Transcranial Magnetic Stimulation (TMS) and Electroconvulsive Therapy (ECT) are highly effective in the treatment of Major Depression, both having been approved by the FDA for treating Treatment Resistant Major Depression.

Pitting TMS against ECT is a bit like trying to compare apples to oranges, as there are many similarities along with key differences. TMS works on some of the same principles as ECT, using electrical currents to stimulate the brain and alter brain functioning. Read more: TMS Myths vs Facts →

Potted History of Electroconvulsive Therapy

Using electric shocks to induce seizure for medical benefit was first theorized in 1938 by an Italian Neurologist, Ugo Cerletti, after witnessing pigs being ‘shocked’ prior to slaughter. The shock appeared to calm and almost anesthetize the animals prior to being butchered. This lulling effect led Cerletti to theorize and experiment with electric shocks to trigger the same ‘healing’ convulsions in patients. Similar to medications that were just then being used to induce seizure, ECT showed promise as a means to 'reset' the brain and resolve fixed depressed mood.

The methods for ECT were of course rudimentary compared to the more advanced and controlled settings used today. As a result of this history and sensationalism by the media over the years, ECT is often viewed as a barbaric and unsafe treatment. ECT treatment of today, however, has come a long way and is much safer and better tolerated than in the past. 

Potted History of TMS

As noted, TMS works on the same principle of using electrical currents to stimulate the brain, but along more targeted and previously identified dysfunctional neural pathways.

The premise for TMS really dates back to the 1830s, when an English scientist, Michael Faraday, discovered the process of electromagnetic induction. It wasn’t until the mid 1980s, however, that this mechanism was theorized as a tool for evaluating and treating Psychiatric and Neurologic conditions. This work was done by Anthony Barker and his colleagues at a University in the UK. They were able to develop a delivery system - a handheld magnetic coil connected to a capacitor - for delivering stimulation to brain tissue. Originally, it was used for research and monitoring brain activity, but the therapeutic benefits quickly became apparent and TMS Therapy was born. Studies have flourished since and new indications are being developed beyond the great success seen with TMS in the treatment of Major Depression.

Like ECT, TMS harnesses electrical current, but it does so in a much more targeted fashion and transmits stimulation safely across the scalp and skull. A pulsating magnetic field induces electrical firing of neurons and synapses approximately only two to three centimeters into the brain. In ECT by contrast, the procedure causes diffuse firing to much deeper tissues at a much larger intensity. This leads to uninhibited electrical firing and a seizure. 

ECT Process

ECT is only administered in a hospital by a Psychiatrist and Anesthesiologist supported by nurses and other staff. Patients must be medically cleared prior to pursuing ECT. The patient is fully sedated and treated within full surgical operation protocols. Additional medication is used to relax muscles and limit muscle pain following the procedure. A strong, but brief, electrical current is administered through electrical conducting material applied on the scalp inducing a seizure for 30-60 seconds. Without ongoing electrical stimulation, a seizure is typically self-limiting and the brain will return to baseline activity without additional intervention. 

Side Effects

Any surgical procedure requiring anesthesia carries risk, as does inducing seizures. ECT is also known for causing memory loss. Treatment can also be associated with nausea, headache, and fatigue, and sometimes jaw or other muscle pain.

ECT- FDA Approved Treatment

TMS Process

Compared to the hospital setting required for ECT, TMS treatment typically takes place in an outpatient clinic. TMS does not require use of general anesthesia or any medications. Patients remain awake and alert prior to, during, and after treatments. Patients can drive themselves to and from their sessions without needing any support or someone to drive them home. 

Read more: What to expect during your TMS treatment visits →

TMS treatment is overseen by a Psychiatrist. The initial “mapping” procedure determines the right stimulation intensity and sets the parameters for treatment and is performed by a Psychiatrist. Follow-up treatments are typically performed by a certified TMS technician with oversight from the Psychiatrist.

A fluctuating electrical current is introduced to a coil of wires which in turn generates a pulsating magnetic field. This field is then directed onto areas of the brain responsible for depression and/or anxiety by placing the coil adjacent to these areas on the scalp. Repeated stimulation occurs, with short intervals between stimulation and each treatment typically lasts three to 18.5 minutes. These two timeframes are the current FDA-approved protocols for Treatment Resistant Major Depression. These stimulations cause excitation of neurons in the tissue two to three centimeters tangential to the center of the coil. This results in connected neurons communicating with one another and, over time, correction of faulty pathways driving depression. The full mechanism of action remains a mystery, but the most common proposed pathway for treatment of depression and associated symptoms is through synaptic plasticity. This term describes how the brain can reorganize and actually grow new neural pathways via synapses - the structures that communicate between neurons. TMS can cause this phenomena and repair damaged networks that cause mental health symptoms.  

In a course of TMS, patients come in five days per week for repeat treatments. On average, patients receive a total of 30 weekday sessions for six weeks with a taper of an additional six sessions over another three weeks. Some patients require maintenance TMS sessions in time similar to ECT. 

Read more: TMS therapy pros & cons →

Side Effects

The most common side effects with TMS can include mild scalp discomfort and headache. A simple over-the-counter analgesic can help if needed and side effects usually diminish after a few sessions. The target stimulation intensity is often reduced at the beginning of a treatment course and then gradually increased to allow for adjustment to the procedure. Rarely, 1 in 30,000 treatments or less, a seizure may occur. This is on par or less likely than risk for seizure with antidepressant use. In light of this, seizure disorder is a contraindication for treatment. Metal in the brain, near the coil, or any magnetically influenced devices in the body also are contraindications for TMS treatment.

TMS-FDA Approved Treatment

TMS Off-label Use

TMS has been used to treat many other mental and neurological disorders. The full potential of TMS has not yet been fully realized and many studies continue to research TMS and its impact on a diverse number of brain health issues.

Inspire TMS Denver always reviews treatment options for patients - including ECT if indicated. We want to ensure you are able to make the most informed decision prior to treatment with TMS. Questions about TMS vs ECT or other information on this page? Please contact us here to see about a free phone consultation.