rTMS

TMS (transcranial magnetic stimulation), sometimes referred to as rTMS (repetitive transcranial magnetic stimulation) is a non-invasive and well tolerated treatment method for depression.

It is a mild form of brain stimulation using a magnetic field. It has been extensively studied for over 30 years with large clinical trials establishing that is an effective treatment for patients with depression. There is also a growing evidence base for its use in other psychiatric and neurological disorders, such as pain management, bipolar disorder, obsessive compulsive disorder, smoking cessation, addictions and post traumatic stress disorder.

Depression is the leading cause of disability worldwide. While there are many effective treatments for depression, first-line approaches such as medication and psychotherapy do not work for everyone. Research into medication options for depression has not significantly progressed over the past few decades and some individuals experience side effects to antidepressants or lack of effective response in terms of their depressive symptoms. In fact, up to two-thirds of people with depression do not achieve adequate relief from the first antidepressant they try. After two months of treatment, research shows that some symptoms can remain for these individuals and each subsequent medication tried is actually less likely to help than the one prior.

The field of neurostimulation has therefore become a focus of research and treatments such as electroconvulsive therapy (ECT), transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS) are becoming more popular. ECT was considered the gold standard for treatment-resistant depression, however, for many people ECT can be too difficult to tolerate due to side effects on memory and cognition. ECT is also not a convenient treatment for some people as it involves having a general anaesthetic. For individuals who have had an inadequate response to medications and therapy alone, TMS is a newer treatment option.

TMS devices operate completely outside of the body and affect central nervous system activity by applying a magnetic field to specific areas of the brain that we know are involved in depression. TMS does not require anaesthesia and is generally exceptionally well tolerated compared to the side effects often seen with medication and ECT. The treatment targets the parts of the brain shown in brain-imaging studies to be abnormally low in activity in depressed patients. The severity of the depression often correlates with the extent of the decline in activity in this part of the brain. The magnetic fields produce small electrical currents (pulses) which then go on to activate cells within the brain which release neurotransmitters (brain chemical messengers) that are known to have an important role in mood regulation. As TMS is is non-invasive, it generally does not have any negative effects on thinking, memory and normal brain functions.

Approximately 50-60% of people with depression can experience a clinically meaningful response with TMS. About one third of these individuals can experience a full remission, meaning their symptoms go away completely. It has been shown that by combining TMS with psychotherapy the patient is more likely to achieve remission from depression. A large study in 2017, showed that after an average of 21 sessions, 66% of patients responded well to the combined approach with lasting effects after 6 months in 65% of the group.

TMS devices operate completely outside of the body and affect central nervous system activity by applying a magnetic field to specific areas of the brain that we know are involved in depression. TMS does not require anaesthesia and is generally exceptionally well tolerated compared to the side effects often seen with medication and ECT. The treatment targets the parts of the brain shown in brain-imaging studies to be abnormally low in activity in depressed patients. The severity of the depression often correlates with the extent of the decline in activity in this part of the brain. The magnetic fields produce small electrical currents (pulses) which then go on to activate cells within the brain which release neurotransmitters (brain chemical messengers) that are known to have an important role in mood regulation. As TMS is is non-invasive, it generally does not have any negative effects on thinking, memory and normal brain functions.

Approximately 50-60% of people with depression can experience a clinically meaningful response with TMS. About one third of these individuals can experience a full remission, meaning their symptoms go away completely. It has been shown that by combining TMS with psychotherapy the patient is more likely to achieve remission from depression. A large study in 2017, showed that after an average of 21 sessions, 66% of patients responded well to the combined approach with lasting effects after 6 months in 65% of the group.

rTMS

TMS (transcranial magnetic stimulation), sometimes referred to as rTMS (repetitive transcranial magnetic stimulation) is a non-invasive and well tolerated treatment method for depression.
It is a mild form of brain stimulation using a magnetic field. It has been extensively studied for over 30 years with large clinical trials establishing that is an effective treatment for patients with depression. There is also a growing evidence base for its use in other psychiatric and neurological disorders, such as pain management, bipolar disorder, obsessive compulsive disorder, smoking cessation, addictions and post traumatic stress disorder.

Depression is the leading cause of disability worldwide. While there are many effective treatments for depression, first-line approaches such as medication and psychotherapy do not work for everyone. Research into medication options for depression has not significantly progressed over the past few decades and some individuals experience side effects to antidepressants or lack of effective response in terms of their depressive symptoms. In fact, up to two-thirds of people with depression do not achieve adequate relief from the first antidepressant they try. After two months of treatment, research shows that some symptoms can remain for these individuals and each subsequent medication tried is actually less likely to help than the one prior. The field of neurostimulation has therefore become a focus of research and treatments such as electroconvulsive therapy (ECT), transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS) are becoming more popular. ECT was considered the gold standard for treatment-resistant depression, however, for many people ECT can be too difficult to tolerate due to side effects on memory and cognition. ECT is also not a convenient treatment for some people as it involves having a general anaesthetic. For individuals who have had an inadequate response to medications and therapy alone, TMS is a newer treatment option.

TMS devices operate completely outside of the body and affect central nervous system activity by applying a magnetic field to specific areas of the brain that we know are involved in depression. TMS does not require anaesthesia and is generally exceptionally well tolerated compared to the side effects often seen with medication and ECT. The treatment targets the parts of the brain shown in brain-imaging studies to be abnormally low in activity in depressed patients. The severity of the depression often correlates with the extent of the decline in activity in this part of the brain. The magnetic fields produce small electrical currents (pulses) which then go on to activate cells within the brain which release neurotransmitters (brain chemical messengers) that are known to have an important role in mood regulation. As TMS is non-invasive, it generally does not have any negative effects on thinking, memory and normal brain functions.

Approximately 50-60% of people with depression can experience a clinically meaningful response with TMS. About one third of these individuals can experience a full remission, meaning their symptoms go away completely. It has been shown that by combining TMS with psychotherapy the patient is more likely to achieve remission from depression. A large study in 2017, showed that after an average of 21 sessions, 66% of patients responded well to the combined approach with lasting effects after 6 months in 65% of the group.

A typical course of TMS consists of 5-7 treatments per week over a 3-4 week period, for an average of 20 sessions in total. Each treatment lasts for approximately 20-40 minutes. You may start to notice an effect within the first 5 sessions. An individual treatment plan will be discussed in detail during your initial consult but for TMS to have the best effect sessions need to be frequent.

Generally speaking, the beneficial effects of TMS may last at least 6 months for the majority of clients. However, a number of clients opt to return for follow up treatment once a month or once every 2-3 months to maintain the effects or to prevent a relapse of depression. Research shows that after six months depressive symptoms are significantly lower than at intake.

TMS has the advantage of not inducing side effects common with antidepressant medications. Unlike other methods of neurostimulation (such as vagus nerve stimulation or deep brain stimulation), TMS does not require surgery or implantation of electrodes. And, unlike ECT, TMS has a much lower risk of seizures and does not require sedation with anaesthesia.

TMS is very well tolerated, but with any medical treatment there are potential side effects. Side effects are generally mild and improve after an individual session and decrease over time with additional sessions. They may include headache; scalp discomfort at the site of the stimulation; muscle twitching of the facial muscles; and light headedness. The treatment parameters can be adjusted to reduce such symptoms. More serious side effects are rare, but may include seizures (<1% risk overall), mania (particularly in people with bipolar disorder) and hearing loss (if there is inadequate ear protection during treatment)

In ECT, large electrical currents are applied in order to create seizure activity across the brain. This therapy requires sedation under medical care in hospital and may be associated with side effects including nausea, confusion and memory loss. TMS stimulation is non-invasive and targeted, so it does not affect the whole brain or create a seizure like we see in ECT therapy. It is done without sedation on an outpatient basis and you can safely return immediately to your daily activities.

Individuals diagnosed with depression, treatment resistant depression (depression that has not responded to psychotherapy and/or medication), individuals with OCD, individuals who wish to taper or cease medication for depression and are looking for therapy to support that process.

Suitability will be assessed at your initial appointment. Due to the magnetic field produced during TMS, the procedure is not recommended for some people who have the following devices: · Aneurysm clips or coils · Stents · Implanted stimulators · Implanted vagus nerve or deep brain stimulators · Implanted electrical devices, such as pacemakers or medication pumps · Cochlear implants for hearing · Any magnetic implants · Any metal fragments, metal device or object implanted in your body. TMS may be contraindicated for patients with dental implants. Patients should seek clarification from their dental specialist. Standard dental fillings and braces are safe for undergoing TMS treatment. Patients who are pregnant or have a history of seizures/epilepsy should not undergo TMS therapy. Patients with facial tattoos which have metallic ink or magnetic sensitive ink should not receive TMS. Patients are asked to remove all facial/ear piercings including tongue piercings prior to each treatment.

The initial session with your psychiatrist will determine suitability for TMS therapy. You will be asked questions regarding your medical and psychiatric history, including current and past treatments for depression. A detailed discussion will be had regarding TMS and potential alternative treatment options. The second session is called a “mapping session”. This takes approximately 20-40 minutes and various measurements are taken of your head to ensure the correct placement of the magnet over your scalp. The exact area is mapped by locating a ‘motor threshold’ by delivering magnetic pulses to the area of the brain responsible for movement. This is done by delivering a series of pulses over the motor cortex part of the brain until a slight twitch of the hand is achieved. The energy level is then lowered and the psychiatrist will prescribe an individual treatment protocol for you. During subsequent sessions, the psychiatrist or nurse will deliver your specific treatment protocol. A qualified TMS nurse will remain with you throughout each TMS treatment. You will relax in a reclining chair for the duration of the treatment. A repetitive tapping or clicking sound can be heard from the magnet that usually lasts a few seconds followed by a pause. Patients may wear ear plugs for comfort. A tapping sensation may be felt on the scalp. Because TMS does not require an anaesthetic and is usually well tolerated without cognitive side effects, patients can generally return to their normal daily activities after treatment.

Unlike some medications, TMS does not affect your ability to drive. The experience of intensive treatment, however, may be tiring. If you would not feel comfortable driving after treatment, we advise you to ask a friend to drive you home after a treatment session.

It is generally recommended to keep medications stable during the course of a TMS treatment programme. You should inform your psychiatrist or TMS nurse of any changes in medication use.

Before commencing TMS we will conduct an intake assessment with one of our psychiatrists as well as a ‘mapping session’ to include the individualised treatment protocol. To be able to obtain Medicare benefits you will need a referral from a GP.

From November 2021, TMS has been listed on the Medicare Benefits Schedule (MBS) for the treatment of major depressive disorder. To be eligible to receive Medicare-funded TMS services you must meet the following criteria:

Be at least 18 years of age;

Be diagnosed with major depressive episode;

Have failed to receive satisfactory improvement for the major depressive episode despite adequate trialling of at least two different classes of antidepressant medications, unless contraindicated;

Have also undertaken psychological therapy unless inappropriate; and

Have not received TMS treatment previously in either a public or private setting.

If eligible, Medicare rebates will be available for:

Up to 35 TMS services for an initial course of treatment; and

Up to 15 TMS services for a course of retreatment

A course of retreatment may be undertaken where there has been a relapse after at least 4 months, and where the initial course of treatment has been successful.

Before commencing your first treatment session, your psychiatrist will plan how the treatment is to be provided including the dosage (as part of a ‘prescription and mapping’ service). A further prescription and mapping service will be required before commencing a course of retreatment. Both of these services will also attract a Medicare rebate.

Further information and patient factsheets can be found here:

http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/419674E7069172A9CA25877800803903/$File/Factsheet-rTMS-Patient.25.10.21.pdf

General

Our psychiatrists see a wide range of age groups. Children are welcome to be referred however for ADHD assessments, patients must be 17 and above. If you have a child who is 16 but may be 17 by the time they are seen, then they are welcome to be referred for ADHD assessment.

There is no specific upper cut-off however this will depend on the particular presentation (eg presentations more likely to be consistent with dementia processes likely will be more suitable for an old age psychiatrist) and the overall physical health of the patient.