Richard Bermudes, M.D., is the founder and chief medical officer of TMS Health Solutions. Relying on advanced therapies that are continuously incorporating new and groundbreaking treatment methods, the company offers a unique, patient-centered experience as it aims to help those struggling with mental health conditions. In particular, TMS Health Solutions specializes in helping individuals with treatment-resistant depression (TRD). One of the advanced therapies the company offers is transcranial magnetic stimulation (TMS), which is a novel Food and Drug Administration (FDA) approved procedure to treat clinical depression.
What exactly is TMS, and why should psychiatrists as well as the general public be aware of it?
As it became clear that treatment-resistant depression is less responsive to medication than what was observed in the late 90’s, TMS therapy has stepped in as an alternative treatment for the mental illness. In 2008, it was approved by the FDA for the treatment of clinical depression in the 30 to 50 percent of patients who had at least one unsuccessful antidepressant treatment course. TMS treatment centers have been rising across the country ever since, including TMS Health Solutions in San Francisco.
During a TMS therapy procedure, a physician or a nurse places a non-invasive machine on top of the head, over the prefrontal cortex area—a region of the brain that is under-active in depressed patients. The device then uses electromagnetic energy to simulate that area of the brain, restoring it to a normal level of function.
TMS therapy is different from electroconvulsive therapy (ECT), which has been an available procedure in the United States for more than 70 years. ECT is effective at alleviating major depressive disorder, but it does come with some drawbacks. It must be administered under anesthesia, thereby prolonging preparation as well as recovery, and its side effects include confusion and memory loss. During TMS treatments, patients remain awake during the course of the treatment, relaxing while seated in a chair.
“You sit in a chair, it takes about 30 minutes, and then you can get up and drive yourself home,” says William McDonald, M.D., a psychiatrist at the Emory University School of Medicine who was involved in the clinical trials that led to the approval of the NeuroStar device, one of the first to be FDA approved for TMS therapy purposes. Treatment side effects of TMS therapy are minimal, with headache and muscle soreness being the most common complaints. Although there is a small risk of seizure associated with this therapy, it is similar to the seizure risk associated with antidepressant medications. Compared to ECT however, TMS is a walk in the park.
The typical course of TMS therapy is made up of 20 to 30 sessions that are administered at a frequency of three to five treatments per week over the course of four to six weeks. Given that TMS machines are expensive themselves, the treatment is not cheap either. It can cost anywhere between $6,000 to $12,000 per course.
According to Dr. Bermudes, TMS is a non-invasive therapy, whereby “We’re not generating a seizure. This is sub-seizure threshold. TMS actually introduced the idea that we could do neuro-modulation without generating a seizure and improve mood.”
However, he does highlight the concept of treating depression as symptom-based when it comes to thinking about the brain. In other words, TMS is prescribed based on measurements of symptoms and its efficacy is assessed based on symptoms as well. There are no visual biomarkers according to Dr. Bermudes, and TMS locations on the prefrontal cortex are determined using careful measurements. Once the patients go through the treatment more symptom-based measurements follow, and more assumptions about what is going on in the brain are made. As such, plenty of questions arise during the process, including how best to deliver TMS therapy and who makes the best candidates for the procedure.
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According to Dr. Bermudes, TMS therapy is very different from antidepressants. “It kind of works in the opposite. Anti-depressants seem to, what they say, work from the bottom up, where cognitive therapy and TMS seem to work from the top down. Where anti-depressants would sort of down regulate limbic systems, and then you’d get more cortical control that way. That’s kind of how I try to keep it, sort of at these upper circuits and lower circuits,” he states.
Dr. Bermudes has received several TMS therapy treatments himself. When asked about what it felt like, he compared it to the sensations he feels following a several-mile run. “I’ve sat through a treatment, sort of randomly, not in a row; I have a similar sensation actually. Like, I just went out for a nice four- to five-mile run, and sort of have this level of optimism about the day and clarity of thinking. That’s been my experience.”
Dr. Bermudes earned his medical degree from the University of California San Diego in 1997. He served as the chief resident for the family medicine and psychiatry program at the University of Cincinnati, after which he completed a fellowship at the Beck Institute for Cognitive Therapy and Research in Philadelphia. He is the founding member of a clinical TMS society, and he chaired the first annual meeting in 2013. He was elected president of the society in 2015.