What is rTMS + evidence

Transcranial magnetic stimulation (TMS) is a procedure which uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of major depression. It’s called a “non-invasive” procedure because it is done without surgery or cutting the skin. Approved by the U.S Food and Drug Administration (FDA), and its Australian counterpart the TGA, TMS is only funded by Medicare for treatment of depression when other depression treatments haven't been effective but is available privately for a wider range of uses.

The FDA (but not yet the TGA) has also approved TMS for obsessive-compulsive disorder (OCD), migraines and as an aid in helping people stop smoking when standard treatments haven't worked well. Research continues into other potential uses for TMS. When used for depression, OCD and to stop smoking, this treatment involves delivering repeated magnetic pulses, so it’s called repetitive TMS or rTMS.

Guidelines for rTMS use in treatment not only of depression but also schizophrenia and chronic pain are published in the Australia and New Zealand Journal of Psychiatry (Hussain et al., 2024). Further studies are promising and ongoing regarding the efficacy of rTMS for treatment of PTSD, anxiety, eating disorders and chronic pain.

Additionally, the evidence for use of rTMS specifically in treatment of depression is reflected in multiple clinical practice guidelines, eg. the RANZCP Clinical Practice Guidelines of Mood Disorders (Malhi et al., 2015). Real world studies featuring patients with treatment-resistant depression place response rates in the order of 50% (Fitzgerald et al., 2016; Slotema et al., 2010) and these patients experience a reduced burden of disease as a result (Brunoni et al., 2017)

Why it's done

Depression is a treatable condition, but for some people standard treatments aren’t effective. rTMS may be successful when standard treatments such as medicines and psychotherapy (talk therapy) don’t work.

Risks

rTMS is a non-invasive form of brain stimulation. Unlike vagus nerve stimulation or deep brain stimulation, rTMS does not require surgery or the implanting of electrodes. And, unlike electroconvulsive therapy (ECT), rTMS doesn’t cause seizures or memory loss. It also doesn’t require the use of anaesthesia. Generally, rTMS is considered safe and well-tolerated, however, it can cause some side effects.

Common side effects

Side effects are generally mild to moderate and improve shortly after a session. Side effects decrease over time with more sessions.

Side effects may include:

  • Scalp discomfort and pain.

  • Headaches.

  • Tingling, spasms and twitching of facial muscles.

  • Light-headedness.

If your side effects persist, your rTMS treatment can be adjusted or your doctor may recommend that you take an analgesic before the procedure. In some rare cases, if headaches or migraines cannot be managed, treatments might need to be stopped.

What you can expect

rTMS is usually done in The Sherpah Clinic. It requires a series of treatment sessions to be effective. Generally, sessions are carried out daily, five times a week, for four to five weeks.

Your first treatment

At the commencement of your treatment, your doctor will identify the best personalised treatments settings for you. This is known as “mapping” and is usually done during your first appointment which may last up to an hour. Mapping is then re-done at intervals throughout the course of your treatment.

Here’s what you can expect during mapping:

  • You’ll be seated comfortably in the treatment room and offered earplugs to wear during the procedure.

  • An electromagnetic coil will be placed against your head and switched off and on to produce stimulating pulses. This results in a tapping sensation on your head and a clicking sound, followed by a pause.

  • The coil will be moved around your head and the energy level adjusted to find the location that causes the fingers or hands to twitch.

  • Once the location is found, a second process of finding the “resting motor threshold” occurs. Strong and weak pulses alternate to determine how much energy is needed to move your fingers or thumb a desired amount.

During each treatment

The determination of the treatment settings to provide the best outcome for you occurs during the first treatment. For subsequent treatments, the coil is positioned according to these pre-determined measurements. The settings are marked onto a treatment cap. These settings are generally revisited at intervals during the course of your treatment.

Here’s what to expect during each treatment:

  • You’ll sit in a comfortable chair, with the magnetic coil placed against your head. The location of the coil for treatment is different from the location where the coil makes your fingers or thumb move.

  • When the machine is turned on, you will feel and hear rapid tapping on your scalp. The pattern will be a few seconds of tapping followed by a pause. The pattern will repeat. You may have scalp discomfort during the tapping, but not during the pauses. You’ll remain awake and alert during the procedure.

Depending on the treatment settings decided by your doctor, the procedure will last from 3.5 minutes to 20 minutes. The latest stimulation type is called “intermittent theta burst stimulation” and requires only a few minutes.

After each treatment

You can return to your normal daily activities after your treatment. You might have a mild headache for a short time afterward. Between treatments, you can usually expect to work and drive.

Results

If rTMS works for you, your depression symptoms may improve or go away completely. Symptom relief may take a few weeks of treatment. The effectiveness of rTMS may improve as researchers learn more about techniques, the number of stimulations needed and the best sites on the brain to stimulate.

Ongoing treatment

After completing an rTMS treatment series for depression, standard care - such as medicine and psychotherapy - may be recommended as ongoing treatment. Maintenance rTMS sessions may also be offered. These could be one session per week or fortnight following your initial course of treatment. If your depression is not fully resolved, or recurs after the initial rTMS treatment course, a further course of rTMS treatment may be recommended by your doctor. Four months after the end of your initial course of treatment, your doctor will arrange a review appointment. At this review, your symptoms will be reassessed and the option for further TMS treatment will be discussed.

Cardiac Guided rTMS at Sherpah Clinic

The Sherpah Clinic is the only clinic in Western Australia to offer Cardiac Guided Repetitive Transcranial Magnetic Stimulation (rTMS), an advanced technique that uses heart rate changes to optimise treatment. During rTMS sessions, the patient's heart rate is continuously monitored, providing real-time feedback to the clinician. This feedback helps verify that the correct brain area is being stimulated and allows for adjustments to the intensity, frequency and location of the magnetic pulses.

Benefits of cardiac guided rTMS include:

  • Personalised treatment: Tailors therapy to individual needs.

  • Improved outcomes: Increases effectiveness by targeting the correct brain areas.

  • Safety: Reduces the risk of overstimulation and other side effects.

By offering this innovative treatment, the Sherpah Clinic enhances neuromodulation therapy, leveraging physiological responses to refine treatment protocols for better patient care.