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TMS versus ECT

By | Deep TMS

By Joshua Bess, M.D.

The first line of treatment for patients suffering from anxiety and depression is typically antidepressant medication and psychotherapy. If these treatments have not been as effective as hoped, it may be time to consider brain stimulation therapy.

There are two kinds of brain stimulation technologies that are FDA-approved for depression. One is Transcranial Magnetic Stimulation (TMS) and the other is Electroconvulsive Therapy (ECT). TMS and ECT are safe and effective treatment options for adults who have tried medication and psychotherapy for anxiety or depression without seeing good results.

Both TMS and ECT work by stimulating specific areas of the brain that regulate mood. In most cases, it makes sense to try TMS first because TMS can improve brain function without cognitive side effects and does not require anesthesia.

TMS involves placing an insulated coil over the scalp to deliver electromagnetic pulses to specific areas of the brain that impact depression. Patients remain awake throughout the treatment, which is non-invasive. The most common side effects are slight discomfort at the site where the coil sits on the scalp during treatment and a mild headache afterward. Patients can resume their usual daily activities, including driving, immediately after a treatment.

Studies have shown that TMS is highly effective for treating medication-resistant depression, with response rates between 40 and 60 percent and remission rates between 35 and 40 percent. While some patients see results in just two weeks, an average treatment course is four to six weeks.

TMS is almost always the first choice for brain stimulation treatment. If a patient is suffering from severe depression and is perhaps even suicidal, ECT may be an appropriate treatment option. ECT is also considered when a patient does not respond to TMS. ECT involves passing electrical pulses through a person’s brain to produce intense brain activity during a brief period of time.

Between 80 and 90 percent of our patients who undergo ECT treatment see improvement. We typically see positive clinical response and substantial reduction in suicidal thoughts among our patients within one to three weeks.

Most of our patients tolerate ECT remarkably well. Immediate side effects can include nausea, headache, jaw pain, muscle ache and muscle soreness, as well as confusion. Patients may also experience memory loss, although memory problems from ECT usually resolve within a couple of months after completing treatment.

Both TMS and ECT can be used in combination with medication and psychotherapy. Many patients have better results when brain stimulation is used to augment existing therapies.

SeattleNTC is the only medical group in the Seattle area that offers both TMS and ECT. We work closely with patients and their referring providers to determine the most appropriate course of treatment.

Repetitive Transcranial Magnetic Stimulation: Potential in the Treatment of Alzheimer’s disease and Dementia

By | Alzheimer’s

by Jennifer Bolton and Serena Smith, TMS Clinicians at SeattleNTC

Alzheimer’s disease is the most common cause of dementia, a general term for the deterioration of brain function. At age 60, the risk of developing Alzheimer’s disease is 1 in every 100 people; this risk increases to 30-50 in every 100 people by the age 85.[1] Alzheimer’s disease is characterized by the loss of memory, language, and judgment that noticeably interferes with occupational and social functioning. There is no known cure for Alzheimer’s disease, however therapies do exist to combat symptoms. Though the exact mechanism is unknown, one such potential therapeutic aid for Alzheimer’s disease and dementia is repetitive transcranial magnetic stimulation (rTMS), a noninvasive form of brain stimulation, administered over the dorsolateral prefrontal cortex (DLPFC). Circuits connecting the DLPFC to deeper areas of the brain, including the basal ganglia, have been shown through imaging studies to be important in many cognitive functions. Stimulating the DLPFC may reinforce these circuits, thereby improving their function.

In a study by Ahmed et al 45 patients diagnosed with Alzheimer’s disease were randomly assigned to receive three different rTMS treatments: bilateral high frequency rTMS (20 Hz), bilateral low frequency rTMS (1 Hz), and bilateral sham rTMS (simulation of rTMS without stimulating the brain). [2] rTMS was administered bilaterally over the DLPFC, and all patients received daily rTMS sessions for five days. The subjects were evaluated in terms of stages of dementia, activity levels, and depressive symptoms. Patients receiving bilateral high frequency rTMS tended to improve more than those in the other treatment groups across all rating scales. A statistically significant difference was found between the outcomes of the patients receiving high frequency rTMS and those patients in the sham and low frequency groups.

Additional analyses were performed after splitting subjects into two sub-groups based on the severity of dementia: mild/moderate dementia and severe dementia. Out of all of the patients receiving high frequency treatment the mild/moderate group significantly improved, whereas those in the severe group did not. Out of all patients receiving low frequency rTMS (1 Hz), there was significant improvement in daily activity scores in the mild/moderate group only. In this same group, there was no significant change in either dementia or depressive symptoms. The group of patients receiving sham treatment for Alzheimer’s disease did not significantly improve in any of the three categories.

This study supports that multiple bilateral high frequency (20 Hz) rTMS treatments administered over bilateral DLPFC of patients with mild/moderate dementia can lessen the severity of dementia and depression as well as improve activity levels. Although additional studies should be conducted to provide more evidence for this treatment, the data presented above indicates that rTMS may hold potential for the treatment of the early stages of Alzheimer’s disease.


[1] Burns A, Jacoby R, Levy R (1991) Neurological signs in Alzheimer’s disease. Aging 20:45–51.

[2] Ahmed MA, Darwish ES, Khedr EM, El serogy YM, Ali AM. (2012) Effects of Low versus high frequency of repetitive transcranial magnetic stimulation on cognitive function and cortical excitability in Alzheimer’s dementia. J Neurol 259:83-92.

Repetitive Transcranial Magnetic Stimulation: A Tool for Long-Term Smoking Cessation

By | Uncategorized

by Jennifer Bolton and Serena Smith, TMS Clinicians at SeattleNTC

Tobacco use is the leading cause of preventable death in developed countries[1]. Despite smokers frequently identifying tobacco use as harmful and expressing a desire to reduce or stop smoking, most smokers have difficulty abstaining. Eighty-five percent of those who attempt to quit smoking without assistance relapse, with the majority resuming use within one week of quitting. Numerous aids have been helpful in increasing immediate abstinence rates, but the long-term outcomes are still disappointing.  After 6 months, common aids, such as nicotine gum and bupropion (a prescription medication) result in abstinence rates of only 19% and 24% respectively. [2]

The addictive properties of tobacco are caused primarily by the action of nicotine on the central nervous system. Initially, nicotine increases the release of dopamine a neurotransmitter or chemical messenger, in the reward centers of the brain. However, prolonged exposure to even low concentrations of nicotine can cause the desensitization of dopamine neurons, making them harder to activate[3]. Decreased activity in the reward-related brain circuits is correlated with higher levels of craving and relapse.

One tool being studied to treat smoking addiction is repetitive transcranial magnetic stimulation (rTMS), a safe and noninvasive method of brain stimulation that uses magnetic pulses to produce changes in brain activity. rTMS can trigger dopamine release and generate lasting changes in neural excitability.  It has been hypothesized that by increasing the activity of the neural circuits involved in nicotine addition, rTMS may help people stop smoking cigarettes

There are two basic forms of rTMS, conventional and deep.  Conventional rTMS, which stimulates relatively superficial layers of the brain, has been shown to reduce cigarette consumption and cravings, at least temporarily, by a decade of research. Amiaz et al. discovered that rTMS administered daily for 10 days to the left dorsolateral prefrontal cortex (DLPFC), a region of the brain with strong connections to reward circuitry reduced the consumption of cigarettes, dependence on nicotine, and the craving provoked by smoking cues.[4] However, these effects tended to fade quickly.

In contrast, a recent study by Dinur-Klein et al. suggests that targeting deeper targets, such as the insular cortices, may offer improved, long-term outcomes. In an attempt to find a more durable treatment, Dinur-Klein et al. used a deep rTMS H-coil to target both the right and left dorsolateral prefrontal cortices as well as the insulae—deep brain structures that have been implicated in craving by neuroimaging studies.[5]

In Dinur-Klein et al.’s study of deep TMS for smoking cessation, adults were recruited who smoked at least 20 cigarettes a day and had previously failed cessation with other treatments. Participants were randomly placed into 6 experimental groups with variations in rTMS frequency (high frequency, low frequency, sham, or simulated stimulation), and differences in smoking cues (with cues and without cues before each treatment).  Each group received a total of 13 daily TMS treatment sessions and had cigarette consumption monitored by self-reports and analysis of urine samples for levels of cotinine, a metabolite that appears in urine after nicotine has been consumed.

In the low frequency rTMS and the sham groups only 9% of participants abstained from smoking at the end of the 13 treatments and none remained abstinent 6 months later.  However, the groups receiving high frequency rTMS showed a significant reduction in cigarette consumption and nicotine dependence. Specifically, the group receiving high frequency rTMS after being shown a smoking cue exhibited the greatest response with a 44% abstinence rate at the end of the 13 treatments and a 33% abstinence rate at a 6 month follow up. Thus, being shown a smoking cue followed by high frequency rTMS more than quadrupled the likelihood of abstinence after the 13 treatments and helped subjects maintain long-term abstinence.

In conclusion, deep TMS has promise as a safe, effective, and durable treatment for cigarette addiction.  However, these findings are very preliminary, and additional research is necessary prior to the routine clinical application of rTMS for this indication.  


[1] World Health Organization (2013): WHO report on the global tobacco epidemic. Geneva: World Health Organization

[2] Agency for Healthcare Research and Quality (2008): National Guideline C Treating tobacco use and dependence: 2008 update. Rockville MD: AHRQ. Page 109.

[3] Pidoplichko V, DeBiasi M, Williams J, Dani J (1997): Nicotine activates and desensitizes midbrain dopamine neurons. Nature V 390: 401-404.

[4] Amiaz R, Levy D, Vainiger D, Grunhaus L, Zangen A (2009): Repeated high-frequency transcranial magnetic stimulation over the dorsolateral prefrontal cortex reduces cigarette craving and consumption. Addiction 104:653-660.

[5] Dinur-Klein L, Dannon P, Hadar A, Rosenberg O, Roth Y, Kotler M, Zangen A (2014): Smoking cessation induced by deep repetitive transcranial magnetic stimulation of the prefrontal and insular cortices: A prospective, randomized controlled trial. Biol Psychiatry 76:742-49.

Repetitive Transcranial Magnetic Stimulation and Associative Memory Enhancement

By | Uncategorized

by Jennifer Bolton and Serena Smith, TMS Clinicians at SeattleNTC

Transcranial magnetic stimulation (TMS), a noninvasive method of brain stimulation, has recently been shown to enhance neural pathways in the brain that are associated with memory function. In memory processing, superficial regions of the brain, such as the lateral-parietal cortex, connect to deeper memory control centers, such as the hippocampus. Because TMS can stimulate only the outer few centimeters of the human cortex, the lateral-parietal cortex has been identified as a target area over which TMS could be used to affect deeper brain structures or regions involved in memory.

In a study by Wang et. al, healthy subjects receiving  rTMS to the lateral-parietal region of the brain were compared to subjects receiving sham treatments. Sham treatment mimics the feeling of rTMS without stimulating the brain. After 5 consecutive days of rTMS, functional magnetic resonance imaging (fMRI) of the group receiving “real” rTMS indicated increased connectivity between the lateral-parietal region and the hippocampus. This increased regional brain connectivity correlated with improvements on associative memory tests. Differences in regional brain connectivity or associative memory test scores were not seen in the sham group. These results support the theory that rTMS given over superficial brain regions can have downstream effects on deeper regions of the brain more directly involved in memory funtions, resulting in significant improvements in memory testing. rTMS shows much promise as a future treatment of memory dysfunction, however, further studies involving patients with disease pathology are needed.

Wang JX, Rogers LM, Gross EZ, et al. Targeted enhancement of cortical-hippocampal brain networks and associative memory. Science. Published online August 29 2014

Links To news articles about the study:
Magnetic brain stimulation treatment shown to boost memory. The Guardian, August 28 2014

Electrical brain stimulation ‘boosts memory’. BBC News, August 29 2014

Magnetic pulse to head could improve memory of dementia sufferers. The Daily Telegraph, August 28 2014

Brainsway Deep TMS

By | Deep TMS

We have added a new TMS device at our Cherry Hill Office:  Brainsway Deep TMS.  Deep TMS (dTMS) is a new technology that produces significantly deeper cortical stimulation.  Brainsway Deep TMS is approved by the FDA for Major Depressive Disorder.  The FDA indication is based on a 16-week double-blind, placebo-controlled multi-center study, which enrolled over 200 subjects, showing a profound decline in the Hamilton Depression Rating Scale (HDRS-21), a significant remission rate of 32.6% and an even higher response rate in treatment resistant patients.  Brainsway Deep TMS is currently being studied in over 60 clinical trials at leading institutions worldwide.  Approved clinical indications in Europe include Bipolar Disorder, PTSD, Schizophrenia (negative symptoms), Autism, Alzheimer’s disease, Parkinson’s disease, chronic pain and smoking cessation.

Welcome Suzanne Kerns, M.D.

By | SNTC Announcement

We are pleased to introduce Suzanne Kerns, M.D., who joined  SeattleNTC in August 2014.   Dr. Kerns completed her undergraduate studies at the University of North Carolina in Chapel Hill.  She attended medical school at the University of Sydney, Australia, followed by psychiatry residency at Duke University.  Dr. Kerns subsequently completed a Fellowship in Brain Stimulation at Medical University of South Carolina under the guidance of Mark S. George MD, a founding father of transcranial magnetic stimulation (TMS).  Special clinical interests include women’s mental health, post-traumatic stress disorders and addiction disorders—and especially the developing applications for brain stimulation in these areas.

Likelihood of Remission from Depression with Medications vs. TMS vs. ECT

By | Uncategorized

Depression is now the leading cause of disability in the world (WHO, 2012), and Transcranial Magnetic Stimulation (TMS) is increasingly recognized as an important treatment option by both clinicians and insurance companies

As such, we are frequently asked about the relative effectiveness of medications vs. TMS vs. ECT for treatment-resistant depression.  While head to head studies of the 3 treatments have not been completed, it is interesting to compare large, multi-site, frequently cited studies of the 3 treatment modalities administered to patients with similar levels of treatment resistance.

These findings are a useful reminder to regularly assess the severity of depression in our patients using depression rating scales, and to be sure that patients with treatment-resistant depression are being progressed through a series of treatment steps including, if appropriate, an evidence-based psychotherapy, additional medication trials, TMS or ECT.


Seattle Neuropsychiatric Treatment Center (SeattleNTC) is committed to providing high quality, evidence-based therapies for depression, anxiety, obsessive compulsive disorder and related conditions that have not responded to first-line treatments such as medications and psychotherapy.


At SeattleNTC:

  • Caring for patients is our passion
  • We feel privileged that patients, families and loved ones ask us for help during the most challenging times of their lives
  • Patients who seek our care have often suffered for months or years
  • We strive to be accessible and can typically schedule an initial consultation within 1-2 weeks
  • We use state of the art brain stimulation procedures to help patients get their lives back on track as quickly as possible
  • We strive to provide the most personalized and the highest quality of care possible


 All patients are seen for one or more initial consultation appointments to:

  • Review their psychiatric treatment history
  • Gather information from significant others, psychiatrists, therapists and primary care physicians
  • Discuss the treatment options in detail
  • Collaboratively establish an initial treatment plan


Depression and other psychiatric conditions are often resistant to treatment

  • After 3 failed medication trials, depressed patients only have a 17% chance of responding to additional medication trials
  • The same patients have a 58% chance of responding to TMS and a 60-80% chance of responding to ECT
  • Patients often suffer through many ineffective medication trials before TMS or ECT is considered

To Contact Us:

Please Call 1-206-467-6300

Our Office Locations:


1600 E Jefferson Street, Suite 401
Seattle, WA 98122


18100 Union Hill Road
Redmond, WA 98052