Transcranial Magnetic Stimulation (TMS)

Deep TMS is a safe, noninvasive, medication free treatment initially developed for treatment-resistant depression. The outpatient procedure involves the use of an electromagnet, similar to those used in an MRI scanner.

The magnetic pulse stimulates specific regions of the brain, inducing brief activity of brain cells causing new healthier synapses to form, changing the way patients think and feel. TMS is typically used in patients with treatment-resistant mental illness after treatment with medication and therapy has not been effective.

Deep Transcranial Magnetic Stimulation is FDA cleared for Major Depressive Disorder, Obsessive Compulsive Disorder, and Smoking Cessation in adults using protocols that consisted of one treatment per day for several days. Different TMS coils/helmets and protocols are used depending on what is being treated. TMS can also be used off-label and is being studied for conditions like bipolar disorder and other substance use disorders, in children and adolescents and using protocols consisting of multiple treatments per day. Of note, while the FDA recently cleared a multiple TMS/day protocol known as SNT, this is not yet commercially available. When Magnus Medical launches their device, we anticipate being amongst the first practices to put it into clinical use.

At Fermata, we use an FDA-cleared BrainsWay® deep TMS device (dTMS) and use a H-1 coil and a H-7 coil. You can learn more about the BrainsWay® dTMS machine and how it works here: BrainsWay’s Innovative Technology.

The SAINT/SNT protocol was developed by Nolan Williams at Stanford university and consists of 10 treatments per day over 5 days instead of the traditional 1/day for 6-8 weeks. In a groundbreaking study published in the prestigious American Journal of Psychiatry in 2021, this accelerated protocol provided remission from depression in 90% of patients with treatment resistant depression in as little as 3 to 5 days. The SNT protocol utilizes a traditional TMS machine rather than the deep TMS machine we use and these traditional rTMS machines can miss the target if positioned suboptimally. Therefore, the SNT protocol uses a combination of MRI and computer modeling to “neuronavigate” to the optimal spot. With deep TMS machines, this type of targeting is not relevant so our protocol is similar to SNT but does not include neuronavigation. We are participating in ongoing research to better understand if there are difference in efficacy between these two methods, as well as if accelerated TMS can be helpful for other conditions including OCD and Bipolar disorder.

dTMS is classified by the FDA as a minimal-risk procedure. Most of the potential side effects are minor. Reported effects include temporary headache, fatigue, or neck stiffness (from wearing the helmet). Typically, these decrease as the body adjusts. The only documented long-term side effect is hearing loss—but that’s only a risk if you decide not to wear earplugs (which we provide for you).

A documented but rare side effect (one out of every 30,000 high-energy treatments) is induced seizure. While this is scary, the chance of it happening at all is extremely small, and all recorded incidents have been brief without lasting effects to the patient. We have a specific safety protocol at Fermata to mitigate the seizure risk by taking brain measurements  (called “measuring the motor threshold”) prior to every session. Many clinics only take these measurements once a week, and while it may add slightly more time onto your session, our data supports it as a successful preventative measure. Because of this practice, we deliver the precise amount of power that your brain needs on that day, and not a single Hz more.

No. Think of dTMS like a weight-lifting regimen at the gym. Lifting weights will make your muscles bigger and stronger while you’re on the regimen and for a period of time after. But just like lifting weights doesn’t permanently change your muscles, dTMS doesn’t permanently change your brain. It is meant to be used at part of a comprehensive treatment program that could also include medications, therapy and lifestyle changes. Some people have asked if TMS can cause brain damage On the contrary, studies assessing cognitive function found participants had improved ability to switch between mental task and solve problems, with no cognitive deficits. Many people choose TMS over ECT due to this.

While you are seated, a helmet containing a large magnet is placed on your head. If you think of the hair-dryer chair in a salon, the dTMS chair and helmet look very much like this! An extensively trained TMS technician will be nearby, controlling the degree of stimulation and monitoring real-time data transmitting directly from your brain to precisely target the neurons we want to fire. Each treatment lasts between 10 and 30 minutes. While the dTMS magnet is similar to those in an MRI machine, dTMS is administered solely through the helmet, targeting only the brain. While traditional TMS takes place once per day, at Fermata we offer accelerated protocols consisting of up to 10 treatments per day for 5 days, approximately 50 minutes apart. In between treatments, patients are welcome to relax outside of the TMS room or explore the neighborhood.

Unfortunately, insurance companies move a little slower than the field and have not yet caught up to the science. Therefore, the TMS services we offer at Fermata are typically not covered by insurance plans. Dr.MacMillan works hard as the co-chair of the CTMSS Insurance Committee to change that in the future. The more patients request these services from their insurance plans, the more likely they are to start listening! If you are looking for once-per-day insurance based TMS for depression or OCD in NYC, we recommend our colleagues at Hudson Minds.

Yes! We welcome patients from all over the world. If you live in a state where we are not licensed or outside of the United States, we would have a virtual informational meeting in advance, collect intake paperwork and then a formal in-person consultation when you arrive at our office. There are a number of hotels within walking distance to our Williamsburg office, including the Hoxton (1 min walk), the Wythe Hotel (3 min walk), the Williamsburg Hotel (3min walk) and the William Vale (5 min walk).