There are a number of contraindications to rTMS as a treatment for depression. These include: a history of epilepsy or serious brain conditions such as recent stroke *blood clots or bleeding in the brain; heavy alcohol intake or withdrawal from alcohol; taking drugs which cause seizures; severe or recent heart disease; presence of metal in the brain or scalp such as cochlear implant *metal rings, earings and hearing aids must be removed before the treatment. All patients are screened using a standard questionnaire before rTMS treatment.

Efficacy of rTMS treatment for major depressive disorder (MDD) has been well established over the recent years using different clinical populations as well as differing forms of TMS (high frequency, low frequency, bilateral) It is a NICE approved treatment.

States the evidence on repetitive transcranial magnetic stimulation for depression shows no major safety concerns. The evidence on its efficacy in the short-term is adequate, although the clinical response is variable. Repetitive transcranial magnetic stimulation for depression may be used with normal arrangements for clinical governance and audit.

During the consent process, clinicians should, in particular, inform patients about the other treatment options available, and make sure that patients understand the possibility the procedure may not give them benefit.

Adapted from the STAR*D report by Rush et al. 20061

• Outcomes such as remission can decline with each treatment step.1
• Undergoing several treatment steps before becoming symptom free is also more likely to lead to relapse, and consequently increased use of healthcare resources may be expected.1,2
• This serves to highlight the need for more effective short- and longer-term treatments….in more depressed patients sooner in the treatment sequence.
• Rush AJ et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 2006; 163(11): 1905-1917.
  Mauskopf JA et al. Nonresponse, partial response, and failure to achieve remission: humanistic and cost burden in major depressive disorder. Depress Anxiety 2009; 26(1): 83-97.
• STAR*D study showed that about 30% of patients fail to respond to antidepressants, for these people they need a different type of treatment, rTMS can be effective for people who do not respond to antidepressants or psychological therapies.

In 2018 Prof Alex O’Neill-Kerr co-wrote the amended position statement for the RCPSych to read that a qualified rTMS Technician or equivalent with adequate training and competencies can administer the rTMS and monitor for side effects during the treatment. The RCPsych standards are maintained in the clinic and adhered to.

Prof Alex recently published data in the Open Journal of Depression that relates to a cohort of 144 patients treated with rTMS between 2015 and 2017. For all the patients, the Hamilton Rating (HAM-D) remission rate was 25.5% and the response rate 40.4%. The CGI *a measure of improvement in depression (remission rate *i.e. the number of people who had no symptoms of depression at the end of treatment) was 52% this is significantly better than data published in the international literature e.g. Downer (Downer et al. rTMS of the Dorsomedial Prefrontal Cortex for Major Depression, Brain Stimulation (2015 208-215) quotes the most recent international studies in rTMS having 30-35% remission rates.

Yes, you can drive or go back to work and carry out your normal daily activities after TMS.

There are very few side effects to rTMS and these are generally when having the treatment. The international scientific community has evaluated the available evidence in administration of TMS in both clinical and research setting and has developed a safety protocol (Rossi et al. 2009) which is used in the clinic *this includes wearing earplugs during the treatment.

The potential side effects of TMS include transient acute hypomania, syncope (*fainting), transient headache and local discomfort (*where the magnetic coil discharges). Generally, TMS is well tolerated by patients and even if you do have some discomfort from the magnetic coil this usually diminishes the more treatments you have. Most people find any discomfort goes away by the second treatment. If you have a headache after treatment an ordinary headache tablet will help. If you are having theta burst then you may feel tired and drowsy after the treatment. If you do feel tired, have a nap, the brain heals itself whilst you are sleeping and will be making new connections whilst you are asleep.

A summary of key adverse effects from the meta-analysis of rTMS studies as reported by Slotema et al (2010) is shown in the table below.

• More communication and verbalisation, joining in conversations, wanting to go out and meet people.
• Return of the ability to solve complex problems and make decisions.
• Feel like a fog has lifted.
• Improved concentration and memory.
• Sleep improved.
• Positive thoughts, thinking about activities, carrying out activities such as cooking and shopping.
• Depressed mood fades away.

Yes, below are some of the published data.

Griffiths, C., O’Neill-Kerr, A, Millward T, da Silva, K. (2019) Repetitive transcranial magnetic stimulation (rTMS) for depression: outcomes in a United Kingdom (UK) clinical practice 30th March 2019. International Journal of Psychiatry in Clinical Practice;

• All patients were treated with a fixed dose protocol starting at 60% and increasing to a maximum of 75%.
• None of the patients had a resting motor threshold measured.
• Response and remission rates, respectively, were 40.4% and 25.5% for the HAM-D; 35.6% and 20.8% for the BDI; and 51.1% and 52.1% for the CGI
• Griffiths, C., O’Neill-Kerr, A, De Vai, R., da Silva, K. (2019). Impact of repetitive transcranial magnetic stimulation on generalised anxiety disorder in treatment resistant depression. Annals of Clinical Psychiatry.

None of the patients had a resting motor threshold measured.

We generally suggest staying on your current medication until you complete your course of treatment. You may find that you become more sensitive to sedative medication as you continue your treatment with rTMS. The TMS consultant can advise you and your treating clinician about appropriate medication changes.

This is a discussion to be had with your treating clinician (*GP&Consultant). Generally, if you have gone into remission (*i.e. you have no symptoms), have less severe and less duration of illness stopping the antidepressant may be an option. Generally mood stabilising medication should be continued.

Top up refers to having 3-4 TMS treatments to regain remission if symptoms return. The number and duration is specific to the individual and is decided with you and the TMS practitioner.

This refers to regular treatments usually monthly after your initial course of treatment. This can be discussed with the TMS technician and usually depends on duration and severity of illness and age, usually continuation treatment is advised in people over 60.

Yes, older people (over the age of 60) have less plasticity and therefore are more likely to have a response (i.e. a 50 % reduction in symptoms) rather than remission (*i.e. no symptoms) at the end of treatment. They may also require longer courses and more treatments.

Generally, a course is 4~6 weeks (*20 to 30 treatments) but this is dependant on your response. There are some people who respond after 2 weeks. Treatment is usually given once a day 5 days a week.

Yes, accelerated treatment protocols can be given in which multiple treatments are given in a day (up to 5 per day) This can be discussed with staff when planning your treatment protocol. This can complete your course of treatment in a week to 10 days.

Poster presentation, Soomro et al Royal College of Psychiatrists Annual International Conference, June 2019

10 people addicted to cocaine from the Centre for Neuromodulation and Smart TMS clinics

The visual analog scale for craving was used with a significant reduction in craving scores following treatment (p = 0.008)

Clinicians and patients subjectively reported abrupt cessation of cocaine craving at around day 7 (4,200 pulses)

The picture below shows a quantative EEG map *a way of visualising brain activity( in someone with OCD. The red areas show hyper connectivity in an area of the brain called the supplementary motor area. After discussing with the patient we treated the overconnected area with inhibitory TMS. After 10 treatments the OCD was significantly better and the red area was now showing normal connectivity, the green area.

YBOCS = 36/40 Treated at SMA (FC1 and FC2 1 Hz 20 minutes each)

YBOCS 13&40

Yes, response rates to TMS are better in Bipolar Disorder, there is a small chance of inducing a manic or hypomanic episode though and you should weigh up the risks with your treating clinician.

This depends on which type of TMS you have. Standard rTMS treatment for depression is 40 minutes long (*although this can be reduced to 20 minutes in certain situations). The anxiety treatment is 20 minutes long.

If you have Theta burst treatment (*a modified version of TMS in which 50 Hz bursts of TMS are given by a more powerful TMS machine) the depression treatment is just over 3 minutes and the anxiety treatment is 40 seconds.