rTMS Flashcards
(7 cards)
what is it
Repetitive Transcranial Magnetic Stimulation (rTMS) is an effective treatment for major depressive disorders. It involves the focal application of a localised, pulsed magnetic field to the cerebral cortex, inducing small electrical currents which stimulate nerve cells.
broad evidence base
There is a good evidence base for the therapeutic efficacy of rTMS in major depressive disorder.
Those with treatment resistant depression who respond to rTMS treatment (approximately 50% of patients) will subsequently experience a lower burden of disease.
There is some evidence for the use of rTMS in schizophrenia, but less than that for depression. rTMS has further been investigated for use in a range of other disorders such as post-traumatic stress disorder, obsessive compulsive disorder, autism spectrum disorders, substance dependence and chronic pain conditions. The preliminary evidence of efficacy is encouraging in several of these disorders. However, at this time there is a lack of large scale / multi-site trials supporting the use of rTMS in the treatment of psychiatric disorders other than depression.
Treatment with rTMS can occur in combination with psychological therapies or medications, but does not generally occur concurrently with electroconvulsive therapy.
in pregnancy
little data
not contraindicated
There is little safety data on the use of rTMS in pregnant women. Though current
evidence is limited to case series, the theoretical risk of rTMS is thought to be low
due to the rapidly dissipating magnetic field from the stimulation coil and the
distance of the foetus from the coil (Taylor et al., 2018). Nonetheless, the use of
rTMS in this group requires a careful assessment of the patient’s situation and
detailed informed consent. Careful discussion of known and potential risks of rTMS
compared to alternative modalities of treatment is warranted. It is advisable for
these discussions to include other family members as appropriate. Outcomes in this
group should be closely monitored and where possible, employed to inform an
empirical evidence base.
child and adolescent
lacking evidence
only in research trial
There is little safety and efficacy data on the use of rTMS in children and
adolescents. rTMS should only be given to those aged under 18 within an approved
research protocol or under circumstances where there are limited other treatment
options and potential clinical benefit is considered to outweigh the known and
unknown risks of treatment in this group. This would require a careful assessment
of the patient’s circumstances, family situation, developmental stage and maturity,
capacity to provide informed consent, including an understanding of known and
potential risk
pre-assessment
• No specific pre-treatment preparation is required prior to a treatment session. Patients sit in a
comfortable chair during the treatment sessions. Ear plugs or other hearing protection should
be provided to minimise potential discomfort caused by noise generated by the coil.
PPG16: Repetitive transcranial magnetic stimulation (rTMS)
• Psychiatrists must ensure that a pre-rTMS evaluation is undertaken that includes a full
psychiatric assessment, as well as consideration of relevant investigations if indicated.
A medication review must also be completed prior to the administration of rTMS.
• Before prescription of rTMS, patients should be assessed for factors which place them at
greater risk of rTMS related complications, especially seizures. Metal implants, cochlear devices
• rTMS is associated with a small risk of treatment-emergent affective switching. This should be
discussed with all patients, particularly those with a history of bipolar affective disorder in whom
the risk may be increased. The use of mood-stabilising medication in patients with bipolar
affective disorder, particularly those with a history of manic switching, would seem likely to
reduce this risk but has not been formally evaluated.
Monitoring during treatment sessions and the treatment course
• During each course of therapy, patients should be monitored by appropriately trained and
supervised clinicians2
including ongoing assessment of mental state, treatment response and
any side effects should be reviewed as well as any unusual experiences.
• Appropriate facilities to manage any complications from rTMS, including seizures, should be
available.
• Daily monitoring of patients by clinicians should include assessment of factors that may alter
the seizure threshold. This includes any changes in medication prescribed, alcohol or other
substance use, and evidence of acute neurological symptoms or a decline in physical health.
• Protocols should be in place to allow for the timely management of the common side-effects of
rTMS including scalp discomfort and headache. Pain can improve over the course of the
treatment, and headache may be eased with the use of analgesia. A switch from highfrequency to low-frequency stimulation protocols may be warranted if these side-effects
continue to be a barrier to treatment continuation.
• Clinicians supervising rTMS therapy should have the capacity to identify signs of an emergent
manic switch and have protocols in place to respond appropriately.
psychotic depression
unclear
if psychotic, severe, very resistant, significant risks-> consider ECT
