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BlogDepressionTMS (Transcranial Magnetic Stimulation)

TMS and ECT: What’s the Difference?

By December 12, 2023December 27th, 2023No Comments
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Transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT) both use electrical impulses to treat people with mental health disorders, but TMS and ECT are not the same, and the differences are important to understand. 

In the 21st century, treatment for mental health diagnoses leverages new technologies and techniques that help patients manage complex, treatment-resistant diagnoses which, in the past, did not always respond well to traditional methods.

New approaches to psychotherapy include treatments like dialectical behavior therapy (DBT), which is based on cognitive behavioral therapy (CBT) but includes elements of mindfulness and distress tolerance skills that help patients manage disruptive symptoms. Lifestyle changes are now a common component of treatment, too: exercise, healthy eating, and positive social support all form important elements of personalized treatment programs. With regards to technology, one new approach uses advances in brain stimulation to relieve symptoms of depression and other diagnoses: transcranial magnetic stimulation (TMS).

When people hear or read about TMS, they often immediately associate it with another form of brain stimulation for mental health diagnoses: electroconvulsive therapy (ECT).

TMS is not ECT. Although they appear similar from the outside, there are significant differences between the two treatments. These differences often determine which approach is best for each patient.

There are similarities and differences between transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT). ECT is around 80 years old, with the first recorded instance of treatment recorded in Italy in 1938. On the other hand, the technology used in TMS is similar to the technology behind magnetic resonance imaging (MRI), which researchers developed in the 1970s. The first recorded use of TMS for mental health applications dates to the late 1990s. ECT has been around far longer than TMS, which is a relatively new technique in the treatment of mental health diagnoses.

Brain Stimulation and Mental Health Treatment

To understand the differences between these two treatments, it’s important to know where they fit in the big picture of mental health treatments. Scientists and treatment professionals classify TMS and ECT as brain stimulation therapies (BSTs).

According to the National Institute of Mental Health (NIMH), there are three types of BST now in use for mental health treatment and two in the clinical trial phase. These treatments are currently in use, and have received approval from the Food and Drug Administration (FDA):

  • Electroconvulsive therapy (ECT)
  • Repetitive transcranial magnetic stimulation (rTMS)
  • Vagus nerve stimulation (VNS)

These two treatments are currently in the clinical trial phase:

  • Magnetic seizure therapy (MST)
  • Deep brain stimulation (DBS)

How do BSTs Work?

All five of these treatments have one thing in common, which is indicated by name of the category of the treatments themselves, brain stimulation therapy. All five achieve their therapeutic effect by using either electricity or electromagnetism to stimulate specific areas of the brain. There are two different types of brain stimulation:

  1. The use of electrical currents, as in electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), and deep brain stimulation (DBS).
  2. The use of electromagnetic pulses, as in transcranial magnetic stimulation (TMS) and magnetic seizure therapy (MST).

In addition, there are two different goals for the use of either electrical currents or electromagnetic pulses:

  1. The induction of a temporary seizure, as in ECT and MST
  2. The stimulation of specific parts of the brain, as in TMS, VNS, and DBS

Most people understand the difference between the first two points, above. An electrical current is what we get when we attach wires to the positive and negative poles of a battery. An electromagnetic impulse, on the other hand, requires a specialized machine that generates a magnetic field to deliver the pulses

We’ll clarify the difference between inducing a seizure and stimulating the brain. The idea behind inducing a temporary seizure is, in a nutshell, to allow the brain to do something akin to a reset or a hard reboot. After the seizure – or a series of controlled seizures induced over time – specific brain areas can return to typical functioning that’s not associated with a mental health diagnosis.

Stimulation is similar, but not as extreme. Electromagnetic pulses elicit an increase in neurotransmitters associated with mental health healthy functioning and a decrease in neurotransmitters associated with the presence of mental health symptoms. That’s an oversimplification, but it’s accurate.

Transcranial Magnetic Stimulation (TMS) and Electroconvulsive Therapy (ECT)

There are significant differences between these two BSTs. However, before we look at the differences, we’ll discuss the similarities.

TMS and ECT are similar in the following ways:

  • They’re both indicated for helping people diagnosed with treatment resistant depression and other mental health diagnoses that don’t respond well to first-line treatments.
  • The most common application for both is helping people with treatment-resistant depression
  • Both require a patient to have tried – without success – typical, first line treatment for depression such as psychotherapy + antidepressant medication.

What this means is that neither TMS nor ECT is the first treatment option for a person diagnosed with depression, but rather an option a provider may present after initial treatments fail to achieve the desired therapeutic effect. They’re also both considered noninvasive treatments. ECT is more intense, which is not the same is invasive, but the intensity of ECT is one reason many people decline ECT treatment when they learn it’s an option for depression treatment.

That brings us directly to the differences between these two BSTs. We mention the intensity of ECT, which we’ll address below. Before we get there, though, it’s important to understand that these two treatments are different in three primary ways:

  1. The number of diagnoses they’re approved to treat. TMS has a broader base of application than ECT, although it’s a newer treatment.
  2. The method and milieu of treatment delivery. One is rather complex, while the other is relatively simple.
  3. The side-effects associated with the treatments. Again, one treatment has serious side-effects and potential complications, while the other has relatively few side effects and associated complications.

TMS and ECT: Differences in Indications

  • Transcranial magnetic stimulation is FDA-approved for:
    • Treatment-resistant depression
    • Obsessive-compulsive disorder (OCD)
    • Post-traumatic stress disorder (PTSD)
    • Anxiety diagnoses
    • Anxious depression
    • Smoking cessation
  • Electroconvulsive therapy is FDA-approved for:
    • Major depressive disorder/severe depression
    • Treatment-resistant depression
    • Schizophrenia
    • Catatonia
    • Psychosis

TMS and ECT: Differences in the Treatment Delivery Milieu and Method

  • TMS:
    • Uses magnetic pulses to stimulate specific brain areas
    • Pulses delivered by a small coil or cap placed directly on the scalp
    • Treatment administered in an outpatient office setting
    • Does not require:
      • Anesthesia
      • Sedation
      • Immobilization
    • Treatment sessions typically last 20-30 minutes, beginning to end
    • Patients typically engage in 20-30 daily sessions over the course of several weeks. The number of sessions varies by patient and treatment response
    • Treatment with TMS is durable, and benefits can last for months after treatment
  • ECT:
    • Uses electrical currents to induce a temporary seizure in specific brain areas
    • Requires:
      • Admission to a hospital
      • Anesthesia/sedation
      • Muscle relaxers
    • Patients are unconscious and immobilized during treatment
    • Treatment sessions typically last around an hour, beginning to end
    • Patients typically engage in 6-12 treatment sessions over the course of 1-2 months. The number of sessions varies by patient and treatment response
    • Treatment with ECT is not as durable as treatment with TMS, and benefits may fade after treatment

This component – the delivery method and milieu – is a major difference between these two treatment methods. Treatment with ECT happens in a regular hospital or psychiatric hospital, requires the use anesthesia and muscle relaxers, and requires a patient to be sedated and immobile. Treatment with TMS, on the other hand, occurs in an outpatient setting and does not require anesthesia or muscle relaxers. During a TMS session, patients are awake and aware.

TMS and ECT: Differences in Side-Effects

  • TMS:
    • Mild headache during or immediately after treatment
    • Tingling at stimulation site
    • Twitching in face muscles during treatment
  • ECT:
    • Headache
    • Muscle aches
    • Nausea
    • Temporary changes in heart rate and blood pressure
    • Temporary arrhythmias, or irregular heartbeat
    • Disorientation/confusion
    • Long-term memory deficits

The length of these two lists is informative: it’s clear TMS has fewer side-effects, and they’re not as disruptive as the side-effects associated with ECT.

The severity of the potential side-effects, combined with the intensity of the treatment, mean that ECT is rarely used as an initial treatment for depression, except in extreme cases. Patients are not allowed to drive home from sessions and are advised not to drive within 24 hours of a treatment session. In addition, patients who participate in a series of ECT treatments often take time off work and time away from other forms of therapy or treatment during a course of electroconvulsive therapy.

On the other hand, treatment with TMS is not as intense, and the side-effects don’t prevent patients from driving themselves to and from TMS treatment sessions. Patients engaging in TMS therapy can also continue to participate in the typical activities associated with daily life, including work, exercise, socializing, and – if it’s part of their routine – weekly or biweekly psychotherapy sessions.

Transcranial Magnetic Stimulation (TMS) and Electroconvulsive Therapy (ECT): How Do You Choose Which One Is Best For You?

Both these forms of brain stimulation can offer relief from the symptoms of severe, treatment-resistant depression when first-line treatments – with psychotherapy and antidepressants – do not provide adequate symptoms relief.

Although it’s effective, ECT has a bad reputation among the general public, which is more a result of the media than how ECT currently works. In film, television, and common cultural shorthand, ECT is often portrayed and/or discussed as a brutal, barbaric, and archaic form of treatment. People think of it as electroshock therapy and associate it with movies like “One Flew Over the Cuckoo’s Nest” or depictions of sanitoriums from the early 20th century. It’s important for anyone reading this article to understand that ECT protocols are modern and safe and that ECT can help people with extreme depression when nothing else works.

With that said, the side-effects of ECT can be extreme. Those, combined with the need for hospital admission, anesthesia/sedation, and the disruption ECT causes to daily life, mean that many people decline ECT when offered, in favor of a less invasive, less restrictive treatment like TMS.

Patients deciding between TMS and ECT should consider the following factors.

Assessments and Referrals

The outcome of a comprehensive mental health assessment and the advice of their mental health treatment provider are critical. Patients who know and trust their providers should listen carefully to what they advise. If a physician or psychiatrist recommends a treatment, they have a good reason. Patient and provider should have an open and honest discussion about the possible benefits and drawbacks of any course of treatment. We advise patients to learn everything they can about their treatment, and make an informed decision based on real facts.

Treatment Goals

This is an important thing to weigh before engaging in ECT or TMS. The goals for each individual patient depend on the history and course of their diagnosis. For a patient with treatment-resistant depression, the goal is most often symptom reduction or full remission. We advise patients to discuss the benefits of each treatment and weigh them against the potential side-effects, and make a decision based on what’s best for them.

Accessibility and Feasibility

In some cases, practical considerations rule: if a treatment is not available in a convenient location, or a location a patient cannot make work with their lives, then it’s off the table. If a treatment is available in a convenient location, that may make a significant difference.

The feasibility component is slightly different. For instance, patients may learn about ECT and think it’s a viable option. Then, they may learn about the side-effects, the method and delivery milieu, and realize it’s not something that will work: the logistics may simply make it impossible. The same patient may learn about TMS – the milder side-effects, the less intense/intensive delivery milieu – and decide it’s a better fit for them.

TMS or ECT? Take a Whole-Person Approach

We understand that deciding which method of mental health treatment to pursue is not easy. With regards to TMS and ECT, we advise patients to consider how the different modalities would impact their lives. For many patients, TMS is a more realistic option, based on a combination of the treatment delivery and milieu and the potential side-effects. With that said, it’s critical for anyone reading this article to understand that this article cannot make a diagnosis or treatment referral: that’s for a licensed and qualified treatment professional.

We advise patients interested in either TMS or ECT review the basic facts above, have a serious conversation with their mental health treatment provider about their options, and choose the modality that fits their current treatment plan, their overall treatment goals, and helps them reach their long-term, personal goals. That’s what we mean by a whole-person approach. We advise each individual to choose the modality that makes the most sense for them in the big picture, and gives them the best chance at leading a full, independent, and fulfilling life.

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