If you or a loved one have had failed attempts with traditional antidepressant drugs, you may be considering alternative treatment options such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS).
Both non-invasive treatments are FDA-approved for major depressive disorder (MDD) and have been shown to relieve depressive symptoms in a significant number of patients. However, TMS has milder side effects and lower risks than ECT and is preferable for many patients as a result.
In this article, we provide a detailed comparison of these two treatments to educate potential patients about the differences and help them decide which may be the best for them.
We compare TMS and ECT in terms of:
Transcranial Magnetic Stimulation (TMS) is an outpatient treatment that uses magnetic fields to stimulate a part of the brain that’s consistently impacted by depression. The brain region it targets is called the dorsolateral prefrontal cortex (DLPFC), which is associated with a patient’s ability to feel positive feelings, including reward and motivation.
During a TMS treatment session, an electromagnetic coil is positioned directly above the DLPFC, and magnetic pulses are delivered at specific intervals to stimulate the nerve cells in that area. The aim is to increase activity in that region which, in turn, can alleviate symptoms in depressed patients.
In the original form of TMS, known as repetitive transcranial magnetic stimulation or rTMS, patients receive daily sessions, five days a week, with 20-30 sessions delivered over 4–6 weeks. Some patients see improvements after 2–4 weeks, while others only see the antidepressant effects of rTMS after treatment is completed.
Due to the extensive time commitment required from patients, researchers developed an accelerated TMS protocol with multiple daily sessions, shortening the treatment course to just one week. This condensed timeframe makes it easier for patients to complete the treatment.
In 2018, the FDA approved a novel form of accelerated TMS known as Intermittent Theta-Burst Stimulation (iTBS). This approach mimics theta waves, which the hippocampus uses to connect with other areas of the brain. iTBS employs a different magnetic pulse pattern (delivered in triplets) and administers treatment in just three minutes, compared to the 37 minutes required for rTMS treatment.
In addition, it applies pulses at 80% of the brain’s motor threshold (compared to high-frequency pulses of 110%–120% with rTMS), making it even safer for patients. Many patients notice improvements soon after beginning treatment. Additionally, there is a reduction in suicidal ideation, indicating that iTBS may be a rapid treatment option for patients at high risk of suicide.
The SAINT-iTBS protocol, which we offer at our clinic (explained below), combines theta-burst stimulation with functional MRI and neuronavigation to ensure precise coil placement over the specific area of the brain targeted by TMS. This way, healthcare practitioners can accurately position the magnetic coil over the DLPFC for each patient. This approach is now considered the “gold standard” for treating treatment-resistant depression.
A comparison of remission rates for rTMS/iTBS, electroconvulsive therapy (ECT), and SAINT-iTBS.
TMS is associated with relatively few side effects, risks, and complications. The most likely side effects are mild and usually don’t last more than a few minutes after each session. Often, patients get used to the procedure after a few sessions, and side effects dissipate.
Common short-term side effects include:
The most serious potential side effect of TMS is a seizure, but these are extremely rare. The risk of having a seizure from a TMS session is less than 0.01% per session or less than 1 in 10,000 sessions.
The original form of TMS, rTMS, has been shown to improve depression symptoms in about 50% of patients, with over 30% achieving remission (i.e., a significant decrease in or disappearance of signs and symptoms of depression). When combined with psychotherapy, success rates are even more impressive with response and remission rates of ~66% and ~55% respectively.
Response and remission rates of various monotherapeutic and combinatory antidepressant treatments based on the largest studies and datasets available. [Source]
Accelerated TMS and iTBS seem to be at least as effective as rTMS, with response rates around 50% and almost 30% achieving remission. Patients receiving multiple sessions each day tend to experience improvements in symptoms faster than patients receiving daily sessions, and the effects are still visible months after their treatment.
These results are already significantly better than antidepressant drugs, but the new SAINT-iTBS protocol can produce even better outcomes. In a randomized clinical trial, about 85% of patients responded to the SAINT-iTBS treatment, while around 78% achieved remission. All participants had treatment-resistant depression and had failed at least two other depression treatments. Encouragingly, one month after treatment, 60% of patients remained in remission.
The rapid achievement of high response and remission rates with SAINT-iTBS, combined with minimal side effects, makes it one of the most effective fast-acting treatments available today. However, there is limited data on the long-term durability of these outcomes. While some patients may experience lasting remission or symptom reduction, others might require periodic follow-up treatments to maintain effectiveness. This seems to help patients remain symptom-free and avoid relapse. As such, combining TMS with cognitive behavioral therapy (CBT), which has been shown to produce strong long-term outcomes, is likely to offer the best results for patients.
The costs associated with TMS sessions vary greatly depending on geographic location, provider expertise, the type of TMS used, and insurance coverage. In most cases, the cost of a TMS treatment course ranges from $6,000 to $15,000 without insurance.
With insurance, out-of-pocket costs can be significantly reduced. However, depending on your provider and specific policy, you may need to have tried two to four antidepressant medications and/or therapy with a psychiatry or psychology specialist before you can qualify for TMS coverage.
Clinics with advanced technology, or offering additional services, such as medical evaluations or talk therapy, may charge higher fees.
At our clinic, Cognitive FX, we follow the newly FDA-approved SAINT-iTBS protocol, including the use of fMRI and neuronavigation for precision coil placement. Currently, less than ten clinics in the U.S. offer this treatment.
Patients receive ten TMS sessions per day over five days for 50 sessions total. In an effort to improve outcomes for our patients, we also include cognitive behavioral therapy (CBT) as a part of our treatment. When combined with the traditional method of TMS (rTMS), CBT improved response and remission rates by ~8% and ~19% respectively. Additionally, CBT is likely to produce sustained improvement over time once SAINT-iTBS has concluded.
Our TMS treatment is ideal for most patients with treatment-resistant depression. However, we do not treat patients under the age of 16 or over 65. Additionally, as a safety measure, we do not treat patients who have a history of seizures or who are currently actively suicidal and in need of crisis care.
If you are interested in receiving TMS therapy at Cognitive FX, click here to learn more and see if you’re a good fit for treatment.
Electroconvulsive therapy (ECT) is a medical procedure that involves passing a mild electric current through the patient’s brain, causing a short seizure. It’s most commonly used in patients with severe major depression or bipolar disorder who have not responded to other treatments.
During ECT sessions, electrodes are placed on the patient’s scalp and a highly controlled electric current is applied while the patient is under general anesthesia. The electrical current applied to the brain causes a brief seizure which changes some of the neural networks in the brain. Repeated a few times a week for a short period, ECT can significantly reduce depressive symptoms in many patients. Typically, ECT works much faster than antidepressant drugs, making it a good option for patients who are at risk of harming themselves or others.
ECT can help patients experiencing several mental health conditions, including:
Before beginning a series of ECT treatments, patients receive a thorough psychiatric assessment, a medical examination, and sometimes a basic blood test and electrocardiogram (ECG) to check heart health.
Patients typically receive ECT two or three times a week for a total of six to twelve treatments, depending on the severity of symptoms and how quickly the symptoms respond to the treatment.
At the time of each treatment, a patient is given general anesthesia and a muscle relaxant, and electrodes are attached to the scalp at precise locations. In addition, patients get electrocardiography (ECG) leads on their chest to monitor recovery and electroencephalogram (EEG) leads on their head to monitor brain waves during the seizure.
Patients may receive unilateral ECT or bilateral ECT. In bilateral ECT, electrodes are placed on both sides of the patient’s head. The treatment affects the entire brain. In unilateral ECT, one electrode is placed on the top of the patient’s head and the other is placed on the right temple. This treatment affects only the right side of your brain. Some hospitals use “ultra-brief” pulses during ECT. These last less than half a millisecond, compared to the standard one-millisecond pulse. The shorter pulses are believed to help prevent memory loss.
Generally, patients recover quickly and can return to their usual activities a few hours after the procedure. If patients experience any side effects, their healthcare team may advise them not to return to work or drive for a few days.
ECT is associated with various side effects, some of which can be problematic for patients. Possible side effects include memory loss and other cognitive issues, as well as headaches, nausea, dizziness, muscle pain, insomnia, high blood pressure, and heart problems.
ECT can be a safe option to treat depression and is often more effective than antidepressant medication. Studies show that over half of patients with depression respond to ECT within the first week. Overall, almost 80% show significant improvements, and about 40% to 60% of patients achieve remission after a few weeks of treatment.
ECT seems more effective in treating patients who were not exposed to multiple rounds of antidepressant drugs before ECT sessions or are not suffering from other psychological conditions. This treatment is especially effective in treating patients with suicidal ideation or at risk of harming themselves. The exact number of treatments needed to stop these intrusive thoughts is not well established, but typically patients experience improvements early in the course of treatment.
In addition, ECT is also effective in treating patients suffering from severe depression associated with psychosis, who experience remission rates of up to 90%. However, the period without symptoms appears to be short-lived for these patients.
ECT is also effective in treating patients with bipolar depression during the manic phase, with about 50% of patients reaching remission. However, there are many drug alternatives and typically ECT is limited to patients with specific contraindications to these medications or those who do not experience any improvements after a pharmacological treatment.
In patients with schizophrenia, ECT can be used to treat catatonic symptoms and treatment-resistant cases. Studies show that remission rates are around 80% with ECT alone and can reach 100% when combined with antidepressant drugs. ECT has been used in several other conditions such as obsessive-compulsive disorder (OCD), postpartum depression, and Parkinson's disease, with varying degrees of success.
After the initial ECT sessions, typically patients move on to maintenance ECT, pharmacotherapy, psychotherapy, or a combination of various treatments. Stopping ECT sessions abruptly is associated with a more than 80% relapse rate. Patients should aim to have regular ECT sessions to maintain remission, starting at weekly sessions and gradually increasing the interval between sessions. Starting treatment with antidepressants reduced by half the number of patients who relapsed in the first year after their ECT treatment.
It’s estimated that ECT costs between $300 and $1000 per session. As patients need 5 to 15 treatments for the initial treatment, followed by 10 to 20 maintenance treatments per year, the annual cost of ECT can easily exceed $10,000.
Despite these high costs, a study found that, given ECT’s higher efficacy compared to antidepressant medications, it is still a cost-effective treatment for patients with treatment-resistant depression. In addition, many insurance plans cover psychiatric disorders, which may include at least a partial reimbursement of the cost of ECT.
Electroconvulsive therapy (ECT) is an effective treatment for depression, with nearly 80% showing significant improvement and 40–60% achieving remission. It is particularly effective for patients with suicidal ideation but is often avoided due to serious side effects like cognitive impairment. Additionally, patients often relapse within six months after stopping ECT, even with antidepressants.
Transcranial Magnetic Stimulation (TMS) is a non-invasive method of brain stimulation for treatment-resistant depression. Unlike ECT, TMS does not require anesthesia or induction of seizures. In addition, side effects are mild and short-lived. Patients may experience headaches and scalp discomfort, but these tend to dissipate after a few TMS sessions. About 50% of patients respond to rTMS, and over 30% achieve remission.
Previously, ECT was considered superior to TMS, but the latest TMS protocol, SAINT-iTBS, outperforms ECT. Around 85% of patients responded to the SAINT-iTBS treatment in a randomized controlled study, with 78% achieving remission and 60% remaining in remission after one month. Like rTMS, it involves lower risks and milder side effects compared to ECT.
|
ECT |
rTMS |
SAINT-iTBS |
|
|
Efficacy |
Almost 80% of patients respond and about 40% to 60% achieve remission after a few weeks of treatment. |
About 50% of patients respond to the treatment and over 30% achieve remission. |
About 85% of patients responded and around 78% achieved remission in a randomized controlled trial. One month after treatment, 60% of patients remained in remission. |
|
Risk of Relapse |
The risk of relapse is high, especially if patients stop ECT sessions abruptly. Patients need to continue receiving maintenance ECT sessions to maintain remission. This means patients need to commit to long-term treatment. |
Around 50% of patients relapse up to one year after treatment, but this value can be reduced to 40% if patients undergo rTMS maintenance sessions. |
Relapse rate for the SAINT protocol is estimated to be up to 50% six months after treatment discontinuation. However, maintenance sessions and/or cognitive behavioral therapy (CBT) can significantly reduce this. |
|
Side Effects |
Many patients who undergo ECT experience temporary memory loss and confusion. Usually, confusion clears up within a few minutes, and memory loss usually goes away within a few months. Patients may also experience nausea, headaches, jaw pain, or muscle aches. There have been a few cases of fatal accidents after ECT sessions, but these cases are extremely rare and occur in less than 1 in 10,000 ECT sessions. |
Most patients experience minimal or only mild side effects, including headaches, scalp pain, dizziness, temporary tinnitus, and unusually high sensitivity to sound. Often, patients get used to the procedure after a few sessions, and side effects dissipate. The most serious potential side effect of TMS is a seizure, but these are extremely rare. The risk of having a seizure from a TMS session is less than 0.01% per session or less than 1 in 10,000 sessions. |
|
|
Procedure |
Electrodes are placed on the patient’s scalp and a highly controlled electric current is applied while the patient is under general anesthesia. |
The procedure is non-invasive. A magnetic coil is applied over the brain, and there is no need for surgery or anesthesia. Patients can return to their normal daily activities once their daily sessions are completed. |
|
|
Treatment Duration |
Two or three sessions per week are administered over 3 to 6 weeks, depending on the severity of symptoms and how quickly the symptoms respond to the treatment. |
Daily sessions for 4 to 6 weeks. |
Multiple sessions daily for one week. |
|
Contraindications |
Some patients should not receive ECT treatment, including those with certain heart conditions, recent bleeding in the brain, or suffering from chronic obstructive pulmonary disease. |
Patients with metal implants on the brain, taking certain medications, or with a history of seizures should not receive TMS treatment. In some cases, it may be possible for patients to still receive TMS even if they fit into one of the above categories. If this applies to you, discuss your suitability with your doctor. |
|
|
Accessibility |
ECT sessions require multiple providers with highly specialized advanced training. In practical terms, this means this treatment is often not available in smaller healthcare facilities and communities. |
rTMS is easily available in many clinics around the country. |
At the moment, less than 10 clinics in the US offer SAINT-iTBS, which means patients may have to travel some distance to get this treatment. |
|
Costs |
ECT costs between $300 and $1000 per session. Patients need 5 to 15 sessions followed by 10 to 20 maintenance sessions, which means the annual cost of ECT can easily exceed $10,000. |
The cost of TMS sessions ranges from $6,000 to $15,000 without insurance. With insurance, out-of-pocket costs can be significantly reduced. Patients may need to have tried two to four antidepressant medications and/or therapy with a psychiatry specialist before they can qualify for TMS coverage. |
|
If you are interested in receiving TMS therapy at Cognitive FX, click here to learn more and see if you’re a good fit for treatment.
With traditional antidepressant medications only working effectively for about one-third of patients, researchers and clinicians are continuously developing new treatment options for...
Traditional antidepressant medications involve a trial period of weeks or months before it can be determined whether or not they are working. If a medication doesn’t work — and it’s been shown that ...
