TMS vs ECT – Everything You Need to Know About Both Treatments

TMS (Transcranial Magnetic Stimulation): a non-invasive brain therapy that administers magnetic pulses to brain regions thought to play a role in the symptoms of clinical depression.

ECT (Electroconvulsive Therapy): a brain therapy that uses electric currents to induce a seizure while the patient is sedated. There is no scientific evidence (yet) of how ECT does this.

This article was medically reviewed by Dr. Troy Noonan, MD Psychiatry. Dr. Noonan received his M.D. from Finch University at the Chicago Medical School, Psychiatry Residency and fellowship at the University of South Florida (USF) College of Medicine. He is Certified by the American Board of Psychiatry & Neurology.

TMS vs ECT – Introduction

This article is a complete TMS vs ECT comparison, including definitions, history, a breakdown of risks and side effects, debunking of common misconceptions, and much more.

TMS is most often used by patients who are interested in treating depression without medication. While TMS and ECT are both typically used after antidepressants have failed, this does not make either one a “last resort” treatment. There are other reasons antidepressants are, currently, more popular, and I think you’ll be surprised to learn why.

Aside from both being brain therapies, TMS and ECT are about as different from one another as a saxophone is from a guitar. They use different technologies, they have different levels of effectiveness and safety, and they are vastly different in terms of patient experience.
TMS vs ECT Pros and Cons

In this article, we will explore these differences and do a full cost benefit analysis of TMS vs ECT treatments. For now, let’s start our TMS vs ECT analysis with a brief history and explanation of each treatment.

TMS vs ECT – Risks, Side Effects, and Misconceptions

Common Side Effects of TMS Therapy

  • TMS vs ECT - Side EffectsScalp Discomfort: fleeting discomfort in the head or scalp where the TMS pulses are applied.
  • Facial Twitching: slight movement of the eyelid or jaw during stimulation. This happens because of superficial nerve branches and muscle groups being stimulated.
  • Headaches (non-migraine): sometimes reported after TMS treatment sessions. This is particularly common early during the treatment and typically decreases as the treatment progresses.

Rare Side Effects of TMS Therapy

  • Manic or Hypomanic Symptoms: induction of manic/hypomanic symptoms (e.g., irritability, agitation). Most doctors put TMS therapy on pause until these symptoms have resolved, which they usually do.
  • Decreased Auditory Acuity: this can be avoided by wearing ear protection like foam earplugs. Most doctors require patients to wear earplugs during TMS treatments.
  • Syncope Vasovagal Response: a medical term for fainting or passing out, usually caused by temporary drop in blood flow to the brain. Other causes can be heightened anxiety, hypoglycemia, hyperventilation, or dehydration.
  • Seizure Induction: this is extremely rare during TMS (estimated 0.001%, or approximately 1 in 89,000 TMS treatments) and related to the motor cortex’s direct stimulation or stimulation of adjacent brain areas with the spread of neuronal excitation to the motor cortex.

Common Side Effects of ECT

#1: Memory Loss

Memory loss is one of the biggest concerns for people considering ECT, and with good reason. Most patients experience some permanent memory loss for events occurring during the treatment and a few days or weeks prior. I found some claims that these memory problems usually improve within a couple of months after treatment ends. However, I also found some contradicting claims on this matter. For example, this is a quote I found in an In-Depth Report on ECT, written by Irving M. Reti, M.B.B.S., the director of the Electroconvulsive Therapy Service at The Johns Hopkins Hospital. “Although it’s difficult to tease out which memory deficits are caused by the depression (depression is, after all, a disease associated with damaging cognitive effects) and which are caused by ECT, it is clear that both retrograde memory— the recall of events that occurred before the treatment—and anterograde memory—the ability to absorb new knowledge afterward—deteriorate as ECT treatment progresses.” This is telling us that memory loss isn’t a temporary side effect of ECT therapy, but something that can grow worse as the treatment progresses. Keep in mind that this quote comes from a report written by advocates of ECT. I will explain later why this is a substantial red flag for anyone considering ECT. TMS vs ECT - Side Effects Compared

#2: Confusion

Some ECT patients experience confusion for a few minutes or even several hours after treatment. This includes the patient not knowing where they are or why they are there. In rare cases, the confusion can last several days or even longer, and is most noticeable in older adults.

Miscellaneous Physical Side Effects

Some patients experience physical symptoms on the day of their ECT treatment, including headaches, nausea, jaw pain or muscle aches. These symptoms are usually treated with medications. Other medical complications might involve adverse reactions to anesthesia (required for administering ECT). Heart rate and blood pressure also increase during ECT, which can, in rare cases, lead to serious heart problems. Other long term side effects of ECT might include apathy, loss of creativity, loss of drive or energy, trouble concentrating, loss of emotional responses, and difficulty learning new information.

Myths and Misconceptions About TMS and ECT

While researching for this article, I found dozens of incorrect statements from laypeople about TMS therapy and about ECT. They ranged from the ignorant, to the paranoid, to the conspiratorial. While many of them are not worth commenting on, I did find a few that could be misleading to those unfamiliar with TMS or ECT therapies. “TMS/ECT is an experimental technology.” This is pure nonsense. By definition, experimental therapies are still in the experimental stage and don’t yet have enough statistically significant data (good or bad) available to draw a stable scientific conclusion about their safety and/or effectiveness. Both TMS and ECT have decades worth of experimental data available, and they’re both approved by the FDA. This doesn’t mean they are right for everyone, but to call either one experimental is patently false. “TMS/ECT isn’t covered by insurance.” While this is false, it’s understandable why people say it. As of right now, major medical insurance companies require a patient to try antidepressants (and prove that they have been unsuccessful) before the company will agree to pay for TMS. This has led some people to believe that TMS is a “last resort” therapy. However, the requirement to try antidepressants before trying TMS has less to do with how safe or effective TMS therapy is, and more to do with the current practices of major insurance companies. “TMS is the same thing as ECT.” Hopefully, the detailed explanations above, and the list of side effects for each therapy, have debunked this all-too-common myth. As I mentioned before, TMS and ECT are about as different from one another as a saxophone is from a guitar. They use different technologies, they have different levels of effectiveness and safety, and they are vastly different in terms of patient experience. Other misconceptions about both of these therapies seem to be based on ignorance about their side effects and how the treatments are actually carried out. Both therapies have also been the target of multiple smear campaigns in the media, some of which seem designed to prey on the general public’s lack of awareness about treating depression without medication. This is especially interesting when you compare the side-effects and success rates of TMS and ECT with the side-effects and success rates of common antidepressant medications. Most importantly, I found no serious claims about TMS or ECT being addictive or overdosing, both of which are hot topics of debate regarding antidepressant medication. READ MORE: Antidepressants and addiction

TMS vs ECT – A Cost Benefit Analysis

Now that we’ve finished our basic TMS vs ECT analysis, let’s wrap this up with a cost benefit analysis. We’ll examine what the data says on both effectiveness and safety.

TMS vs ECT – Effectiveness

TMS vs ECT - Benefits ComparedWhile researching this article, I found many statements like this one in various articles and whitepapers written by ECT advocates or past patients:

“ECT is the most effective treatment for depression.”

What I didn’t find was any scientific data proving it to be more effective than TMS therapy. In fact, I found the opposite.

By “scientific,” I mean data gathered through controlled clinical trials or lab research, not by people who administer the treatment to patients and have potential for biased reporting or data-gathering.

For example, I found the following quote in an In-Depth Report on ECT:

“Doctors who perform ECT essentially treat people who are medication resistant or who have suboptimal responses to the medicines, and about 85% of these difficult-to-treat patients improve with ECT. This is a remarkably high response rate in a severely depressed group of people.”

Anytime you we a specific number quoted (like the 85% above), we should ask where that number came from, how it was quantified, and who reported it. This report didn’t reveal any of these factors. It did not say who the “doctors who perform ECT” were or how many of them reported results.

For all we know, it could only be talking about a handful of people. It also didn’t say how the data was gathered or reported or even how the doctors reporting the data arrived at the numbers that gave way to the 85% average.

This is vastly different from getting data from controlled experiments administered by third parties where you can see exactly how the experiments were conducted, how the results were gathered, and how many patients were involved in the study, and whether the results were tested against a control group. These are probably things you should know before going under anesthesia and having someone run electricity through your brain.

Regarding TMS, controlled clinical trials have revealed that 83% of Neurostar (a TMS machine manufacturer) patients see a positive response with only an 11% relapse rate across all study patients. Only 37% of patients required more TMS, and 85% of these patients re-achieved a clinical benefit. I’ll explain in a moment why this low relapse rate is important.

Another Stanford Study on TMS therapy sampled twenty-one participants who were experiencing severe depression and who had been unresponsive to antidepressants, talk therapy, or other brain stimulation (like ECT). The researchers used a form of TMS, called “intermittent theta burst stimulation (iTBS)” to treat the participants. The study concluded that TMS quickly relieved symptoms of severe depression in 90% of the participants. This score was quantified by a score of less than 11 on the Montgomery-Asberg Depression Rating Scale.

While this study involved a small group of people and no control group, it’s more transparent than a claim of an 85% success rate that’s not backed by any specifics on how the conclusion was reached or reported. It’s also more evidence of the low remission rate for TMS therapy. Nolan Williams, MD, assistant professor of psychiatry and behavioral sciences and senior author of the study, said:

“There has never been a therapy for treatment resistant depression that’s broken 55% remission rates in open-label testing.”

Williams also remarked that ECT, though often quoted as the most effective treatment for depression, averages a 48% remission rate for treatment resistant depression. While this 48% is a disputed number, it’s not far off from what the data tells us. According to one study of 347 patients across seven hospitals, ECT, remission rates were between 30.3%-46.7%. The study found that the poorer outcomes were more common for people with comorbid personality disorder, schizoaffective disorder, and longer episode duration (i.e., longer periods with depression symptoms).

Another study on ECT effectiveness in treating major depression found that patients fifty-nine years old and younger experienced a “significantly lower rate of ECT response (54%)” than patients between sixty and seventy-four years old (73%), with an “intermediate rate of response (67%)” for patients seventy-five and older. Even the best results from this study don’t come near the 85% quoted above.

To summarize, the research reveals two important things when comparing the effectiveness of TMS vs ECT:

  • TMS has a higher success rate.
  • TMS has a lower remission rate.

This low remission rate turns out to be a big deal when we examine the safety differences between TMS and ECT.

TMS vs ECT – Safety

Comparing the earlier list of (potential) TMS side effects with the (potential) ECT side effects will tell you a lot about the safety differences between these two therapies. But there’s a more troubling factor that I’d like to point out about ECT and its potential effects on your memory. This is a quote I found in the In Depth Report on ECT, mentioned earlier in this article:

“ECT is not a cure. Its major limitation is that its benefits are often short lived. Without maintenance drug therapy following ECT, virtually all patients would relapse within six months.”

“Unfortunately, only most patients rebounded, not all. Some still scored worse than before ECT on the autobiographical memory test. And on that test, just over 10% of the patients showed severe deficits. Women and elderly people appeared to be most vulnerable.”

While it’s true that ECT is not a cure for depression, this admission about the high remission rates of ECT are concerning in light of this statement (from the same report):

Statement #1:

“…it is clear that both retrograde memory— the recall of events that occurred before the treatment—and anterograde memory—the ability to absorb new knowledge afterward—deteriorate as ECT treatment progresses.”

Statement #2:

“ECT is not a cure. Its major limitation is that its benefits are often short lived. Without maintenance drug therapy following ECT, virtually all patients would relapse within six months.”

Regardless of how well ECT works, if the effects wear off, you seem to have three choices: maintenance drug therapy, more ECT, or try TMS next. Maintenance drug therapy doesn’t give much hope if you opted for ECT because you didn’t want to be on antidepressants or, worse, if they didn’t work in the first place. Regarding the second option, consider these two statements (again, from the same report) about the effect of ECT on long and short-term memory:

“Unfortunately, only most patients rebounded, not all. Some still scored worse than before ECT on the autobiographical memory test. And on that test, just 10% of the patients showed severe deficits. Women and elderly people appeared to be most vulnerable.”

“Although it’s difficult to tease out which memory deficits are caused by the depression (depression is, after all, a disease associated with damaging cognitive effects) and which are caused by ECT, it is clear that both retrograde memory— the recall of events that occurred before the treatment—and anterograde memory—the ability to absorb new knowledge afterward—deteriorate as ECT treatment progresses.”

If memory deteriorates as ECT treatment progresses, this sends up a red flag when considering the higher remission rate of ECT therapy. It tells us that the positive results are more likely to die off over time, while the effects on memory are likely to worsen.

While researching the question of safety, I also looked for statistics on the mortality (aka, death) rate for TMS vs ECT. The ECT-related mortality rate was estimated at 2.1 per 100,000 treatments. In comparison, a recent analysis of the mortality rate for people undergoing anesthesia for surgical procedures was about 3.4 per 100,000. This tells us that death by ECT is exceedingly rare. However, I did not find any evidence of death by TMS.

SOURCE: Article on the mortality rate of electroconvulsive therapy.

While we’re talking about safety, I’d like to share one more important point (also from the report mentioned above) about how ECT therapy works:

“Depression is believed to be caused by an imbalance in the brain’s chemical messenger system. ECT works to rebalance that system. But exactly how it accomplishes this remains a mystery to neuroscientists and psychiatrists. Many rodent studies have been conducted in hopes of better understanding ECT’s mechanism of action, but they have not been informative in any definitive way.”

In other words, no one knows how ECT works. This is another shocking quote from the In-Depth Report on ECT mentioned earlier. If ECT had a better success rate, a lower remission rate, and if it wasn’t potentially dangerous to your long- and short-term memory, this might not matter. But when you combine all these factors, ECT starts to look less and less appealing.

I suggest that when you see a statement from anyone about ECT being the “most effective treatment,” you should ask whether that claim is based on objective and published data, or on opinion. Now, let’s talk about the (non-medical) downside of TMS therapy.

TMS vs ECT – Insurance Considerations

TMS vs ECT - NeurostarAs of right now, major medical companies require patients to jump through considerable hoops before they will pay for TMS therapy. However, this does NOT mean that TMS is an “experimental treatment.” Medical insurance is an unbelievably complicated industry, wound up in a lot of government regulations and red tape. The obstacles have little to do with TMS and a lot to do with the bureaucratic nature of the healthcare system and the medical insurance industry. Thankfully, medical practices offering TMS therapy are used to guiding new patients through this qualification process and can do the same for you. As positive results of clinical studies continue to come in, insurance companies will likely make moves to cover TMS at the start of a patient’s treatment. Unfortunately, as of now, treating depression without medication isn’t the first resort. Treating Depression Without Medication One of the biggest benefits of TMS is that it’s non-invasive, and non-disruptive to your everyday life. TMS patients can literally drive themselves to the doctor on lunch break, get treated, drive back to work and have a normal and productive day. Treatment cycles typically last six to eight weeks (including five 20-minute treatments per week), after which most patients experience lasting relief from the symptoms of severe depression. Mental Health Management Group’s doctors have practiced since 1996, treating hundreds of patients with depression and other mental health challenges. We have helped patients manage a variety of mental illnesses and behavior disorders and to achieve things that would have been impossible without our help. Our patients have become artists, musicians, doctors, lawyers, and much more. We’ve seen problem teens graduate high school and we’ve helped adults (young and old) graduate from college. If you’re looking for a safe, effective way to be free of depression without medication, Mental Health Management Group would like to help you learn more about TMS. Mental Health Management Group has two certified TMS technicians and a friendly administration staff that can help you with the complicated process of meeting the TMS qualifications for your insurance provider. To see if you or a family member qualify for TMS treatment, please fill out the patient referral form and one of our practitioners will call you. Join the hundreds of thousands of TMS patients who have reclaimed their lives without relying on antidepressants. This concludes our analysis of TMS vs ECT.

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