TMS Considerations

In Australia rTMS is an approved treatment option for the management of treatment resistant depression, referring to depression that has not responded to two standard anti-depressant medication trials. Depression is a common condition and for some patients can be a chronic, severe and disabling illness and it is not uncommon for symptoms to not respond adequately to initial treatment trials. Neurostimulation has been a long established treatment option for the management of serious mental illness but traditionally this has involved Electroconvulsive Therapy (ECT). Whilst ECT continues to be practiced as a modern, safe and effective treatment it usually involves an admission to hospital and the use of a general anaesthetic. TMS is an alternative evidenced based neurostimulation treatment option and is performed at our medical rooms, with the patient awake and does not require any additional medication. TMS involves magnetic stimulation of the cerebral cortex to specific areas of the brain which research has demonstrated can improve depressive symptoms. TMS can be performed in conjunction with therapy and with most medications. 

• There is some evidence that rTMS might be of assistance for other conditions as well, including OCD, Anxiety and PTSD.
• However, at this time rTMS is only approved in Australia for treatment resistant Major Depression. Due to this only patients who undergo rTMS for Treatment Resistant Major Depression are eligible to receive a medicare rebate.

• TMS utilizes a powerful magnet and so it may not be suitable for some patients with metallic medical implants, although each patient and their relevant implant would need to be assessed as the magnetic field dissipates over distance and many medical implants are not magnetic 
• Whilst overall a safe and well tolerated procedure,  there are certain medical conditions and situations where undertaking rTMS is not advised. While this is uncommon, it is an important part of the initial appointment to explore a patients past medical history to see if rTMS is the right option. 

• All patients referred to our doctors for consideration of TMS are assessed by one of our psychiatrists at an initial assessment appointment
• At this appointment we explore a patient's symptoms, diagnosis, past treatments and medical history to see whether TMS is a suitable option. If TMS is a suitable pathway to explore then a process of education and informed consent is undertaken following which a mapping session can be scheduled.
• A TMS mapping session is undertaken to individualize the treatment to the patient. In this appointment our psychiatrists determine the right anatomical treatment location and the right magnetic energy for the individual person. 
• Treatment can then be scheduled and a course of rTMS typically involves daily treatments, on consecutive weekdays for successive weeks as there is evidence to support that frequent treatments play an important part in the therapeutic effect.
• Our psychiatrists typically meet with patients part way through their treatment course and at the end of treatment to review the response, or at any other time if there are concerns about any aspect of the treatment.  
• During the course of treatment our Doctors remain involved in the treatment although other health professionals trained in TMS may also deliver treatments.

• The process of TMS involves an electro-magnetic coil being placed lightly in contact with the scalp, such that when an electric current passes through the coil a strong magnetic field is generated at a focal point beneath it.  
• The initial mapping session can take up to 30 minutes whilst TMS is tailored to the individual. During this session the coil is moved over a patient's scalp using a step wise increase in energy to locate the motor cortex, as well as to determine the correct amount of energy  required to appropriately stimulate the underlying neurons. The localization of this site also acts as a reference point to guide us on the correct treatment location, which is typically over a patient's pre-frontal cortex. 
• A measuring tape is used to take measurements of the treatment location in reference to certain points of anatomy, such that in the subsequent treatment sessions the correct coil location can be easily and reliably re-positioned.
• A mapping session is usually only performed once at the start of treatment and then treatment sessions can be booked.
• A typical treatment appointment can vary in length as there are a number of differing treatment protocols. The briefest, the Theta Burst protocol for depression is 4 minutes long and the longest protocol is 37 minutes. 
• In a typical session a patient settles into the TMS chair, a few brief screening questions are repeated, and then hearing protection is inserted (as the coil generates a clicking noise and is quite close to the ears). 
• Patients need to remain still during the treatment but a clinician monitors for movement and the coil can easily be re-positioned if necessary.