What is Transcranial Magnetic Stimulation?

An Interview with Dr. Alan Schneider

Written and transcribed by Sophie McMullen & Izabella Zatorski, Clinical Operations Team

Interview of Dr. Alan Schneider, Psychiatrist at Foresight

Alan L. Schneider, MD, DFAPA, DABAM originally trained in internal medicine and then psychiatry at the UCLA residency program, where he was chief resident in psychiatry. He is board certified in psychiatry, addiction medicine, and geriatric psychiatry, and formerly in psychiatric administration. He is the former Chief of Psychiatry at Cedars Sinai Medical Center, Chief of Chemical Dependency and Opiate Treatment for the Greater Los Angeles VA, and now serves as Western Regional Medical Director of Aetna Behavioral Health. He also has a 17 year history of research in pharmacologic psychiatry. He was the recipient of numerous individual research grants and an early participant in TMS research in the United States. He held the rank of Associate Professor of Psychiatry at the UCLA School of Medicine the UCI school of medicine for a combined 21 years, is now an Assistant Clinical Professor of Psychiatry at the USC/Keck School of Medicine. He has published numerous articles in pharmacological research and is an active consultant to the Medical Board of California and the US Department of Justice. What is Transcranial Magnetic Stimulation and how does research say it can help?

Anthony Barker and his team introduced Transcranial Magnetic Stimulation (TMS) in 1985. They demonstrated that TMS was able to stimulate precise areas of the brain by applying a machine to an area of the motor cortex responsible for controlling movement of muscles, which resulted in a specific area of the hand to twitch. It has been used to study several cerebral regions and is now primarily used to stimulate the left prefrontal cortex as a treatment for depression. TMS is a non-invasive technique that is implemented when a patient is awake. The process of TMS involves the use of a small magnetic coil positioned lightly on your head. Magnetic fields pulse ON and OFF on the targeted area of the brain. The idea of this magnetic pulsation is that the magnetic field on the outer side of the skull induces a small electric current on the inner side. It is the rate of change of the current that affects people — this is known as Faraday’s law. The speed of the current helps by allowing depolarization of local neurons and neurotransmitters to be released. This induction — not the magnetic field itself — is the critical component to the effects of TMS. Dr. Schneider explains how the magnet location does not have to be exact because there is enough spread of interneurons that travel through the brain and hit the areas that need to be targeted. These areas include the anterior cingulate gyrus, ventromedial prefrontal cortex, and amygdala. The current penetrates approximately 2-3cm beyond the skull to stimulate major brain regions known to affect mood. Ultimately, areas of the brain associated with emotions and memory known as the limbic system are activated via neural pathways resulting in improved mood and reduced depression.

How does TMS differ from ECT?

The key differentiation between TMS and electroconvulsive therapy (ECT) is that TMS is performed on awake and alert patients versus those in ECT who require light anesthesia and the presence of an anesthesiologist. This means a patient can safely drive themselves to and from their treatment session. ECT is a process that involves the use of a generalized electrical current that travels through the brain and induces a seizure. This is directly in contrast to TMS which uses magnetic fields. Magnetic fields allow for more precise results because the magnetic field is focalized. Dr. Schneider explains ECT is much more involved than TMS. ECT requires a suite of professionals, while treatment for TMS typically involves only one treating physician and one TMS technician. With ECT, patients must be monitored more closely, and there are more side effects. TMS is easier to perform and has fewer side effects.

Many people get scared about brain stimulation. How can we reassure them that TMS is safe?

In the beginning stages of development of TMS, there were two primary negative outcomes with which the FDA was concerned. The first was an auditory concern, because of the sound the TMS machine generates. When the machine is placed over the head it produces a loud clacking sound every time it fires. It was determined early on that this would not cause hearing problems for the patients. The second and more important concern was if you stimulated somebody at certain parameters, what was their likelihood to have a seizure. In 1996, an international workshop was set up to develop the standard for TMS. This standard was designed to ensure that the patients receiving the treatment would not undergo seizure. Now, machines are automatically set up to adjust to the right parameters. This convention set up a standard of guidelines for TMS including ethical requirements, stimulation parameters, neuropsychological monitoring, and medical management of seizures. These industry wide guidelines ensure that TMS is completely safe. However, the potential psychological effects of having a seizure granted the patient has a history of seizures can be significant and should not be ignored.

What diagnoses can TMS treat?

Major depressive disorder (MDD) and obsessive compulsive disorder (OCD) are the only two FDA approved diagnoses for TMS treatment. Foresight exclusively offers TMS for the treatment of MDD, as this is what is covered by most insurance companies.

Who is eligible and what are the requirements?

TMS is a procedure for people diagnosed with MDD who have failed psychotherapy, failed multiple adequate trials of antidepressant medication, and are at least 18 years of age. There is a list of criteria that needs to be met before starting TMS and these vary by insurance company. If you are currently undergoing a treatment or taking a medication for MDD that is working well, then consult with your provider to see if TMS is right for you. To learn more you can call your insurance company and ask about TMS coverage or our neuropsychology department can do this for you.

How is TMS administered and what does treatment look like?

TMS is administered over the course of approximately 35 sessions, which takes place over four to six weeks. Each session lasts 20-25 minutes in duration. In terms of what the treatment looks like, you’ll recline comfortably in a treatment chair. A small, curved magnetic coil will be positioned lightly on your head. The device delivers focused magnetic stimulation directly to the target areas of the brain. You’ll hear a clicking sound and feel a tapping sensation on your head. You can resume normal activities immediately after treatment because there are no effects on alertness or memory. Follow up sessions can be required beyond the four to six week period on an as-needed basis per the treating provider’s discretion. This treatment is administered by the presiding physician, as well as one specially trained TMS technician.

What does the patient actually feel? What are the short-term and long-term side effects?

When a patient is undergoing TMS treatment the machine gently touches the scalp and begins firing off magnetic pulses. According to Dr. Schneider, this sensation can be slightly unpleasant for some, though not painful. It is rare that people will ever want to stop treatment midway through. He went on to describe that most people tend to adapt to this sensation over time. In the short term, some patients may experience headaches, scalp discomfort at the site of the stimulation, tingling, spasms, twitching of facial muscles, or lightheadedness. According to Johns Hopkins Medicine, TMS is well-tolerated and associated with few side effects. There are no known long-term side effects.

Are there any other interventions a client should follow to make TMS most effective?

Dr. Schneider advises that individuals continue psychotherapy treatment throughout the course of TMS treatment, as well as follow ups with their treating physician. The treating physician will continuously monitor progress and assess if more booster sessions are needed in the future.

Does it interact with other medications or substances?

TMS largely does not interact with any medications or substances, however any patient should talk to their treating physician to consider any possible interactions. The Mayo Clinic website does state that TMS is not recommended for people who have certain metal implants or devices. How would I get an appointment?

Start by meeting with your psychiatrist and ask them about it. There is a list of qualifications that need to be met before you start TMS. You would then have an evaluation session with the treating physicians, who would prescribe TMS for you if it is their recommendation. Foresight currently offers TMS in our Oakland and Irvine clinics. More locations will be forthcoming.

Is it covered by insurance? If not, could I pay out of pocket?

Currently Foresight does not have a policy for paying out of pocket. Paying out of pocket could be financially prohibitive due to the cost of the treatment and the extensive in-office time. Contact a staff member if you would like to discuss a quote.

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If you or someone you care about is experiencing treatment-resistant depression, inquire about an appointment with a psychiatrist or nurse practitioner at one of our clinics.

We would also like to offer a special thank you to Dr. Schneider for taking the time to answer these questions and provide a promising look into the future of mental health!