Understanding TMS Therapy for Anxiety Disorders: Indications and Efficacy

Transcranial magnetic stimulation is growing more and more popular in the fields of psychiatry and behavioral health. Originally approved for the treatment of refractory depression, the FDA has approved it for additional uses in recent years. In 2021, this procedure received FDA approval for anxiety that occurs comorbidly with depression. Given this fact, it’s helpful to understand the role of TMS therapy in the treatment of anxiety disorders.

Research with TMS for Anxiety Treatment?

Prior to FDA approval, the effects of TMS on anxiety symptoms were well-researched. A 2015 study in Psychiatry Research assessed the benefits of 20 sessions of deep TMS in 95 patients with unipolar depression. Results showed that patients experienced large reductions in anxiety after TMS treatment, even when not taking antidepressant medication.?

A more recent research report, published in a 2022 edition of the Annals of Clinical Psychiatry, reviewed the results of 13 different studies that evaluated TMS in patients with anxiety disorders. The results of meta-analysis showed that TMS significantly improves symptoms for patients with generalized anxiety disorder.?

For patients who have anxiety, TMS applied at a low frequency over the right dorsolateral prefrontal cortex appears to be most beneficial, whereas those who have comorbid depression tend to see better improvement with higher frequency pulses.?

Device Approval?

The BrainsWay device is the first to receive approval for treating anxiety occurring alongside depression. This is a deep TMS device that stimulates the dorsolateral prefrontal cortex, as neurons in this area of the brain are believed to be responsible for symptoms of anxious depression.?

Determining When a Patient May Benefit from TMS?

While SSRI medications in combination with talk therapy, and primarily CBT, are often the first line of treatment for anxiety, the truth is that not all patients will respond to these usual treatment modalities. In fact, about 40% of patients do not respond to these methods.?

When a patient doesn’t receive adequate symptom relief with one or more trials of medication, or they are not able to tolerate medication due to side effects, they may benefit from a referral for TMS services. Patients can continue to take medication and participate in therapy while undergoing TMS.

A patient who isn’t improving through medications or therapy alone may find the relief they’re seeking by adding TMS to their treatment regimen. Keep in mind that TMS is FDA approved for anxiety that occurs alongside depression, but not other forms of anxiety, such as generalized anxiety that exists without comorbid depression.?

In summary, if you’re treating patients with anxiety, the following indications suggest that TMS could be beneficial:

• The patient has anxiety occurring alongside depression.
• The patient has not received substantial symptom relief with medications.
• The patient lives with chronic symptoms of anxious depression.?
• The patient has discontinued medications because of the severity of side effects.?

Contraindications to TMS

TMS can be beneficial for patients who experience long-term anxious depression and who do not find adequate relief through medication. However, some patients may not be candidates for TMS. These include:

• Patients with medically implanted devices that are metal sensitive or magnetic (such as cochlear implants, cardiac defibrillators, vagus nerve stimulators, staples, or stents)?
• Individuals with a history of seizures or epilepsy
• Those who have a neurological condition, such as dementia, cerebrovascular disease, severe or repetitive head trauma, or increased intracranial pressure
• Patients with tumors in the central nervous system?

If you’re unsure of whether a particular patient is a candidate for TMS, BrainsWay offers a referral consultation service to provide you with guidance.?

Talking with Patients

When a patient has chronic anxious depression, or they simply aren’t finding relief with medications, it may be time to talk with them about adding TMS to their treatment regimen. Below are some helpful talking points that can be useful when discussing a TMS referral with a patient:

• TMS is a non-invasive procedure, meaning they won’t need to undergo anesthesia, and they can return to work and other activities after a session.
• They can continue to take medication and participate in therapy; TMS is not meant to take the place of other treatments but rather to enhance them.
• TMS can be completed in a 20-minute session, so it can easily be incorporated into a busy lifestyle.?
• TMS is safe and well-tolerated, and in most cases, side effects are mild. Headaches are the most commonly-experienced side effect, and many patients find that TMS comes with fewer side effects than antidepressant medications.?
• TMS not only stimulates areas of the brain involved in mood; it also improves communication between neurons, and these effects can be long-lasting.?

With its current approval status for anxious depression, TMS can be an excellent treatment add-on for patients who have chronic or treatment-resistant depression that occurs “with anxious distress,” as per DSM-5 diagnostic criteria. If you’re treating patients with this condition, it’s important to understand how to talk to them about TMS, as well as when it’s time to make a referral. Given the increased interest in TMS, and the expansion of its uses, you may find that TMS is approved for additional uses in the future.?

If you’re treating patients in the Los Angeles area, Pulse TMS is an invaluable resource for your practice, and you may even find that the benefits of this service allow your patients to engage more fully in psychotherapy. We will coordinate our treatment with the plans you already have in place for your patient, in addition to updating you with regard to their progress. Contact us today to make a referral.?

Sources: 1)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8864803/

2)https://www.sciencedirect.com/science/article/pii/S0165178115306971?casa_token=8uTL4idPbTgAAAAA:ryRa3Zle6ku_ypeHstNAVI_696TLYWMbOt24-7q6Vw5iB-N8DMyZRcqrkUEdBJR56rUhRcW2-V4

3)https://www.aacp.com/wp-content/uploads/2022/08/0822-ACP-Dwivedi.pdf

4)https://www.brainsway.com/treatments/anxious-depression/

5)https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=34522&ver=29#:~:text=Transcranial%20Magnetic%20Stimulation%20(TMS)%20is%20FDA%20approved%20for%20the%20treatment,depression%20and%20obsessive%2Dcompulsive%20disorders.&text=It%20is%20a%20non%2Dinvasive,region%20of%20the%20cerebral%20cortex.

6)https://www.ajmc.com/view/with-anxiety-common-in-depression-dsm-5-specifier-aids-screening