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By Dr. David Woo - March 5, 2020
Published on March 5, 2020. Updated on January 24, 2024.
Transcranial magnetic stimulation (TMS) is proven to relieve symptoms of depression in patients who don’t find symptom relief with other treatments like antidepressants and therapy (1,2). The majority of TMS patients experience no side effects, or mild effects such as temporary headache or scalp irritation. However, some patients may experience a “dip” at some point during the treatment.
What Is The TMS “Dip?”
A TMS dip is when a patient’s symptoms temporarily get worse during the treatment period. It can be a frustrating experience for patients who were looking forward to seeing positive results as soon as possible, but is usually a bump on the road to recovery. But why does this dip happen? And how common is it?
To gain a better understanding of the TMS dip, let’s first take a look at how TMS works.
How Does TMS Work To Relieve Symptoms Of Depression?
TMS uses magnetic waves to stimulate the electrical activity of neurons (nerve cells) in the brain that are either underactive or inactive. TMS is administered using a special coil that is carefully positioned over a specific part of the head. The position of the coil ensures that the magnetic pulses target a specific region of the brain known to be associated with depression (the dorsolateral prefrontal cortex, or DLPFC).
TMS reactivates these formerly underactive neurons, causing them to release neurotransmitters (chemicals that act as connectors between neurons, allowing them to communicate), forming new neural pathways (3,4,5).
When an individual is suffering from depression, their brain is accustomed to functioning in certain patterns using specific neural pathways—similar to a habit. TMS disrupts these neural “habits” associated with depression and allows the brain to form new patterns. New neural pathways allow the brain to start using new communication patterns that positively affect the patient’s thinking and behavior.
The construction of new pathways takes time, usually weeks. This is because, to create these new connections, the brain must produce and use a lot of energy. The brain uses certain substances, like fatty acids, amino acids, and phospholipids, to generate energy to form new neural pathways. That’s why TMS treatment requires around 12 weeks of regular sessions.
What Are The Signs Of A TMS Dip?
When experiencing a dip, patients may feel a sudden worsening of depression symptoms, such as:
- Sadness
- Hopelessness
- Fatigue
Experiencing a dip during TMS treatment can feel frustrating and stressful. But it’s important to keep in mind that the effects of a TMS dip are only temporary.
How Common Is The TMS Dip?
In our clinic, roughly 20% of patients experience a temporary exacerbation of symptoms, the so-called “dip.” During a dip, patients may experience worsening depression or anxiety.
TMS isn’t the only treatment that sometimes comes with a dip that may make it feel like you seem worse. Patients taking antidepressant medications may also experience a dip. At first, their symptoms may seem to get worse, and the side effects of the medication may not seem worth the benefits. But for most patients, over time, the brain adjusts to the medication and patients begin to see a relief of symptoms. However, many patients will never see relief from symptoms with antidepressants, and for those patients, TMS is an excellent alternative.
When Does The TMS Dip Happen?
For the minority of patients who do experience a TMS dip, the phenomenon often occurs after the 2nd or 3rd session, so week 2 or 3 of treatment, assuming the typical schedule of weekly sessions. Most patients will overcome this dip by the 4th and 5th sessions of TMS therapy as the brain adjusts to the treatment and their mood begins to stabilize.
TMS Side Effects
TMS therapy has been FDA-approved for depression and OCD, with no detected impact on cognitive functions such as memory or concentration. The majority of TMS patients experience no side effects. However, some will encounter temporary mild side effects such as headaches and tingling sensations in the scalp, jaw, or face, which typically resolve within one to two weeks. TMS is non-systemic, which means that any side effects are limited to the treatment area. Certain metal implants near the head or neck may be considered a risk factor, and individuals with implants should consult with their doctor to see if they are suitable candidates for TMS. In terms of side effects, TMS favorably compares to antidepressant medications that can have long-term disruptive side effects, including weight gain and sexual dysfunction. Indeed, many patients turn to TMS after having found the side effects of antidepressants to be intolerable.
Does TMS Make You Tired?
TMS can induce fatigue in some individuals, as the increased neuronal activity or blood flow activated during a session can tire a patient as if they had had a “mental workout,” especially during longer or frequent sessions.
What Should You Do If You Experience A Dip During TMS Treatment?
If you’re currently undergoing TMS therapy and are experiencing a dip, talk to your doctor. It’s very important to continue with treatment, even if a dip occurs. Your doctor can talk to you about how to manage your symptoms during the dip and may recommend that you integrate wellness practices into your depression treatment.
Madison Avenue TMS & Psychiatry offers talk therapy and TMS for depression and other mental health conditions. Contact us online or call (212) 731-2033 to book an appointment or consultation.
Resources:
- Tendler, A., Goerigk, S., Zibman, S., Ouaknine, S., Harmelech, T., Pell, G., Zangen, A., Harvey, S., Grammer, G., Stehberg, J., Adefolarin, O., Muir, O., MacMillan, C., Ghelber, D., Duffy, W., Mania, I., Faruqui, Z., Munasif, Fi., Antin, T., Padberg, F., Roth, Y. Deep TMS H1 Coil treatment for depression: Results from a large post marketing data analysis. Psychiatry Research. 2023;324. Link. Accessed January 04, 2024.
- Gogulski, J., Ross, J. M., Talbot, A., Cline, C. C., Donati, F. L., Munot, S., Kim, N., Gibbs, C., Bastin, N., Yang, J., Minasi, C., Sarkar, M., Truong, J., & Keller, C. J. Personalized Repetitive Transcranial Magnetic Stimulation for Depression. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging. 2023;8(4), 351-360. Link. Accessed January 04, 2024.
- Neurostar Advanced Therapy. What is the Mechanism of Action in NeuroStar TMS Therapy? Link. Published on June 07, 2021. Accessed January 04, 2024.
- Jannati, A., Oberman, L. M., & Rotenberg, A. Assessing the mechanisms of brain plasticity by transcranial magnetic stimulation. Neuropsychopharmacology. 2023;48(1), 191-208. Link. Accessed January 04, 2024.
- Huntley, J. H., Rezvani Habibabadi, R., Vaishnavi, S., Khoshpouri, P., Kraut, M. A., & Yousem, D. M. Transcranial Magnetic Stimulation and its Imaging Features in Patients With Depression, Post-traumatic Stress Disorder, and Traumatic Brain Injury. Academic Radiology, 2023;30(1), 103-112. Link. Accessed January 04, 2024.
Dr. David Woo is the owner and head clinical psychiatrist at Madison Avenue TMS and Therapy in New York City. Dr. Woo has been seeing patients in private practice since 2002, always with the goals of combining evidence-based medicine with psychodynamic psychotherapy and collaborating with other mental health professionals to ensure the best possible outcomes for his patients. He has been certified to administer TMS at his practice since 2017. His greatest clinical interests include helping patients suffering from depression, anxiety, and obsessive compulsive disorder.
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