Did you know that it’s possible to condense an entire treatment course of TMS into just 5 days?

First, a little background and history. The most common treatment course for TMS consists of one session per day for 5 days per week, for 6 weeks followed by an additional 6 sessions over the following 2-3 weeks. We’ll refer to this approach as the “standard course.” In total, the standard course adds up to 36 sessions over 8-9 weeks. During the standard course, should you decide to go to a provider with an expertise in Personalized TMS, they may try to optimize sleep, anxiety, motivation, and emotion, in addition to the common mood disorder symptoms one might be experiencing. This generally takes a bit of time, and there can sometimes be a bit of “trial and error” involved as the correct protocol gets dialed in. There is often somewhat of a balance between protocol placement and frequency in order to find the exact parameters to alleviate all negative symptoms and achieve remission.

It’s important to note a few important things regarding the standard TMS course. First, the number of sessions per week were chosen out of convenience to people who work 9-to-5 jobs. In particular, most of the clinical research laboratories looking at how effective TMS was in the 1990’s adhered to a traditional 9-to-5 schedule. As such, no one really examined how effective TMS is for depression when treating 5 days per week compared to 3 days, 4 days, 6 days, or 7 days. Secondly, when TMS was first FDA-approved in 2008, the FDA wasn’t quite sure how long to limit one course of TMS to. The FDA ended up deciding to recommend a course of approximately 6 weeks, because antidepressant medication like SSRIs and SNRIs take, on average, 6 weeks to start working. Additionally, the FDA added in the 6-session “taper” because medication would also require a taper. TMS is NOT a medication, and doesn’t work like most medications do in the brain, as TMS is a targeted treatment and medications are systemic treatments.

The frequency is also something that needs to be considered when looking at TMS protocols. For the purpose of this article on accelerated TMS, it’s important to note that depression treatment using TMS often consists of an excitatory protocol applied to the left dorsolateral prefrontal cortex. This protocol was historically a 10 Hz protocol, where the machine would pulse 10 times per second for about 5 seconds, followed by a 26 second interstimulation interval. This went on for about 45 minutes. Later on, the FDA realized that cutting the interstimulation interval in half would not impact efficacy nor would it impact the safety of the treatment, so the protocol was reduced to about 20 minutes. A few years later, the FDA also cleared a protocol called “intermittent theta burst,” which appeared to be interchangeable with its’ excitatory 10 Hz cousin. The main difference is that theta burst stimulation uses a frequency that is endogenous to the human brain when forming new memories, meaning that if one were to record the electrical activity of someone learning something new, they would see this frequency. This protocol is generally administered in 3-minute increments.

Ideally, these parameters should be personalized to each individual as opposed to a blanket rule by a regulatory body. However, people do tend to do quite well with the standard course of TMS, with success rates hovering around 50-80%. Most TMS centers cite that they are able to help patients achieve remission about 50% of the time, and are at least able to help improve symptoms (as in, a case of severe depression is reduced to a mild depression) 80% of the time. While these rates are certainly nothing to scoff at, there’s a new type of TMS in town: Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT™), or hereinafter referred to Accelerated TMS. Accelerated TMS is a bit different than any of the incremental changes with TMS we’ve seen thus far. Instead of adjusting a frequency or schedule, Accelerated TMS changes the frequency, schedule, and number of sessions.

Accelerated TMS uses an excitatory protocol applied to the left dorsolateral prefrontal cortex, just like in the standard course. However, the frequency used is intermittent theta burst 3 times in a row, for a total of 9 minutes per session. Sessions are held on the hour, every hour, for a total of 10 sessions per day. This is then repeated for 4 more days, for a total of 50 sessions over 5 days. This approach has now been examined by two randomized clinical trials (the gold standard for clinical research), which have shown favorable results: in the first study, 90.5% of participants achieved remission, while in the second study, 79% of people doing Accelerated

TMS achieved remission by day 5. However, there are pros and cons to do Accelerated TMS that certainly need to be considered.

Pros:
Can achieve remission in a week
If remission isn’t achieved, at least knows that TMS isn’t the right modality for them

Cons:
Insurance won’t cover this approach in the foreseeable future
It’s difficult to regulate sleep for people with insomnia

Our team at Bespoke Treatment is happy to offer the Accelerated TMS protocol by request across all our offices in California, Nevada, and Arizona. Of course, approval for this protocol will be entirely subject to a medical clearance by our psychiatric team. Feel free to reach out to schedule an evaluation today.