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Repetitive Transcranial Magnetic Stimulation

What is repetitive transcranial magnetic stimulation?

Repetitive transcranial magnetic stimulation (rTMS) is a form of brain stimulation therapy used to treat depression and anxiety. It has been in use since 1985. The therapy involves using a magnet to target and stimulate certain areas of the brain.

The U.S. Food and Drug Administration approved rTMS as a treatment for major depression when other treatments haven’t been effective. Sometimes doctors use rTMS in addition to traditional treatments.

Though rTMS has been available for more than 30 years, there isn’t much data on its long-term success. Some people with depression credit it with dramatically reducing their symptoms. Others say it’s had little effect on their condition. Comedian Neal Brennan, the cocreator of “The Chappelle Show,” has spoken out about undergoing rTMS treatments and how they helped his depression. In March 2016, he told Trevor Noah of “The Daily Show” that rTMS “did more for my depression than anything I’ve ever done.”

It did more for my depression than anything I’ve ever done.
– Neal Brennan, cocreator of “The Chappelle Show.” Stated above while talking about TMS on “The Daily Show.”

Why is rTMS used?

TMS is mainly used to treat severe depression. Repetitive transcranial magnetic stimulation is usually recommended only after medication and psychotherapy fail to work. Doctors suggest taking at least one round of prescription antidepressants before exploring the possibility of rTMS. Antidepressants and psychotherapy may be used in combination with rTMS.

The most qualified candidates for rTMS are people with depression who haven’t had success with other methods. People who aren’t in good enough health for a procedure such as electroconvulsive therapy (ECT) might be better candidates for rTMS. This is true for those who have a higher risk for seizures or may not tolerate anesthesia, which is needed for ECT.

How does rTMS work?

RTMS is a noninvasive procedure. Sessions of rTMS typically last anywhere from a half hour to an hour. During rTMS you will sit or recline while an electromagnetic coil is held near your head. A doctor places the electromagnetic coil against the forehead near the area of your brain that regulates mood. The coil then passes magnetic pulses to a targeted part of your brain. This induces an electrical current in specific nerve cells. It’s thought that these electrical currents stimulate brain cells in a complex way that can reduce depression.

The prefrontal cortex of the brain is often the region doctors choose to target for depression.

What are the possible side effects and complications of rTMS?

Pain isn’t usually a side effect of rTMS. However, people may describe the sensation of the magnetic pulse as uncomfortable. Some people describe this as a knocking or tapping feeling with each pulse. The electromagnetic pulses can cause muscles in the face to tighten or tingle.

The procedure is associated with mild to moderate side effects, including:

  • feelings of lightheadedness
  • temporary hearing problems, due to the sometimes loud magnet noise
  • mild headaches
  • tingling in the face, jaw, or scalp

Though rare, rTMS does come with a small risk of seizures.

Depending on your magnetic strength, the noise can be a mild clicking noise to extremely loud. These pulses feel like someone tapping with their finger on your head very fast and hard. This tapping feeling can cause your eyes or cheeks to twitch or shake.
– Sofhia Samimi, rTMS technician

How does rTMS compare to ECT?

Several therapies exist that involve stimulating the brain in different ways. Electroconvulsive therapy (ECT) is one such treatment. ECT involves placing electrodes on strategic areas of the brain and creating an electric current that essentially causes a seizure to occur in the brain. The procedure is performed under general anesthesia. Doctors also give the person undergoing ECT a muscle relaxant to keep them from shaking during the stimulation portion of the treatment. This differs from rTMS because people receiving rTMS don’t have to receive sedation medications. Not requiring sedation is beneficial because it reduces the risks for potential side effects.

One of the other key differences between the two is the ability to target certain areas of the brain. When the rTMS coil is held over a certain area of the brain, the impulses travel only to that part of the brain. Electroconvulsive therapy is unable to target specific areas.

While doctors use both rTMS and ECT to treat depression, ECT is usually reserved for patients with severe and potentially life-threatening depression. Other conditions that ECT may be used to treat include:

  • bipolar disorder
  • schizophrenia
  • suicidal thoughts
  • catatonia (when a person isn’t responding to others or their surroundings)

Electroconvulsive Therapy»

Who should avoid rTMS?

There are some people who can’t get rTMS, even if they could benefit from it. The magnetic coil used in the treatment can be dangerous for anyone who has metal implanted somewhere in their head or neck.

Examples of people who shouldn’t get rTMS include those with:

  • aneurysm clips or coils
  • bullet fragments or shrapnel near the head
  • cardiac pacemakers or implantable cardioverter defibrillators (ICD)
  • facial tattoos that have magnetic ink or ink that is sensitive to magnets
  • implanted stimulators
  • metal implants in the ears or eyes
  • stents in the neck or brain

A doctor should conduct a thorough examination and take a medical history before using the therapy.

What are the costs of rTMS?

RTMS is considered a fairly new depression treatment and there isn’t a large amount of data on its long-term effects. For this reason insurance companies don’t always pay for treatment. Coverage for the treatment often depends on a person’s individual health needs and policy. Many doctors’ offices recommend people contact their insurance companies in advance to determine if the treatment could be covered, even in part.

While the treatment costs can vary based on location, the average costs for treatment can range from $6,000 to $12,000 for a four- to six-week treatment course. Some hospitals, doctors’ offices, and healthcare facilities offer payment plans or discounted programs for those who are unable to pay the entire amount.

What is the duration of rTMS?

Doctors will create an individual prescription for a person when it comes to treatment. However, most people will go to treatment sessions that last anywhere from 30 to 60 minutes about five times a week. The treatment duration usually lasts between four and six weeks. This number of weeks could be shorter or longer depending on the individual’s response.

What do the experts say about rTMS?

Researchers have written a number of research trials and clinical reviews on rTMS. Some of the results include:

  • A 2013 data review published in the journal Neuropsychopharmacology found rTMS treatments that delivered more than 1,200 magnetic pulses total made people with major depression more responsive to treatment. The study’s authors said rTMS has “clinically meaningful benefits” for those suffering with depression.
  • According to Johns Hopkins Medicine, people who are highly treatment resistant usually experience fewer benefits to rTMS than people who aren’t as treatment-resistant. More severe treatment resistance may require other therapies, such as ECT.
  • A 2014 data review published in the Journal of Clinical Psychiatry found people who receive rTMS were five times more likely to have remission of their symptoms than people who didn’t receive TMS treatments.
  • A 2014 article published in the journal Clinical Neurophysiology found that rTMS had strong evidence that supported its effectiveness in treating conditions like depression, pain, and schizophrenia.

Many studies now in progress have researchers examining the long-term effects of rTMS and finding out what types of symptoms best respond to the treatment.

Having been a TMS technician for the past two years, I have witnessed many patients come in extremely depressed and desperate for any kind of relief from their daily struggle. For many patients, this treatment is their last alternative before having to undergo the invasive treatment of electro shock therapy. This treatment without a doubt helps those who stay committed to the six-week program. Results vary from patient to patient but I have seen many depressed patients be lifted gradually from their depression over the course of treatment.
– Sofhia Samimi, rTMS technician

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