Living with bipolar disorder can feel like a rollercoaster of emotions, with alternating periods of extreme emotional highs and lows. For many people, medications and therapy can provide relief, but not everyone finds these treatments effective or enough on their own.
Transcranial magnetic stimulation (TMS) offers a promising alternative for managing the depressive symptoms of bipolar disorder. This treatment is already FDA-approved for managing depression, and it’s non-invasive, non-pharmaceutical, and generally well-tolerated with minimal side effects.
In this article, we’ll explore what you need to know about TMS therapy for bipolar disorder, including how it works, what the research says, and who it’s suitable for.
What is bipolar disorder?
Bipolar disorder is a mental health condition that causes extreme fluctuations in a person’s mood and energy levels. People with bipolar disorder will experience episodes of mania – feelings of euphoria, energy, and impulsiveness – followed by depressive episodes of sadness, hopelessness, and low energy.
These mood changes can last days, weeks, or months. Although people with bipolar disorder may feel stable in between these episodes, the condition can be severe and affect a person’s life, work, and relationships.
According to the National Institute of Mental Health, approximately 2.8% of adults in the United States are diagnosed with bipolar disorder. Bipolar disorder typically emerges in the late teens or early adulthood, although it’s also possible to develop bipolar disorder later in life.
Types of bipolar disorder
There are three main types of bipolar disorder: bipolar I, bipolar II, and cyclothymia:
- Bipolar I: Bipolar I is defined by at least one full manic episode lasting a week or longer. For some people, this manic episode may be severe enough to require hospitalization and lead to significant impairment or psychosis. People with bipolar I can also experience depressive or hypomanic episodes.
- Bipolar II: Bipolar II involves at least one episode of hypomania (a less severe form of mania) that lasts at least four days, and one major depressive episode that lasts two weeks or more. Unlike bipolar I, bipolar II doesn’t involve manic episodes and its depressive episodes are often more frequent and severe. This type of bipolar disorder is more commonly diagnosed in females.
- Cyclothymia: Cyclothymia involves chronic mood swings with periods of hypomanic and depressive symptoms that don’t fully meet the criteria for manic or major depressive episodes. Although less severe than bipolar I or bipolar II, cyclothymia mood swings last at least two years in adults or one year in children.
Keep Reading: What’s Bipolar Disorder? How Do I Know If I Have It?
Bipolar disorder symptoms
The three main symptoms of bipolar disorder are mania, hypomania, and depression. Each type of bipolar disorder involves varying combinations and intensities of these symptoms, but a person must experience at least one period of mania or hypomania to receive diagnosis.
Mania symptoms
Mania is a state of heightened energy, impulsivity, and euphoria. It can also involve signs of psychosis like hallucinations or delusions.
Common signs of mania include:
- Feeling extremely euphoric or unusually irritable
- Speaking rapidly or jumping quickly between ideas
- Having racing thoughts
- Difficulty concentrating
- Acting impulsively, like overspending or making spontaneous life-changing decisions
- Sleeping very little or feeling no need to rest
- Experiencing an inflated sense of self-confidence or invincibility.
The impulsivity of mania can lead to risky actions, like driving recklessly, misusing substances, or engaging in unsafe sexual activities. While there are people who engage in these behaviors without having bipolar disorder, people with mania wouldn’t normally partake in these activities when their mood is stable.
Hypomania symptoms
Hypomania is a milder form of mania. It has many of the same symptoms but with lesser intensity. Hypomania doesn’t involve symptoms of psychosis and tends to be less disruptive to a person’s life and relationships.
People experiencing hypomania might feel unusually energetic or productive. Friends or family are often the first to notice hypomanic changes as those experiencing it will often just feel like they’re ‘on top of their game’.
Depression symptoms
Depression symptoms in bipolar disorder are often referred to as bipolar depression. This involves feelings of sadness, fatigue, lethargy, and lack of motivation.
Symptoms of bipolar depression include:
- Low mood
- Feelings of hopelessness
- Lack of interest in activities previously enjoyed
- Oversleeping or difficulty sleeping
- Changes in weight or appetite
- Difficulty concentrating or making decisions
- Thoughts of death or suicide.
The only difference between unipolar and bipolar depression is that bipolar depression involves periods of mania or hypomania.
Bipolar disorder treatment options
Treating bipolar disorder often involves a combination of medications, psychotherapy, and in some cases, alternative therapies like electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS).
Medications
Medication is the most common treatment for bipolar disorder. The type and dosage prescribed will depend on a person’s individual symptoms, however common medications include:
- Mood stabilizers: These medications help manage manic, hypomanic, and depressive episodes. They include lithium, valproic acid, divalproex sodium, lamotrigine, and carbamazepine.
- Antipsychotics: Antipsychotic medications are used to stabilize mood and manage manic or hypomanic episodes. These include olanzapine, risperidone, quetiapine, and aripiprazole.
- Antipdepressants: Adjunctive antidepressant treatment can be used cautiously to treat depressive symptoms, however they can sometimes cause manic or hypomanic episodes. For that reason, they’re often paired with mood stabilizers or antipsychotics.
- Antidepressant-antipsychotic combination: The medication Symbyax combines fluoxetine (an antidepressant) and olanzapine (an antipsychotic) to treat bipolar depression.
Of these medications, only 3 are approved for acute bipolar depression: Symbyax, quetiapine, and lurasidone.
Electroconvulsive therapy (ECT)
ECT is sometimes used to treat severe symptoms in people who don’t respond to medications. This treatment involves passing a small electrical current through the brain to trigger a brief seizure, which can help alleviate symptoms of mania or depression.
While ECT has sometimes been negatively portrayed in the media, it is a safe and effective treatment for bipolar disorder. A course of ECT is typically completed over 6 to 12 sessions.
Transcranial magnetic stimulation (TMS)
TMS is a procedure that uses magnetic pulses to stimulate nerve cells in parts of the brain linked to mood regulation. It is FDA-approved for major depressive disorder, which makes it an effective treatment option for those with bipolar depression.
The benefits of TMS is that it’s non-invasive and non-systemic, meaning it doesn’t require surgery or affect the whole body like medication does. It also has minimal side effects, which can make it effective in cases where people cannot tolerate medications.
See: TMS vs. ECT: Which is better?
What is Transcranial Magnetic Stimulation (TMS)?
TMS is a non-invasive, non-pharmacological therapy that uses magnetic pulses to stimulate targeted areas of the brain. It is FDA-approved for treating depression and obsessive-compulsive disorder (OCD), however research shows it can also be effective for a range of other mood disorders and neurological conditions – including bipolar disorder.
TMS therapy involves placing a specialized electromagnetic coil on the scalp. This coil generates magnetic pulses that target specific regions of the brain involved in mood regulation – in bipolar disorder, the focus area is often the left prefrontal cortex. Through a series of repeated sessions, TMS can restore normal brain function and alleviate symptoms of various conditions.
There are a few different types of TMS therapies:
- Repetitive transcranial magnetic stimulation (rTMS): This is the most common form of TMS. It involves delivering repeated magnetic pulses over 20-30 minute sessions.
- Theta burst stimulation (TBS): This is a faster, more high-frequency form of TMS that uses bursts of magnetic pulses to reduce session times.
- Deep transcranial magnetic stimulation (dTMS): This type of TMS targets deeper parts of the brain compared to rTMS, making it more effective for certain psychiatric disorders.
- Accelerated TMS (aTMS): This is a more intensive version of rTMS, involving multiple sessions per day over 1-2 weeks.
See: Short-Term and Long-Term Efficacy of Accelerated Transcranial Magnetic Stimulation for Depression
How does TMS work for bipolar disorder?
So far, the research into TMS for bipolar disorder has mostly focused on its ability to address depressive symptoms like persistent sadness, low energy, and difficulty concentrating.
Research indicates that TMS may help reduce:
- Feelings of hopelessness and sadness
- Restlessness or sluggishness
- Lack of interest in activities previously enjoyed
- Excessive sleep or lack of sleep
- Difficulty making decisions
- Appetite or weight changes
- Feelings of guilt, shame, or worthlessness
- Changes in appetite
- Suicidal ideation.
TMS is especially helpful in cases where a person hasn’t responded to traditional treatments, like medication, or experiences unpleasant side effects. One of the major benefits of the treatment is that it is generally well-tolerated with minimal side effects.
Research on TMS for bipolar disorder
Research into TMS therapy for bipolar disorder has primarily focused on its ability to manage depressive symptoms. While some studies have looked into how the treatment affects manic symptoms, the results are unclear or mixed. Here’s what we know so far.
In one 2019 review, TMS was found to significantly reduce depressive symptoms in bipolar disorder across multiple studies. The same research examined TMS’s effect on manic symptoms but found mixed results.
In 2020, an analysis found that 77% of participants with bipolar depression symptoms experienced a 50% or greater reduction in their Montgomery-Asberg Depression Rating Scale (MADRS) scores after undergoing TMS. Of those who participated in 25 or more sessions, 41% achieved remission, indicating little-to-no depressive symptoms.
TMS has been granted a ‘breakthrough device designation’ for bipolar disorder by the FDA. This essentially means that the FDA recognizes its potential and is accelerating a path for its formal review.
Continue Reading: How Successful is TMS Therapy?
What to expect from TMS treatments for bipolar disorder
TMS therapy for bipolar disorder typically involves 36 sessions spread over several weeks, with each session lasting around 20-30 minutes. Here’s what you can expect from the procedure:
- Preparation: You’ll start by sitting comfortably in a chair while your TMS technician explains the process and answers any questions.
- Placing the coil: An electromagnetic coil will be placed on your scalp, near your forehead. This coil targets specific brain regions linked to bipolar disorder symptoms.
- Brain mapping: During the first session, a brain mapping process helps identify the correct part of the brain to target and the ideal strength of magnetic pulses. This ensures treatment is effective and comfortable.
- Stimulation: Once the target area is identified, repetitive magnetic pulses are delivered to stimulate nerve cells and help address symptoms. These pulses are painless, though some people feel a slight tapping or tingling sensation against their scalp.
- Monitoring: Throughout the session, the technician will monitor your comfort and adjust the intensity of pulses as needed.
- Post-session: After the session, you can immediately resume your daily activities as usual, including driving yourself to work or school.
- Follow-ups: TMS therapy is administered over multiple sessions. The exact number will depend on your specific symptoms and response to treatment.
If you’re taking medications for bipolar disorder, you’ll likely continue using them during TMS therapy unless advised otherwise by your mental healthcare provider.
Potential side effects of TMS
TMS is a safe and non-invasive therapy with minimal side effects. Most people tolerate it well, and any discomfort is usually mild and temporary. It often subsides as the body adjusts to treatment over time.
That said, potential side effects of TMS include:
- Mild headaches
- Lightheadedness
- Neck or scalp discomfort
- Tingling or tingling sensations
- Drowsiness.
In extremely rare cases, TMS can trigger seizures in some people. This is unlikely to happen, however if you have any concerns don’t hesitate to discuss them with us before treatment.
Read More: TMS Side Effects: All You Need to Know
Who shouldn’t get TMS therapy?
TMS is not suitable for everyone. You may not be eligible for TMS therapy if you:
- Have a history of seizures, epilepsy, or other neurological conditions
- Are pregnant or breastfeeding
- Have experienced a traumatic brain injury, brain tumor, or stroke
- Are currently using stimulant medications.
TMS is also not recommended for people with non-removal metallic objects in the head or neck, such as:
- Deep brain stimulators
- Cochlear implants
- Aneurysm clips or coils
- Neck, brain, or heart stents
- Implanted electrodes
- Shrapnel or bullet fragments
- Vagus nerve stimulators.
The magnetic pulses in TMS therapy can interfere with these objects and pose a safety risk. Dental fillings and braces are safe and will not interfere with treatments.
If you’re unsure whether TMS is suitable for you, don’t worry. We will discuss the treatment with you in detail during your initial consultation to ensure it’s appropriate and safe for you.
Try TMS for bipolar disorder
If you or someone you know would like to explore alternative treatment options for bipolar disorder, our team at BestMind Behavioral Health is here to support you. We offer TMS therapy for bipolar disorder at our comfortable clinics in Colorado, Oregon, and Washington, where you’ll be supported by our compassionate and caring team of mental health professionals.
To discuss whether TMS therapy is a suitable treatment option for you, contact us now for a consultation.
