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    The Use of TMS and Benzodiazepines for Depression

    The Use of TMS and Benzodiazepines for Depression

    Author: GIA Miami
    Published: June 21, 2022

    At Gia Miami, we specialize in repetitive transcranial magnetic stimulations - rTMS or TMS for short. It's a mouthful, but if you're new to TMS, don't let the long name put you off. TMS treatment is a novel, evidence-based therapy that is also non-invasive and painless. It employs magnetic pulses of equal size and strength to a standard MRI machine.

    rTMS has been FDA-approved for the treatment of:

    • Major depressive disorder
    • Anxiety disorders
    • PTSD
    • Substance use disorders

    rTMS clinical trials have shown particular success in alleviating the symptom severity of treatment-resistant depression. Therapists across the country have begun prescribing transcranial magnetic stimulation for clients with depressive symptoms that aren't getting significantly better with historic treatment methods, are at risk of addiction to sedatives, or are at risk of retraumatization from talk therapy.

    How Repetitive Transcranial Magnetic Stimulation Treatment (RTMS) Works

    In a standard rTMS treatment session, the client is comfortably seated or reclined while the healthcare professional fits a magnetic coil onto the top of their head and calibrates the machine to the individual. Over the next 30-40 minutes, the doctor will apply approximately 3,000 fast magnetic pulses, typically to the prefrontal cortex - the part of the brain that becomes dysregulated in individuals who live with major depression.

    Research is still looking into the exact mechanism by which rTMS works. Currently, theory stipulates that this intervention has a therapeutic effect on the way neurons in this section of the nervous system fire, treating dysregulation at its physiological root, and returning the client to mental health.

    Do I Need to Discontinue Medication?

    Major depression is highly comorbid with a variety of other mental health disorders. Generalized anxiety disorder and depression are the classic cases, with the prevalence of both conditions manifesting in one individual estimated to be as high as 60%. In medical practice, this means that care needs to be taken to assess all of a client's concurrent treatment methods and medications before prescribing any therapeutic intervention for a single symptom cluster.

    Benzodiazepines are one such therapy that we need to pay attention to. They are among the more commonly prescribed medications in the mental health world, useful in treating anxiety, panic disorder, alcohol addiction, seizures, acute spasms, sleep disorders, and sometimes benzodiazepine addiction itself. In our practice, this means that many of our potential clients who come to us looking for support with treatment-resistant major depressive disorder or breakthrough symptoms are either currently using benzodiazepines or will soon be prescribed them.

    What does that mean for rTMS treatment? The two most common questions are:

    • Is it safe for patients undergoing rTMS therapy to continue the use of psychotropic medications?
    • Do benzodiazepines affect the clinical outcome of TMS therapy?

    These concerns need to be addressed one at a time.

    Concomitant Medication Use and rTMS Treatment Safety

    It's natural and wise to have safety concerns about combining more than one type of therapeutic brain intervention at once. The good news is that because rTMS is a generally well-tolerated, non-invasive, non-pharmaceutical treatment, it does not interact chemically with any other medications that a client is taking. The most typical side effects for rTMS treatment (if any are experienced at all) include scalp tingling, momentary lightheadedness, and mild headaches - not experiences that can dangerously augment pharmaceutical side effects for patients taking benzodiazepines or antidepressant medication.

    Benzodiazepine Use and TMS Therapy Clinical Outcome

    Safety is one thing, but clients should also be concerned about whether their rTMS treatment outcomes are affected, for better or for worse, by concomitant medication.

    TMS treatment was first developed almost 40 years ago, and the wealth of research looking into the many permutations of therapeutic interactions is growing, but unfortunately in medical time, that means it is still a reasonably young treatment. Many studies have delved into and proven the effectiveness of repetitive transcranial magnetic stimulation as a 'monotherapy' (undergone on its own) and in combination with antidepressants, but the research into its outcomes combined with sedatives paints a less conclusive picture.

    No Effect

    In a short metanalysis published in the journal Brain Stimulation's 'correspondence' section in 2020, Fitzgerald et al looked at data from two separate recently completed clinical trials with a collective pool of 185 subjects undergoing TMS therapy. Their research group found that benzodiazepine use had:

    • No effect on MADRS scores comparing patients and their levels of experienced depression
    • No effect on response rate to treatment.

    What's more, their subject pool included many types of rTMS treatment and different sedative dose frequencies (ie: regularly or 'as needed'). They found that despite all these different combinations of factors, benzodiazepine use never had any impact on rTMS outcome for these two treatment groups.

    Slow-Down Effects

    In one of the larger-scale studies looking into how to enhance rTMS treatment outcomes, published in 2019, Kaster et al saw a pattern in rTMS clients:

    • Some responded to treatment of major depressive symptoms quickly (rapid response)
    • Some responded in a steady (linear) way

    What was significant about their findings with regards to benzodiazepine use was that TMS study subjects who were using benzodiazepines were far less likely to find themselves in the rapid response group. In other words, their evidence points toward the conclusion that mixing TMS and benzodiazepines may slow down the time it takes for the effectiveness of repetitive transcranial magnetic stimulation to sink in.

    Reduced Effects

    In a study that compared the clinical response to rTMS therapy between one group of 73 subjects taking concurrent lorazepam (Ativan) and 176 subjects taking no sedatives, Deppe et al found that depression scores were far lower after treatment for the unmedicated group. Specifically, their findings were:

    • Only 18% of individuals on lorazepam experienced a greater than 50% reduction in symptoms, compared to
    • 38% of individuals not taking benzodiazepines who had the same rTMS treatment outcome

    In other words, they found that mixing TMS and benzodiazepines reduced the likelihood of an excellent clinical outcome by no less than 20%.

    So What Should I Do?

    To conclude, individuals who want to look into treating major depression with magnetic stimulation rTMS treatment but have safety concerns about their anti-anxiety medication should understand that there is no evidence for health complications related to mixing these two therapies.

    However, keep in mind that some studies have associated poorer clinical outcomes for rTMS in clients who continue taking these medications. At the end of the day, the research looking at the relationship between benzodiazepine use and rTMS outcome has not been conclusive, so it is important to tread carefully. If you would like to discontinue benzodiazepine use in order to get the most out of your treatment period, make sure that you consult with your medical practitioner first.

    At Gia Miami, advancements in addiction science inform optimal clinical practice, and each and every client's individual case is addressed with care. If you are concerned about your treatment outcomes combining TMS and benzodiazepines, we can offer advice and support aimed at giving you the best course of treatment possible regardless of your decision.

    We also offer a range of outpatient treatment modalities administered by renowned treatment specialists that can supplement and augment your experience with us and provide long-term non-pharmaceutical strategies for building your resilience against anxiety for good. For more information about how we can serve you, feel free to contact our 24-hour line at 561-462-4099.

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