The Game Changer: Transcranial Magnetic Stimulation (TMS) for Depression Treatment in Athletes

By: Dr. Chris Taplin, MD, FRCPC, Psychiatrist

In the demanding world of sports, the spotlight often shines on physical prowess and performance, but the mental well-being of athletes is a critical component often overlooked. Depression, a silent adversary, has a prevalence in athletes between 10% and 30% which is in line with that of the general population¹. The pathway to depression is often multifaceted and may include the stress of competition, injury, performance expectations, and the pressure to balance sport and life responsibilities. In addition, for many athletes there continues to exist the stigma that depression or mental illness represents an inherent weakness in the individual rather than a common and treatable mental health condition that impacts millions regardless of where they come from or who they are.

With respect to treatment options. Traditional treatment for a clinical depression relies on medications or psychotherapy. However, both have significant limitations for athletes. Psychotherapy can be effective for mild to moderate depression with long-lasting benefits, but it can be hard to find the right type of therapy and the right therapist and it also takes longer to work. Medications are also an effective treatment for depression. The advantage is that they typically work faster but the side effect profiles are often problematic for athletes including physical fatigue, headaches, weight gain, sexual side effects and dizziness.

Enter Transcranial Magnetic Stimulation (TMS)

TMS is a proven treatment for depression and treatment-resistant depression (failed at least 2 anti-depressant trials). Response rates are high with more than 3 in 5 individuals with treatment resistant depression having a clinically significant response to treatment. TMS has been known to have antidepressant effects since 1995. However, it is only with recent advances in technologies, protocols, and dosing over the past 5-10 years that this treatment modality has shown consistency in its results for the acute treatment of depression. This led to its near-universal coverage by insurance providers in the United States. However, in Canada, TMS is not as well known and has only recently become available in the past 5 years through private clinics in most major cities in Canada. Previously, individuals could only access the treatment through research studies.

In addition to its proven benefits, TMS is particularly well-suited to athletes for 4 main reasons:

1. No weight gain or systemic side effects
2. Rapid improvement in symptoms:
   2. Recent accelerated protocols such as the SAINT protocol out of Stanford University have demonstrated 90 % remission of depression symptoms within 1 week². This allows high-performance athletes to continue with their pursuits unimpeded. In contrast, therapy shows gains over months and years while medications start to show a benefit within 4 to 8 weeks of reaching a therapeutic treatment dose.
3. No detriment to performance
   3. If anything, TMS has shown preliminary outcomes to potentially improve performance in terms of short-term memory tasks and focus³.
4. No special authorization required. Unlike some other treatments, there is no concern around the use of TMS with respect to doping and therefore, no special requirements or burdensome paperwork and scrutiny is required.

What are the common side effects?

The vast majority of individuals tolerate TMS without concern when it is appropriately delivered and titrated gradually. In our community clinic, there has been no dropouts due to tolerance.

1. Mild Headache / Scalp irritation
2. Fatigue
3. Transient Dizziness

What are the serious and rare side effects?

1. Focal seizure (Risk is 6 in 10, 000 patients treated)
2. Risk of switch to hypomania or mania
3. Syncope or vasovagal reactions

What are the contra-indications?

1. Conductive, ferromagnetic, or other magnetic sensitive materials implanted in the head or within 10 cm of the treatment coil. (Anything that is MRI safe is TMS safe).
2. Patients at high risk of seizure
   1. History of a seizure disorder, ongoing alcohol use disorder

What are the main barriers to TMS Treatment?

1. Cost:
   1. In Canada, TMS is often not covered under provincial healthcare plans and often is not covered under extended health benefit plans. Therefore, for an individual with treatment resistant depression, an acute treatment course can cost between $5,000 to $10, 000.
2. Time:
   1. An acute treatment course of TMS requires a significant time commitment from the individual upfront. Individuals generally require 30 to 50 sessions to achieve a clinical response. These sessions can be delivered over the course of anywhere between 1 week to 6 weeks.

In Summary

Transcranial Magnetic Stimulation is making a significant impact for individuals with depression. It is an ideal treatment for athletes given its efficacy and favourable side effect profile. If you have a client who is not responding to or not interested in traditional treatments for depression, then I would highly recommend considering TMS as a treatment modality. Mental Health Clinics specializing in TMS treatment are now available in most major Canadian cities. Any questions about TMS may be directed to our clinic e-mail at info@tmslife.com and we will get back to you as soon as possible.

Webpage: www.tmslife.com

LinkedIn: www.linkedin.com/in/chris-taplin-psychiatrist/

References

1. Reardon, C. L. (2017). Psychiatric comorbidities in sports. Neurologic Clinics, 35(3), 537-546.
2. Cole, E. J., Stimpson, K. H., Bentzley, B. S., Gulser, M., Cherian, K., Tischler, C., … & Williams, N. R. (2020). Stanford accelerated intelligent neuromodulation therapy for treatment-resistant depression. American Journal of Psychiatry, 177(8), 716-726.
3. Luber, B., & Lisanby, S. H. (2014). Enhancement of human cognitive performance using transcranial magnetic stimulation (TMS). Neuroimage, 85, 961-970.