TMS, which stands for transcranial magnetic stimulation, is a form of neuromodulation that utilizes a pulsing magnetic field to induce electrical current. This innovative psychiatric treatment utilizes Faraday’s law of electromagnetic induction, such that a magnetic field is produced by passing electric current through a wire coil (Horvath et al., 2011). When placed against the scalp, current from the magnet passes through the skull and electrically stimulates neurons directly beneath it. This electrical stimulation, when tuned to a high enough frequency of more than 10 Hz, results in depolarization, or excitation of nerve cells, causing them to fire at an increased rate. Increased neuronal firing in turn modulates connectivity and activates pathways involved in mood regulation.
TMS received FDA approval for the treatment of major depression in 2008, and it is recommended by the American Psychiatric Association. In patients with major depressive disorder, daily, repetitive TMS works to induce long-term activation of nerve cells that are otherwise underactive.
Dr. Cohen offers TMS in a discreet, private office setting in the heart of Manhattan on W 57th St, with a view towards Central Park and NYC Landmark Alwyn Court.
Dr. Cohen will provide a full consultation on the indications for TMS as well as review psychopharmacology history and options.
Dr. Cohen works closely with patient’s primary psychiatrist, TMS technician, and device manufacturer, Neuronetics, Inc., to provide optimal treatment outcomes.
@ Principium Psychiatry
Dr. Cohen is a board certified psychiatrist. He is a Clinical Assistant Professor of Psychiatry at Weill Cornell Medical College of Cornell University, where he teaches. Dr. Cohen is a Fellow of the American Psychiatric Association and a Member of the New York Academy of Medicine. He is President of the New York Society for Adolescent Psychiatry.
Decades of clinical research support the idea that in patients with major depressive disorder, the left dorsolateral prefrontal cortex is hypoactive (or less active relative to control). Thus, TMS treatment involves placing the magnet on the head so as to target this region in a precise manner, allowing for the reversal of this underactivity and therefore, alleviation of depressive symptoms.
The dorsolateral prefrontal cortex, which is the area being targeted during TMS treatment, is implicated in functions such as cognitive control, working memory, and motivation. Furthermore, the DLPFC is involved in modulating other areas of the default mode network, including cingulate cortex and parietal areas, as well as areas within the limbic system, responsible for emotional response and memory consolidation, such as the amygdala and hippocampus.
The antidepressant effects of TMS are well-cited in the literature. In a randomized placebo-controlled trial, daily repetitive TMS (rTMS) over the left dorsolateral prefrontal cortex (DLPFC) for 5 consecutive days was found to have significant, long-term improvement in patients with treatment-resistant depression (Pascual-Leone, et al., 1996). In a separate, large-scale multisite randomized controlled trial, 301 patients with treatment-resistant Major Depressive Disorder experienced significant reduction in severity of depressive symptoms with twice the remission rates in the TMS treatment group compared to the placebo group. Patients achieved clinically significant improvement as a result of daily TMS treatment at 4-6 weeks. Overall response rate to TMS was 62.8%, with a mean 40.7% reduction of depression rating scores from baseline (O’Reardon et al., 2007).
TMS was found to induce long-term changes in regional blood flow in areas correlating with depression symptoms. Particularly, it resulted in increased brain activity in the left prefrontal cortex, right medial frontal lobe and left middle frontal gyrus, areas that are often underactive in patients with depression (Nahas et al., 2001).
Response rates from multisite clinical trials show 30-40% of patients with treatment-resistant depression achieve remission following daily, repeated TMS on the left dorsolateral prefrontal cortex over several weeks. The overall response rate to a standard TMS treatment course is about 60%, with about 50% reduction of depression symptoms compared to baseline, with improvements in symptoms such as anhedonia, energy, focus and motivation.
Figure 2: Here, we see a PET scan comparing the brains of depressed patients and non-depressed control. The areas shown in warmer colors indicate higher metabolic activity, which, as we can see, are noticeably dampened in patients with depression.
During treatment, patients sit comfortably in a reclining chair, and a magnetic coil is gently placed against the left side of their scalp. Each treatment session ranges from 20 minutes to one hour. During sessions, patients can chat, watch television, or listen to music. Patients will hear a clicking noise, but they do not typically feel pain or discomfort. Patients are awake, and there is no use of anesthesia. TMS produces few to no side effects. Some patients may experience a mild headache and slight tenderness in the treatment area over the first few sessions, but this can easily be addressed with over-the-counter Advil or Tylenol.
Figure 3: TMS utilizes a pulsing magnetic field to electrically stimulate neurons at the treatment site. This electrical stimulation results in the excitation of nerve cells, causing them to fire at an increased rate.
Figure 1: Stimulation of dorsolateral prefrontal cortex during TMS induces long-term potentiation of neurons, which leads to increased activity and strengthened connectivity within crucial brain circuitry related to mood regulation, motivation, working memory, and attention.
Transcranial Magnetic Stimulation, or TMS, is the latest generation of direct brain stimulation therapy for the treatment of depression. Using non-invasive technology, the regions of the brain implicated in depression can be stimulated, to treat debilitating symptoms depression. TMS does not involve medication and is performed on an outpatient basis.
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For inquires about TMS at Principium Psychiatry, please contact our office.
Yiling Wang earned her bachelor's degree in Neuroscience from Duke University, where she worked as a research assistant at the Department of Psychiatry and Behavioral Sciences. She is completing her graduate studies in Neuroscience and Education at Columbia University and is a certified TMS technician.
The standard treatment protocol involves 36 sessions daily, administered over 4 - 6 weeks. TMS treatments are done five times a week from Monday to Friday. Each session ranges from 20 minutes to one hour. Treatment parameters, which are determined determined during the initial appointment, are tailored to each individual patient, and modified across the treatment course as needed.
We welcome local as well as international clients. Located near Carnegie Hall and Columbus Circle, our location offers proximity to top of the line hotels and accommodations. Clients will have access to New York's numerous attractions while receiving treatment.
Ziv Ezra Cohen, M.D.