Repetitive Transcranial Magnetic Stimulation (rTMS) involves using a device that generates magnetic pulses to stimulate specific areas of the brain. These magnetic pulses can help regulate the activity of brain cells in targeted regions to help with certain psychiatric disorders that have not responded to medications and/or psychotherapy.

Patient require 25 to 35 sessions in order for the achieved response to be consolidated.

To receive rTMS, you'll need to first consult with a psychiatrist who can provide a referral for the treatment.

Before starting rTMS treatment, patients undergo a psychiatric assessment by a consultant psychiatrist. This assessment will determine suitability and safety of rTMS in the patient.

During this assessment the psychiat ist determines the appropriate treatment protocol for the patient. This includes deciding which areas of the brain to target and in discussion with the patient, the frequency of treatment.

The mapping session is the first session of rTMS treatment course. During this session the psychiatrist identifies the specific areas of the brain that will be targeted during the treatment by determining the optimal placement of the magnetic coil on the patient’s scalp to achieve the desired stimulation of the target brain regions. This process helps ensure precise and effective delivery of rTMS therapy tailored to the individual's needs.

Around 20-40 percent of people with depression do not feel better or recover following existing standard treatments (antidepressant medications and psychotherapy). If a patient has not responded to two adequate courses of antidepressants from at least two different classes of anti-depressants they are considered treatment-resistant and will qualify to try rTMS. As said before, rTMS is a neuromodulation therapy that uses magnetic fields to enhance neuronal plasticity—this involves developing new and stronger connections between brain neurons. By modulating neurons and getting them to fire by applying magnetic fields, neurotransmitters and other chemicals are released that will result in neuronal changes and improvement of depressive symptoms.

A 2023 meta-analysis which looked at 19 randomized double-blinded sham-controlled found that patients with major depressive disorder (MDD) who received repetitive transcranial magnetic stimulation (rTMS) as an adjunctive therapy after two antidepressant treatment failures were 2.25 times more likely to respond (i.e. 50 percent reduction in symptoms) to rTMS treatment compared to those who received a sham (placebo) rTMS. Also it was found that the chance of achieving remission (i.e. minimal or no symptoms) in the same group of patients (those whe were treated with rTMS) was 2.78 times higher compared to those who received the sham (placebo) rTMS.

FDA’s decision-making process typically involves reviewing multiple studies and sources of data. The article “Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomised controlled trial,” published by O’Reardon et al. in Biological Psychiatry in 2007, was a pivotal study that contributed significantly to the FDA’s decision to approve rTMS for the treatment of depression. The authors in a double-blind, multisite study included 301 medication-free patients with major depression who had not benefited from prior treatment and randomised them to active rTMS or sham rTMS (placebo). The authors concluded that Transcranial magnetic stimulation was effective in treating major depression with minimal side effects. It offered clinicians a novel alternative for the treatment of depression.

Dhvani D. Mehta and colleagues conducted a Systematic Review and Meta-analysis by comprehensively analysing published studies from 2000 to 2023 to show the efficacy of neuromodulation (NM) methods, such as repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), and deep brain stimulation (DBS), in treating substance use disorders (SUDs). The researchers identified 94 studies that met their inclusion criteria with a total 4306 participants. The study was conducted to evaluate how these NM methods could improve behavioral outcomes in SUDs.

The research team carried out an extensive literature search using databases like MEDLINE, PsychINFO, and PubMed, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The studies included in their review were those that recruited participants diagnosed with SUDs and employed NM interventions like rTMS, tDCS, or DBS. The included studies either had a sham stimulation, a control group receiving no intervention, or an active control arm. For DBS studies, due to ethical constraints, control groups were not used.

The review found that rTMS could be effective in reducing substance use and craving, particularly when multiple stimulation sessions were applied targeting an area of the brain called the left dorsolateral prefrontal cortex (DLPFC). The effect sizes were medium to large, suggesting significant impact. tDCS also showed medium effect sizes in reducing drug use and craving, though these effects were less consistent and robust compared to rTMS.

The study concludes that NM methods, particularly rTMS and tDCS, may offer promising treatment options for SUDs. However, the authors note that future studies should aim to understand the underlying neural mechanisms of NM, evaluate extended treatment durations, accelerated administration protocols, and long-term outcomes with biochemical verification of substance use.

The study was published on 12 December 2023. You can find the link to this paper here

While rTMS is currently only formally approved for the treatment of depression, substantial evidence is accumulating that show rTMS is an effective treatment for OCD and is worth trying especially when other pharmacological or psychological treatments (i.e. exposure and response prevention) have failed to be effective. One good piece of evidence in support of effectiveness of rTMS in OCD came from a study published by Perera et.al. in Biological Psychiatry Cognitive Neuroscience and Neuroimaging in 2021 where the authors in a meta-analysis synthetised data from 26 randomised controlled trials involving 781 participants. The authors showed that rTMS has a modest but significant effect on reducing the obsessive compulsive symptoms.

Yes. Quite a lot! One systematic review and meta-analysis that supports the (off-lable) use of repetitive transcranial magnetic stimulation (rTMS) in treating Post-Traumatic Stress Disorder (PTSD) is titled "Non-invasive brain stimulation for posttraumatic stress disorder: a systematic review and meta-analysis," published in Translational Psychiatry in 2020. The authors included a total of 15 randomized controlled trials (RCTs), incorporating 359 patients in their analysis. The results revealed that rTMS is an effective treatment for reducing the core symptoms of PTSD, demonstrating a large effect size. The study assessed various rTMS protocols, such as different target sites and stimulation frequencies, and found that while there were no significant differences between them in terms of their impact on PTSD symptom reductions, rTMS overall showed significant clinical improvements. This meta-analysis is notable for its systematic approach and the inclusion of a large number of RCTs, making it a valuable resource in understanding the role of rTMS in PTSD treatment. This academic paper can be accesses here.

No. You should continue taking your prescribed medication(s) until advised otherwise by your prescriber.

A typical rTMS session lasts approximately 20 to 30 minutes, depending on the treatment protocol. The frequency of sessions varies but is often administered 4 to 5 days a week.

Yes, Medicare Australia offers rebates for Repetitive Transcranial Magnetic Stimulation (rTMS) for eligible patients. According to the Medicare Benefits Schedule (MBS), the services covered include initial treatment mapping and delivery of an initial course of rTMS treatment of up to 35 sessions. Additionally, for patients who have undergone successful treatment but experience a relapse, a retreatment course of up to 15 sessions is also subsidised. Eligibility for these rebates requires patients to be over 18 years old, diagnosed with a major depressive episode, and have not received satisfactory improvement from at least two different classes of antidepressant medications, among other criteria.