Transcranial Magnetic Stimulation (TMS and rTMS) and Menopause

As men and women age their bodies change hormonally. For some people, menopause has drastic emotional repercussions, up to and including depressions of clinical proportions. In select cases off-label rTMS may help decrease the sadness, fatigue, irritability, and mood swings associated with post-menopausal clinical depressive illness.

If you feel that you may be experiencing feelings of depression related to menopause symptoms, Chrysalis TMS Institute in Boca Raton, Florida is available for a free TMS consultation for women's life cycle-related depression.

Transcranial Magnetic Stimulation (TMS and rTMS)
for Postpartum Depression and Nursing Mothers

Postpartum depression (PPD) is a prevalent illness, affecting 10-15% of new mothers. Postpartum Depression (PPD) is the most common complication of childbirth and is a significant public health concern. It is known to adversely impact maternal-infant bonding, childrearing practices, and can lead to suicide and infanticide. The current treatment approaches to Postpartum Depression (PPD) are suboptimal. Many mothers are reluctant to take medication because of concerns about side effects or exposure of their newborn infant through breastfeeding.

Treatment options for Postpartum Depression (PPD) are currently limited to psychotreatment, pharmacotreatment, and electroconvulsive treatment (ECT). Studies have found psychotherapeutic interventions to be an accepted intervention for Postpartum Depression (PPD). Treatment in the form of individual treatment, peer support, and/or group treatment has been found to be helpful in alleviating the anxiety, irritability, and feelings of detachment experienced by women who have Postpartum Depression (PPD). Specifically, interpersonal psychotreatment (IPT) is a proven, effective treatment for mild-to-moderate Postpartum Depression (PPD) and an alternative to pharmacotreatment, especially for women who are breastfeeding. However, IPT may not be the treatment of choice for women who have moderate-to-severe symptoms and/or have a history of severe depression in the past, or have had previous reproductive-related depressive disorders. In addition, only limited information regarding the durability of IPT exists and it has been shown that its beneficial effects may be time limited.

Physicians generally prefer pharmacotreatment to treat women with Postpartum Depression (PPD). However, patient acceptance of the use of psychotropic medication for the treatment of PPD is limited by maternal concerns regarding infant exposure through breastfeeding and the unknown future effects of such exposure. As a consequence of the perceived risk of breastfeeding while on medication, as well as other concerns, such as the potential impact of medication side effects on late night child care, a significant number of women report that they would not consider using psychotropic medication to treat their Postpartum Depression (PPD). The end result is that many women choose to expose their infant to the adverse effects of PPD rather than receive treatment.

ECT has been the primary device-based treatment for treating unremitting major depression for over 6 decades, and is perhaps the most broadly effective treatment for major depression. Although there are no systematic trials of ECT in Postpartum Depression (PPD), case literature supports its effectiveness in postpartum psychiatric states. ECT, however, has well-documented adverse effects, including headache, muscle pain, and memory deficits. In addition, recovery time from each ECT treatment may take several hours, which can limit the ability of a new mother to care for her infant

Repetitive transcranial magnetic stimulation (rTMS) is a recently US Food and drug Administration-approved depression treatment, which uses briefly pulsed, powerful magnetic fields to induce focused electrical currents in the brain, depolarizing neurons. Recent meta-analyses have shown that rTMS is superior to placebo conditions in the treatment of patients with major depressive disorder (MDD). Unlike psychotherapeutic interventions, patients receiving rTMS respond rapidly, often within 2-4 weeks, and the response can be sustained. Repetitive TMS is unique compared with other somatic depression therapies because there are no systemic side effects that would interfere with child care and no risk of exposure to the infant through breastfeeding. Thus, the use of rTMS for the treatment of Postpartum Depression would address many of the short comings of medication.

The clinical research done so far in the USA, Australia and Brazil suggests strongly that TMS could be an effective form of treatment for Postpartum Depression. Unlike medications used in the treatment of depression, which bring the possibility of transfer to the infant during nursing, TMS's few side effects such as a mild headache are limited solely to the patient.

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Transcranial Magnetic Stimulation (TMS and rTMS) During Pregnancy

Up to 23% of expectant women either enter pregnancy already suffering from a major depressive episode, or become clinically depressed during their pregnancy. Ongoing depression during pregnancy is associated with negative maternal and fetal outcomes. Women who are depressed and pregnant often do not eat properly, cannot sleep, and become excessively irritable, overwhelmed, and anxious. Furthermore, being depressed and pregnant substantially increases the risk of postpartum depression. Maternal depression also increases the risk of low birth weight, developmental delay and neurobehavioral difficulties. Children of depressed mothers are more likely to have conduct problems and emotional instability, and are at increased risk of requiring psychiatric care.

Because the risks of clinical depression are substantial, it is important to seek professional care. The risks of antenatal maternal depression must be carefully balanced against the risk of various potential treatments in pregnancy, for both maternal and fetal health.

Transcranial Magnetic Stimulation (TMS), the use of magnetic pulses to stimulate specific areas of the brain that are associated with depression, may be an option in cases where non-invasive, non-systemic treatment for depression during pregnancy is preferred or indicated. To completely avoid medication exposure to the developing fetus during pregnancy, TMS can be used as monotreatment. In more complicated cases, TMS may also be employed as an augmentation treatment instead of adding a second or third drug to address more resistant depressions during pregnancy.

Medications for psychiatric disorders are notorious for being unsafe to take during pregnancy or while breast-feeding. So what about pregnant and nursing women suffering from depression and other acute or chronic psychiatric illnesses? In select cases, off-label rTMS therapy has been beneficial in aiding pregnant women and nursing mothers who have clinical depressions or other psychiatric disorders.

During TMS treatment for depression, the magnetic field produced by the FDA-approved NeuroStar TMS device does not emit any ionizing (x-ray) or radiofrequency (cell phone) radiation, nor does it affect any areas below the shoulder. Furthermore, unlike medication, the magnetic pulses released by the TMS machine do not enter the bloodstream to expose a developing in-utero baby, which is also reassuring. Recently, an open-label pilot study showed that 7 out of 10 pregnant patients responded to TMS treatment for depression, with no negative pregnancy outcomes. Other case reports also show promising results.

Of course, women of childbearing age with depression who wish to become pregnant are best advised to be stabilized prior to conception. It is estimated that close to 70% of pregnant women with a history of depression who discontinue their antidepressants relapse. Optimally, therefore, a woman should enter pregnancy having already been successfully treated for depression to complete remission. Thus, women who are treated with TMS for depression should ideally be followed for a period in order to ensure stability and continued remission, prior to attempting conception. If some depressive symptoms return during pregnancy after a history of successful TMS treatment, then booster TMS treatments can be effective.

Nevertheless, it is best to plan ahead with TMS treatment in order to be free of depression prior to pregnancy.

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Transcranial Magnetic Stimulation (TMS and rTMS)
for Postpartum Depression

"TMS treatment response for Postpartum Depression was rapid, robust and durable" is how psychiatrist dr Keith Garcia of Washington University School of Medicine in St Louis summarises his research on a novel approach to the alternative treatment of postpartum depression using TMS and rTMS. His project had been designed to assess three questions; was TMS and rTMS - transcranial magnetic stimulation - effective in bringing about a rapid improvement in patient mood, how long did any beneficial effect last and did it have a positive effect on maternal bonding.

Dr. Garcia believes that this new TMS approach could bring mothers with Postpartum Depression (PPD) an effective alternative treatment that side-steps the possibility of drug side effects, both in patients and their infants. Additionally, it brings a bonus of improving mother-infant bonding. "We believe TMS and rTMS may become a preferred alternative treatment for PPD", he writes in the conclusion of his research report.

TMS and rTMS had its origins in the mid 1980s as an exercise in scientific curiosity. A medical scientist in England had discovered that a strong magnetic pulse directed into a brain (his own) evoked a striking effect on his body - it made his thumb 'twitch' involuntarily. This vivid demonstration of the interaction of magnetism and brain tissue quickly got the attention of psychiatrists: they foresaw in the technique, a benign way to stimulate parts of the brain involved in mental illnesses such as depression to improve patients' health.

The twenty years of clinical research since then lead to TMS and rTMS - the use of trains of multiple magnetic pulses to stimulate the brains of people with psychiatric disorders. Across the world, TMS and rTMS is now used as an effective treatment for depression.

The regions targeted by the TMS therapist lie within the brain's frontal cortex - regions that underlie the hairline at the top of the forehead. Studies on people with depression have shown that this region, about the size of a quarter, in the left hemisphere has unusually low activity: the equivalent zone in the right hemisphere shows the opposite - an overactivity. The TMS therapist's goal is to restore a healthier state by boosting left-side activity and diminishing right-side activity.

The magnetic pulses interact with the nerve circuits in the target area and promote an increase in blood flow and alteration of neurotransmitter behavior. These changes in the target zones are communicated to deeper structures within the brain - notably the limbic system, a key region for mood control - and exert there, a sustained effect that lifts mood.

Patients need neither sedation nor anesthesia for the treatment. They sit in a comfortable reclining chair and the therapist positions a magnetic coil over the area to be treated (picture) and delivers the series of magnetic pulses to the brain: many patients feel a "pecking like" sensation over the nearby eyebrow (it is the consequence of the face's muscles responding to the magnetic stimulus) but soon most are able to ignore it. 10% of patients have a mild headache after the session: apart from these two, TMS and rTMS seem remarkably free of side effects, much less so than anti-depressant drugs. Each treatment session lasts about 45 minutes.

The response to TMS and rTMS treatment can be very rapid - some patients feel their mood begin to lift during the first two weeks of treatments. Dr. Keith Garcia's research group found that the majority of women in his pilot study were restored to their former sense of well being by the end of two weeks of daily rTMS sessions.

At the TMS Center in La Jolla, we have specialised so far in treating patients who have had their depression for many years – all had failed to respond adequately to any course of medication. Even among patients with this level of intractable illness, TMS is proving remarkably effective. 60% of our patients have shown substantial clinical improvement – many have gone into remission.

Too Much Risk Associated With SSRI Usage and Pregnancy, Research Suggests

Elevated risk of miscarriage, preterm birth, neonatal health complications and possible longer term neurobehavioral abnormalities, including autism, suggest that a class of antidepressants known as selective serotonin reuptake inhibitors (SSRI) should only be prescribed with great caution and with full counseling for women experiencing depression and attempting to get pregnant, say researchers at Beth Israel Deaconess Medical Center, Tufts Medical Center and MetroWest Medical Center.

"Depression and infertility are two complicated conditions that more often than not go hand in hand. And there are no definitive guidelines for treatment," says lead author Alice Domar, Ph.D, Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Executive Director of the Domar Center for Mind/Body Health at Boston IVF. "We hope to provide a useful analysis of available data to better inform decisions made by women and the providers who care for them."

Domar and colleagues conducted a review of published studies evaluating women with depressive symptoms who took antidepressants while pregnant. The results appear online Oct. 31 in the journal Human Reproduction.

"There are three main points that stand out from our review of the scientific studies on this topic," says senior author Adam Urato, MD, Chairman of Obstetrics and Gynecology at MetroWest Medical Center and a Maternal-Fetal Medicine specialist at Tufts Medical Center. "First, there is clear and concerning evidence of risk with the use of the SSRI antidepressants by pregnant women, evidence that these drugs lead to worsened pregnancy outcomes. Second, there is no evidence of benefit, no evidence that these drugs lead to better outcomes for moms and babies. And third, we feel strongly that patients, obstetrical providers, and the public need to be fully aware of this information."

Over the last 20 years antidepressant usage has increased 400 percent. Antidepressants are now the most commonly prescribed medication in the United States for people between 18 and 44 years of age, the childbearing years for most women. And as women enter their late 30s and early 40s they are more likely to experience infertility.

"According to the Centers for Disease Control, more than 1 percent of the babies born in the USA each year are the result of an IVF cycle," write the authors. "And most women will report symptoms of depression during infertility treatment, especially following unsuccessful treatment cycles."

As many as 11 percent of women undergoing fertility treatment report taking an SSRI to combat depressive symptoms, but Domar and colleagues found no evidence of improved pregnancy outcomes with antidepressant usage, and in fact, found the opposite. They also found plenty of controversy around SSRI efficacy. Many studies found SSRIs to be no more effective or only slightly more effective than placebos in treating depression. "More broadly, there is little evidence of benefit from the antidepressants prescribed for the majority of women of childbearing age-and there is ample evidence of risk," the authors write.

For starters, there is mounting evidence that SSRIs may decrease pregnancy rates for women undergoing fertility treatment. Additionally, studies consistently show that women using antidepressants experience increased rates of miscarriage. There is also a strong signal of congenital abnormalities, the most noted of which is the association between the use of the antidepressant, Paxil, and cardiac defects. In 2005, this association prompted the FDA to ask Paxil's manufacturer, GlaxoSmithKline to change Paxil's risk factor from a C to a D, where a D rating indicates a demonstrated risk to the fetus.

"Preterm birth is, perhaps, the most pressing obstetrical complication," write the authors. In more than 30 studies, the evidence overwhelmingly points to increased risk for early delivery in women who are taking antidepressants. "This is a significant finding because we know that babies born before 37 weeks are at risk for many short and long-term health problems," says Urato. "Caring for premature babies adds up to billions of dollars in healthcare expenditures."

Available data also suggests that antidepressant usage, especially if it extends beyond the first trimester, leads to an increased risk of pregnancy-induced hypertension and preeclampsia. "Given the importance of the hypertensive disorders of pregnancy in terms of maternal and newborn morbidity and mortality, and the widespread use of antidepressants during pregnancy, further investigation into this area will be essential," write the authors.

Similarly, long-term exposure to SSRIs appears to correspond to an increased incidence of birth weight falling below the 10th percentile, coupled with increased rates of respiratory distress.

The health complications associated with antidepressant usage can be carried into infancy and beyond. A 2006 study showed that infants exposed to antidepressants in utero had a 30 percent risk of Newborn Behavioral Syndrome, most commonly associated with persistent crying, jitteriness and difficulty feeding. In more rare instances the syndrome can produce seizures and breathing difficulties leading to the need for intubation. Studies have also shown delayed motor development in babies and toddlers. And a Kaiser Permanente study showed a "two-fold increased risk of autism spectrum disorders associated with maternal treatment with SSRI antidepressants during the pregnancy, with the strongest effect associated with treatment during the first trimester."

"There is enough evidence to strongly recommend that great caution be exercised before prescribing SSRI antidepressants to women who are pregnant or who are attempting to get pregnant, whether or not they are undergoing infertility treatment," says Domar. "We want to stress that depressive symptoms should be taken seriously and should not go untreated prior to or during pregnancy, but there are other options out there that may be as effective, or more effective than SSRIs without all the attendant risks."

Domar and team looked at studies assessing different treatment modalities for depression in the general population, including psychotherapy, exercise, relaxation training, yoga, acupuncture and nutritional supplements. While many of these options were shown to provide some benefit, psychotherapy, specifically cognitive behavioral therapy (CBT) showed the most promise. "There is overwhelming evidence that CBT is equivalent to antidepressant medication in the treatment of mild to moderate depression and more recent research indicates that it is effective in the treatment of severe depression as well," write the authors.

A 2008 study showed impressive results for CBT in depressed women undergoing infertility treatments. The results showed that 79 percent of women who received CBT reported a significant decrease in symptoms, compared with 50 percent of women in the medication group.

"These alternative treatment options may not be appropriate for everyone, still we think it's important for women on an antidepressant who are considering becoming pregnant to have a conversation with their physician about the risks and benefits of continuing to take their medication," says Domar. "Because at this point in time, with no data to indicate an advantage to taking an SSRI during pregnancy, the research all points to increased risk."

In addition to Domar and Urato, other co-authors include: Vasiliki A. Moragianni, MD, MS and David A. Ryley, MD of Beth Israel Deaconess Medical Center and Boston IVF.