Repetitive Transcranial Magnetic Stimulation (rTMS)

What is rTMS?

Transcranial Magnetic Stimulation (TMS) is a non-invasive brain stimulation technique used to treat people with certain conditions. It is TGA approved for the treatment of treatment-resistant depression (TRD). In some settings, it is being explored as a treatment for other conditions including generalized anxiety disorder, addiction, and chronic pain, and it has been FDA approved for treatment of obsessive compulsive disorder (OCD). Some parts of the brain work differently in conditions such as depression and OCD. TMS is a medical device that generates brief magnetic pulses that non-invasively stimulates the underlying brain region. When pulses of TMS are delivered repetitively, this is called repetitive TMS {rTMS).

How does it work?

rTMS targets the left or right dorsolateral pre-frontal cortex (DLPFC) with high or low frequency, respectively, magnetic pulses. With high frequency, left-sided rTMS, we aim to stimulate the DLPFC, as it tends to have reduced activity on the left side in depression. This approach tends to help most with things like amotivation and malaise, but it improves depression more globally as well. With low frequency, right-sided rTMS, we aim to down regulate the DLPFC, as it tends to have heightened activity on the right side in depression. This approach tends to help most when there is considerable anxiety, but it improves depression more globally as well.

What is it like to have rTMS?

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

How effective is rTMS?

According to Miron et al. (2021), about 50% of people with treatment-resistant depression respond to rTMS (depressive symptom severity is halved), and about 30% of people go into remission (recover fully from depressive symptoms).

Who is rTMS for?

rTMS is a treatment consideration for anyone who has treatment-resistant depression. You cannot have rTMS if you have metal plates in your head. Dental fillings and most piercings are okay.

How do you define treatment resistance?

Having an incomplete or poor response to at least two classes of antidepressants is the minimum definition of treatment resistant depression. For Medicare rebates, you also need to have engaged in psychotherapy.

Is rTMS the same as ECT?

rTMS and electroconvulsive therapy (ECT) are very different, although they are both neurostimulation techniques. The way that they stimulate brain cells is different, and the aim of stimulation is different. rTMS does not require anaesthesia and does not involve the intentional production of a seizure. It stimulates the a specific region of the brain instead.

How long does it take?

A single rTMS session will last about 30 minutes based on various treatment parameters. An outpatient course of treatment for depression usually consists of 20-35 treatments over the course of 5-7 weeks although this can vary depending on a person's response. Maintenance rTMS may be required, which depends on a person's response, perhaps twice a week or even once a fortnight for example. 

What are the side effects? 

rTMS is a well-tolerated procedure with few side effects. The most common side effects are scalp irritation underneath the magnet, headache, and/or fatigue. rTMS is free from side effects caused by many antidepressants such as gastrointestinal upset, sexual dysfunction, weight gain, and dry mouth. The most serious side effect is seizures, but the risk of seizures is extremely low.

What is the cost?

Medicare subsidies are available for the first 35 sessions (an acute course) for treatment resistant depression and further maintenance sessions 4 months later. The total out of pocket 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, each session is $200. 

Do I need a referral?

You need a referral to access Medicare rebates for psychiatry services, but you don't need a referral for a specific treatment.