efficay of TMS among major depressive patients

1. PRESENTATION ON REVIEW
ARTICLE
EFFICACY OF TRANSCRANIAL
MAGNETIC STIMULATION
AMONG MAJOR DEPRESSIVE
DISORDER PATIENTS
SUDHEN SUMESH KUMAR
NEHRU COLLEGE OF NURSING

2. SOURCE OF INFORMATION
Asian J. Nursing Edu. and Research 6(4): October- December
2016, 538
ISSN 2231-1149 (Print) 2349-2996 (Online) www.ajner.com
REVIEW ARTICLE
Efficacy of Transcranial Magnetic Stimulation [TMS] among
Major Depressive Disorder Patients: A Review
Bahubali. J.G, Sudhen Sumesh Kumar et al, School of
Nursing & Midwifery, Dept. of Psychiatric Nursing, College of
Health & Medical Sciences (CHMS), Haramaya University, Harar,
Ethiopia. *Corresponding Author Email: parshw007@gmail.com

3. INTRODUCTION
Depression is a significant contributor to the global burden of disease
and affects people in all communities across the world.
India has the highest rate of major depression in the world. It is
estimated that by the year 2020 the burden of depression will
increase to 5.7% of the total burden of disease.
It clearly depicts that the need for alternative and convenient
treatment modality for depression as a whole. TMS proves to be one
of the effective mode of treatment for depression. In terms of its
convenience of treatment it’s quite promising and lesser number and
severity of side effects as compared to other mode of treatment

4. Depression in Indian Scenario
A study based on the World Health Organization's World
Mental Health Survey Initiative has said that India has the
highest rate of major depression in the world. Some of the
studies have addressed the prevalence of depression are as
under: It is estimated that by the year 2020 if current trends
for demographic and epidemiological transition continue,
the burden of depression will increase to 5.7% of the total
burden of disease and it would be the second leading cause
of disability-adjusted life years (DALYs), after ischemic heart
disease.

5. Depression in Indian Scenario
Many studies have estimated the prevalence of depression in
community samples and the prevalence rates have varied
from 1.7 to 74 per thousand population.
A meta analysis conducted by Reddy and Chandrasekhar
reported, prevalence of depression to be 7.9 to 8.9 per
thousand population and the prevalence rates were nearly
twice in the urban areas.
Studies on the elderly population, in any setting have shown
that depression is the commonest mental illness near about
522/1000 elderly population and relative morbidity too.

6. Depression in Indian Scenario
Lifetime prevalence of all depressive disorders taken
together is over 20% that is one in five individuals. By now, it
is evident that the depression has a major impact upon the
society, family and individual disability and at the same time
it poses significant burden upon the strata of the society.
These above statistics clearly depicts a need for promising
treatment method alternative to psychological treatments
(behavioral activation, cognitive behavioral therapy, and
interpersonal psychotherapy or antidepressant medication
(SSRIs and TCAs) to optimize the outcomes. One among the
alternatives is electroconvulsive therapy (ECT); however, ECT
is associated with significant side effects and discomfort,
most notably memory impairment..

7.  Repetitive transcranial magnetic stimulation (rTMS) has
been shown to be an effective therapeutic tool for the
treatment of several neuropsychiatric disorders, including
Major Depressive Disorder and schizophrenia

8. What is Transcranial Magnetic Stimulation?
 Transcranial magnetic stimulation (TMS) is a safe
and non-invasive treatment that uses magnetic
fields to stimulate nerve cells in the brain to
improve symptoms of depression. TMS is typically
used when other depression treatments haven't
been effective

9. What is Transcranial Magnetic Stimulation?

10. Brief History of TMS
 In 1997, in Canada Transcranial Magnetic Stimulation was
approved to practice and in 2002 it got approved as a
treatment for medication-resistant depression. In USA, 2008
FDA approved Neuro Star TMS Therapy as a treatment for
depression. Presently this technique is widely used for
treatment of refractory depressive disorder.
 Since its introduction more than 20 years ago, use of
transcranial magnetic stimulation in major depression
remains the most studied clinical application in Psychiatry.
Studies have ranged from uncontrolled clinical observations
of therapeutic effects to randomized, controlled clinical
trials.

11. Basic Principles Involved In The Procedure
Electromagnetism: In 1831, Michael Faraday found that
when two coils are close together and a current is passed
through one, as the current is turned on and off, a brief
pulse of electricity passes through the second coil. The
magnetic field created by the electrical current in the first
coil extends into the second coil, and when this magnetic
field starts and stops, it creates a current in that coil. These
are termed the primary and secondary currents. A secondary
current can be induced in any conductor (water-melon,
brain) which is close to a coil through which a primary
current is pulsed.

12. Physiology Involved In The Procedure
 When TMS is applied, the induced electric field causes a flow
of current, electric charge accumulates on neural membranes,
causing depolarization. With the flat, figure coil which is in
common use, depolarization occurs at about the junction of
the grey and white matter. At this point, axons with cell bodies
in the grey matter bend (altering physical properties) as they
descend deeper into the brain. This is at about 2 cm below the
face of the coil, and the induced electric field at this point is
about 70 V/m.28 Interestingly, the stimulation is electrical,
and not a magnetic effect
 TMS is assumed to act upon the catecholamine and brain-
derived neurotrophic factor

13. Course of TMS: Although treatment varies by individual, a
typical treatment course consists of:
Average of 20-30 treatment sessions
5 treatments per week
Each treatment session lasts approximately 30-60 minutes
Conducted over a 4-6 week period

14. What to be Expected by the Patient During
the Procedure ???
 Patients is made to relax in a treatment chair and remain
awake and alert.
 The TMS Therapy device will deliver magnetic pulses.
These pulses will feel like tapping on the scalp. The
technician can make adjustments if the tapping is
uncomfortable.
 After a treatment session, patients can immediately
return to their normal routine, including driving. In
clinical trials, most patients experienced a positive
response to TMS Therapy by the fourth week of
treatment.
 The result may be evident among some patients
immediately, while others may take longer

15. BENEFITS OF TMS
FDA clinical trials showed that 2 out of every 3 patients
reported a reduction in depression symptoms at the
completion of the acute phase of TMS Therapy.
TMS Neurohealth Center studies showed that 3 out of every 4
patients reported a reduction in depression symptoms at the
completion of the acute phase of TMS Therapy

16. BENEFITS OF TMS
Non-Systemic – nothing enters the bloodstream
Non-Sedating – patient remains awake and alert during
treatment and can resume usual routine
Non-Invasive – nothing is inserted or implanted into the
body Non-Drug – no drug related side effects such as weight
gain, drowsiness, sleeplessness, stomach upset or sexual
problems
FDA Cleared & Proven – 2 out of every 3 patients had a
reduction in depression scores after a 4-week treatment
period
Covered by Most Insurance Plans – Patients can be assisted
with the reimbursement and financing process

17. Side Effects
The most common side effect associated with TMS Therapy
was
 Mild to moderate scalp discomfort.
 Other common side effects included:
 Minor twitching around the facial muscles and eye;
Toothache;
 Mild or moderate headache.
 Rare risk of seizure associated with TMS Therapy (0.1% per
acute treatment course).

19. Contraindications:
TMS Therapy is contraindicated in patients with
 Implanted metallic devices or non-removable metallic
objects in or around the head. Likely to produce
unnecessary heat.
 Patients with implanted Pacemaker; magnetic field may
hamper the functioning of pacemaker. Advisable to
perform the TMS therapy in switched off mode of
pacemaker in specialised unit.
 Family history of epilepsy Pregnancy was early
considered to be a contraindication, but the risk to a
foetus from TMS to the brain of a mother is certainly less
than that of medications

20. Repetitive TMS may be less likely to work if:
 Mental illness includes detachment from
reality (psychotic symptoms)
 Chronic depression
 Ineffective sessions of Electroconvulsive
therapy (ECT)

21. TMS FACILITY IN INDIA AND ABROAD
It was pioneered in India in 2007, by Dr. Sanjay Chugh, a
renowned Delhi based Neuro-Psychiatrist after undergoing
rigorous training from in Harvard Medical School, South
Carolina.
Later on in January 2011 he with the partnership of Dr. Anjali
Chhabria established the TMS clinic at Mind temple, Delhi. In
Canada, it is being widely used after approval as a treatment
for medication resistance depression since 2002.
It’s now frequently used treatment in US (2008), UK,
Australia, Brazil, Israel, Egypt, Cost Rica etc.

22. CONCLUSION
In India it needs to be equipped in terms
of training and education to the experts,
very importantly creating awareness
among patients and family about the
treatment facility.