Depression is a well-known, widespread mental health disorder.  Traditionally, treatment has consisted of medications or talking therapies, but these are not fully effective for everyone.  A significant number of people continue to suffer daily from the impact of depressive illness.  This increase in the prevalence of major depressive disorder has driven a movement towards exploring alternative ways of combating this debilitating condition.  Two of the most promising developments are Transcranial Magnetic Stimulation (TMS) and Spravato®.  Both of these treatments have proved effective when used alone, and by combining the two treatments, it is possible to deliver a more effective long-term option for the management of depression.

Understanding Depression

According to Mental Health America (2024), around 21 million adult Americans and 3.7 million teens are impacted by depression every year.  Major Depressive Disorder (MDD) can become so severe that it starts to impact multiple areas of life.  The key symptoms of a depressive illness are:

• Feeling overwhelmingly sad, anxious, empty or emotionally numb
• Overwhelming fatigue/exhaustion
• Sleep problems – early waking, difficulty getting to sleep, waking during the night
• Appetite/weight loss or gain
• Feeling restless, irritable or quick to anger
• Loss of joy in life, with reduced interest in activities and hobbies
• Loss of libido
• Physical symptoms, such as pain in the body or digestive issues, that do not respond to treatment and for which no other cause is found
• Cognitive issues – difficulty remembering, lack of focus, brain fog
• Feelings that life is hopeless, low self-worth, feeling hopeless or guilty
• Thoughts of self-harm, suicide and death

Traditional treatments include antidepressant medications.  The most popular are selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).  These act on the neurotransmitters (chemicals) within the brain and may help lift mood and reduce anxiety.  Along with psychotherapies, these are often the first option given to people who have depression.  They are effective for many people, but a significant number of people experience less effective results.  The medications can take some time to start working and may produce unwanted side effects in some people.

 

Transcranial Magnetic Stimulation (TMS)

The FDA has approved Transcranial Magnetic Stimulation for the treatment of depression, and it has been used with consistently good results since 2008.  Over the years, there have been multiple research studies that have confirmed the efficacy of the treatment, with over two-thirds of people achieving long-term relief of depressive symptoms.

Unlike traditional forms of medication, TMS does not produce any system-wide side effects.  TMS is non-invasive, and there is no need for any anesthesia or sedation.    During a TMS session, magnetic pulses are delivered via an electromagnetic coil.  This coil is placed against the scalp and can help stimulate specific brain areas.

How does TMS Work?

For people with depression, TMS is used to target the pre-frontal cortex, which is the brain region associated with mood regulation.  In depression, there is often a simultaneous need to stimulate activity in the left dorsolateral pre-frontal cortex (DLPFC).  The magnetic pulses stimulate the neurons within the brain to become more active.  The result is elevated mood and a reduction in the cognitive impact of depression.

Additionally, TMS has been shown to help regulate some of the neurotransmitters directly implicated in depression, serotonin and dopamine.  TMS treatment can increase these chemicals’ production and reuptake without the systemic effects experienced with pharmacological solutions, which can be significant for some people.

What is Spravato®?

Spravato® is a nasal spray containing a drug called esketamine.  This drug is a derivative of ketamine, which the FDA approved in 2011 for patients with treatment-resistant major depressive disorder.   Spravato®  is usually given alongside a traditional oral antidepressant.  The main benefit is that it acts exceptionally quickly, with people reporting relief hours or days after starting the medication.  This speed of action is in marked contrast to traditional oral or antidepressants, which slowly build up over time.

How Spravato® works

Esketamine is a type of drug known as an NMDA receptor antagonist.  Put simply, it blocks the action of a chemical within the brain (glutamate).  This chemical helps the brain develop new pathways (plasticity) and increases communication between brain cells.  The effectis that there is an increase in communication between nerve cells.  By affecting glutamate, Spravato® causes an increase in a protein that increases the growth and connection of nerve cells within the brain.  Brain-derived neurotrophic factor (BDNF) helps keep the brain cells connected and healthy so they function at full capacity.  This capacity is often lacking in depressive illness.  In this way, Spravato® brings a rapid improvement in the symptoms of depression.

Several clinical trials have shown that Spravato® is hugely effective when used with oral antidepressants, particularly for people whose depressive illness has been resistant to the usual treatments.  It is particularly quick to act on ideas of suicide and preoccupations with death.

TMS and Spravato® – a winning combination

The combination of Spravato® with TMS provides a synergistic effect, maximizing the potential of both modes of treatment to help people with treatment-resistant depression.

Triple action impact of TMS and Spravato®

 

Neural Pathways

TMS and Spravato® target different neural pathways and work on different chemicals within the brain.

TMS – affects the production of dopamine and serotonin by magnetic stimulation of the pre-frontal cortex, the area of the brain associated with mood regulation.

Spravato® – impacts the action of glutamate to increase the production of a protein within the brain that rapidly increases the development of new neural pathways.

Increasing Neuroplasticity

TMS and Spravato® work together to amplify the effect of both treatment methods.  This complementary effect leads to fast, sustained improvements in mood.  It helps relieve cognitive symptoms like brain fog and loss of focus.

TMS – increases activity within the brain by stimulating cells within the pre-frontal cortex and encouraging the development of new pathways within the area of the brain associated with low mood.

Spravato® – increases connections within the brain by stimulating the release of the BDNF.

Complementary speed of action

Combining the two treatments can offer the benefits of both immediate and long-term effects.

TMS is delivered over several weeks to produce a gradual onset but long-lasting benefits.

Spravato® – provides rapid relief of symptoms, which can be critical for people in severe distress, including those with thoughts of suicide.

The combination of Spravato® and Transcranial Magnetic Stimulation, alongside oral antidepressant medication, is a new hope for people with treatment-resistant depression.

Starting on Spravato®

The first step is a full assessment by our trained medical professionals.  This assessment looks at the severity of the depression, the impact of previous treatments and the duration of the illness.  It will take a complete medical history to identify any conditions that may make the individual unsuitable for Spravato® therapy.  The success of the treatment is most likely in patients who meet the criteria for inclusion in the program.

Combining Spravato® and TMS

Our team will establish an individualized program for delivering and integrating Spravato® treatment and Transcranial Magnetic Stimulation.

Spravato® administration

Starting the Spravato® aims to give the patient rapid relief from the unpleasant symptoms of depression.  Its speed of action makes it ideal for patients who are losing hope or starting to focus on thoughts of suicide.  The medication is a nasal spray taken twice weekly at the center.

Concurrent/subsequent TMS

An individualized program of TMS treatments can start during or after the first Spravato® therapy.  TMS therapy is given daily as an outpatient for several weeks.  It is monitored and evaluated for effectiveness throughout the course of treatment and adjusted as necessary.

Monitoring the treatments

TMS and Spravato® have few side effects and are well tolerated by most patients, and all patients are monitored during their treatment.  Patients are observed for all the main side effects:

• Spravato® can cause dizziness and raised blood pressure.
• TMS can cause scalp discomfort during treatment. Some patients report a mild but rapidly resolving headache following TMS.

Maintaining results

All patients are offered regular follow-up appointments, which look at the effectiveness of the therapy and any potential side effects.  The need for maintenance sessions, if any, will be discussed at this time.  These appointments are essential to ensure the treatment plan can be adjusted to give the patient the most effective and sustained benefits.

Booking treatment at the Southern Colorado TMS Center

The Southern Colorado TMS Center has been at the forefront of the delivery of Spravato® and Transcranial Magnetic Stimulation (TMS) therapies since 2011.  Our team of trained clinicians specialize in planning and delivering effective treatment regimes.  We understand that by combining the unique mechanisms of both therapies, we can offer our clients a more effective, complementary and comprehensive treatment for resistant depressive illness.  If you are suffering from this debilitating condition, don’t hesitate to get in touch with us today.  We offer a free, no-obligation consultation with a member of our specialist team to discuss your personal needs or those of a family member.

We look forward to helping you on your journey to better mental health.