Express TMS® (Theta Burst Stimulation)
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Express TMS® (Theta Burst Stimulation)

Theta burst stimulation is a rapid, evidence-based treatment for mental health conditions

The National Institute of Mental Health (NIMH) estimates that 13.1 million adults in the United States experienced serious mental illness in 2019.1 These illnesses—which include psychotic disorders, bipolar disorder, autism, major depression, severe anxiety, and obsessive-compulsive disorder (OCD)—are classified as “serious” when they significantly interfere with an individual’s ability to function or engage in daily activities.2

Although clinicians consider medication and talk therapy to be gold-standard treatments for many of these illnesses, a large proportion of sufferers find that these traditional options do not provide full, long-term relief from troubling mental health symptoms. For instance, up to 30% of people with schizophrenia,3 70% of people with obsessive-compulsive disorder,4 and 10-30% of people with major depressive disorder5 do not improve after medication treatment. For these millions of people who do not respond to traditional treatment options, innovative therapeutic interventions may offer relief where other methods have failed.

For many, hope has come in the form of an innovative new therapy called transcranial magnetic stimulation (TMS), a painless, non-invasive treatment that conveys short magnetic pulses into areas of the brain that are associated with mental illnesses. TMS has already received approval from the Food and Drug Administration (FDA) in 2008 as a treatment for major depressive disorder6 and in 2018 as a treatment for OCD.7 Given the immense success of TMS as a treatment for these disorders, neuroscientists have sought to optimize the treatment protocol to address a wider range of mental health conditions with greater speed and efficacy.

A new form of TMS known as theta burst stimulation (TBS or Express TMS®) has also recently received FDA approval as a treatment for major depressive disorder.8 In general, the goal of TMS is to stimulate and regulate abnormally functioning brain cells, which may tend to over-activate, under-activate or otherwise activate in imbalanced patterns. Express TMS® is especially optimized to alter neural activation because the treatment protocol mimics the brain’s natural learning patterns.

As early as the 1980s, neuroscientists discovered that both rodents and humans exhibit a unique pattern of neural activation (called theta rhythms) while learning new information, such as exploring a new environment, doing a new task, or forming memories. During the theta rhythm, brain cells activate approximately every 30 milliseconds at a frequency of about 5-7 Hz.9 Scientists realized that a TMS procedure targeted to artificially induce these theta rhythms could stimulate long-term changes in brain cell activation, therefore helping the brain permanently learn to regulate brain cells and the patterns of brain activation related to mental illness.

During any TMS treatment session, a small wire coil is positioned directly above the targeted brain region, often the prefrontal cortex (the front area of the brain). This coil produces a magnetic field that painlessly stimulates electrical activity in the brain, typically applied at a low frequency for 20 to 40 minutes. In contrast, the unique TBS protocol rapidly applies higher-frequency bursts for a shorter duration (bursts of three 50-Hz magnetic pulses every 200 milliseconds for 20 to 40 seconds at a time), which imitates the brain’s natural physiological theta rhythm.

Like a standard TMS treatment course, patients typically complete five Express TMS® sessions per week for four to six weeks. However, while a conventional TMS session lasts 20-40 minutes, a session with Express TMS® may be as brief as 3 minutes, expanding treatment accessibility to patients with limited time and resources.

A large-scale clinical trial conducted in 2018 found that treatment with the Express TMS® protocol was equally effective to conventional TMS treatment among patients with major depressive disorder. After completing a full four-to-six-week therapeutic course of standard TMS or Express TMS®, both participant groups showed comparable improvements on the Hamilton Rating Scale for Depression (HRSD-17), a well-validated depression assessment tool, and reported similar side effects (typically a brief and mild). Critically, the Express TMS® protocol was considered more favorable because it is equally effective at less than one-tenth the duration of the standard protocol.10

Encouraged by the safety and efficacy of Express TMS® for major depressive disorder, neuroscientists have begun to study the protocol as a treatment for other mental health conditions. For instance a 2014 study found that treatment with Express TMS® reduced symptoms in schizophrenic patients significantly more effectively than standard TMS.11 Another study found that patients who were treated with Express TMS® for post-traumatic stress disorder (PTSD) were significantly less likely to experience a relapse one year after treatment then those who received a placebo TMS protocol.12 Express TMS® also has been found to decrease repetitive, compulsive behaviors associated with autism.13 Ongoing studies predict that Express TMS® will also treat other debilitating mental health conditions, including anorexia nervosa14 and obsessive-compulsive disorder (OCD),15 equally or even more effectively than the standard TMS protocol.

Both standard TMS and Express TMS® offer patients faster, more tolerable relief from troubling mental health symptoms than traditional medications, which can take months to reach full effectiveness and can be associated with unpleasant side effects. Yet only Express TMS® can rapidly alleviate symptoms in 90 total minutes spread over a six-week treatment course with few side effects.16 Although at this time Express TMS® is only FDA-approved as a treatment for major depressive disorder, ongoing research shows promise that the cutting-edge protocol will receive formal approval for a wide array of mental health conditions in the coming years. Recognizing the unparalleled benefits of this therapy, TMS Program is pleased to offer Express TMS® for our patients seeking immediate relief from the burden of mental illness.

1 National Institute of Mental Health. (2020). Prevalence of Serious Mental Illness (SMI). Retrieved from: https://www.nimh.nih.gov/health/statistics/mental-illness.shtml#part_154788

2 National Institute of Mental Health. (2020). Mental Illness. Retrieved from: https://www.nimh.nih.gov/health/statistics/mental-illness.shtml

3 Lally J, Gaughran F, Timms P, & Curran SR. (2016). Treatment-resistant schizophrenia: Current insights on the pharmacogenomics of antipsychotics. Pharmacogenomics Perspectives in Medicine, 9:117-129.  

4 How is OCD Treated? International OCD Foundation (2020). Retrieved from: https://iocdf.org/about-ocd/ocd-treatment/

5 Kellner M. (2010). Drug treatment of obsessive-compulsive disorder. Dialogues in Clinical Neuroscience, 12(2):187-197.

6 Horvath JC, Mathews J, Demitrack MA, & Pascual-Leone A. (2010). The NeuroStar TMS Device: Conducting the FDA-approved protocol for treatment of depression. Journal of Visualized Experiments, 45.

7 Food and Drug Administration. (2018). FDA permits marketing of transcranial magnetic stimulation for treatment of obsessive compulsive disorder. Retrieved from https://www.fda.gov/news-events/press-announcements/fda-permits-marketing-transcranial-magnetic-stimulation-treatment-obsessive-compulsive-disorder

8 Brooks M. (2018). FDA clears three-minute brain stimulation protocol for depression. MedScape Medical News. Retrieved from: https://www.medscape.com/viewarticle/911408

9 Hill AJ. (1978). First occurrence of hippocampal spatial firing in a new environment. Experimental Neurology, 62(6):282-297.

10 Blumberger DM, Vila-Rodriguez F, Thorpe KE, et al. (2018). Effectiveness of theta burst versus high-frequency repetitive transcranial magnetic stimulation in patients with depression (THREE-D): a randomised non-inferiority trial. The Lancet, 391(10131), 1683–1692.

11 Zhao S, Kong J, Li S, et al. (2014). Randomized controlled trial of four protocols of repetitive transcranial magnetic stimulation for treating the negative symptoms of schizophrenia. Shanghai Archives of Psychiatry, 26(1):15-21.

12 Petrosino NJ, Wout-Frank MV, Aiken E, et al. (2020). One-year clinical outcomes following theta burst stimulation for post-traumatic stress disorder. Neuropsychopharmacology, 45:940–946.

13 Abujadi C, Croarkin PE, Bellini BB, et al. (2018). Intermittent theta-burst transcranial magnetic stimulation for autism spectrum disorder. Brazilian Journal of Psychiatry, 40(3):309-311.

14 US National Library of Medicine. (February 2020 – ongoing). Theta burst stimulation in anorexia nervosa (ANTS). Identifier: NCT03984344. Retrieved from: https://clinicaltrials.gov/ct2/show/NCT03984344

15 US National Library of Medicine. (July 2019 – ongoing). rTMS in the treatment of obsessive-compulsive disorder. Identifier: NCT03649685. Retrieved from: https://clinicaltrials.gov/ct2/show/NCT03649685

16 Oberman L, Edwards D, Eldaief M, & Pascual-Leone A. (2011). Safety of theta burst transcranial magnetic stimulation: A systematic review of the literature. Journal of Clinical Neurophysiology, 28(1):67-74.