TMS (transcranial magnetic stimulation)

Enhances neuroplasticity

Dosing

5 days a week for 6 weeks

Cost is copay x 30, or deductible (usually $8000-12000)

Management

More effective than augmentation for TRD. Treats bipolar depression but difficult to get approved there. Not known to work for psychotic depression (use ECT for that).

You can augment TMS in depression by:

1. Have patient do something active that creates a positive mood before treatment (eg walk in woods, read favorite spiritual text, music, comedy, puzzles).
2. Use with psychotherapy or light therapy
3. Add d-cycloserine for first 2 weeks. This glutamatergic enhances learning/neuroplasticity and significantly increases remission 10-fold on TMS, but is difficult to find (use an independent pharmacy and have them compound the 250 mg capsules into smaller sizes to save money, should cost $200-300 for 2 weeks). Dose is d-cycloserine for first 2 weeks of treatment (100 mg 1-2 hours before each TMS session).

In theory, deep TMS is more effective than standard TMS, but the two were equal in a head-to-head trial so not likely to make much difference.

SAINT TMS is difficult to find but very effective (remission rates of 70-90% in TRD after 5 days of 10-hour/day treatment). Find SAINT providers.

TOLERABILITY: Jaw tension, headache.

RISKS: Rare seizures (lower risk than with antidepressants).

EMR Text