Can TMS be Used to Treat Bipolar Disorder?

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What is Bipolar Disorder?

Bipolar disorder is a mental health condition that causes extreme highs (mania or hypomania) and lows (depression) in emotion as well as changes in sleep, activity, thinking, and behavior. It was formerly known as manic depression.

About 5.7 million adult Americans, or 2.6% of the population, suffer from bipolar disorder.¹ You may experience euphoric mood swings and bursts of greater productivity if you have bipolar disorder. But, unfortunately, this high is always followed by an emotional collapse, often leaving you feeling depressed, worn out, and possibly involved in legal, financial, or relationship issues.

Bipolar disorder comes in various forms with different symptoms, including mania or hypomania and depression. Below are the three main types of bipolar disorders:

• Bipolar I disorder: At least one manic episode has occurred in your life, possibly preceded or followed by severe depression or hypomanic episodes. Sometimes mania can induce psychosis, causing you to lose track of reality.
• Bipolar II disorder: A milder form of mood elevation, which alternates between times of extreme depression and milder hypomanic episodes.
• Cyclothymic disorder: Brief periods of depression interspersed with bursts of hypomania, although not in the same manner or for as long as full hypomanic or full depressive episodes.

Hypomania and mania have similar symptoms while being two distinct types of episodes. Nonetheless, mania is more severe than hypomania, leading to more obvious problems with interpersonal relationships, jobs, academics, and social interactions. In addition, mania-related psychosis might necessitate hospitalization.²

For both manic and hypomanic episodes, three or more of the following symptoms are present:

• Unusually happy, jittery, or wired
• Increased energy, activity, or irritability
• Inflated sense of happiness and confidence (euphoria)
• Less sleep required
• Unusual chattiness
• Flustered thinking
• Distractibility
• Making poor choices, such as shopping binges, sexual risks, or poor investment choices

The symptoms of a major depressive episode are severe enough to significantly interfere with daily activities, including job, school, social interactions, or romantic relationships. Five or more of the following symptoms constitute a depressive episode:

• Depressed mood: sadness, emptiness, hopelessness, or tears
• Irritability can be a sign of depression in children and teenagers
• Loss of interest in or lack of enjoyment in all, or nearly all, activities
• Significant weight loss, weight gain, or change in appetite (failure to gain weight as expected in children may indicate depression)
• Sleep issues
• Agitation
• Sluggish behavior
• Fatigue or a decrease in energy
• Self-doubt or excessive or inappropriate feelings of guilt
• Reduced capacity for thought or concentration, or indecision
• Suicidal ideation, preparation, or attempt

Treatments for bipolar disorder primarily include both medication and counseling. The following are all options for treating bipolar disorder:

• Cognitive Behavioral Therapy (CBT): Understanding the relationships between concepts, emotions, and behaviors is the goal of this evidence-based approach. Before changing how you think about a situation to change how you react to it, you and a therapist decide on goals together.
• Family-Focused Therapy: Your loved ones will attend therapy sessions with you, including psychoeducation about bipolar disorder, training in improving communication, and instruction in problem-solving techniques.
• Group Psychoeducation: A group facilitator guides the gathering of individuals with bipolar disorder, frequently joined by family members. Some groups have a strict agenda that focuses on education and skill development. Others are focused on sharing one’s experiences and soliciting advice from those who have faced similar challenges.
• Interpersonal and Social Rhythm Therapy (IPSRT):³ During this individual therapy, you’ll record daily, the times you go to sleep, wake up, what you do, and how your moods are affected by changes to these routines. The clinician advises you on managing daily routines and sleep-wake cycles to stabilize moods. Along with identifying one or more interpersonal problem areas, you and your therapist also discuss potential preventative actions to avoid the recurrence of the same problems.
• Dialectical Behavior Therapy (DBT): Individual and group treatment are included in DBT. It offers techniques for mindfulness and acceptance, such as how to accept your thoughts, feelings, and associated physical sensations in the moment. Also, it teaches you how to manage your emotions, put up with discomfort, and effectively interact with others.
• Medications: Certain mental health medications can be used to treat the symptoms of bipolar disorder. You may need to test out several different ones with the assistance of a healthcare professional before determining which one is most effective.
• Electroconvulsive Therapy (ECT):⁴ ECT aims to shock the brain with tiny electrical shocks to startle it into a brief seizure that will reset its chemical balance. Even while it’s still a last-resort option when therapy and medications have failed, the process is now much better managed, safer, and has fewer dangers and side effects.
• Transcranial Magnetic Stimulation (TMS):⁵ TMS for bipolar disorder is a non-invasive procedure that stimulates cells in parts of the brain by delivering electromagnetic pulses using an electromagnetic coil. These pulses can control brain activity in specific regions, potentially returning them to normal. Restoring the stability and balance in the brain helps reduce symptoms associated with the condition.

TMS Treatment for Bipolar

Transcranial Magnetic Stimulation, or TMS, is a non-invasive alternative therapy that uses electromagnetic fields to activate brain regions that aren’t functioning well. A small coil is positioned over the head throughout the treatment. Without obstructing the scalp and bone, the magnetic field produced by the coil’s electric current can influence the activity of the nerve cells. In addition, the magnetic pulses’ position, magnitude, and frequency affect the magnetic stimulation.⁶

You’ll be led to a treatment area, instructed to sit in a recliner, and given earplugs to wear throughout the process. Next, the TMS psychologist will place an electromagnetic coil against your scalp close to the forehead during treatment of about 20 to 40 minutes. The electromagnet then produces a steady stream of painless magnetic pulses, activating specific areas of the brain.

The electromagnetic coil will frequently turn on and off, creating stimulating pulses. This causes a tapping or clicking sound for a short period before pausing. The tapping feeling will also be felt on the forehead, a procedure known as mapping.

The doctor will gradually increase the magnetic dose until your fingers or hands begin twitching to calculate the necessary amount of magnetic energy. This is called the motor threshold and is a benchmark for finding the appropriate dose. Depending on symptoms or adverse effects, the brain stimulation level can be adjusted throughout bipolar TMS treatment.⁷

According to some studies, some patients with bipolar disorder have benefited from repetitive transcranial magnetic stimulation (rTMS), particularly when initial treatment is followed by maintenance therapy. In this case, rTMS for bipolar disorder is initially administered several times per week and then reduced to once weekly. Treatment is then maintained by receiving it once every few weeks or months. Maintenance therapy is especially helpful in preventing relapse or remission for those who have not responded to conventional treatments.

TMS treatment for bipolar disorder helps you get the most out of supplementary treatments like psychotherapy by reducing the symptoms of depression. Furthermore, TMS may make bipolar medications more effective.

To treat bipolar depression with TMS, the left prefrontal cortex may be stimulated, while the right prefrontal cortex may be inhibited.⁸ It has been suggested that right-sided cortical activity is reduced in bipolar mania while left-sided activity is comparably increased. Also, when the right prefrontal cortex is engaged, TMS might have therapeutic effects on mania.⁹ According to this theory, low-frequency TMS promotes cortical inhibition, while high-frequency TMS induces cortical stimulation.¹⁰

According to a review of studies published in 2019, studies investigating rTMS for depressive symptoms showed promise. However, studies investigating its use for manic episodes were conflicting.¹¹

Furthermore, in a 2020 study, researchers evaluated 44 persons with bipolar disorder who received TMS and were experiencing depressive symptoms. There were no participants available who met the criteria for mania. The following outcomes were noted:

• 77% of respondents satisfied their response criteria
• 41% of patients with at least 25 treatments met remission criteria

Of those who began the trial, four (10% of the study participants) stopped TMS therapy for bipolar disorder because they were worried about their mania being triggered.¹²

Insurance may be able to help cover the cost of TMS.

Athena Care is in-network with most major insurance plans. Find out more about your insurance coverage by calling your insurance company or by contacting us below. One of our care coordinators can help you navigate your insurance coverage to get the care you need.

When Should TMS be Used to Treat Bipolar?

Researchers have noted that those who have not responded to psychological or pharmaceutical intervention may benefit from TMS for bipolar disorder. However, TMS only has FDA approval for adults between 18 and 70 who have major depressive disorder or obsessive-compulsive disorder (OCD) and have not responded to conventional treatments.

Fortunately, the FDA designated TMS as a “breakthrough device” in 2020 for treating bipolar disorder. Although it is not a formal approval, this shows interest, is often supported by data, and offers an expedited route for FDA review.¹³

Although there is evidence of its overall effectiveness and safety, there is a necessity for additional clinical trials and research to thoroughly comprehend the efficacy and safety of TMS therapy for bipolar disorder.¹⁴

How Will I Know TMS Treatment for Bipolar is Working?

Treatment for most mental health disorders requires a time commitment. In addition, it’s essential to attend all treatment sessions and take any medication(s) as directed.

Some individuals won’t see any changes until many weeks following treatment, while others may quickly notice an improvement. For example, you may notice a decrease in your depressive symptoms. On the other hand, it’s possible that some patients won’t notice any changes or improvements at all.

Are There any Side Effects or Risks of Using TMS for Bipolar?

According to research, most TMS side effects are mild to moderate, if they occur at all. However, they may consist of the following:¹⁵

• Headaches (most common)
• Lightheadedness
• Scalp pain
• Neck pain
• Tingling
• Face twitching
• Sleepiness
• Altered state of mind during treatment
• Seizures (most rare)¹³

There is a slight chance that TMS will induce mania. However, research has shown that this risk is comparable to any selective serotonin reuptake inhibitor (SSRI) in a person with bipolar depression. While it is possible to induce mania, some case reports have shown that it does not happen suddenly. As long as parameters are well monitored, research has shown that TMS for bipolar depression is an efficient and secure solution.¹⁷

Who Should Avoid TMS for Bipolar Treatment?

People with certain medical implants should avoid TMS therapy for bipolar disorder. Metal implants or gadgets that interact with magnetic fields can cause complications. In addition, you may not be eligible for TMS if you have stents, implanted stimulators, a pacemaker, a medicine pump, cochlear implants, or gunshot fragments in your body.

Metal in areas that exceed 10cm from the head is usually acceptable.¹⁸ Additionally, people with certain medical issues, like a history of seizures and brain damage, should avoid TMS. Those who are pregnant should also avoid bipolar TMS treatment.

Finally, inform your TMS administrator about any prescription or over-the-counter medications, supplements, or vitamins you are taking. Certain drug combinations can cause serious complications. It’s crucial to discuss the above concerns with your doctor before TMS therapy for bipolar disorder.

Cost & Insurance Coverage for TMS for Bipolar

The following are average costs for bipolar TMS treatment. These costs may vary by location and other factors. Therefore, they may not reflect the actual price you’ll pay in Tennessee.

Because TMS for bipolar disorder is not yet FDA-approved, many insurance companies will likely not provide coverage. TMS treatment typically costs between $400 and $500 a session.¹⁹ The overall cost may be around $15,000 because most patients require numerous sessions to reach desired results.

Athena Care has multiple TMS treatment clinics in Tennessee. We are also in-network with most major insurance plans. Therefore, filling out our free and confidential online insurance verification form is the best way to obtain all the information needed to begin TMS therapy for bipolar disorder.

Allow our highly experienced, knowledgeable care coordinators to handle the challenges of contacting your insurance carrier for more information about your coverage. After submitting the no-obligation form, a care coordinator will review your policy and explain your options. Any information you provide or discuss will remain confidential.