Suicide is a complex medical and social problem and takes a staggering toll on US public health claiming the lives of over 45,000 people annually. The problem is gradually worsening. Suicide rates went up more than 30% in half of the US since 1999. Any intervention attempting to reduce the risk of suicide should be considered and this document focuses on the possible use of TMS as an add-on intervention for the treatment of depression and suicidal behavior.
Many people who died by suicide are not known to have a diagnosed mental health condition. However, approximately 45% of individuals who died by suicide consult a primary care physician within one month of death.
Although there is no effective algorithm to predict suicide in clinical practice, improved recognition and understanding of clinical, psychological and biological factors may facilitate the identification of high risk individuals and assist in treatment selection. For more specific information the reader may like to review CDC and NIMH recommendations.
Psychotherapies (DBT, CBT), antidepressant medication (SSRI’s, venlafaxine, bupropion), lithium, clozapine, and neuromodulatory treatments (including TMS and ECT) can often prevent suicidal behavior.
TMS has shown efficacy as antidepressant intervention, was approved by FDA for the treatment of depression, consensus treatment recommendation have been published by psychiatric professional organizations and is widely use across the country in private practice and academic centers.
TMS affects brain cortico-limbic imbalances related to depression. Suicidal thinking also likely involves disrupted emotional regulation and executive function in cortico-limbic networks. Given the putative mechanism of TMS in restoring the balance of cortical networks, TMS holds promise as a rational, brain-based treatment approach for depression and suicidal thoughts.
There has been interest in examining TMS for suicidal thinking in adults (George et.al). Preliminary evidence indicates that high doses of repetitive transcranial magnetic stimulation applied to the left prefrontal cortex may be an effective treatment to rapidly decrease suicidal ideation (Hadley D. Anderson et.al). An open label TMS study in 19 subjects adolescents with depression and suicidal ideation (Croarkin et.al) suggested that TMS mitigated suicidal ideation and improvement of depressive symptom severity. Accelerated iTBS (a form of TMS) in depressed suicidal patients (Desmyter S et.al) decreased suicidal ideation in 12 subjects. A Study of 41 inpatients in suicidal crisis showed that those who received high-dose TMS three times daily for three consecutive days (by George et.al) showed lower and more rapidly declining scores in suicide scales in comparison to sham treatment. Daskalakis et al reported that TMS is effective in reducing suicidal thinking in a significant portion of people with hard-to-treat depression. Forty percent of people in the study reported that they no longer experienced suicidal thoughts after receiving TMS.
TMS treatment may provide secondary benefits such as daily interpersonal contact over 6-8 weeks with the treating psychiatrist and other TMS personnel and may also provide more structure and comfort, and may afford more opportunities to interact and monitor patient status, increasing the likelihood of identifying signs of possible suicide attempts.
TMS continues to evolve and deep TMS is now available making it possible to penetrate in the brain more deeply with still relatively low-invasive magnetic stimulation parameters. TMS is not a treatment of suicidality, although it is an important treatment of depression that many times presents with suicidal behaviors. According to some publications, up to 60% of suicides occur in the context of depressive disorder making TMS an important tool for clinicians and a great source of hope for patients.
Oscar G. Morales, MD
Senior Medical Advisor
Founder (2009) and Director McLean Hospital TMS
Faculty Psychiatry Residency Program
McLean Hospital – Massachusetts General Hospital MGH
Harvard Medical School