The Truth About Transcranial Magnetic Stimulation For Bipolar Disorder

If you’re reading this, you’re probably somewhat familiar with Transcranial Magnetic Stimulation (TMS Therapy). TMS was first FDA approved for Major Depressive Disorder (MDD) in 2008. Specifically, practitioners and insurance companies most utilized TMS for treatment-resistant depression, which is not clearly defined but generally refers to someone trying at least two antidepressant medications and a few months of talk therapy. The definition of treatment-resistant depression may change depending on the study, insurance company, or doctor.

A Brief Summary of Bipolar Disorder

MDD is a type of “unipolar depression.” Unipolar depression means that a sufferer’s state doesn’t shift between mania and depression; instead, when triggered, a person with unipolar depression will enter a depressive episode. When someone shifts between mania and depression, they are diagnosed with Bipolar Disorder. Manic episodes are typically characterized by periods of high energy, extreme impulsivity, euphoria, inability to concentrate, and unusual propensity to engage in risky behavior (e.g., gambling). While the guidelines change every few years, a person is generally considered to have diagnosable Bipolar Disorder if they have had at least one manic episode throughout their lives – even if it was just one episode induced by a clear external trigger (e.g., antidepressant medication or recreational drug). There are also two different variations of Bipolar Disorder, related to how severe the manic episodes are. Bipolar I typically involves a more energetic and destructive manic period, while Bipolar II involves less mania and typically a lower level of depression. As one can guess, these distinctions become somewhat arbitrary.

Does TMS Work For Bipolar Depression?

Yes, but there are important nuances to understand. Most doctors would worry that TMS would be too stimulating for someone with bipolar depression, and that it could “flip” that person into a manic episode. There is a small risk of TMS inducing mania, but studies have shown that this risk is about the same as any SSRI inducing mania in someone with Bipolar Depression. Some case reports have illuminated that, while triggering mania is possible, it is not something that happens overnight. Studies have demonstrated that TMS is an effective and safe intervention for individuals with bipolar depression, as long as parameters are being watched closely. Interestingly, one particularly well done study showed that TMS improved cognition in depressed individuals with bipolar disorder.

Personalized TMS For Bipolar Disorder

A competent team at a TMS clinic will evaluate changes in energy levels, sleep, motivation, and mood on a daily basis. At our clinic, we make a special note if someone has a previous bipolar diagnosis, and we pay close attention to our treatment parameters. For instance, we may lower the stimulation level, adjust the number of pulses per session, or even use a more relaxing protocol on a different part of the brain entirely. A center that cannot adjust their protocol based on individual responses will pose a higher risk to someone with bipolar depression. We almost always end up treating bipolar patients with a bilateral TMS protocol.

Our Experience Treating Bipolar Depression With TMS

While TMS isn’t yet FDA approved for bipolar disorder, we have noticed in our offices that individuals with bipolar depression have better response rates than individuals with unipolar depression. There haven’t been any large-scale studies that show this yet, but we think this is because the brain of a bipolar individual has more flexibility in terms of switching between states (“the two poles”), and as such, can shift from depression to feeling better more easily. However, if a center had machines that didn’t allow for a personalized approach, we would be concerned about both the safety and efficacy of treatment.


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