What Is Accelerated TMS?
TMS therapy has been used in clinical psychiatric practice since 2008 in the USA following its clearance by the FDA. It is non-invasive and drug-free, with none of the systemic side effects associated with medications. Despite its breakthrough success in achieving remission from depression, a major challenge of conventional repetitive transcranial magnetic stimulation (rTMS) has been the inconvenience of daily treatments, and the consequent long duration of the treatment course.
Fortunately in 2018, a new breakthrough in TMS revolutionized our treatment options with the development and FDA-approval of Intermittent Theta-Burst Stimulation (iTBS). Just like rTMS, iTBS is a non-invasive brain stimulation treatment that is FDA-cleared for treatment-resistant depression (TRD). It uses a different magnetic pulse at a higher frequency, delivering the treatment in just over 3 minutes. iTBS was proven in 2018 to be as effective as rTMS with obvious advantages in time. This also opened the door to newer methodologies for providing TMS therapy—most importantly, the ability to provide multiple sessions a day. This is called accelerated TMS. Accelerated TMS evolved over time to allow the course of the treatment to be shortened from 6 weeks to just 5 days!
The term accelerated TMS is used in the medical literature to describe any TMS therapy protocol utilizing more than one TMS session per day. Today, the terminology “accelerated TMS” and “accelerated TBS” is commonly used to describe the protocol in which the patient receives 10 TMS therapy sessions a day for 5 days for a total full course of 50 TMS therapy sessions, allowing an entire treatment course to be completed much more quickly than previously available.
Is Accelerated TMS Therapy Effective?
Clinical research supports the efficacy of accelerated TMS or TBS therapy for depression treatment. Based on a 2016 study, it was concluded that Accelerated TBS treatment in depressed, suicidal patients is safe and well-tolerated and may have the potential to acutely decrease suicidal ideations.
A study published in the Journal of Affective Disorders in 2016 found that 20 sessions of iTBS given 5 sessions a day for four days is safe and may lead to meaningful clinical responses within two weeks after stimulation.
In 2018, a clinical trial compared accelerated high-frequency rTMS (arTMS) with accelerated intermittent theta burst stimulation (aiTBS) in the refractory depressed state. The clinical efficacy was not significantly different between both protocols. This supports the potential of the accelerated stimulation to shorten the treatment duration from the depressed state to the response and remission state.
What is the SAINT Protocol?
The most recent breakthrough in accelerated TMS came from Stanford University and was published in the prestigious peer-reviewed American Journal of Psychiatry in April 2020. It also received public media coverage, such as this inspiring story on CBS News. Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression (SAINT-TRD) proved the efficacy and safety of accelerated TBS protocol for depression. In this clinical trial, 21 participants with TRD received 50 iTBS sessions delivered in 10 daily sessions over 5 consecutive days. A remarkable 19 of 21 participants (90.48%) met the criteria for remission immediately after SAINT. In the intent-to-treat analysis, 19 of 22 participants (86.4%) met the remission criteria. Neuropsychological testing demonstrated no negative cognitive side effects. This provided additional support for the safety and tolerability of accelerated iTBS. In addition, efficacy was surprisingly high. A randomized controlled trial called SNT was conducted to validate the effect, and confirmed the efficacy of the SAINT TMS protocol.
Can I receive the SAINT Protocol at Amy Mednick MD TMS?
The main difference between the SAINT protocol and our aiTBS program is that we don’t use brain imaging to determine the magnetic stimulation's target area. Instead, we use a non-MRI-based navigation system that calculates the target area based on the patient's skull measurements, a reliable system developed from the field of EEG technology. (Please see last week's post for a comparison of the two methods.) While SAINT TMS protocol is FDA-cleared, it is still not commercially available for TMS clinics to acquire. That means our Accelerated TMS program is not FDA-cleared, but it is available today. This makes our program an alternative for those looking for fast relief from depression while awaiting the production and commercial availability of the official SAINT TMS device.
To be clear, Accelerated TMS without MRI is not SAINT, but it is what we have available until a TMS device capable of delivering the SAINT protocol with MRI is developed.
If you are interested in accelerated TMS, please speak to your primary psychiatrist and have them complete our referral form or call Dr. Mednick’s office. Please note that most insurance plans do not cover accelerated TMS.
Why do I have to be referred by a psychiatrist?
Accelerated TMS can be an intense experience, as you will be receiving a lot of treatment in a small amount of time. We want to make sure that you come into that experience well-informed and with a strong support network. Dr. Mednick works on a consultative basis – i.e., she will not be your primary psychiatrist but will work with your current doctor to make sure the treatment plan is right for you. This also ensures that you will have close follow-up when you complete TMS treatment.
Is my satisfaction guaranteed?
We cannot guarantee that you will have positive results. We can only reassure you that 60-70% of patients do have positive results, or up to 90% in the Stanford SAINT study. If you do not feel better at the end of the 5 days, you can opt to have more treatments, or you can resume regular psychiatric treatment. Keep in mind that many participants in the clinical trials experienced benefits at a delayed interval of up to 2 weeks after completing treatment.
What will my day look like?
You will receive a 9-minute treatment every hour. This will occur in a dedicated treatment room that will be yours for the week-long course of treatment. We will aim to fit in 10 treatments per day, but the number may be lower depending on when you would like to arrive and leave. You will meet with Dr. Mednick each morning and have your treatment re-calibrated.
The room has a couch that can be set up as a bed if you would like to catch up on sleep in between sessions. There is also Wifi and a working space, with a neutral background, in case you would like to conduct work or video calls in between your sessions. We can provide lunch if you choose, and have a wide variety of snacks and beverages available. Your comfort is our priority!