How does it work?

Like many other antidepressant treatments that are available in clinical practice, the exact mechanism by which rTMS produces relief from depression is still unknown.

At a physiological level the effects of rTMS are frequently reported to be due to changes in synaptic plasticity (the ability of nerve cells in the brain to connect and disconnect). Synaptic plasticity has been widely studied as a mechanism to explain learning and memory (Luscher and Malenka 2012). Studies indicate that large scale brain networks are disconnected in patients with depression, and the degree of the change in their connectivity can predict the severity of depression (Salomons et al. 2014). Repetitive stimulation in areas of these networks can result in increased connection in the brain and reduction or elimination of depressive symptoms. Research suggests that rTMS results in changes in regional brain blood flow and metabolism, and applying rTMS at specific areas of the brain can enhance this region’s connectivity with other regions that are crucial for regulating emotional processing (Kito et al. 2008).

The picture above shows the blood flow in a non depressed brain *uniform on both sides and lots of yellow areas showing good blood flow, in contrast the brain on the left show large blue areas where blood flow, and therefore brain activity, is low.

It has long been known that stimulating nerves at more than 5 times per second causes the nerves to connect together, this was remarked on by Hebbs who discovered the phenomenon as nerves that fire together wire together. Similarly if nerves are stimulated once a second they disconnect, this phenomenon is used to treat anxiety with rTMS.

In 2008, rTMS was approved by the United States Food and Drug Administration (FDA) for treatment of patients suffering from depression who have not achieved satisfactory improvement from one antidepressant medication at or above the minimal effective dose and duration in the current episode. In England, the National Institute for Health and Care Excellence (NICE 20015) issued guidance for the use of rTMS recommending it as a treatment for depression. The Royal College of Psychiatrists have issued a statement on rTMS recommending it as a treatment for depression, Prof Alex was part of the steering committee of the Royal College of Psychiatrists which wrote the College standards for rTMS.

What can I expect during my treatment?

A psychiatrist will screen you to ensure that rTMS is a suitable treatment for you
A suitably trained TMS practitioner will place the coil in the correct position and set the parameters of the machine
A suitably trained TMS practitioner or health care assistant will be with you at all times during your treatment. You will be asked to wear earplugs during the treatment as the discharge from the coil can be quite loud *similar to the noise an MRI makes
You may withdraw your consent at any time
You can decide how your treatments will be tailored to your requirements, for example whether you would like the TV or radio on, whether you would like to talk to the nurse or health care assistant, or you would like to simply relax
The practitioners will ask questions about how you are progressing and will conduct weekly assessment of your depressive symptoms, they may ask you about any discomfort you may have from the magnetic field
The consultant psychiatrist may review your progress during the four weeks of treatment, they will also be gathering information about your progress from the practitioners. The consultant psychiatrist will also be ensuring that the prescriptions are written up, and that the dosing and placement of the coil is correct.
Practitioners or the consultant psychiatrist may ask to do a motor threshold measurement, this involves placing the magnet over the motor cortex (the part of the brain that controls muscle movement) and looking for a flicker in the opposite thumb
The consultant psychiatrist will not ordinarily conduct weekly reviews but be assured that the consultant will be taking your views and relatives views as well as practitioner observations into account when making decisions about your treatment
It is important to understand that Transforming Mind Solutions is not responsible for your interim or ongoing psychiatric care, the staff will advise your treating team and consultant/GP of your progress, but are not responsible for making any changes to or monitoring your medication. Your care including emergencies, crisis and or hospitalisation remains the responsibility of your referring team