDA approval, most of the treatment difference between esketamine and placebo was observed at 24 hours, demonstrating an earlier response than other treatments. In one particular clinical trial by Canuso, Carla M, et al , intranasal esketamine (brand name Spravato) showed a significantly rapid improvement in depressive symptoms, including some measures of suicidal ideation, among depressed patients at imminent risk for suicide.

Thus far, most research has been on ketamine infusion, which is racemic ketamine. This is sometimes called intravenous, or IV, ketamine. It is a mixture of two mirror-image molecules: “R” and “S” ketamine. While it was approved decades ago as an anesthetic by the FDA, it is used off-label to treat depression. On the other hand, S-ketamine or Esketamine (Spravato), was FDA approved in March 2019. Sparavto is given as a nasal spray. It uses only the “S” molecule of Ketamine.

Spravto has good clinical evidence of efficacy. The main study by Popova, Vanina, et al, showed a clinically relevant, favorable improvement in depressive symptoms with esketamine (either 56 mg or 84 mg) nasal spray plus a newly initiated antidepressant as assessed by change in MADRS score after 28 days in adult patients with treatment-resistant depression and clinically meaningful benefit 24 hours after the first dose. In a systemic review by Zheng, Wei et al , four RCTs with seven active arms covering 708 patients with MDD on intranasal esketamine (n = 419) and placebo (n = 289) were included. Compared with placebo, adjunctive intranasal esketamine was associated with significantly greater study-defined response.

What conditions are treated with TMS?

To avoid drug misuse or abuse, the esketamine nasal spray treatment is only available at certified healthcare facilities and can only be administered by a healthcare provider. Spravato or esketamine nasal spray treatment is administered twice weekly for four weeks, followed by once weekly for an additional four weeks, then every one to two weeks after that. After each dose, the patient must be monitored by a healthcare provider for two hours to watch for adverse side effects, including dissociation, sedation, cognitive impairment, and elevated blood pressure, and the patient is not allowed to drive or operate heavy machinery until the following day. Patients who responded or remitted to esketamine were less likely to relapse if they continued with maintenance.

Now that we know that TMS can help TRD and Ketamine can help TRD, how about combing both together. Can TMS plus Ketamine help as augmentation for each other?

TMS plus Ketamine

Despite the augmentation potential for the combination of ketamine and TMS therapy simultaneously, not much research was done to clarify its efficacy. We lack sufficient data supporting doing intranasal Esketamine (Spravto) with TMS therapy. We have some data showing the effectiveness of IV racemic ketamine plus TMS therapy. A study by Best, Steven R D, et al , examined the clinical benefits of combining two established depression treatments, TMS and ketamine infusion, for patients suffering from treatment-resistant depression. The impressive and statistically significant reduction in CGI-S values for 28 participating patients indicated a synergistic effect. Furthermore, results confirmed the long-term remission (two years following treatment) achieved. TMS plus Ketamine combines the rapid onset of relief, commonly experienced with ketamine infusions, with the longer-term benefits observed with TMS treatments . TMS’s higher intensities were achievable through the conscious sedation/moderate anesthesia resulting from the ketamine infusion, which resulted in high treatment efficacy and reduced drop-out from TMS. The requirement of fewer treatment sessions further improves patient adherence to the protocol.

In conclusion, TMS plus Ketamine is a promising augmentation approach for the treatment of depression. The combination of TMS plus intranasal Esketamine (Spravato) deserves further clinical investigation as it could be very promising as a potent, rapid, and long-lasting treatment for depression .

Tricare Psychiatrist

admin@floridatmsclinic.com (Khaled Bowarshi) — Sun, 29 Nov 2020 19:19:28 GMT

Tricare Psychiatrist at Florida TMS Clinic

Are you looking for a Tricare psychiatrist near Tampa, FL? You are in luck! Florida TMS Clinic joined Tricare in-network to provide psychiatric services to our men and women in service and their families.

Many patients end up on google search for - Tricare psychiatrist near me or psychiatrist Tricare near me - often they are led to a national list of doctors and may or may not lead to what they are looking for. We decided to make the search easier to have a dedicated page for our Tricare patients to understand their options.

As you are probably aware, it is not easy to find a psychiatrist nowadays. It is unique to see a psychiatrist in-network with Tricare as it is a complicated process to join the network. We at Florida TMS Clinic decided to prioritize military patients and their families, showing appreciation for their service.

Dr. Bowarshi at Florida TMS Clinic is a Tricare psychiatrist provider specializing in treating mood disorders like Major Depressive Disorder, Generalized Anxiety Disorder, and Post Traumatic Stress Disorder. Dr. Bowarshi uses TMS or Transcranial Magnetic Stimulation to treat refractory depression. Florida TMS Clinic is the best TMS Clinic in the Tampa Bay area, with many patients traveling across the country to receive care at our clinic in Wesley Chapel, FL, northern Tampa suburb.

Military Mental Health in Tampa

The state of Florida hosts 21 military bases . Tampa hosts one of the largest, which is MacDill Air Force Base. MacDill Air Force Base is a United States Air Force installation located in western Florida, approximately 7 miles south of Tampa. MacDill AFB is home to about 95,300 military members and their families. These are:

Joint Service Active Duty: 19,900

Joint Service Civilians: 2,900

Family Members: 34,600

Retirees: 37,900

At Florida TMS Clinic, we treat Depression, Anxiety , and PTSD. We prioritize our active duty service members and their families.

Veterans Mental Health in Tampa

Tampa was ranked as the number one city for Veterans in a 2019 survey. With more than 98,000 veterans, Tampa and its surrounding Hillsborough County communities have the 27th largest population of veterans in the country, according to the U.S. Department of Veterans Affairs .

Tampa is home to James A. Haley Veterans' Hospital, one of the largest VA hospitals in Florida. Florida TMS Clinic provides TMS therapy services to Veterans referred to our clinic from the VA via the VA-CCN, the Veterans Affair- Community Care Network.

Military Families Mental Health in Tampa

In 2017 The Department of Defense did a survey screening for depression and stress among spouses of military personal. Of 367,706 people married to military personnel, 92 percent reported feeling an increase in stress levels during their spouse's deployment, while 85 percent said they felt anxious or depressed.

How does TMS work? Learn more here

How do I find a military Tricare psychiatrist near me?

You already did! Dr. Bowarshi at Florida TMS Clinic provides psychiatric care to military personnel and their families. You can also log in to your Tricare plan and search for Tricare in-network psychiatrist near me by zip code. Click to schedule .

Does Tricare cover TMS therapy?

Yes. Tricare covers TMS therapy for depression.

How do I schedule an appointment to speak with a Tricare psychiatrist?

To schedule an appointment to speak with Dr. Bowarshi. Please book your 15-minute phone call here . This 15 min phone call is free of charge. If you like to seek mental health care at Florida TMS Clinic, our office will schedule you for a full hour intake evaluation.

TMS Therapy for Postpartum Depression

admin@floridatmsclinic.com (Khaled Bowarshi) — Sat, 21 Nov 2020 19:42:03 GMT

TMS for Postpartum Depression

TMS therapy is a revolutionary treatment for depression that doesn’t involve taking any medications. This makes TMS therapy an ideal treatment option for new mothers suffering from postpartum depression, especially those planning to breastfeed their newborn. As TMS therapy is a medication-free treatment for depression, there is no harm to the baby.

In this article, we will discuss more postpartum depression, treatment options, and the advantages of TMS therapy for postpartum depression.

What's the success rate of TMS? Find out here.

Postpartum Depression

Giving birth to a baby is one of the most precious experiences in a woman’s life. The full host of emotions could be triggered that included joy, excitement, and some anxiety. It also can result in a desirable emotional state of depression.

What is postpartum depression?

A good percentage of new mothers could experience a mild form of depression known as "baby blues" after childbirth, “Baby blue” symptoms could include mood swings, crying spells, anxiety , and difficulty sleeping. Baby blues typically begin within the first two to three days after delivery and may last for up to two weeks.

A smaller percentage of new mothers could experience a more severe, long-lasting form of depression known as postpartum depression. Rarely, an extreme mood disorder called postpartum psychosis also may develop after childbirth.

For those experiencing postpartum depression, prompt treatment can help the mother manage symptoms and help the mother bond with her newborn baby.

What are the symptoms of postpartum depression?

Postpartum depression signs and symptoms can include:

Depressed mood or severe mood swings
Excessive crying
Difficulty bonding with your baby
Withdrawing from family and friends
Loss of appetite or eating much more than usual
Inability to sleep (insomnia) or sleeping too much
Overwhelming fatigue or loss of energy
Reduced interest and pleasure in activities you used to enjoy
Intense irritability and anger
Fear that you're not a good mother
Hopelessness
Feelings of worthlessness, shame, guilt, or inadequacy
Diminished ability to think clearly, concentrate or make decisions
Restlessness
Severe anxiety and panic attacks
Thoughts of harming yourself or your baby
Recurrent thoughts of death or suicide

It's important to call your doctor as soon as possible if the signs and symptoms of depression have any of these features:

Don't fade after two weeks
Are getting worse
Make it hard for you to care for your baby
Make it hard to complete everyday tasks
Include thoughts of harming yourself or your baby
If you have suicidal thoughts
If at any point you have thoughts of harming yourself or your baby, immediately seek help from your partner or loved ones in taking care of your baby and call 911 or your local emergency assistance number to get help.

Also, consider these options if you're having suicidal thoughts:

Seek help from your primary care provider or other health care professional.
Call a mental health professional.
Call a suicide hotline. In the U.S., call the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) or use their webchat on suicidepreventionlifeline.org/chat.
Reach out to a close friend or loved one.
Contact a minister, spiritual leader, or someone else in your faith community.

Causes of Postpartum Depression

What causes postpartum depression?

It is thought that many factors play roles in causing postpartum depression. This includes

Physical changes:

Hormonal changes like decreased estrogen and progesterone. The pregnancy hormones and the sharp decline of these hormones shortly after delivery are considered the biggest factor in triggering postpartum depression. Also, the hormones produced by your thyroid gland also may drop sharply, which can leave you feeling tired, sluggish, and depressed.

Emotional changes:

This could include sleep deprivation, feeling overwhelmed, feeling anxious about your ability to care for your child.

What are the risk factors for postpartum depression?

Some of the following may increase your chances of having postpartum depression:

You have a history of depression, either during pregnancy or at other times

You have bipolar disorder

You had postpartum depression after a previous pregnancy

You have family members who've had depression or other mood disorders

You've experienced stressful events during the past year, such as pregnancy complications, illness, or job loss

Your baby has health problems or other special needs

You have twins, triplets, or other multiple births

You have difficulty breast-feeding

You're having problems in your relationship with your spouse or significant other

You have a weak support system

You have financial problems

The pregnancy was unplanned or unwanted

Postpartum Depression Treatment Options

How to treat postpartum depression?

Psychotherapy is usually the first-line treatment for mild to moderate depression. Psychotherapy and medication antidepressants like Zoloft or Sertraline could be considered by your doctor. But what if you didn’t want to be on any medications. Or you have not responded to antidepressant medications. Is there an alternative safe treatment for depression that is completely drug-free? The good news, Yes. It is called TMS or Transcranial Magnetic Stimulation therapy .

TMS Therapy for Postpartum Depression

Does TMS therapy work for postpartum depression?

Yes. TMS therapy can help with postpartum depression without any of the risks of medications on the bother or newborn child. This is because TMS is a medication-free treatment for depression and there no risk of passing any chemicals via breastmilk

Transcranial Magnetic Stimulation (TMS), FDA-cleared treatment for major depression, is an effective, non-invasive procedure that uses magnetic stimulation to stimulate specific areas of the brain. It is an attractive option for those who cannot use or have not responded to traditional antidepressants . In the case of postpartum depression, and if breastfeeding is desired by the mother then TMS is the safest option for the newborn.

How does TMS work? Click here to learn more.

Are there any studies on TMS therapy for postpartum depression?

Yes, a few studies proved the efficacy and safety of TMS therapy for postpartum depression. We will go over the main ones in this paragraph.

A study by Cox and colleagues, 2020 investigated the efficacy of TMS or rTMS in a group of women with postpartum depression (PPD). In this study, six women with postpartum depression received 20 sessions of 10 Hz rTMS over the left dorsolateral prefrontal cortex (DLPFC) over a 4 week period (5 days per week). Symptoms of depression and anxiety were measured weekly, as well as 3 months and 6 months after study completion. Four of the six patients achieved remission from depression at study completion. At 3 and 6 months follow-up, four subjects maintained remission from depression at 3 months, and three subjects remaining in remission from depression at 6 months.

Another study by Garcia et al, 2010 showed consistent results. In this open-label study, nine women with postpartum depression were treated with 20 rTMS treatments over a 4 week period. Eight patients in this sample achieved remission (88.9%). The treatment effect endured over time; seven remained in remission at the 6 months follow up.

A study by Myczkowski et al, 2012 also showed a similar effect. In this randomized, placebo-controlled, double-blind pilot study, 14 women with postpartum depression were randomized to receive 20 sessions of rTMS or sham treatments (placebo) over a 4 week period. Assessed at two weeks after treatment conclusion, there was a reduction in depressive symptoms and severity of illness, as well as improvement in social and cognitive functioning.

Another open-label study by Brock et al, 2016 looked into TMS therapy for postpartum depression. In this trial, 25 women with postpartum depression received rTMS up to five times per week for up to 8 weeks. 19 out of 25 women completed the study; 14 out of the 19 participants (73.7%) achieved remission by the end of 8 weeks of treatment with TMS.

TMS vs ECT for postpartum depression

While TMS is often compared to electroconvulsive therapy (ECT), it has many advantages. For one, its mechanism of action does not require induction of a seizure or anesthesia which are required for ECT. Therefore, the patient remains alert throughout the rTMS treatment. She would be able to resume her usual activities immediately following each treatment, and there is no observable impact on cognitive functioning. And there is no exposure to any additional medications.

Click here to learn more about TMS vs ECT

In summary

All clinical trials conducted so far indicate that TMS therapy is effective, safe, and well-tolerated in women with postpartum depression. TMS treatment resulted in improvement in depressive symptoms which were maintained over 3 to 6 months of follow-up. Remission rates were relatively high, ranging from 66% to 90% in open-label trials.

While TMS is a promising non-pharmacologic treatment for postpartum depression, we must consider the burden this treatment carries. TMS therapy requires daily commitment 5 days a week for 6 weeks. Although the treatment sessions are brief, the fact that they occur on a daily basis could be very demanding, particularly for a new mother with depression.

In conclusion, TMS therapy is an alternative treatment option for depression that is particularly appealing to breastfeeding mothers suffering from postpartum depression.

10 Reasons Why Florida TMS Clinic Is the Best Transcranial Magnetic Stimulation Clinic in the Tampa Bay Area

admin@floridatmsclinic.com (Khaled Bowarshi) — Wed, 11 Mar 2020 21:31:20 GMT

10 Reasons Why Florida TMS Clinic Is the Best Transcranial Magnetic Stimulation Clinic in the Tampa Bay Area.

Transcranial Magnetic Stimulation is one of the best treatments for Treatment Resistant Depression or TRD. Considering how safe and tolerable TMS is compared to other options, TMS is arguably the best treatment for Treatment Resistant Depression. If you live in the Tampa Bay area you might wonder which clinic is the best for you. We made a list of the top 10 reason why we think we provide the best TMS in Tampa.

1. The Most Advanced TMS Technology in 2020

Florida TMS Clinic uses the latest 3D navigation TMS system approved by the FDA in May of 2019. Navigated TMS tracks the coil position in relation to the patient’s head assuring the best accuracy in treatment location. Other TMS clinics use outdated TMS systems made in 2008. Florida TMS Clinic is 12 years ahead in the medical technology we use.

How does TMS work? Click here to learn more.

2. Theta Burst Stimulation

In addition to the conventional Transcranial Magnetic Stimulation widely known to require 19 minutes per session, Florida TMS Clinic also uses intermittent Theta Burst Stimulation. This TMS technology allows for better time efficient delivery of the treatment in as short as 3 minutes per session.

3. Accelerated TMS

With accelerated TMS protocol, patients can have multiple sessions a day (up to 10 sessions) shortening the duration of the treatment to 5 days only. This novel treatment protocol comes from Stanford University. It requires the above technology of Theta Burst Stimulation. Florida TMS Clinic is the only TMS clinic to offer Accelerated TMS in Florida !

4. Double Board-Certified Psychiatrist

At Florida TMS Clinic, you will be seen by Dr. Bowarshi is an M.D. who has extensive training and board certifications in Medicine and Psychiatry and received his TMS training at Duke. Many psychiatric clinics in Tampa Bay area are staffed by “mid-level clinicians”. This means ARNP, PA, DNP. These titles stand for nurse practitioner, physicians assistants! We offer the highest level of care to our patients. No “midlevel” care is accepted at Florida TMS Clinic.

5. Supportive Professional Staff

Florida TMS Clinic is very proud of the compassionate care provided by the staff members. From the moment you call to the last day of your TMS therapy . You become a member of our family for life. All our staff members are invested in the well-being of every single patient we treat.

6. Excellent Reputation

Florida TMS Clinic opened in November 2019. In less than 4 months, we were able to leave a great impact that was notable by every patient that visited our practice. You can always read the reviews and the comments written by our patients. But even more, you can come experience our 5-star care for yourself.

Read our TMS reviews

7. Affordable Private Pay Fee Schedule

TMS is a covered benefit by most major insurance plans. Florida TMS Clinic accepts all major commercial insurances. This includes United, Blue, Aetna, Cigna, Humana and Medicare. More importantly, we provide an aggressively discounted fee schedule for private pay patients. From day one, our vision was to make TMS practical and affordable. Unlike most other clinics in the united states we have a transparent fee schedule.

Learn more about the cost of TMS therapy

8. No Hidden Fee

When we say free consultation, we mean a free consultation! This is a full evaluation by a psychiatrist completely free of charge. We DON’T charge for add-ons. Sometimes we add TMS treatment to the right side to help with anxiety. We don’t charge extra for that. Other clinics charge $200-$300 extra per session for anxiety treatment even when insurance is covering the cost of the depression treatment .

9. Flexible Scheduling

We work with our patients to accommodate their work and personal life schedule. I a matter of fact, we are receiving our second TMS chair in March of 2020 to give the maximum flexibility to our patients. We call our waiting room a lobby as our goal for no one to wait.

10. Easy Access to I-75

We chose our location wisely. We are at the heart of the fastest growing neighborhood in Tampa Bay, Wesley Chapel . We are 2 minutes away from SR-56 and I-75. This puts us in a 35-minute driving radius from almost everywhere in Tampa.

Please let us know if you have any feedback or any suggestions that could make us even better. We would love to hear from you. Call us at 813-TMS-BEST or 813-867-2378.

Is it the ‘Holiday Blues’ or is it Depression?

admin@floridatmsclinic.com (Khaled Bowarshi) — Fri, 06 Dec 2019 19:26:46 GMT

Is it the Holiday Blues or Depression?

For many, the holiday season is filled with joy, celebration, and meaningful time spent with loved ones. However, for some, this time of year can bring about overwhelming feelings of stress, sadness, and loneliness . These emotional struggles are often called the “holiday blues.” But sometimes, they can signal something more serious — clinical depression .

Understanding the Holiday Blues vs. Depression

The holiday blues often stem from increased stress, busy schedules, financial strain, or missing loved ones. These feelings are usually temporary and fade once the season ends.

By contrast, depression lingers far beyond the holidays and significantly interferes with daily life. People with a history of difficult life events — such as divorce, job loss, bereavement, chronic illness, trauma, or substance use — are at greater risk of developing depression.

Symptoms of Depression

Unlike the temporary holiday blues, Major Depressive Disorder (MDD) includes persistent symptoms such as:

Constant sadness or frequent crying
Loss of interest in social or enjoyable activities
Low energy and fatigue
Sleep changes (insomnia or excessive sleeping)
Changes in appetite or weight
Feelings of worthlessness, hopelessness, or guilt
Poor concentration and memory issues
Decreased sex drive
Recurrent thoughts of death or suicide

Depression affects nearly 15 million people in the U.S. , making it one of the most common and disabling mental health conditions.

Current Treatment Options

The most common treatments for MDD include antidepressant medications and counseling (psychotherapy) . While helpful for some, medications often present challenges:

Lack of effectiveness – Some patients simply do not respond.
Unwanted side effects – Including nausea, weight gain, headaches, dry mouth, drowsiness, and sexual dysfunction.

Because of these limitations, many patients are now turning to Transcranial Magnetic Stimulation (TMS therapy) .

What is TMS Therapy?

TMS (Transcranial Magnetic Stimulation) is a non-invasive, FDA-approved treatment for depression . It uses gentle, targeted magnetic pulses to stimulate the left prefrontal cortex — the area of the brain responsible for regulating mood.

Unlike medications, which affect the entire body, TMS focuses only on specific brain regions that are underactive in depression. MRI studies confirm that these areas can “switch back on” when stimulated with TMS, helping restore healthy brain function.

Benefits of TMS:

Drug-free and non-invasive
No systemic side effects
No anesthesia required — patients remain awake and alert
Safe, gentle, and well-tolerated
Shown to improve symptoms and lead to long-term remission

TMS at Florida TMS Clinic

While many clinics provide TMS therapy in lengthy 40-minute sessions, Florida TMS Clinic is the only provider in the Tampa Bay area offering navigated 3-minute TMS treatments. This means patients can complete therapy much faster, without sacrificing effectiveness.

A typical course of treatment includes:

5 sessions per week
Over 4–6 weeks
Averaging 30 total treatments

This accelerated approach is both convenient and highly effective for busy patients.

TMS vs. ECT (Shock Therapy)

Unlike electroconvulsive therapy (ECT) , TMS does not use electricity or cause seizures. Instead, it uses a safe magnetic field to reset brain circuits. Patients can immediately resume normal activities after each session.

The Bottom Line

If your feelings of sadness fade after the holidays, you may simply be experiencing the holiday blues . But if symptoms persist, worsen, or interfere with daily life, it may be clinical depression — and professional help is essential.

At Florida TMS Clinic , Dr. Khaled Bowarshi, a double board-certified psychiatrist , provides advanced, compassionate care using the most modern treatment options, including TMS therapy .

TMS offers hope for long-term relief from depression, so you can reclaim your life — during the holidays and beyond.

Questions You Need to Ask Your TMS Doctor

admin@floridatmsclinic.com (Khaled Bowarshi) — Fri, 22 Nov 2019 03:27:42 GMT

Questions You Need to Ask Your TMS Doctor.

So, you decided to gain your life back. You are sick and tired of being sick and tired. You realized that medications are not effective enough. You need something to bring joy back to your life. You learned about TMS. You made the choice to get TMS therapy . Congratulations! This decision could change your life forever. Now you are faced with some tricky questions: Is there more than one type of TMS? Are there different TMS machines and technologies? Which one is right for you? How long should you be treated? How much does it cost?

In this article, I will point out some of the important questions you might want to ask before choosing a TMS clinic .

What kind of TMS machine does your clinic use?

Not all TMS are created equal. As of 2019 there are 7 different manufacturers of TMS systems. Some are capable of performing one type of TMS but not the others. It might be of importance you to find out which machine your TMS clinic use and what TMS protocols it provides. For example, the most commonly utilized TMS machine is NeuroStar. It uses an old technology that is not capable of performing iTBS or nTMS . iTBS offer a much shorter during of treatment sessions. nTMS uses a navigation system to precisely determine the location of the TMS coil on the patient head. The old technology from 2008 uses manual measures to locate the target. This makes it operator-dependent and subject to technician errors.

Who is going to perform your TMS?

It is important to know how involved your psychiatrist is. In many TMS clinic , you meet the psychiatrist only once during the first session. After that all you see is a TMS technician. This is not the standard of care. It is recommended that the psychiatrist re-evaluates you every 5th session. During the re-evaluation, your psychiatrist will repeat your motor threshold determination. The magnetic energy could change periodically as you go along with the treatments. Which makes this reevaluation very important. Also, it is mandated that the treatment delivery is supervised by a psychiatrist on the premises.

How does TMS work? Click here to learn more

How long should you be treated?

It depends on the protocol followed as mention above. Old TMS machines will do the session in 19 minutes. New TMS machines can deliver your treatment in about 3 minutes. Also, the total number of sessions varies based on your progress. A typical course is usually one session a day, 5 days a week for 6 weeks then taper off over 3 weeks with 6 more sessions. This is a total of 36 sessions. Currently, clinical trials are evaluating multiple sessions per day for 5 days only. Results are very promising.

How much does it cost?

Yeah, Sure. TMS is covered by most insurances. But you still need to know how much it costs. Firstly, because we all should be educated consumers of healthcare services. Secondly, you might find alternative options that brings your healthcare dollars more value. Here is an example; Joe has XYZ commercial insurance with $6,000 deductibles and 20% copay. Other than depression , Joe was generally healthy, and he didn’t spend more than $1,000 on medical expenses throughout the year. This means he still need to pay $5,000 to meet his deductibles before his insurance plan start paying anything. Joes goes to a multi-facility TMS corporation to get his TMS . He didn’t realize that this facility had negotiated higher fees with his insurance company. The cost for his TMS is about $8,000 total. He will pay $5,000 + $600 copay for a total of $5,600 while his insurance will pick $2,400 of the “covered service”. If Joe had investigated further, he would have come across a clinic like Florida TMS Clinic that provides the most advanced TMS technology for the cost determined by research .

Florida TMS Clinic goes above and beyond to make sure that every patient gets access to best treatment possible.

Battling Depression? Think Outside The Pill Box!

admin@floridatmsclinic.com (Khaled Bowarshi) — Wed, 20 Nov 2019 21:41:08 GMT

Battling Depression? Think Outside The Pill Box!

One of the most common ailments that doctors treat annually is depression. In fact, according to the World Health Organization, depression is the leading cause of disability worldwide. Nearly 15 million people in the United States are affected by depression. While most know of Major Depressive Disorder or MDD, many fail to recognize Treatment Resistant Depression or TRD. TRD is commonly defined as a failure of treatment to produce response or remission for patients after two or more treatment attempts of adequate dose and duration.

The typical treatment options for MDD are antidepressant medications and counseling therapy. Some of the most common drug classes prescribed are selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). The widely known drugs, like Prozac, Zoloft, and Cymbalta play a role in how the neurotransmitters affect the mood by lessening anxiety levels and creating a more peaceful, calm demeanor.

While the treatment options mentioned above are helpful for some people, the problem lies in two distinct categories. Number one, depression is just a simple label that is placed over a very complicated, in-depth, disease with countless causes. And number two, a vast majority of patients do not respond well to the medications prescribed. The good news is that there is an alternative that has helped a myriad of patients, and even better, this alternative therapy is non-invasive with no systemic negative side effects .

What is TMS?

TMS (Transcranial Magnetic Stimulation) uses a highly targeted magnetic pulse to stimulate nerve cells in the area of the brain thought to control mood, the left prefrontal cortex. The magnetic pulses have shown to have a positive effect on the neurotransmitters of the brain, leading to reduced depression symptoms and long term remission, and the procedure is done right in the comfort of the office setting. This non-invasive therapy that helps to improve the symptoms of depression through magnetic stimulation in the brain. This procedure uses magnetic fields to stimulate nerve cells in the brain.

In patients with depression , the prefrontal cortex in the brain is often atypical, showing patterns of abnormality. The TMS device uses magnetic stimulation in the brain’s area that controls emotions.

This is achieved through a magnetic coil that adheres to the patient’s scalp. The magnetic therapy generates a micro-electrical current, which stimulates the brain. The patient is awake throughout the therapy session. No seizure or sedation required! Patient continue their normal daily activity once done.

How does TMS help patients with depression and anxiety?

Medications affect the entire brain and body, yet TMS distinctively treats the brain. The magnetic pulses stimulate certain areas of the brain that are out of sync. These areas are specifically targeted depending on the patient’s needs.

Years ago, people thought depression was a chemical imbalance. We now know that depression and anxiety are not completely explained by chemical imbalances. MRI imaging shows clear areas that are actively off in the brain of depressed or anxious patients. These specific areas are then stimulated with TMS therapy . Many people are unaware that if depression is not treated, MRI imaging will show degeneration in the brain.

TMS Treatment is Gentle and Safe

Despite, what comes to mind, TMS is NOT electrical shocks. TMS is a safe, magnetic field that causes the brain to reset itself and recircuit areas that are damaged or dormant via gentle stimulation. TMS therapy does not require anesthesia, and during the treatment, patients are awake, as TMS therapy requires no anesthesia or sedation, and it is completely non-invasive. TMS stimulates the brain and generates a state of non-depression. Many patients report a feeling of improvement after just a few treatments.

The typical initial treatment course consists of 5 treatments per week over a 4-6 week period, for an average of 20-30 total treatments. Other providers offer long, drawn out treatment sessions that lasts approximately 20-40 minutes for each session. Newer advanced technology using Theta Burst Stimulation allowed for a significantly shorter duration per session. To the exact, each session will take only 3 minutes and 9 seconds of your precious time! Even more advancement in medical technology allowed for the use of 3D navigation system to position the magnetic coil on the targeted area with optimal precision. Think of the infrared 3D camera system that enables face unlock feature on your latest iPhone. Navigated TMS uses similar concept but much more sophisticated to determine the positioning of the magnetic coil. In a matter of fact, this technology is the latest in the field of TMS. Stim-Guide Navigation TMS system was just cleared by the FDA a few months back. Florida TMS Clinic was the pioneer to bring such advanced technology to our area. Florida TMS Clinic is the ONLY provider of navigated 3-minute T MS in Tampa Bay Area.

How does TMS work? Click here to learn more.

Read our fall article on Health & Wellness Magazine website .

Florida TMS Clinic goes above and beyond to make sure that every patient gets access to best treatment possible.

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New Treatments for Depression

TMS Devices | 2025 Review

TMS Devices Review

NeuroStar

BrainsWay

MagVenture

Apollo

Ultimate rTMS

Blossom

NexStim

MagStim

Others:

TMS Machines Comparison Table

SAINT TMS | FDA Cleared Accelerated TMS Protocol [2023 update]

Special Offer: ONE-D Accelerated TMS Therapy for Just $1800!

SAINT TMS Depression Treatment

Is 90% Too Good To Be True?

Chapter 1: Accelerated TMS

Accelerated Transcranial Magnetic Stimulation | Terminology, History, and Importance.

Evidence Supporting Accelerated TMS

1. Left-Sided High-Frequency Accelerated TMS

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2. Right-Sided Low-Frequency Accelerated TMS

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3. Accelerated Intermittent Theta Burst Stimulation

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Chapter 2: Navigated TMS

1. The case for Neuronavigation

MRI navigation might be better... At least on paper!

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2. The case against Neuronavigation

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Navigation is not better… At least not clinically relevant.

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3. Functional Connectivity MRI Targeting

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How about functional connectivity MRI targeting? That must be better. Or is it?

﻿

Chapter 3: SAINT

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Functional Connectivity MRI Targeted High Dose Accelerated Theta Burst Stimulation

What is SAINT Depression Treatment Protocol?

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Is SAINT too good to be true?

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What is SNT Depression Treatment Protocol?

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Key differences in results reporting in SAINT vs. SNT

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What did SNT prove?

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The three proven ingredients for SAINT/SNT success.

1. Dose per session:

2. Density:

3. Number of sessions:

The one unproven ingredient for SAINT/SNT success:

fcMRI

Cortical Depth Adjusted Intensity... Necessary or Gimmick?

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SAINT Durability: The "fast on / fast off" phenomenon of SAINT & SNT

Summary:

Conflict of Interest Disclosure:

TMS Therapy Near Me In Tampa [2024]

TMS THERAPY NEAR ME

A Step By Step Guide To Find The Best TMS Clinic

TMS Therapy Clinics Ranking Criteria

1. TMS Doctor