Repetitive Transcranial Magnetic Stimulation (rTMS)

What is rTMS?

Transcranial Magnetic Stimulation (TMS) is a non-invasive brain stimulation technique used as a form of mental health therapy to treat individuals with specific conditions. It is TGA approved for the treatment of treatment-resistant depression (TRD). In some settings, it is being explored as a potential treatment for other conditions, including generalized anxiety disorder, addiction, and chronic pain, and it has received FDA approval for the treatment of obsessive-compulsive disorder (OCD). Certain areas of the brain function differently in conditions like depression and OCD. TMS is a medical device that generates brief magnetic pulses to non-invasively stimulate the underlying brain region. When these pulses of TMS are delivered repetitively, this is referred to as repetitive TMS (rTMS).

How does it work?

rTMS targets either the left or right dorsolateral pre-frontal cortex (DLPFC) using high or low-frequency magnetic pulses, respectively. With high-frequency, left-sided rTMS, the goal is to stimulate the DLPFC, which typically shows reduced activity on the left side in individuals with depression. This method helps primarily with symptoms like amotivation and malaise but also contributes to an overall improvement in depression. Conversely, low-frequency, right-sided rTMS aims to down-regulate the DLPFC, as it often exhibits heightened activity on the right side in depression. This approach is particularly beneficial when anxiety is significant, while also aiding in the overall improvement of depression.

What is it like to have rTMS?

I have written an article here about the experience of undergoing rTMS. Many people describe the sensation of the magnetic pulse as a 'tapping' feeling.

How effective is rTMS?

According to Miron et al. (2021), approximately 50% of individuals with treatment-resistant depression respond positively to rTMS, with depressive symptom severity being halved, and about 30% of people achieving complete remission from depressive symptoms.

Who is rTMS for?

rTMS is a treatment consideration for anyone suffering from treatment-resistant depression. However, individuals with metal plates in their head are not suitable candidates for rTMS. Dental fillings and most piercings are acceptable.

How do you define treatment resistance?

The minimum definition of treatment-resistant depression is having an incomplete or poor response to at least two classes of antidepressants. For Medicare rebates, it is also required to have engaged in psychotherapy.

Is rTMS the same as ECT?

While both rTMS and electroconvulsive therapy (ECT) are neurostimulation techniques, they are quite different. The methods they use to stimulate brain cells differ, as do their stimulation goals. rTMS does not require anesthesia and does not involve intentionally inducing a seizure; instead, it stimulates a specific area of the brain.

How long does it take?

A single rTMS session lasts about 30 minutes, depending on various treatment parameters. An outpatient treatment course for depression typically involves 20-35 sessions over 5-7 weeks, although this can vary based on an individual's response. Maintenance rTMS may be necessary, which could occur twice a week or even once a fortnight, depending on the person's needs.

What are the side effects?

rTMS is generally well-tolerated, with few side effects reported. The most common side effects include scalp irritation under the magnet, headache, and/or fatigue. Unlike many antidepressants, rTMS is free from side effects such as gastrointestinal upset, sexual dysfunction, weight gain, and dry mouth. The most serious side effect is seizures, but the risk of experiencing seizures is extremely low.

What is the cost?

Medicare subsidies are available for the first 35 sessions (an acute course) for treatment-resistant depression, with further maintenance sessions available four months later. The total out-of-pocket cost at The Bendigo Rainbow Hub is $800 for a course of rTMS with Medicare (approximately $23 per session). DVA gold and white card holders are bulk-billed through DVA. Without Medicare, DVA, or health fund coverage, each session costs $200.

Do I need a referral?

A referral is needed to access Medicare rebates for psychiatry services, but it is not necessary for a specific treatment.