Depression is a highly recurrent disorder. Estimates are that more than 50% of patients experience repeat episodes of depression (Kupfer et al., 1996). Transcranial magnetic stimulation (TMS) is an evidence-based therapy for the acute treatment of major depression, with a high rate of treatment response. Following adequate response to an acute course of TMS (i.e. 36 sessions administered every weekday), patients often wonder whether to continue TMS to maintain clinical benefit.
The general rule of thumb for maintenance has been to use antidepressant medication, with TMS often prescribed “as needed,” that is, if the patient feels symptoms return. In many cases, a more active approach may be taken wherein scheduled maintenance TMS is initiated soon after completing the acute course. A clinician will generally go this route if she determines the patient would benefit from a more robust maintenance plan. At this point, a distinction should be made between “maintenance TMS” and “reintroduction” of another acute course. Whereas maintenance TMS consists of regularly scheduled TMS treatments over a prolonged period of time, reintroduction consists of initiating another acute course of TMS treatment.
The most common TMS maintenance strategy used in clinical practice is one session per month. In a 2016 paper, a group of researchers explored the efficacy of this strategy in sustaining symptom relief over a one-year period for unmedicated patients with major depression who initially responded to an acute course of TMS (Philip et al., 2016). Upon completion of the acute phase, patients identified as “responders” were subsequently randomized to one of two maintenance groups: maintenance TMS or observation only. Compared to the observation only group, the maintenance TMS group had longer time to relapse, that is, they felt better for longer. Patients were safely maintained off antidepressant medication over the course of one-year. Although the result did not reach statistical significance, it mirrors our clinical experience at Principium Psychiatry.
The findings from this pilot study highlight the need for further research on maintenance TMS. These findings give reason to believe that a different maintenance paradigm may be required than the predominate method of once-monthly TMS for those with severe depression. Particularly for patients with more severe forms of depression, two or more monthly TMS treatments may be indicated. Bearing that in mind, it is important to discuss with a psychiatrist what the ideal maintenance strategy may be for you.
If you are in the New York City area and searching for a treatment facility to help manage your depression, contact Principium Psychiatry at 212-335-0236 for more information or to schedule a consultation. Specializing in mood and anxiety disorders, Principium Psychiatry has a team of highly skilled clinicians and offers a range of treatments — TMS treatment, psychotherapy, pharmacotherapy, ketamine infusions, and Spravato.
