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When medications aren’t working for people living with depression, it may feel like relief from their symptoms is out of reach. Fortunately, there are other options. One such option is TMS, or transcranial magnetic stimulation. Dr. Zeeshan Faruqui, Director of Interventional Psychiatry at Keystone Behavioral Health, gives information on this innovative treatment.

TMS

Transcranial magnetic stimulation is a noninvasive treatment for depression that uses magnetic fields to stimulate nerve cells in the brain. TMS is often used when other treatments for depression haven’t worked. This treatment for depression is called repetitive TMS or rTMS because it uses magnetic pulses that are sent out over and over again.

How it works

During a rTMS session, an electromagnetic coil is put against your scalp near your forehead. The electromagnet sends a magnetic pulse that stimulates nerve cells in the part of your brain that controls your mood and is involved in depression. This does not hurt. It is thought to wake up parts of the brain that are less active in people who are depressed.

Repetitive stimulation is used to treat major depression by changing how the cortical regions and neural circuits connected to them work. An alternating current is run through a metal coil that is placed against the scalp. This creates rapidly changing magnetic fields that pass through the skull almost unhindered and cause electric currents that depolarize neurons in a specific area of the surface cortex. Some TMS devices can also stimulate structures deeper in the brain. Repetitive TMS creates a magnetic field that is similar to that of a standard magnetic resonance imaging (MRI) machine (about 1.5 to 3 Tesla). However, the TMS field is focused (under the coil), while the MRI field is large and fills the room where the MRI machine is.

Even though we don’t fully understand how rTMS works biologically, the stimulation seems to change how the brain works, which has been shown to ease depression symptoms and improve mood. There are many ways to do the procedure, and experts may change their methods as they learn more about the best ways to treat patients.

Depression can be treated, but standard treatments don’t always work for everyone. Most of the time, repetitive TMS is used when standard treatments like drugs and talk therapy don’t work. Usually, rTMS is done while the patient is awake and sitting in a chair that reclines. Since no anesthesia is used, patients can drive themselves to and from their appointments, which usually last 30 to 40 minutes.

rTMS is a way to treat depression by stimulating the brain without hurting it. It is not like vagus nerve stimulation or deep brain stimulation in that it doesn’t involve surgery or electrodes being put into the brain. And, unlike electroconvulsive therapy (ECT), rTMS doesn’t cause seizures or require sedation or anesthesia.

Side effects

Most of the time, rTMS is safe and well-tolerated. But it can have some negative effects. Most side effects are mild to moderate, get better quickly after the session, and get less severe as more sessions are done. Some possible side effects are: headache, scalp pain where the stimulation took place, facial muscles that tingle, spasm or twitch and lightheadedness. Your doctor can change the amount of stimulation to ease your symptoms, or he or she may suggest that you take an over-the-counter painkiller before the procedure.

Uncommon side effects

Rarely are side effects severe, but they are possible. People with bipolar disorder are more likely to have seizures and mania, and if you don’t have good ear protection during treatment, there could be some impact on your hearing. No other long-term side effects of rTMS are known.

Before receiving treatment

You will need an evaluation by a psychiatrist to talk about your depression, and some lab tests might be needed. These tests make sure that rTMS is safe and the right choice for you. Tell your mental health provider if:

You are pregnant or are thinking about having a baby, you have tried rTMS before (and discuss your outcome), you’re taking any prescription or nonprescription drugs, herbal supplements, vitamins or other supplements (and how much of each you’re taking), you have had seizures or have a family history, you have other problems with your mental health such as drug abuse, bipolar disorder or psychosis, you have brain damage from something like a brain tumor, a stroke or a traumatic brain injury, you get frequent or severe headaches, and any other health problems you may have.

People who have metal or medical devices in their body will need to talk to the TMS provider as they may not be able to receive the treatment due to the strong magnetic field it creates. rTMS can sometimes still be an option, but the procedure is not recommended for some people who have: aneurysm clips or coils, stents, stimulators including deep brain or vagus nerve stimulators, electrical implants such as pacemakers and medication pumps, electrodes to track how the brain works, cochlear implants, bullet fragments and any other metal or magnetic devices or objects.

Maintenance treatment

For patients with unipolar major depression who respond to TMS and are at risk for a relapse, it is reasonable to use TMS for maintenance treatment. TMS is usually given along with antidepressants, but it can also be used as the only treatment. Maintenance TMS usually uses the same stimulation settings as the initial treatment, unless side effects make it necessary to change them. But there is no standard for how often maintenance TMS sessions should happen, or if one schedule is better than another.

The most common maintenance TMS schedule seems to be one in which the number of sessions is gradually reduced over several months. Many clinicians decide on the schedule based on how the patient responds.

Treatment schedules are being studied and we will learn more over time. One schedule option is daily treatments being cut from five to three in the first week of maintenance treatment, two in the second week, and one in the third week. After four weeks of one session a week, the schedule changes to two sessions a month for two months, then to one session a month. The number of sessions could be increased or decreased based on how well the patient was doing. Another schedule being studied is five sessions over three days every month.

There are no formal recommendations yet as to how long maintenance TMS should be given. In different studies, the length of time has been anywhere from about six months to six years. Based on indirect evidence from studies of maintenance pharmacotherapy, patients with unipolar major depression who are likely to have major depressive episodes again are good candidates for maintenance TMS that lasts at least one year and up to three years.

If you are interested in TMS therapy, talk to your healthcare provider. Our team members at Keystone Behavioral Health are also happy to answer any questions you may have. Call or text us at 717-709-7930 for more information.

To read what Keystone Health patients are saying about their experiences with TMS, click here.

This article contains general information only and should not be used as a substitute for professional diagnosis, treatment or care by a qualified health care provider.

Get to know the newest provider at Keystone Women’s Care, Certified Registered Nurse Practitioner, Erica Dailey!

What led to you to becoming a CRNP?

At a young age, I had a very close family member suffer from a female-related terminal illness. During that time, I received exposure to medical staff, equipment, and experiences that some may never come across in a lifetime. This experience, however, intrigued not only my nursing journey but also my interest in Women’s Health. In high school, I also had an opportunity to be in a program that provided clinical time in different areas of Chambersburg Hospital. After my time in Labor and Delivery, I knew I had found my match!

What do you like about working in the Women’s Care field?

Women’s health has always been a passion of mine. My previous history of working as a Labor and Delivery nurse really helped push myself to further my education and career. As a I woman, I feel like I am able to connect and relate to my patients in a special way.

Where did you go to college?

I went to Indiana University of Pennsylvania (IUP) for my bachelor’s in nursing. I went to The University of Cincinnati for my master’s in nursing/ Womens Health Nurse Practitioner (WHNP) .

What is your favorite part of your line of work?

Pregnancy has always been my passion. I think it’s so fascinating to learn about all the changes a woman’s body goes through while growing an entire human being. I also love to counsel my patients about their menstrual cycle and bodies. Health education in the US is so poor, and my goal is to inform women, so they feel empowered to manage their own health goals.

Why did you choose to work at Keystone?

As a prior patient of Keystone, I knew the type of environment and care I would be expected to give as a provider within the group. Keystone Health has been such a breath of fresh air. I love that I feel like I’m a vital part of this family and that the work I do actually matters. I love the variety of patients our practice brings, and I hope my patients can feel how much I care about them!

What are your hobbies and interests outside of work?

Outside of work, you can usually find me enjoying the outdoors, reading, trying recipes, or simply spending quality time with my husband, family, and friends. We have two Aussies, Penelope, and Wylie, who make our lives exponentially more fun! I also love to travel and try new places, food, and experiences as much as I can.

Where is your hometown, and if you are new to the area, what do you like about Franklin County so far?

I was born and raised in Chambersburg, PA and left around 5 years ago to go to Bloomsburg, PA for my husband’s hometown and job. We both worked and lived there as nurses throughout my education. Once I completed my master’s, I didn’t originally have plans to move back to Chambersburg.  However, the perfect job came along, and we were ready for change. It has been exciting to come back to Chambersburg and re-lay my roots. My friends and family are still in the area, and it’s been nice to be closer to them.

What’s an interesting fact about yourself or something people might be surprised to know about you?

I am expecting my first baby with my husband, Ryan, this upcoming May!

Is there anything else you’d like people to know about you?

I am prepared at the master’s degree level as a Women’s Health Nurse Practitioner (WHNP) specializing in both obstetrics and gynecology. Before completing my master’s, I worked for over six years as a RN in labor and delivery. As a WHNP, I can provide comprehensive OB/gynecological services, including well women’s care, contraceptive counseling/family planning, sexual health education, and pre-and postnatal care. I am passionate about advocating for women’s rights in healthcare and reproductive justice.

Welcome to the Keystone family, Erica!

For more information about Keystone Women’s Care, click here.

As the number of deaths due to COVID continues to climb, scientific developments in the fight to save lives gives hope to those who are most at risk. While vaccinations remain our best defense, medications are now available for select patients who test positive for COVID-19. Dr. Raghavendra Tirupathi, Medical Director of Infectious Diseases at Keystone Health, shares information about these new medications and who is eligible to take them.

What medications are available?

Two new antiviral medications, Paxlovid (nirmatrelvir-ritonavir) and Lagevrio (molnupiravir), are currently available in the US under emergency use authorization. These two drugs are authorized for treatment of patients with mild to moderate COVID-19 who are not currently hospitalized but are at high risk of developing severe disease. Nirmatrelvir-ritonavir and molnupiravir are only approved for use within five days of the onset of symptoms.

Who would be a good candidate for these medications?

These medications should be considered for patients with symptoms of COVID-19 who test positive for COVID and either are an older adult (aged 65 years or older) or are aged 12 years or older with an underlying condition that increases risk of severe outcomes of COVID-19 (such as cancer, heart disease, diabetes, lung disease, developmental disorders and obesity). These medications can be prescribed regardless of the vaccination status if the patient has the above risk factors.

People who develop symptoms of COVID-19 should get tested as early as possible. Those who test positive for COVID and are at high risk of severe illness should contact their doctor to find out if they are eligible for treatment.

What’s the cost?

Paxlovid and molnupiravir are provided to patients for free, although pharmacies may request insurance information for dispensing charges. To avoid spreading COVID, patients should use drive-through windows to pick up oral antiviral medications for COVID-19. Home delivery options may be available for patients who do not have transportation.

Are there side effects?

Paxlovid cannot be given to people with severe kidney or liver disease and should not be taken with certain other drugs (such as amiodarone, colchicine, and statins). Doctors may stop or replace such medications temporarily while a patient is taking paxlovid, or they may decrease the dose of a medication that interacts with paxlovid. Patients should provide a complete list of medications, including over-the-counter and herbal products, to their doctor or pharmacist before starting this medication.

Molnupiravir should not be prescribed to patients who are pregnant or attempting to become pregnant. Men who have sexual contact with individuals of childbearing age should use a reliable method of contraception consistently while taking molnupiravir and for 3 months afterward. Use of molnupiravir is not authorized for patients younger than 18 years due to potential effects on bone and cartilage.

Are other treatments available?

The other option to prevent severe disease in high-risk patients who develop COVID is a monoclonal antibody called bebtelovimab which has to be given within 7 days of the onset of symptoms. Administration will happen with physician orders, and in a clinical setting. This could be an alternative option for those who are not able to get the above antiviral medications for any reason.

This article contains general information only and should not be used as a substitute for professional diagnosis, treatment or care by a qualified health care provider.