Anxiety poses significant treatment challenges, but Transcranial Magnetic Stimulation (TMS) offers promise for treatment-resistant patients by targeting specific brain regions.
Combining TMS with pharmacotherapy and psychotherapy enhances treatment outcomes, showing great potential for personalised symptom reduction and management.
Advanced TMS systems like the H-coil provide deeper stimulation and superior benefits, offering the best results available to people with treatment-resistant anxiety.
Introduction
Anxiety disorders represent a complex array of psychological conditions which can affect every aspect of a person’s life. Despite the availability of treatment options like pharmacotherapy and psychotherapy, addressing the diverse presentations of anxiety remains challenging. In this context, innovative interventions such as Transcranial Magnetic Stimulation (TMS) offer promise in improving existing treatment approaches, potentially providing relief where conventional methods fall short. In this article, I will explore the definition and diagnosis of clinical anxiety, the current methods of treatment, and how TMS may provide the key to improving treatment outcomes.
Anxiety
Anxiety is a broad term that, in psychiatry, encompasses a wide range of symptoms such as excessive worry, restlessness, irritability, difficulty concentrating, and sleep disturbance. There are a number of specific clinical anxiety disorders that are diagnosable only when several of these symptoms are present for more days than not over a 6 month period. These symptoms must also not be better explained by other psychiatric conditions such as bulimia, anorexia, or schizophrenia [1]. The most prevalent of these anxiety disorders is Generalised Anxiety Disorder (GAD), with studies estimating it to affect between 4 and 8% of the general population [2,3]. While GAD is common across all age and demographic groups, it has been shown to be twice as prevalent in females than males and often presents in early-to-mid adulthood [3]. Other GAD risk factors include having a family history of anxiety or other psychiatric disorders, childhood trauma, low socioeconomic status, and chronic illness.
Treatment for GAD is usually centred around a combination of prescription medications, such as benzodiazepines or selective serotonin reuptake inhibitors (SSRIs), and psychotherapy such as cognitive behavioural therapy. However, this approach does not work for everyone. Psychological interventions like psychotherapy, are often a long, arduous and expensive process, which many patients find overwhelming and difficult to commit to [4]. Medication, while having the potential to reduce symptoms within a relatively short amount of time, can often cause unwanted side effects such as fatigue, nausea, sleep disturbance, loss of libido, weight-gain, and addiction. Furthermore, recent research has found that 20-60% of psychiatric patients are treatment resistant, meaning that their prescribed medication will have little-to-no effect and may require alternative treatments [5].
TMS for anxiety
TMS is a noninvasive treatment that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of several psychiatric disorders. It is generally only prescribed to treatment-resistant patients who have already tried other methods such as medication or psychotherapy. It works by delivering electromagnetic pulses to specific areas of the brain, which can adjust brain activity and improve symptoms. In patients with clinical anxiety disorders, Functional magnetic resonance imaging (fMRI) studies have found hyperactivity in a part of the brain called the dorsolateral prefrontal cortex (DLPFC) [6]. TMS treatment of anxiety involves the stimulation of the DLPFC in order to increase activity in this area of the brain and reduce symptoms.
Research has shown TMS to be both safe and effective at reducing the symptoms of GAD. For example, one meta-analysis of 6 studies found that TMS applied to the DLPFC produced clinically significant reductions in self-rated anxiety scores in 97 patients, when compared with sham TMS [7]. These findings are supported by several other studies, finding that TMS was more effective than sham at reducing symptoms of anxiety in GAD patients [8], and depressed patients with comorbid anxiety [9].
TMS and medication for anxiety
While TMS treatment alone has been shown to be safe and effective at treating symptoms of anxiety, research has also found it to be a beneficial adjunct treatment for people already taking anxiolytic (anti-anxiety) medications such as benzodiazepines. One such study is a meta-analysis of 21 clinical studies involving a total of 1481 participants with clinical or comorbid anxiety disorders. In this study, TMS treatment combined with medication was shown to be more effective at reducing self-reported anxiety than medication alone [10]. Support for these findings comes from a recent RCT, in which Deep TMS (dTMS) was found to be more effective at treating GAD symptoms than both sham TMS treatment and anxiolytic medication [11].
TMS and therapy for anxiety
Similarly to pharmacological interventions like anxiolytic medication, TMS has been shown to be an effective adjunct treatment when combined with psychological interventions such as psychotherapy. While there is less published research on this topic, the available evidence shows clear support for treatment plans which combine the two approaches. For example, in one meta-analysis of 11 studies, researchers found that a combination of cognitive or behavioural interventions and TMS were more effective at reducing self-reported anxiety than each treatment alone, and significantly more effective than sham treatment combined with psychological interventions [12]. However, this analysis concluded that more research is needed in order to fully assess the efficacy of TMS combined with psychological interventions for the treatment of anxiety.
dTMS vs. rTMS for anxiety
While TMS, in general, has been shown to be a safe and effective treatment for patients with clinical depression, there are a number of different TMS systems available to patients, which use different treatment protocols and magnetic coils to provide stimulation. The most commonly used coil is known as the Figure-8 (F8) coil, which most TMS manufacturers use. However, there is a more advanced coil called the Hesed-coil (H-coil). The H-coil was patented by Brainsway and is used exclusively in Brainsway machines. The difference between these 2 coils is that the H-coil is able to stimulate deeper regions of the brain than the F8 coil, which is why H-coil TMS is often referred to as Deep TMS (dTMS). This difference is highlighted in the research, with one study finding that not only was dTMS more effective at reducing anxiety symptoms than sham TMS treatment, but it was also more effective than anxiolytic medication and rTMS using the F8-coil. H-coil dTMS treatment produced significantly higher response and remission rates than F8-coil treatment, and the benefits lasted longer [11].
Conclusion
In light of the multifaceted nature of anxiety disorders, the exploration of innovative therapeutic approaches becomes essential. Transcranial Magnetic Stimulation (TMS) emerges as a promising intervention, demonstrating efficacy in reducing anxiety symptoms, particularly when traditional treatments falter. Notably, studies highlight the effectiveness of TMS, especially Deep TMS (dTMS) with the H1 Coil, surpassing conventional methods such as pharmacotherapy and conventional TMS techniques. Moreover, the efficacy of its combination with pharmacological and psychological interventions underscores its potential as an adjunctive therapy in comprehensive treatment plans for anxiety disorders. As research continues to advance, further exploration into the nuances of TMS protocols and its integration with existing treatments holds promise in enhancing outcomes for individuals grappling with anxiety.
References
1. Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.15, DSM-IV to DSM-5 Generalized Anxiety Disorder Comparison. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t15/
2. Anxiety and generalised anxiety disorder (GAD) | Royal College of Psychiatrists. (2022, May). Www.rcpsych.ac.uk; Royal College of Psychiatrists. https://www.rcpsych.ac.uk/mental-health/mental-illnesses-and-mental-health-problems/anxiety-and-generalised-anxiety-disorder-(gad)
3. What are the risk factors for the development of generalized anxiety disorder? (2023, December). Clinical Knowledge Summaries; National Institute for Care and Health Excellence. https://cks.nice.org.uk/topics/generalized-anxiety-disorder/background-information/risk-factors/
4. Rozental, A., Castonguay, L., Dimidjian, S., Lambert, M., Shafran, R., Andersson, G., & Carlbring, P. (2018). Negative effects in psychotherapy: commentary and recommendations for future research and clinical practice. BJPsych Open, 4(4), 307-312.
5. Howes, O. D., Thase, M. E., & Pillinger, T. (2022). Treatment resistance in psychiatry: state of the art and new directions. Molecular psychiatry, 27(1), 58-72.
6. Song, P., Tong, H., Zhang, L., Lin, H., Hu, N., Zhao, X., Hao, W., Xu, P., & Wang, Y. (2022). Repetitive Transcranial Magnetic Stimulation Modulates Frontal and Temporal Time-Varying EEG Network in Generalized Anxiety Disorder: A Pilot Study. Frontiers in psychiatry, 12, 779201. https://doi.org/10.3389/fpsyt.2021.779201
7. Parikh, T. K., Strawn, J. R., Walkup, J. T., & Croarkin, P. E. (2022). Repetitive transcranial magnetic stimulation for generalized anxiety disorder: a systematic literature review and meta-analysis. International Journal of Neuropsychopharmacology, 25(2), 144-146.
8. Cui, H., Jiang, L., Wei, Y., Li, W., Li, H., Zhu, J., Pang, J., Wang, J., & Li, C. (2019). Efficacy and safety of repetitive transcranial magnetic stimulation for generalised anxiety disorder: A meta-analysis. General psychiatry, 32(5), e100051. https://doi.org/10.1136/gpsych-2019-100051
9. Clarke, E., Clarke, P., Gill, S., Paterson, T., Hahn, L., & Galletly, C. (2019). Efficacy of repetitive transcranial magnetic stimulation in the treatment of depression with comorbid anxiety disorders. Journal of affective disorders, 252, 435-439.
10. Cui, H., Jiang, L., Wei, Y., Li, W., Li, H., Zhu, J., Pang, J., Wang, J., & Li, C. (2019). Efficacy and safety of repetitive transcranial magnetic stimulation for generalised anxiety disorder: A meta-analysis. General psychiatry, 32(5), e100051. https://doi.org/10.1136/gpsych-2019-100051
11. Pell, G. S., Harmelech, T., Zibman, S., Roth, Y., Tendler, A., & Zangen, A. (2022). Efficacy of deep TMS with the H1 coil for anxious depression. Journal of clinical medicine, 11(4), 1015.
12. Vergallito, A., Gallucci, A., Pisoni, A., Punzi, M., Caselli, G., Ruggiero, G. M., ... & Lauro, L. J. R. (2021). Effectiveness of noninvasive brain stimulation in the treatment of anxiety disorders: a meta-analysis of sham or behaviour-controlled studies. Journal of Psychiatry and Neuroscience, 46(6), E592-E614.