DEPRESSION IS a major contributor to the overall burden of disease. A leading cause of disability worldwide, depression affects more than 264 million people around the globe and is especially prevalent in vulnerable populations, such as pregnant or postpartum women, older adults, and young people.1 Further, the number of Americans with untreated depression is growing, especially among young people and people who are socioeconomically vulnerable.2
In 2008, the FDA approved transcranial magnetic stimulation (TMS) as a treatment option for people with depression who had not responded to or demonstrated improvement from standard therapies, including pharmacotherapy and psychotherapy. The FDA followed in 2011 with safety guidelines regarding the use of TMS. Clinical trials and meta-analyses have shown repetitive TMS to be an effective treatment modality in the management of patients with treatment-resistant depression.3,4 This article compares and contrasts TMS with electroconvulsive therapy (ECT) and describes the risks and benefits of TMS, nursing assessments, interventions, and considerations for nurses caring for these patients before and after the procedure.
Electroconvulsive therapy (ECT), or shock therapy, has been the gold standard for treatment-resistant/refractory depression since its introduction in 1938. Over the years, many improvements to ECT have been made. It is currently performed using general anesthesia and a neuromuscular blocking agent. In addition to possible anesthesia-related adverse reactions, other complications include aspiration pneumonia, fractures, dental and tongue injuries, and adverse reactions affecting cognition, primarily memory.5
TMS is generally a safe and well-tolerated treatment option, providing new hope to patients with unipolar major depression.6,7 TMS uses an alternating current passed through a metal coil placed against the scalp. Rapidly alternating magnetic fields pass through the skull and induce electric currents that depolarize neurons in a focal area of the surface cortex; some TMS devices may also stimulate deeper brain structures.6
TMS and ECT: A comparison
The mechanisms for TMS and ECT as treatments for depression are not fully understood. Both therapies are neuromodulating, and some experts hypothesize that they both “reset the brain” or “reboot the brain” like a computer. By modifying brain activity, these procedures can help control one's mood or depression.4
TMS and ECT can both be performed in inpatient and outpatient settings. Maintenance treatments for relapse prevention can also take place in either setting. However, ECT requires general anesthesia, whereas TMS does not. Consider the following differences between the two therapies.8
ECT is a procedure in which a person under general anesthesia receives controlled electric currents that pass through their brain (one or both sides) to induce a controlled seizure. The seizure affects the neurons in the brain and the way chemicals work in the brain.9
ECT is initially a hospital-based treatment performed 3 days a week, often Monday, Wednesday, and Friday. Patients can move to an outpatient setting after they receive initial ECT treatments. Regardless, patients may need to take time off work and must arrange transportation when they receive outpatient treatment.10
Even though both ECT and TMS are short in duration, ECT is associated with greater risks. Patients who undergo ECT require nothing-by-mouth (NPO) status and vascular access. After the procedure, vital signs, oxygen saturation, and level of consciousness should be closely monitored.
Patients who undergo ECT are at increased risk of memory loss and cognitive impairment compared with patients treated with TMS. Nursing care should include cognitive assessment before and after ECT and assessment of worsening depression, increased suicidality, or thoughts of self-harm.
TMS is performed with patients awake and seated in a comfortable reclining chair similar to a dental chair. (See How does TMS work?) Patients will not need to take time off work and can drive themselves to and from sessions, which typically last 30 to 40 minutes, because the procedure does not require anesthesia or provoke a seizure.6 However, TMS does pose some risks. A generalized tonic-clonic seizure is the most serious adverse reaction of repetitive TMS, but the risk is comparable to that for antidepressant medications.7 Other risks include hearing loss, scalp pain or discomfort (including scalp burn), headaches, and vasovagal syncope.7 Hearing loss can be prevented with foam earplugs or noise protection ear coverings.
Unlike ECT, TMS does not require patients to be NPO, and they may eat and drink right up until the time of the procedure. The TMS preprocedure checklist should include assessing for any metal in the patient's hair, such as bobby pins or clips, and implanted devices that could be displaced by the magnetic field generated by repetitive TMS. Guidelines released by the FDA in 2011 advise staff to assess for contraindications to TMS, such as a pacemaker, spinal or bladder stimulator, previous skull opening or trauma, family history of epilepsy, and the presence of a metallic foreign body.11
Before and after the procedure, nurses must perform a skin assessment of the scalp and face. Besides the nonremovable metallic devices, nurses should assess for metallic tattoos on the face and neck as well as facial piercings. Facial piercing jewelry should be removed and the physician should be notified of nonintact skin or rashes before and after treatment.
Patient education includes telling patients that they will feel a tapping sensation over the front part of their head and hear a clicking sound when undergoing TMS. For this reason, they will be provided soft, comfortable earplugs for ear protection. Although the procedure is noninvasive and pain is subjective, one-third of patients may experience a painful sensation in the scalp from the TMS pulses. However, the pain will diminish over the course of treatment and immediate adjustments can be made to decrease it.12
Reassure patients that they can ask to have the treatment stopped at any time, even during the procedure. In addition, tell patients that a mild headache after the procedure is not unusual, but to contact their healthcare provider if the headache is severe and does not improve.
Is TMS a better solution?
Literature comparing ECT to TMS has found that although ECT was generally more effective, it generated more complaints of adverse reactions.13 Patients often preferred TMS to ECT because of its convenience and lower cost. An ECT procedure takes 5 to 10 minutes, but the seizure itself is less than 1 minute. Recovery from the anesthesia takes approximately 1 hour. TMS lasts 30 to 40 minutes. TMS is targeted to a specific site in the brain (reducing adverse reactions associated with ECT), allowing the patient to be awake during the procedure. Both ECT and TMS require multiple sessions. ECT treatments usually take place 3 days a week and vary from 6 to 12 treatments before a patient can go to a maintenance schedule. TMS usually takes place 5 days a week, Monday through Friday, for approximately 4 to 6 weeks before going to maintenance.9
Zhao and colleagues found TMS more cost-effective as well.14 However, other authors found the increased time duration of TMS and the financial burden problematic.15 TMS is not experimental, so private insurance companies and Medicare both provide TMS coverage depending on the patient's benefit plan. However, this is not necessarily the case worldwide.16 Patients need to be fully informed of treatment options in order to make the best choice for their personal situation. Insurance, out-of-pocket expenses, and any inconveniences of either procedure need to be individually evaluated.
Healthcare providers not only need to consider the risk and benefits of ECT versus TMS, but also the full impact these therapies have in a patient's life. For example, TMS may be preferred for a pregnant patient who wants a nonpharmacologic method to treat her depression during pregnancy or breastfeeding. Patients may also find TMS to be less disruptive to their daily routine. TMS should be considered a useful treatment option when there are concerns about cognitive adverse reactions or anesthesia risks associated with ECT, as TMS is safe and tolerable in older patients.17 However, any patient who is acutely or actively suicidal and/or potentially at risk for self-harm needs to go directly to an ED for an evaluation and possible inpatient treatment to ensure the patient's safety.
Depression is treatable. More than a decade after its initial FDA approval, TMS is generally considered a safe and well-tolerated treatment option for patients with depression who have not responded to other types of treatment. TMS is associated with fewer risks than its more traditional counterpart, ECT, and it is less disruptive to a patient's daily routine. As healthcare professionals, we must be knowledgeable about treatment options. TMS is a promising innovative approach to treating depression that is available and supported by evidence.
How does TMS work?6
TMS can treat depression by stimulating cortical regions of the brain and associated neural circuits. It passes an alternating current through a metal coil placed against the scalp to generate rapidly alternating magnetic fields that pass through the skull and produce electric currents that depolarize neurons in a focal area of the surface cortex. TMS is provided in a series of pulses called a train, and stimulation parameters include frequency, intensity, train duration, intertrain interval, and number of trains per session.
2. Weinberger AH, Gbedemah M, Martinez AM, Nash D, Galea S, Goodwin RD. Trends in depression prevalence in the USA from 2005 to 2015: widening disparities in vulnerable groups. Psychol Med
3. Janicak PG, Dokucu ME. Transcranial magnetic stimulation for the treatment of major depression. Neuropsychiatr Dis Treat
4. Janicak PG, Sackett V, Kudma K, Cutler B. Advances in transcranial magnetic stimulation for managing major depressive disorders: the utility of TMS
for treating depression continues to widen, as the technology is refined. Curr Psychiatr
5. Kellner C. Overview of electroconvulsive therapy (ECT) for adults. UpToDate. 2018. www.uptodate.com
6. Holtzheimer PE. Technique for performing transcranial magnetic stimulation (TMS). UpToDate. 2018. www.uptodate.com
7. Holtzheimer PE. Unipolar depression in adults: indication, efficacy, and safety of transcranial magnetic stimulation (TMS). UpToDate. 2019. www.uptodate.com
9. National Alliance on Mental Illness. ECT, TMS, and other brain stimulation therapies. 2020. www.nami.org/Learn-More/Treatment/ECT,-TMS-and-Other-Brain-Stimulation-Therapies
10. Wang J, Widge AS. Neuromodulation approaches to mood disorders. Psychiatr Times
. 2020. www.psychiatrictimes.com/article/neuromodulation-approaches-mood-disorders
12. Scherrer K, Salmas V. Frequently asked question about transcranial magnetic stimulation. http://med.stanford.edu/content/dam/sm/pain/documents/tms-faqs.pdf
13. Magnezi R, Aminov E, Shmuel D, Dreifuss M, Dannon P. Comparison between neurostimulation techniques repetitive transcranial magnetic stimulation vs electroconvulsive therapy for the treatment of resistant depression: patient preference and cost-effectiveness. Patient Prefer Adherence
14. Zhao YJ, Tor PC, Khoo AL, Teng M, Lim BP, Mok YM. Cost-effectiveness modeling of repetitive transcranial magnetic stimulation compared to electroconvulsive therapy for treatment-resistant depression in Singapore. Neuromodulation
15. Sonmez AI, Camsari DD, Nandakumar AL, et al. Accelerated TMS for depression: a systematic review and meta-analysis. Psychiatry Res
16. Rapposelli D. TMS versus ECT: that is the question. Psychiatr Times
. 2016. www.psychiatrictimes.com/tms-versus-ect-question
17. Sabesan P, Lankappa S, Khalifa N, Krishnan V, Gandhi R, Palaniyappan L. Transcranial magnetic stimulation for geriatric depression: promises and pitfalls. World J Psychiatry