Enhancing Mental Health Treatment: Combining Medication and TMS Therapy

Mental health conditions affect millions worldwide, causing distress and uncertainty. While traditional treatments often rely on psychiatric medications, innovative therapies like Transcranial Magnetic Stimulation (TMS) are gaining traction. In this article, we explore how combining medication with TMS therapy can provide substantial benefits for individuals with mental health disorders, such as depression, anxiety, and ADHD. We’ll also discuss situations where TMS therapy may be preferable to medications alone.

Medications for Mental Health Disorders

Mental health disorders can be debilitating, and psychiatric medications have emerged as a valuable tool in symptom management for many individuals. These medications are designed to target specific neurotransmitters in the brain that are responsible for regulating mood, emotion, and behavior. By balancing these neurotransmitter levels, medications can help reduce symptoms involved in various mental health conditions such as depression, anxiety, and attention deficit hyperactivity disorder.

Depression

Depression is a complex mood disorder with hallmark features that include persistent sadness and a loss of interest, often leading to a diminished quality of life ⁵. While depression diagnosis primarily relies on clinical assessment, the absence of specific lab tests necessitates the exclusion of other potential causes ⁵.

Treatment for depression often involves a combination of psychotherapy and medications, such as the following ⁵:

• Selective Serotonin Reuptake Inhibitors (SSRIs): Certain antidepressants, like Prozac (fluoxetine), Zoloft (sertraline), and Lexapro (escitalopram), are often considered the first-line treatment for depression. They help regulate serotonin levels in the brain, improving mood and reducing depressive symptoms. 
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Medications such as Effexor (venlafaxine) and Cymbalta (duloxetine) are effective in treating depression, particularly in cases of severe or treatment-resistant depression. 
• Tricyclic Antidepressants (TCAs): While effective, TCAs like Elavil (amitriptyline) and Tofranil (imipramine) are associated with significant side effects and are less commonly used today.
• Monoamine Oxidase Inhibitors (MAOIs): MAOIs, such as Nardil (phenelzine) and Parnate (tranylcypromine), are reserved for cases of depression that do not respond to other treatments. They can have serious dietary and drug interaction restrictions.

Psychotherapies like cognitive-behavioral therapy (CBT) are often used in conjunction with antidepressant medication to provide comprehensive treatment for depression ⁵.

Anxiety

Anxiety disorders encompass a set of mental health conditions where individuals experience an intense and often irrational sense of fear or apprehension about future events or situations. These conditions are marked by heightened stress levels, and the fear typically revolves around anticipated future threats or dangers, even if those threats may not be immediate or realistic ⁶.

These conditions involve thoughts, emotions, physical reactions, and actions focused on preparing for expected threats ⁶. Pathological anxiety happens when someone sees a threat as much bigger or more dangerous than it really is, causing them to react too much or inappropriately.

Treatment for anxiety typically involves a combination of psychotherapy, such as cognitive-behavioral therapy (CBT), and medication, such as the following ⁶:

• Selective Serotonin Reuptake Inhibitors (SSRIs): These drugs, Prozac (fluoxetine), Zoloft (sertraline), and Lexapro (escitalopram), are often considered the first-line treatment for anxiety disorders. They help regulate serotonin levels in the brain, improving mood and reducing anxiety.
• Serotonin-norepinephrine reuptake Inhibitors (SNRIs): Medications like Effexor (venlafaxine) and Cymbalta (duloxetine) are also effective in treating anxiety, particularly Generalized Anxiety Disorder (GAD). 
• Benzodiazepines: Drugs like Xanax (alprazolam) and Ativan (lorazepam) are used for the short-term management of acute anxiety symptoms. They provide rapid relief but may lead to tolerance and dependence with long-term use.
• Tricyclic Antidepressants: While effective, these drugs, such as Elavil (amitriptyline) and Tofranil (imipramine), are associated with significant side effects and are less commonly used today.
• Beta-Blockers: Medications like propranolol and atenolol can help control physical symptoms of anxiety, such as rapid heart rate and trembling.

It’s essential to note that the choice of medication depends on the specific anxiety disorder and individual factors. Treatment plans are often tailored to each patient’s needs, and a combination of therapies may be recommended for the best results. Regular monitoring and follow-up are also crucial, as anxiety disorders can significantly impact a person’s daily life and overall well-being.

ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is a prevalent psychiatric condition that affects children and adults and is characterized by inattention, hyperactivity, and impulsivity. For an ADHD diagnosis, these symptoms must appear before age 12, persist for at least six months, and disrupt daily life in multiple settings ⁹.

The approach to treating ADHD primarily involves medication and therapy. Medications used to manage ADHD symptoms include ⁹:

• Stimulants: These are the most common medications for ADHD and include amphetamines like Adderall and methylphenidates like Ritalin. They increase certain neurotransmitters in the brain to improve attention and focus.
• Non-Stimulants: Atomoxetine, also known as Strattera, is a non-stimulant medication used to treat ADHD. It works by affecting norepinephrine levels in the brain, helping to enhance attention and reduce impulsivity and hyperactivity.
• Alpha-Agonists: Medications like guanfacine (Intuniv) and clonidine (Kapvay) may be prescribed to manage specific symptoms of ADHD, such as impulsivity and hyperactivity.

Therapies like psychoeducation and cognitive-behavioral programs can also be highly effective, particularly when combined with medication. An interprofessional healthcare team consisting of psychiatrists, pediatricians, pharmacists, and caregivers plays a pivotal role in diagnosing and treating ADHD ⁹.

Transcranial Magnetic Stimulation (TMS)

TMS therapy is a non-invasive, cutting-edge treatment that has gained traction recently. It involves using specialized electromagnetic coils to deliver painless magnetic pulses to specific brain regions. These pulses stimulate neurons, impacting mood regulation and symptom relief [10]. Unlike electroconvulsive therapy, TMS therapy does not require anesthesia, and individuals can go about their day after treatment.

TMS Treatment for Depression and Anxiety

Transcranial Magnetic Stimulation (TMS) therapy has emerged as a promising alternative for treating depression, major depressive disorder, and treatment-resistant depression, offering clinical response rates of approximately 50% to 55% and remission rates of 30% to 35%, which are comparable to traditional antidepressants but with fewer side effects ¹¹.

TMS therapy is designed to target specific brain regions, particularly the dorsolateral prefrontal cortex (DLPFC), known to be associated with mood regulation. It can be administered in two primary ways: high-frequency stimulation of the left DLPFC for the alleviation of depressive symptoms or low-frequency stimulation of the right DLPFC to address both depression and anxiety. Typically, patients undergo daily TMS sessions over three to six weeks, totaling 20 to 30 sessions ¹¹.

TMS therapy has demonstrated the potential to sustain antidepressant effects over an extended period. Patients who respond positively to acute TMS treatment often continue to experience these benefits during a one-year follow-up period, highlighting the therapy’s capacity for sustained efficacy ⁸.

TMS in ADHD Treatment

While medications are effective for many individuals with ADHD, many do not respond well to standard treatments. Repetitive Transcranial Magnetic Stimulation (rTMS), a non-invasive technique that modifies brain activity, shows promise in mitigating clinical symptoms in adults with ADHD. A pilot study revealed that rTMS, particularly when targeting the right prefrontal cortex (rPFC), significantly improved ADHD symptoms. This approach holds potential as a non-pharmacological intervention for individuals with treatment-resistant ADHD, with EEG-based biomarkers showing promise for patient selection ².

Combining Medications and TMS Therapy: A Winning Strategy

The synergy between patients taking psychotropic medications and undergoing TMS therapy offers an exciting approach to mental health treatment. Medications provide foundational support by stabilizing symptoms, while TMS therapy delivers precise magnetic stimulation to targeted brain regions. Research indicates that this combined approach can lead to more sustained acute treatment outcomes compared to medications alone ⁷.

A recent observational study investigated the efficacy of TMS in reducing symptoms of depression and anxiety in patients with treatment-resistant depression. The study included 38 patients with TRD who were randomly assigned to two groups. One group received genuine high-frequency TMS, while the other received a placebo or sham version of TMS. It’s worth noting that all patients continued with their regular medication throughout the study ¹.

According to the study findings, the group that received real TMS experienced a significant decrease in both depression and anxiety symptoms. On the other hand, the placebo group only witnessed a notable reduction in anxiety, with no significant change in depression. Additionally, when the two groups were compared, it was found that those who received real TMS had a much more significant reduction in depression symptoms. By the end of the study, 63% of the participants responded well to the combined treatment, 15% showed partial improvement, and 42% achieved complete remission from their depression symptoms ¹.

This research demonstrated that when used alongside conventional medication, TMS can be a valuable treatment option for individuals with treatment-resistant depression. It not only helps alleviate depression but also relieves accompanying anxiety symptoms.

TMS as a Standalone Treatment

Transcranial Magnetic Stimulation (TMS) offers a distinct alternative to traditional medications when treating mental health disorders. The choice between these two approaches depends on various factors, and here are some key considerations for opting for TMS as a standalone treatment ³:

• Treatment Resistance or Intolerance: TMS becomes a viable option when an individual has not responded well to multiple trials of different medications or has encountered significant side effects from medication use.
• Specific Indications: TMS stands out as an independent treatment for depression, particularly in cases of medication-resistant depression and occasionally for Obsessive-Compulsive Disorder (OCD).
• Preference for Non-Pharmacological Options: Some individuals prefer non-pharmacological treatments due to concerns about potential side effects or wanting to avoid medications altogether. TMS provides a medication-free alternative for treatment. 
• Medication Contraindications: TMS can be a suitable alternative when a person cannot tolerate medications due to underlying medical conditions, allergies, or interactions with other medications they are taking.

Clinical studies suggest that TMS can be an effective treatment option for patients with major depression, with 50-55% response rates and remission rates of 30-35%. Unlike traditional antidepressant medications, TMS often leads to sustained mood improvement and has fewer side effects. This makes TMS particularly valuable for individuals who haven’t experienced improvement with other treatments. Additionally, a significant percentage of patients, ranging from 30% to 64%, report effective symptom relief, especially in cases of depression. As for side effects, TMS is generally associated with mild and diminishing side effects throughout treatment, with the most commonly reported side effect being a headache. Other less frequent side effects include scalp discomfort or facial twitching. While the possibility of seizures is the most severe risk associated with TMS, studies indicate that the chance of experiencing a seizure is exceptionally low, estimated at around 0.03%, with no recorded instances of long-term harm ¹⁰.

The Timeliness of Symptom Reduction with TMS Therapy

The speed at which symptoms improve with TMS (Transcranial Magnetic Stimulation) therapy can vary depending on the specific mental health condition being treated ¹². TMS therapy involves regular sessions, usually five days a week, over several weeks, lasting around 20 to 50 minutes ¹². For individuals suffering from depression, it is important to note that TMS therapy is not a quick fix, and noticeable improvements usually occur after three to six weeks of treatment ¹². However, the positive effects of the therapy tend to last for an extended period, with many patients experiencing relief for over a year after their treatment ¹².

In contrast, there is still little information about how quickly TMS therapy can relieve anxiety. Researchers are still studying this aspect of the therapy. When it comes to ADHD, TMS therapy can have a rapid impact on attention. After a single TMS session targeting a specific part of the brain, individuals may experience a positive effect on their attention as soon as 10 minutes later ⁴. Although the results are fast, it is essential to understand that TMS therapy is not a one-time solution for ADHD. Further research is needed to determine the long-term effectiveness of TMS therapy ².

A Comprehensive Approach to Mental Health Care

Individuals facing mental health conditions such as depression, anxiety, and ADHD can choose medication, TMS therapy, or a combination of both for treatment. Integrating medication and TMS therapy offers a comprehensive approach that addresses the multifaceted nature of these disorders. By combining the stabilizing effect of medications with the targeted stimulation of TMS therapy, individuals have a more nuanced and effective approach to treatment, providing hope and relief. Ongoing research reveals the potential of TMS therapy in mental health care, further improving the quality of life for those with mental health challenges.

If you or someone you know is seeking effective solutions for mental health conditions like depression, anxiety, OCD, or ADHD, contact Neuro Wellness Spa to learn more about starting TMS therapy and discover the right treatment for you. Our dedicated team of psychiatrists is ready to guide you toward improved mental well-being by assessing your need for psychiatric medications and/or TMS therapy based on your specific symptoms and mental health goals. Don’t wait—your mental wellness matters. Reach out now for a brighter tomorrow.

References

1. Akpınar, K., Oğuzhanoğlu, N. K., & Uğurlu, T. T. (2022). Efficacy of transcranial magnetic stimulation in treatment-resistant depression. Turkish journal of medical sciences, 52(4), 1344–1354. https://doi.org/10.55730/1300-0144.5441

2. Alyagon, U., Shahar, H., Hadar, A., Barnea-Ygael, N., Lazarovits, A., Shalev, H., & Zangen, A. (2020). Alleviation of ADHD symptoms by non-invasive right prefrontal stimulation is correlated with EEG activity. NeuroImage. Clinical, 26, 102206. https://doi.org/10.1016/j.nicl.2020.102206

3. Anxiety & Depression Association of America (2023, June 7). Transcranial Magnetic Stimulation (TMS). https://adaa.org/finding-help/transcranial-magnetic-stimulation

4. Bloch, Y., Harel, E. V., Aviram, S., Govezensky, J., Ratzoni, G., & Levkovitz, Y. (2010). Positive effects of repetitive transcranial magnetic stimulation on attention in ADHD Subjects: a randomized controlled pilot study. The world journal of biological psychiatry: the official journal of the World Federation of Societies of Biological Psychiatry, 11(5), 755–758. https://doi.org/10.3109/15622975.2010.484466

5. Chand SP, Arif H. Depression. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430847/

6. Chand SP, Marwaha R. Anxiety. [Updated 2023 Apr 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470361/

7. Cusin, C., & Dougherty, D. D. (2012). Somatic therapies for treatment-resistant depression: ECT, TMS, VNS, DBS. Biology of mood & anxiety disorders, 2, 14. https://doi.org/10.1186/2045-5380-2-14

8. Janicak, P. G., & Dokucu, M. E. (2015). Transcranial magnetic stimulation for the treatment of major depression. Neuropsychiatric disease and treatment, 11, 1549–1560. https://doi.org/10.2147/NDT.S67477

9. Magnus W, Nazir S, Anilkumar AC, et al. Attention Deficit Hyperactivity Disorder. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441838/

10. National Alliance on Mental Illness (n.d.). ECT, TMS, and Other Brain Stimulation Therapies. https://nami.org/About-Mental-Illness/Treatments/ECT-TMS-and-Other-Brain-Stimulation-Therapies

11. Rizvi, S., & Khan, A. M. (2019). Use of Transcranial Magnetic Stimulation for Depression. Cureus, 11(5), e4736. https://doi.org/10.7759/cureus.4736

12. Stern, A. P. (2020, October 27). Transcranial magnetic stimulation (TMS): Hope for stubborn depression. Harvard Health Publishing. https://www.health.harvard.edu/blog/transcranial-magnetic-stimulation-for-depression-2018022313335