Shirah Vollmer MD

The Musings of Dr. Vollmer

Transcranial Magnetic Stimulation

Posted by Dr. Vollmer on April 15, 2015

TMS, transcranial magnetic stimulation, is an FDA approved treatment for Major Depression, but insurance does not pay, and fees are in the 5 digits. As the rate in which new psychotropics appears diminishes, the rate of neuromodulation treatment increases, in a similar way that technology is on such a rapid rate of change, that treating psychiatric diseases with drugs could become a “so yesterday” phenomena. Of course, this could be another tool in the box, an additive treatment, rather than a substitute, but my fear continues to be that newly minted psychiatrists will trust devices more than they trust their ability to use their words, their feelings, and their imagination to help people. Is this large sum of money better spent on intensive psychotherapy? I wonder. Psychotherapy takes longer, a lot longer, and hence one could argue that this is a “quick fix” in that it is usually administered over a period of one month, instead of many years. Like with the promise of the SSRIs, the hope is that we will find some external treatment to fix the complexities of mood and motivation. My bet, as my readers could predict, is that TMS may significantly help a lot of people, but it will very rarely be a substitute for a deeply analytic experience of understanding oneself. Most people restrict themselves from having a richer experience in life, usually due to unconscious forces which lie deep in the psyche. TMS may provide temporary relief to the human suffering of misery, but it will not substitute for the long road of building self-esteem and self-empowerment. There, I have said it again.

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8 Responses to “Transcranial Magnetic Stimulation”

  1. Jon said

    Shirah, you have indeed said it again. To say it yet another time, but it another way, one must learn to solve the basic problems, not just treat the symptoms. TMS may well indeed alleviate some of the symptoms of Major Depression, but does it address the basic causes of Major Depression? While treating symptoms is good, treating root causes is much better.

    • Well, hello Jon!
      It is interesting in that we are a long way from knowing the basic causes of Major Depression, and yet, we, as a field, have come up with innovative treatments despite our ignorance. Maybe we will work backwards, and from a good treatment, we will determine the cause, but so far that has not happened. We are very much in the dark, which psychodynamic psychotherapists embrace, whereas often those who focus on the T therapies (CBT, DBT, FFT, etc) psychopharmacology and/or neuromodulation deny. This difference of certainty creates major tension in the field. Do we know what we are doing or do we hope we know what we are doing? I vote for the latter. Thanks!

  2. Ashana M said

    I think psychotherapy takes a lot longer partly because we’re really not very good at it. If we got better at it, some of that time difference might diminish some. But I’m basically with you. The gadgets always seem sexy, but older methods that directly work with how we use our minds have more potential for most people–like “talk therapy” or meditation and probably some other old-fashioned approaches.

    I also think one problem is that we keep treating depression as an illness rather than an emotion. We’re going about it the wrong way. It needs to be regulated, like other intense emotions, not “cured.” For some people, it’s biologically based, but for most people it’s not. It’s just an emotion like other emotions, and it persists because the conditions prompting that emotion have persisted. There is, on the one hand, a need to figure out how to manage life with that persistent emotion. How do I go about meeting the demands of life when my brain is telling me that the whole endeavor is totally pointless? Talk therapy can help with problem-solving around that. Then there is also the problem of how to turn the dial down on the emotion–how to regulate it better. Talk therapy can help with problem-solving around that too. Once the intensity of the emotion is moderated somewhat, you can start to think straight again and figure out what’s causing it and how to address the condition prompting it. When the dials are all the way on high, it’s like trying to reason using custard. Of course, medication can help with getting the dials down too, but it’s not necessarily a long-term solution. The next time it happens, all you have in the toolbox is medication. You don’t have the knowledge of how to get the intensity of the emotion more under control in other ways.

  3. Well said, Ashana. Thank you. I agree.

  4. Shelly said

    TMS is new to your toolbox and you say that it is expensive and not covered by insurance. On the other hand, neither is long-term psychotherapy. Do you think a deep self-understanding can prevent the next depressive episode? I do not, specifically since depression is a biological illness partially caused by a chemical imbalance which psychotherapy cannot prevent. Perhaps psychotherapy in conjunction with mood stabilizers and antidepressants can help, but not as a stand-alone treatment. TMS may be like ECT: it may help as a last resort if medications and therapy don’t work.

    • Yes, it may be a last resort, or a first resort, for some, but I do think that a deep self-understanding can prevent the next depressive episode, as for most people depressive episodes have triggers, and when triggers can be managed then the depressive episodes may be diminished in intensity and duration. Trauma, of course, overrides coping skills, and so at these times, then a more intensive intervention is often needed. I want to repeat, as I think it is critical, that one of the benefits to in-depth psychotherapy is the ability to reflect and problem solve such that tough emotional situations become more manageable. Given that both long term psychotherapy and TMS are costly, if one has to pick which way to go, I think that is a very interesting decision. Thanks.

  5. The pdocs I had told me of the ‘cure’ ECTs, but they surely were wrong for my major depression. They just kept giving them to me over and over again with no results (just long-term memory loss). I had never heard of TMS, so this is interesting, but luckily I’m not in that dark place where I was, and medication/therapy is keeping my head above water now. Thanks for the post.

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