Transcranial Magnetic Stimulation (TMS) Service

The Brain Stimulation Program
The Johns Hopkins Hospital
600 N. Wolfe Street
Meyer 3-181
Baltimore, MD 21287

Phone: 410-614-1732
Directions

At Johns Hopkins, we are using the only TMS device approved by the FDA for the treatment of major depression. Repetitive Transcranial Magnetic Stimulation (rTMS) has been shown to be a safe and well-tolerated procedure that can be an effective treatment for patients with depression who have not benefitted from antidepressant medications or cannot tolerate antidepressant medications due to side effects.

What is Transcranial Magnetic Stimulation (TMS)?

TMS is a non-invasive method of brain stimulation that relies on electromagnetic induction using an insulated coil placed over the scalp, focused on an area of the brain thought to play a role in mood regulation. The coil generates brief magnetic pulses, of the same type and strength as those generated by magnetic resonance imaging (MRI) machines. Each magnetic pulse passes easily and painlessly through the skull and into the brain, where it induces brief activity of brain cells underlying the treatment coil. When these pulses are administered in rapid succession, it is referred to as 'repetitive TMS' or 'rTMS,' which can produce longer lasting changes in brain activity.

Why does rTMS work?

No one is exactly sure why rTMS alleviates depression in some patients. However, rTMS has been shown to produce changes in neuronal activity in regions of the brain implicated in mood regulation, such as the prefrontal cortex. The frequency of pulse delivery also influences whether brain activity is increased or decreased by a session of rTMS. Recent studies also suggest that stimulation over the left and right prefrontal cortices can have opposite effects on mood regulation.

When is rTMS used?

Antidepressant medications and psychotherapy are the first line of treatments for major depression. These treatments, however, do not work for all patients. In these instances, rTMS might be used as an alternative treatment, or to augment antidepressant medications or psychotherapy. Patients who have failed to achieve an adequate response from antidepressants, or who are unable to tolerate medications, might consider rTMS therapy.

What happens during an rTMS procedure?

rTMS is a treatment that can be administered in an inpatient or outpatient setting. rTMS therapy involves a series of treatment sessions. For each rTMS session, the patient sits in a specially designed treatment chair, much like the kind used in a dentist's office. Because rTMS uses magnetic pulses, before beginning a treatment, patients are asked to remove any magnetic-sensitive objects (such as jewelry, credit cards). Patients are required to wear earplugs during treatment for their comfort and hearing protection, as rTMS produces a loud clicking sound with each pulse, much like an MRI machine. The TMS operator will first position the patient's head and make several measurements. This is to ensure that the TMS coil will be properly positioned over specific targets in the brain. Once the patient is seated, the treatment coil, which is about the size of a large hand, is suspended over the patient's scalp. Before the rTMS treatment is administered, the TMS operator must measure the patient's motor threshold, by administering several brief pulses. The motor threshold is the minimum amount of power necessary to make the patient's hand twitch, and varies from individual to individual. Measuring the motor threshold helps the physician personalize the treatment settings and determine the amount of energy required to stimulate brain cells. Following this measurement, the coil is repositioned to target the prefrontal cortex. During the treatment, patients will hear a series of clicking sounds and may feel a tapping sensation under the treatment coil. A trained TMS staff member will always be present to monitor the patient during treatment. Patients can stop a treatment at any time by asking a staff member.

Treatment sessions are approximately 40 minutes each, and administered 5 days per week.  A typical course of rTMS is 4 to 6 weeks. However, this can vary depending on an individual' s response to treatment.

Unlike ECT, rTMS does not require any sedation or general anesthesia, so patients are fully awake and aware during treatment. There is no 'recovery time,' so patients can drive home afterwards and return to their usual activities.

What are the side-effects of rTMS?

rTMS is well-tolerated and associated with few side effects. Only a small percentage of patients discontinue treatment because of side effects. The most common side effect, which is reported in about half of patients treated with rTMS, is headaches. These are generally mild and diminish over the course of rTMS therapy. Over-the-counter pain medication can be used to treat these headaches. About one third of patients may experience painful scalp sensations or facial twitching with rTMS pulses. These too tend to diminish over the course of treatment although adjustments can be made immediately in coil positioning and stimulation settings to reduce discomfort. Because the rTMS machine produces a loud noise, earplugs are given before treatment. However, some patients may still complain of hearing problems immediately following treatment. No evidence suggests these effects are permanent if earplugs are properly worn during the treatment.

Moreover, rTMS has not been associated with many of the side effects caused by antidepressant medications, such as gastrointestinal upset, dry mouth, sexual dysfunction, weight gain, or sedation.

The most serious risk of rTMS is seizures. However, the risk of a seizure is exceedingly low. At Johns Hopkins, we follow up-to-date safety guidelines that are designed to minimize the risk of seizures. There have been no reported seizures with the rTMS device we use.

While rTMS is a safe procedure, it is important to point out that because it is a new treatment, there may be unforeseeable risks that are not currently recognized.

Who cannot get rTMS therapy?

Patients with any type of non-removable metal in their heads (with the exception of braces or dental fillings), or within twelve inches of the coil should not receive rTMS.? Failure to follow this rule could cause the object to heat up, move, or malfunction, and result in serious injury or death.? The following is a list of metal implants that can prevent a patient from receiving rTMS:

• Aneurysm clips or coils
• Stents in your neck or brain
• Implanted stimulators
• Cardiac pacemakers or implantable cardioverter defibrillator (ICD)
• Electrodes to monitor your brain activity
• Metallic implants in your ears or eyes
• Shrapnel or bullet fragments in or near your head
• Facial tattoos with metallic or magnetic-sensitive ink
• Other metal devices or objects implanted in or near your head

Who Will Benefit the Most?

Existing evidence to date suggests that patients who are less treatment-resistant respond better to rTMS than those who are highly treatment-resistant. However, there is much yet to be learned about particular variables that may impact response to rTMS. Researchers are presently conducting clinical studies to evaluate who will benefit the most from rTMS therapy. For example, there is a lot of interest in evaluating whether rTMS with antidepressant medications is more effective than rTMS alone.

How Can I Get rTMSTtreatment?

We offer rTMS therapy at Johns Hopkins. However, rTMS therapy is not appropriate for all patients. Before scheduling you for treatment, you much first be evaluated by one of our TMS psychiatrists to determine if rTMS would be safe and appropriate for you. Please call 410-614-1732 for Jesus Gallegos, who can provide you with details on how to be evaluated for rTMS treatment.

Download PDF files of a sample consent form and a patient screening form for metal.

Payment and Insurance

Because it is a relatively new treatment modality, rTMS is not yet covered by many health insurance companies. However we do offer some assistance in securing coverage as outlined below.

The first thing you should do is contact your insurance provider to check on their current coverage policy for rTMS. If they are not presently covering rTMS and you would like assistance in securing coverage, the manufacturer of the TMS machine has developed the NeuroStar Care Connection program, whose number is 1-877-622-2867. Care Connection can check on your benefits and help you negotiate with your insurance provider for reimbursement, which is determined on a case-by-case basis.  In an effort to help you negotiate reimbursement with your insurance company, we will provide you with copies of your initial evaluation as well as all ongoing clinical assessments. We will also help you with filling out your forms. However, it will be your responsibility to mail the insurance claim.

To be evaluated or to learn more, call Jesus Gallegos at 410-614-1732.