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updated: Sept. 20, 2018

1. Introduction

2. For what disorders has TMS shown its efficacy?

3. What are the advantages of TMS?

4. What are the indications of TMS?

5. What are the contraindications to TMS?

1. introduction

Introduced in 1985, Transcranial Magnetic Stimulation (TMS) is a non-invasive and painless technique which, by means of a pulsed electromagnetic field, focally stimulates specific areas of the brain in order to investigate or modulate their functions. 

TMS is increasingly being used for therapeutic purposes because it modulates the activity of neural networks involved in the etiology and pathophysiology of neuropsychiatric and neurological disorders. For example, several studies have shown that the pathophysiology of depression is partly linked to hypo-activity in the left prefrontal cortex and that "normalization" of this area's activity with TMS can improve depressive symptoms.

TMS consists of very brief electric pulses discharged through a stimulation coil applied tangentially to the head, in contact with the scalp. The electric pulses then generate a magnetic field which, in turn, induces an electric current in the nerve cells at the surface of the brain.

tms magproWhen the pulses are delivered in a  repetitive manner for a defined period of time, TMS is called rTMS or repetitive transcranial magnetic stimulation. Applied at a frequency of less than or equal to 1 Hz, i.e. one stimulation per second, rTMS has an inhibitory effect on the area stimulated, whereas at a frequency greater than or equal to 5 Hz, it has an activating effect on the stimulated area.

Over the past two decades, the safety and efficacy of high and low frequency rTMS have been demonstrated in the treatment of depression and other neuropsychiatric and neurological disorders such as auditory hallucinations in people suffering from schizophrenia, more recently, post-traumatic stress disorder, sustance dependence, depersonalization and tinnitus. To date, several thousand patients have been treated with rTMS.

2. for what disorders has tms shown Its eFFICACY?

rTMS has proven its efficacy in the treatment of patients with major depression, with bipolar disorder in their depressive phase and in patients with schizophrenia suffering from auditory hallucinations, post traumatic stress disorder, substance dependence, depersonalization and tinnitus.
Many recent studies have particularly shown the therapeutic efficacy of rTMS in treatment-resistant depression, i.e. depression that does not respond to conventional therapeutic approaches (medications, psychotherapy). It can also be an alternative treatment for people who cannot tolerate their side-effects of antidepressant medications.

      • In the case of treatment-resistant depression, the majority of these studies showed a response rate of at least 50% after a minimum of 21 days of treatment. 
For example, Carpenter and Colleagues (please see Bibliography), who treated 307 patients with rTMS at  high frequency, showed significant improvement in depression severity at the end of treatment (six weeks) with response rate of 58% and 37,1% remission rate.

Furthermore, in a retrospective naturalistic study, 30 high frequency rTMS sessions were administered to 85 depressed patients  taking antidepressant medications (Connolly et al., 2012, see Bibliography). Response and remission rates were of 50,6% and 24,7% ar six weeks, respectively.

The rates of response and remission demonstrated in both naturalistic studies were comparable to the efficacy results observed in two multicenter controlled studies (O'Reardon et al 2007. George et al., 2010, see Bibliography).

In our clinic, the rates of response and remission to date were 60% and 45,5% respectively, in unipolar and bipolar depressed patients treated for four to eight weeks. (see Publications).

      • In the case of auditory hallucinations ("voices"), the majority of studies showed a reduction of at least 50% of these symptoms in 50% of the cases (Please see Bibliography and Publications).

Since 2002, rTMS is approved in Canada and in Israel as a treatment for depression in patients who have not responded to pharmacotherapy and/or to psychotherapy, and who might normally be candidates for electroconvulsive therapy (ECT) . As of October 2008, the Food and Drug Administration (FDA) in the United States approved rTMS for the treatment of major depression resistant to at least one antidepressant medication.

3. what are the advantages of tms?   

  • The main advantage of rTMS is the absence of notable side effects (No weight gain, cardio-vascular complications, sexual side effects, nausea, memory problems…) that are caused by other treatments.

  • Painless and non-invasive  procedure.
  • Does not require anesthesia.
  • Results in few adverse or undesirable effects.
  • Allows a quick onset of therapeutic effects (usually within two to three weeks). 
  • Can be performed in an outpatient setting.

4. what are the indications of TMS?

In our private practice setting, we offer rTMS for the following indications:
  • Depression resistant to treatments prescribed so far. (FDA approved treatment and recommentded by recommended by the Swiss Society of Psychiatry and Psychotherapy
In Off-Label:
  • Auditory hallucinations resistant to treatments prescribed so far.
  • Depersonalization (DPD)
  • Post-traumatic stress disorder (PTSD)¨
  • Substance dependence (eg. cocaine)
  • Obsessive-compulsive disorder (OCD)
  • Tinnitus
  • Fibromyagia

More specifically :

For Resistant Depression:
  • Your psychiatrist or your treating physician has diagnosed you with major depression or with bipolar depression.
  • You currently have depressive symptoms that your physician deems to be severe, including severe depression during pregnancy in certain cases.
  • You have not tolerated or have not responded to at least one antidepressant treatment which you have been taking regularly for a period of at least 2 months.

For Auditory Hallucinations:
  • Your psychiatrist or your treating physician has diagnosed you with a psychotic disorder (schizophrenia, schizoaffective disorder or other psychotic disorders) and you have auditory hallucinations.
  • The auditory hallucinations that you present with are severe and have not responded to at least one antipsychotic treatment which you have been taking regularly for a period of at least 2 months

5. what are the contraindications TO TMS?

rTMS is not indicated in your case if you have one or more of the following contraindications or exclusion criteria:
  • Presence of prosthetic or foreign ferro-magnetic (metallic) objects in the head.
  • Presence of cochlear implants or ocular prosthetics.
  • Electronic equipment implanted in the heart (pacemakers). 
  • History of neurosurgical procedures.
  • Neurological diseases that are susceptible to affect brain structures and cognitive abilities (e.g., intracranial tumors, a history of cerebrovascular accidents, traumatic brain injuries).
  • Personal and/or family history of seizures or epilepsy. 
  • Severe cardiovascular diseases.
  • Treatment with clozapine, bupropion, methadone and/or theophyline (non-exhaustive list). 
  • Under guardianship and/or incapable of giving informed consent.