rTMS vs dTMS for Depression: Which Is Better?
If you’re considering brain stimulation therapy for treating major depression, you may wish to understand the differences between repetitive transcranial magnetic stimulation (rTMS) and deep...
Suffering from treatment-resistant depression (TRD) is both common (you are not alone) and extremely difficult. It can feel incredibly discouraging when you’ve tried antidepressant medication or other depression treatments without finding significant relief.
Fortunately, researchers and clinicians are continuously working to develop better depression treatment options. One of the most promising is SAINT TMS therapy, which is now considered the gold standard treatment for treatment-resistant depression.
Our clinic, Cognitive FX, is one of less than ten clinics in the U.S. currently offering this FDA-approved, fast-acting, outpatient treatment.
In this article, we’ll provide an overview of SAINT TMS for patients searching for help with their depression in the Utah Valley area, or patients who may be willing to travel to receive this novel treatment.
Below, we cover:
SAINT TMS, also called the SAINT protocol or SAINT i-TBS, is a method of transcranial magnetic stimulation (TMS) FDA-approved for major depressive disorder (MDD) and treatment-resistant depression in 2022.
Several characteristics separate SAINT TMS from the original form of TMS (repetitive TMS or rTMS):
In 2018, the FDA approved a new version of accelerated TMS called Intermittent Theta-Burst Stimulation (iTBS). This method uses theta waves, the neural frequencies that the hippocampus uses to connect to other brain regions, form new memories and regulate certain sleep phases.
This method is safe and effective; many patients experience improvements shortly after starting treatment. It is delivered in three-minute sessions instead of the ~40-minute sessions of rTMS. In addition, patients have also noticed a decrease in suicidal ideation, suggesting that iTBS could be an option to rapidly treat patients at high risk of suicide.
In the standard rTMS and iTBS protocols, the location to apply the magnetic coil (which delivers the brain stimulation) is calculated based on triangulation between the patient’s nose, ears, and top of the head. Coil placement involves measuring the scalp 5cm along the parasagittal plane anterior to the activation hotspot in the motor cortex.
This method is easy to implement and requires no further equipment, but it doesn’t account for variations in head size and shape or differences in brain organization between patients. In addition, it relies heavily on how well technicians can find the right spot.
This can significantly impact the overall treatment results, as even missing it by a few millimeters can lower the treatment’s effectiveness.
A much more accurate way involves using functional MRI to determine exactly where the treatment target area is located in the brain. This method, developed by the team at Stanford University, is a defining characteristic of the SAINT protocol.
The SAINT protocol uses "neuronavigation" technology to ensure that the magnetic coil is placed over the exact spot on the patient's head that the fMRI identified as the target area for each treatment session. This is in contrast to standard TMS in which clinicians place the magnetic coil manually during each treatment session, leading to variability in coil placement from session to session.
In contrast to rTMS, which requires four to six weeks of treatment, with ~40-minute sessions five days per week, SAINT TMS offers a more efficient one-week treatment plan. Patients sit for 10 short iTBS sessions daily for five days, making it much more convenient for people to complete amidst work, childcare, and other life commitments.
“First-line treatments like antidepressants and cognitive behavioral therapy (CBT) haven’t helped me to feel any better.”
SAINT TMS is particularly suitable for patients who have tried multiple types of antidepressant medications but failed to experience significant long-term improvements. This outcome is more common than previously thought.
A 2022 reanalysis of the largest antidepressant study ever conducted found that antidepressant medications (such as selective serotonin reuptake inhibitors) only relieve symptoms in about one-third of patients. In addition, trying more than two different antidepressant medications brings little benefit for the patients and less than 2% experienced success with a third or fourth medication.
If you fall into the two-thirds of people for whom antidepressant medications have no effect, you’re likely a suitable candidate for SAINT TMS (and TMS in general).
“My medication no longer feels like it’s working.”
Some patients start feeling better when taking antidepressant medication, but at some point, the medication stops working. This reduced effectiveness may occur because the body builds a tolerance to the medication or patients experience an unexpected difficult situation and the antidepressants aren’t enough to compensate for the extra stress.
As we’ve described earlier, simply trying different prescription drugs is unlikely to help these patients. If you’re in this situation, SAINT TMS could be an alternative to consider.
Further reading: Why aren’t my antidepressants working?
“I’m tired of the negative side effects from my medication.”
Common side effects after taking antidepressant medication include insomnia, headaches, nausea, blurred vision, irritability, anxiety, and irregular heartbeat. Most of these are mild and eventually go away, but others can be serious and have severe long-term consequences.
If you’re struggling to cope with side effects from your antidepressant medication, SAINT TMS could be a better option for you. This treatment is associated with mild and short-lived side effects. Headaches and scalp discomfort are the most common side effects after a TMS session, but these are mild and often disappear after the initial sessions.
The most serious potential side effects of TMS are seizures, but these are extremely rare with less than three patients experiencing a seizure per 100,000 sessions. Even for these patients, the seizure has no serious long-term consequences. There is no evidence that patients can experience multiple seizures during TMS sessions.
In less than 1% of cases, some patients also report unexpected emotional responses, including exaggerated mood swings and manic episodes. These may occur in patients with bipolar disorder and taking antidepressant medication. In all reported cases, these psychiatric changes subsided shortly after treatment and had no long-term consequences.
Further reading: Is TMS safe?
”I’m tired of waiting long periods for depression treatment to take effect. I want faster relief.”
If you’ve been suffering from depression and are frustrated with the time it takes to see if a new intervention will work for you, SAINT TMS can be a great option because it typically begins to take effect within a single week of treatment.
SAINT TMS is a rapid and safe way to relieve depressive symptoms, including suicidal ideation. For example, SAINT can reduce the severity of suicidal ideation in just five days. There is some evidence that patients with suicidal ideation often have damage to areas of the brain that are involved in cognitive and emotional control, which happen to be the areas targeted during TMS sessions.
“I tried repetitive TMS and it didn’t help me.”
Patients who have tried repetitive TMS and failed to see any improvement may be reluctant to try TMS again. However, it is possible that the first TMS treatment failed because the method of placing the coil was imprecise or inconsistent.
As discussed above, SAINT TMS solves this issue using fMRI and neuronavigation. Our operators can ensure that the magnetic coil is precisely placed for every session to maximize treatment efficacy. Other simpler methods rely on external measurements taken over the patient’s scalp and are significantly less accurate.
”I struggle to attend school or go to work.”
Symptoms of depression can seriously affect a person’s ability to manage their daily life, including attending school or going to work. If you’ve been struggling to keep up with your daily responsibilities, SAINT TMS can be a quick way to get the relief you need to get back to managing them.
“I don’t want to take medication for the rest of my life.”
Whether you’re experiencing side effects from your antidepressant medication, or simply don’t want to have to put medication into your body daily for the rest of your life, you may wish to try a non-medication alternative like SAINT TMS.
“I can’t commit to 4 to 6 weeks of daily sessions for TMS treatment.”
Traditional TMS takes 4 to 6 weeks of daily sessions (minus weekends), which is difficult for many patients. Due to work and family commitments, many people don’t have the time to participate in 40-minute treatment sessions five days per week for such a long period.
In contrast, SAINT TMS provides the opportunity to receive major depression treatment in just five days, allowing patients to quickly get back to their daily lives and work commitments.
A comparison of remission rates for rTMS/iTBS, electroconvulsive therapy (ECT), and SAINT-iTBS.
SAINT TMS is proven to be one of the most effective treatments for depression available today. SAINT is more effective and safer than many of the alternatives, including other types of TMS.
In a double-blind randomized clinical trial, about 86% of patients responded to the SAINT treatment, and around 79% reached remission. All participants had treatment-resistant depression and had failed at least two other depression treatments. One month after treatment, 60% were still in remission. In comparison, about 50% of patients respond to rTMS, with just over 30% achieving remission.
SAINT TMS also has a higher efficacy rate compared to first-line antidepressant medication. As we explained above, only one-third of patients experience long-term improvements after trying antidepressant medications. Additionally, fewer than 2% of patients find additional benefits with a third or fourth medication.
Antidepressant medications also come with a range of side effects, including stomach pain, diarrhea or constipation, loss of appetite, dizziness, insomnia, and headaches. In contrast, TMS typically has mild, short-lived side effects, such as headaches and scalp tenderness, which usually resolve after a few sessions.
Two of the most common alternative treatments for depression include electroconvulsive therapy (ECT) and ketamine.
Many patients begin feeling relief just hours after treatment with ketamine, with 50% continuing to experience improvements up to a week later. However, ketamine doesn’t provide the long-term benefits associated with TMS. After six months of ongoing ketamine treatments, only 26% of patients still respond, and just 15% achieve remission.
ECT has success rates comparable to SAINT with almost 80% of patients showing significant improvements, and about 40% to 60% of patients achieving remission after a few weeks of treatment. However, ECT has a higher risk of side effects, including confusion, difficulty concentrating, and memory loss, which isn't the case with TMS.
Further reading:
Ketamine vs. TMS: Compare Side Effects, Effectiveness & Costs (covers both intravenous ketamine and esketamine nasal spray known as Spravato)
While most patients are eligible for SAINT TMS treatment, certain conditions may rule out its use. This includes:
Metal Implants in the Head
TMS isn't suitable for patients with metallic implants near the treatment area, such as cochlear implants, internal pulse generators, medication pumps, aneurysm clips or coils, stents, or bullet fragments. These objects may overheat or malfunction due to magnetic pulses, posing significant risks. However, dental fillings and braces are typically safe.
History of Seizures
Patients with a history of seizures or neuropsychiatric conditions (e.g., epilepsy, multiple sclerosis, traumatic brain injury) may face a higher seizure risk during TMS. Consultation with a healthcare provider is essential to evaluate individual risks and benefits.
Certain Prescription Medications
Some medications may increase seizure risk during TMS. While most patients can still undergo treatment with close monitoring, discussing your medication history with your doctor is critical.
Age Restrictions
At Cognitive FX, patients under 16 or over 65 are currently not treated due to limited research on these age groups. Early studies suggest TMS may be safe, but more evidence is needed.
For personalized guidance, consult your healthcare provider to assess your suitability for TMS and weigh potential risks and benefits.
Typically, a SAINT treatment course ranges from $6,000 to $15,000. Although TMS is deemed medically necessary to treat depression, only repetitive TMS (rTMS) is covered by insurers. No companies currently cover SAINT as a way to treat depression.
If you’re considering rTMS, it’s important to check what criteria your insurance follows. For instance, some companies require patients to have failed four antidepressant medications and psychotherapy, while others are less strict. Some have a list of what medications must be tried first, such as antipsychotics or different classes of antidepressants.
Additionally, coverage may vary based on the severity of symptoms, with some insurers covering moderate cases, while others limit coverage to severe conditions. Even after approval, patients may still need to pay copays or deductibles, though some insurers may cover the full cost. For those needing further financial assistance, payment plans or healthcare financing options like CareCredit may help.
Over the last two decades, we have been pioneers in the treatment of traumatic brain injuries. We use a state-of-the-art brain imaging technique called functional magnetic resonance imaging (fMRI) that allows our operators to find out exactly how the patient’s brain was affected by the injury and design a personalized treatment to cover their needs.
Now, we’re bringing our team’s expertise to help patients recover from moderate to severe depression. We are proud to be one of the first clinics in the country to offer SAINT TMS for treatment-resistant depression.
The SAINT treatment protocol should be executed the same way anywhere you go. However, clinics often offer additional forms of therapy or therapeutic activities to further support patients in their recovery.
In addition to SAINT, our patients also receive cognitive behavioral therapy (CBT) during their treatment. Presently, while SAINT TMS is showing incredibly promising short-term results, there is limited data on the long-term durability of these outcomes. No studies assess the impact of SAINT beyond a few months. To address this, and provide our patients with the best possible chance of sustained remission from their depression, we decided to include CBT as part of our treatment.
CBT has far more scientific and empirical support for treating depression than other forms of psychotherapy, including a significantly greater number of controlled trials supporting its efficacy. The response rate to CBT across studies ranges from 61%–87% with large effect sizes. Furthermore, when combined with the traditional method of TMS (rTMS), CBT improved response and remission rates by ~8% and ~19%, respectively.
If you are interested in receiving TMS therapy at Cognitive FX, click here to learn more.
Dr. Mark D. Allen holds a Ph.D. in Cognitive Science from Johns Hopkins University and received post-doctoral training in Cognitive Neuroscience and Functional Neuroimaging at the University of Washington. As a co-founder of Cognitive Fx, he played a pivotal role in establishing the unique and exceptional treatment approach. Dr. Allen is renowned for his pioneering work in adapting fMRI for clinical use. His contributions encompass neuroimaging biomarkers development for post-concussion diagnosis and innovative research into the pathophysiology of chronic post-concussion symptoms. He's conducted over 10,000 individualized fMRI patient assessments and crafted a high-intensity interval training program for neuronal and cerebrovascular recovery. Dr. Allen has also co-engineered a machine learning-based neuroanatomical discovery tool and advanced fMRI analysis techniques, ensuring more reliable analysis for concussion patients.
If you’re considering brain stimulation therapy for treating major depression, you may wish to understand the differences between repetitive transcranial magnetic stimulation (rTMS) and deep...
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