Dr. Perera is the founding president of the Clinical TMS Society
The Society has over 1500 members in 45 countries and has become the final authority in TMS.
He is the first author of the TMS Guidelines that is the foremost authority of TMS practice principals across the world
Repetitive Transcranial Magnetic Stimulation (rTMS) is a cutting edge treatment that has been FDA approved for the treatment of depression in adults and adolescents and Obsessive Compulsive Disorder (OCD) in adults. TMS is a game changer in psychiatry. Unlike medications that are imprecise, it is the only treatment in psychiatry that directly targets the circuits involved in psychiatric conditions. TMS is a non-invasive office procedure. During a TMS session, a special coil is placed on your head, and it sends magnetic pulses to your brain that activate neurons and brain circuits that help with normalization of mood. TMS treatment involves a series of sessions over a few weeks. It creates longe-lasting changes in brain activity that improve symptoms. TMS is safe and conducted under the guidance of our highly skilled medical professionals, tailored to each person’s needs.
While standard MRIs are scans of brain structure, functional MRIs (fMRI) are x-rays of the mind. By indicating where blood is flowing or oxygen is consumed fMRIs reveal the regions of the brain that fire when people thinking certain thoughts, experience certain feelings, or perform specific tasks. One of the most consistent fMRI findings seen in depressed people is decreased activity in the left prefrontal cortex (PFC) – the frontal part of the brain – which is important for many things including the appreciation of pleasure. If that area is underactive, the individual cannot enjoy activities is thought experience anhedonia – one of the core symptoms of depression. Decreased left PFC function, in turn triggers a whole circuit across the brain that results in the full complement of depression symptoms. TMS is a revolutionary treatment that grabs the bull by the horn by directly stimulating the left PFC until its activity normalizes and the symptoms of depression dissipate. The concept behind TMS is based on Faraday’s law – if you have an electrical field that is moving in a certain direction, it creates a magnetic field perpendicular to it. The device is brought over the head, and a magnetic field of about 4 cm is activated. The field enters the brain and becomes converted back into electrical impulses, and activates brain circuitry in deeper regions.
When depression is successfully treated with drugs or electroconvulsive therapy (ECT) the activity in the left PFC normalizes. However, medications and ECT are very nonspecific. ECT shocks the whole brain while medications go all over the brain and body. Consequently, ECT causes memory problems and drugs take several weeks for onset of therapeutic effects and cause numerous side effects such as weight gain and sexual dysfunction. The pivotal, NIH sponsored STAR*D antidepressant trial showed that only a quarter of patients respond to the first antidepressant and a mere 6.9% respond after failing three medications. Since TMS directly stimulates the left PFC, it is far more effective in treating depression in people who have failed multiple medication trials (~80% response and ~60% remission with TMS compared to ~7% remission with medications) and works far more rapidly (4-6 weeks with TMS compared to 6-12 weeks with medications). Medications cause chemical changes in the brain that are transient leading to relapse of depression when the drug is stopped. TMS by contrast, produces changes in brain circuitry and has far more durable therapeutic effects that are preserved long after the treatment is stopped. Only 30% of TMS responders need to return for additional treatment, and even then, it is typically 6 months to a year later. Since TMS is applied specifically to the left PFC, it does not cause systemic side effects throughout the body like medications or lead to memory loss like ECT. It is safe and essentially side effects free. Thus, compared to conventional antidepressants, TMS is significantly more effective, rapid, durable, safer, and tolerable.
The technology for TMS has been around for over a century. I became involved in TMS research at Columbia in the 1990s and treated my first patient over three decades ago. The clinical benefits and safety were confirmed by over a hundred studies including several large multicenter randomized controlled trials conducted at several leading academic centers of the world including Harvard, Columbia, Cornell, Stanford, Yale, Duke, Oxford, Max Planck Institute just to name a few. While antidepressant medications were discovered by serendipity TMS is the first scientifically based, rationally designed treatment in the history of psychiatry. The scientific basis and biological underpinnings of TMS are better understood than any other psychiatric treatment available.
The typical TMS therapy session is an outpatient treatment that does not involve any medications or anesthetics. You can drive yourself to and from appointments. You sit in a comfortable reclining chair and a curved TMS coil is gently placed over the left frontal part of your head. At the first session we will stimulate your motor cortex to find the exact location and dose to treat. Hence, each treatment is customized based on the anatomy and neurobiology of each and every patient. As the treatment is administered a gentle tapping sensation is felt as the magnetic waves stimulate your brain. You may watch TV, listen to music, or chat with our highly trained, deeply empathic TMS treaters during each session. Each standard treatment is around 20 minutes in duration while Theta Burst TMS is just 3 minutes long. If anxiety is also present, we will treat the left side for depression and the right side for anxiety. These sessions may last a little longer (~35 minutes). We usually begin with standard TMS and graduate onto two back to back 3-minute sessions of Theta Burst if there is no response in three weeks. There is no need for recovery time afterward; you can get straight back to your daily activities. We will perform weekly depression rating scales to assess your progress.
TMS therapy involves one daily session 5-6 days per week for 6-7 weeks for a total of 34 sessions. Some people respond a lot sooner and require fewer sessions. Doing fewer session per week (3-3 sessions) or missing a few sessions during the treatment course is not a problem. Since this a substantial time commitment our team will make every effort to accommodate you at a time that is most convenient to you. We offer early morning, late evening, and Saturday sessions.
TMS is far safer than ECT or medications. Since it is a precision treatment it does not cause systemic side effects such as sexual dysfunction, weight gain or fatigue associated with medications or memory loss associated with ECT. The only discomfort is mild tenderness around the area of treatment during the sessions. The risk of persistent headaches is less than 3%. If this occurs, we will immediately readjust the coil and lower the dose. Indeed, it has been shown to be a highly effective treatment for migraines. The only people who cannot do TMS are those with ferromagnetic metal inside their skull. Non-magnetic nickel and titanium shunts and dental fillings are safe. If it is safe for you to have a head MRI you can have TMS. The only serious complication is a seizure that could occur during the session. This is an extremely rare risk seen in less than 1 in 200,000 sessions. If a seizure occurs our staff is trained to take safety measures and get immediate assistance by calling 911. Since 2010 we have safely treated thousands of patients without complications. There are no long-term adverse consequences of TMS based on 30 years of data in millions of patients across the world. TMS uses less magnetic energy than MRIs scans. There is no radiation involved. There are no cognitive issues such as concentration difficulties or memory loss from the treatment. TMS will not make your illness worse. The only poor outcome is the lack of efficacy seen in around 15-20% of patients.
Your mental health defines your identity and determines your life’s trajectory. It also has a ripple effect on those around you. If you suffer from depression, anxiety, or OCD getting effective treatment early is paramount. The longer you go with no therapy or ineffective treatment the more resistant your illness gets and the more brain damage it causes. In addition, depression is one of the world leading causes of morbidity and mortality in the world. Job loss, relationship difficulties, and medical illness are common among those afflicted with depression. If you have unipolar depression or OCD and have failed to completely respond to two or more antidepressants TMS may be the right choice for you. Antidepressants and therapy get most people halfway better but not fully well, and they live the rest of their lives with partial depression. Do not settle for this, seek to get well and get off all medications. Indecisiveness and hopelessness are common symptoms of depression that make people skeptical. Do not let these feelings get in the way. Some are concerned that TMS has not been around for a long time. This is true but it is vastly superior and more scientifically sound than medications that have been around for 80 years. Would you drive the 2024 Ford Taurus or the Ford Model T that has been around for 120 years? Sadly, many ‘old school’ mental health practitioners are unfamiliar with the treatment and have not made the effort to learn the science and clinical data in support of TMS. In such situations you need to advocate for yourself. Getting a TMS consultation does not mean you need to commit to the treatment. At the consultation you can get more information and then decide if it is right for you. TMS has had a life changing effect in over 6,000 patients we have treated and it certainly can be one of ten best decisions you have made.
It is highly likely that we have treated more patents than any other single location in the country. Based on our extensive experience and research TMS is safe and effective in children, the elderly, and during pregnancy. We have effectively treated children as young as 6-years, adults as old as 100-years, and several pregnant women. Besides unipolar depression, Major Depression in adults, major depression in children, and OCD in adults and children we have had great success in treating the following conditions:
There are several coils available for TMS. During my TMS research as Columbia faculty and in my position as the President of the Clinical TMS Society I became intimately familiar with all the coils. At Contemporary Care we use both the Neurostar and Magventure devices. The former are used in our New York locations and the latter are used in our Connecticut locations. Based on our experience and careful data gathering there is no advantage of one over the other. The Magventure machines do allow us to provide Theta Burst TMS, which appears to be more effective than standard TMS. In addition the specialized Magventure OCD coil has generated exceptional results. The question arises whether standard TMS is as effective as ‘deep TMS’ provided by the Israeli Brainsway coil. Based on my extensive research and data analysis the outcomes with deep TMS are not in any way superior to standard TMS but the side effects including headaches and seizure risk are higher. There is no added advantage to ‘deep TMS’ because the PFC is interconnected to deeper brain regions. As the fMRI pictures shows treating the PFC with the Neurostar or Magventure machine is fully capable of activates interconnected deeper regions of the brain such as the hippocampus and amygdala. In my research in animal models standard TMS was effective in increasing neurogenesis in the hippocampus, and these new neurons were critical for generating an antidepressant response . See Article
All insurance plans including Medicare cover TMS therapy for adults with unipolar depression that have failed two or more antidepressant trials. Most also cover TMNS in adolescent children and those with OCD. In order to get coverage, you need to do a TMS evaluation with us, after which we will get TMS preapproved within 1-2 weeks. Besides a small copay (for which can we offer sliding scales) there will be no financial commitment to you. If we do not take your insurance plan, we can still make an ‘out of network’ contract with your insurance and get TMS covered. Our staff has more experience and more success in getting TJD covered than most others nationwide.
If you are dealing with a serious refractory illness such as depression or OCD and are going to make a major time commitment you must choose the best practice to get your therapy. Not every practice that does TMS is good at it. This therapy involves more than just turning on a machine. There are a lot of technical aspects such as finding the best area to treat, optimizing treatment, and developing customized protocols for each and every patient. This takes great skill, significant experience, and in-depth knowledge. In this regard, Contemporary Care is second to none.
We are unabashedly one of the leading TMS practices in the world!
As one of the top experts in the world on TMS, our clinical director Dr. Tarique Perera was introduced to TMS during his residency, research fellowship, and faculty work at Columbia University. In fact, he lectured on TMS at Columbia’s Brain Stimulation Course for several years. Later as founding President of the Clinical TMS Society and author of the National TMS Guidelines Dr. Perera rose became the face of TMS worldwide. He has trained and supervised one of the premier TMS teams in the country and has treated more patients than any other practice location. At CC, we invest in innovative technology, state-of-the-art equipment, and highly qualified teams to give you the most effective treatment possible.
We are one of the only practices that offer Theta burst TMS, offer the SAINT protocol, use customized coil for OCD, perform bilateral TMS for depression and anxiety, and take virtually all insurance plans including medicare.
We take great pride in having the most dedicated, caring, proficient, and best trained TMS treaters of any practice. Based on careful data analysis, we have, by a wide margin, the best outcome results you will find anywhere.
