fMRI-guided TMS

fMRI-guided, Multi-site TMS

What is TMS at CNS Behavioral Health?
CNS utilizes a very unique and effective approach: fMRI-guided, multi-site TMS. This is the state-of-the-art science of combining functional neuroimaging and TMS treatment. Our team of physicians use personalized neuroimaging to identify various dysfunctioning brain centers and then use TMS treatment to stimulate (or inhibit) those specific brain regions. TMS is a type of treatment where a patient undergoes daily sessions of receiving magnetic therapy for 4-6 weeks. The therapy is very safe and has very few side effects.


How does it work?
CNS uses neuroimaging to identify numerous brain centers which are dysfunctioning, specific to each patient’s problems. Each center is found using precision neuroimaging, with no guess work involved. In combination with input from the patient, their doctor, family, and sometimes neuropsychological testing, a TMS Treatment Plan is made. This is similar to how a surgeon uses Xray or MRI to create a surgical plan. Using this approach, we can target numerous symptoms other than just depression.

The TMS Treatment Plan is formulated depending on whether each specific brain center is over-active or under-active. If a brain center is under-active, we use a particular TMS strategy in order to “turn up” (or stimulate, up-regulate) that center. An example of a brain center which is under-active may be depression, ADHD, or an area of brain injury (TBI). If an area is over-active (e.g. anxiety, OCD, mania, or substance abuse cravings), we use a different TMS strategy in order to “turn down” (inhibit, or down-regulate) that neural network.


How is this different than traditional TMS performed elsewhere?
fMRI-guided, multi-site TMS is very different from traditional TMS for numerous reasons, including:

  1. Personalized Neuroimaging Analysis: psychiatic neuroimaging is used to better identify & understand problematic brain regions from the outset.
  2. Multiple target sites: neuroimaging analysis allows for customized targeting of numerous brain centers, allowing us to tread numerous psychiatric symptoms. Traditional TMS targets only 1 site.
  3. Brain Mappingusing neuroimaging, we acquire precise coordinates for each brain center. There is no guesswork involved, like with traditional TMS – which uses a “one size fits all” general standard scalp location.
  4. Type of Modulation: our technique allows for either stimulating or inhibiting each center (traditional TMS only uses stimulation).
  5. Ongoing TMS Adjustment: this allows us to periodically reassess symptom improvement and adjust our TMS Treatment Plan. Traditional TMS utilizes a “set it and forget it” approach where the patient receives stimulation at 1 standard site for 6 weeks regardless of symptom improvement. At CNS, we will  continuously reassess the patient’s progress (by examining the patient, talking with family and clinicians, and with objective rating scales). Based on progress, we may periodically adjust the treatment plan (including site locations, types and duration of treatment, etc).  Simply put, if it isn’t working as well as we’d like, we adjust things so that it works better.


Is fMRI-guided, multi-site TMS good for different symptoms other than depression?
Yes. Although traditional TMS is currently FDA approved for depression, many studies are currently underway for approval of various other conditions – and because of this, technologies are being developed to treat these other conditions.

The beauty of using personalized neuroimaging analysis is that we do not have to wait for these “one size fits all” technologies to be developed. It allows us to identify and treat symptoms other than depression right now. Just as an X-ray or MRI can guide a surgeon in using a scalpel to treat different anatomical conditions, so too is the case with fMRI-guided, multi-site TMS. 


Who is it good for?
fMRI-guided, multi-site TMS can be helpful for:

  1. Those who have had limited success with medications or traditional TMS.
  2. Those with psychiatric symptoms other than pure depression (e.g. OCD, generalized anxiety disorder, or TBI).
  3. For individuals who have ran into considerable side effects from medications.
  4. It can also be useful for individuals wanting to avoid medications altogether.
  5. It can be helpful medical conditions other than purely psychiatric (e.g. chronic pain, tinnitus, etc).


How effective is it?
Naturally, it depends which symptoms we are treating. But generally at CNS, our studies indicate that approximately 80% of our patients improve considerably. Of those, about 40-50% of individuals go into full remission. The improvement lasts for usually 2-3 years. According to the following study from the NIMH, for depression – fMRI-guided TMS is 200-300% more effective than traditional TMS. http://tinyurl.com/y9xb27zg. The article is from a scientist at the National Institute of Mental Health, a very credible source and universally accepted as an authority on mental health treatment.


How long are the treatment sessions?
Like traditional TMS, the treatment is daily sessions (Mon-Fri), for 4-6 weeks. However, traditional TMS takes 6 weeks or longer. Because fMRI-guided TMS uses precision brain mapping, we are often able to shorten treatment to 4 weeks. The length of each session depends on the TMS Treatment Plan formulated by the doctor, which in turn depends on symptoms and number of target sites. Session lengths can range between 45-90 minutes.


Are there side effects?
Very few. Possible side effects are the same as for traditional TMS, including mild temporary headache or fatigue. These will be discussed with your doctor.


How does it work?
The doctor will first have the patient undergo a series of specialized neuroimaging scans. Depending on the problem, the doctor may even ask the patient to perform specific emotional or cognitive tasks while physically in the scanner. This can help the team to more accurately visualize the affected neural networks. The doctor will then analyze the brain scans, often consulting with other specialists in doing so. Using results from the brain scans as well as each patient’s psychiatric history and testing, the doctor will then formulate a TMS Treatment Plan, which specifies each particular target brain center, type & duration of treatment (stimulation or inhibition), type of magnetic beam and meachine, and other components.


What is Intra-TMS Therapy?
Intra-TMS Therapy is a promising new treatment strategy where we have one of our psychotherapists help the patient perform specific cognitive exercises or other psychotherapy tools while simultaneously receiving TMS treatment. This may possibly amplify the TMS effect and lead to greater improvement of symptoms. 


How much does it cost?
fMRI-guided, multi-site TMS incurs similar costs as traditional TMS but depends on the specific TMS Treatment Plan. It also incurs the additional cost of the initial set of neuroimaging (performed at an outside radiology center) and its analyses. Your doctor will discus all of this with you.


What type of doctor performs it?
fMRI-guided TMS can be done by any physician but is usually a psychiatrist, neurologist, or neuroradiologist. If it is being done for a psychiatric condition, then it is probably best to have a psychiatrist supervising or be a part of the treatment team. This is because a psychiatrist’s entire training and experience is solely dedicated to people living with psychiatric conditions. A psychiatrist is trained to evaluate the entire individual, including not only their brain but also their personality traits, psychological coping mechanisms, childhood or developmental issues, environmental factors (e.g. school, work or family), and to also integrate all of their past psychiatric diagnoses, psychodiagnostic or neurocognitive testing, and history of treatments and medications. However, unfortunately many psychiatrists do not have the necessary knowledge or experience in neuroimaging, and therefore many are not yet performing fMRI-guided TMS. As time goes on and training programs incorporate more of this into their curriculum, this will likely change. In contrast, some neurologists and neuroradiologists are successfully practicing fMRI-guided TMS because of their experience in neuroimaging. However, many of these doctors too aren’t yet performing it because fMRI-guided TMS isn’t yet a part of standard neurology or neuroradiology training programs, either.


Why aren’t more doctors doing it?
fMRI-guided TMS requires the physician and team to have an extensive amount of neuroimaging knowledge, TMS experience, and access to related specialists and machines. Many doctors are just not familiar with it because it is still very new and is an emerging field. Many don’t feel comfortable because they don’t have experience performing it. A physician must have extensive knowledge and expertise in neuroimaging (which many psychiatrists do not have). Traditional TMS is currently a “one size fits all” procedure. This is not the case for fMRI-guided TMS. Physicians who practice fMRI-guided TMS must use their knowledge in analyzing brain scans to customize the treatment for each individual patient. Another reason is because a physician needs to have access to very sophisticated neuroimaging machines, and also to other related specialists (e.g. psychiatrists, neurologists, neuroradiologists). Many psychiatrists operate in a solo private practice and do not have this access. On the other hand, many psychiatrists work in the opposite setting – very large institutions – where it is too logistically difficult to integrate physicians across multiple specialties. fMRI-guided TMS is probably best done with an integrated team approach when specialists from the above fields all give their input. Another reason why many physicians don’t utilize it yet is because it is an additional cost to the patient to obtain the neuroimaging.


This sounds too futuristic. Is it real or is it snake oil?
fMRI-guided TMS is an incredibly promising technology. In contrast, many products and services make numerous promises about their mental health benefits (e.g. vitamins, etc), some of which are not backed up by any medical research. It is the duty of physicians to educate (and if necessary, to protect) patients from these. Therefore, many  physicians hold high levels of skepticism as a filter for their patients who may not have the same medical expertise. Generally, this is a good thing. However, sometimes skepticism holds a physician back if she is not educated about the latest treatment advances. Occasionally this happens with fMRI-guided TMS because many physicians are simply not yet aware of it. Individually, the components of fMRI-guided TMS are generally all FDA-approved for different indications (e.g. MRI for ruling out lesions), but not yet when used in concert (as is the case for fMRI-guided TMS). There are  many studies from reputable institutions showing benefit far beyond traditional TMS. As already mentioned, http://tinyurl.com/y9xb27zg is a study from the NIMH which estimates that fMRI-guided TMS is 200-300% more effective than traditional TMS.