A Concierge Service for Prospective Patients in Noble Park

Transcranial Magnetic Stimulation (TMS) is now available at our NeuroCentrix centre in Noble Park. Approved by the FDA, TGA and recognised by the Royal Australian and New Zealand College of Psychiatrists.

TMS is a safe, effective, evidence-based treatment for major depression [16]. Emerging evidence also supports TMS in several other conditions such as tinnitus, PTSD, OCD, and chronic pain [4, 5, 9, 18, 19].

NeuroCentrix provides a concierge service for prospective patients in Noble Park. If a patient is covered by WorkCover, Department of Veteran Affairs or the Transport Accident Commission, we will handle the application for TMS funding on their behalf to assist in accessing treatment.

Mechanism of TMS

TMS uses a magnetic field to induce an electrical current through targeted areas of the neural cortex. Lower magnetic frequencies (less than 1 Hz) produce an inhibitory effect, while higher frequencies (more than 5 Hz) produce an enhancing effect [1, 2, 3].

Several neuroimaging studies on major depressive disorders show hypoactivity of the left dorsolateral prefrontal cortex and hyperactivity of the right DLPFC. The studies show that TMS helps normalise these abnormalities in both structure and function [1, 2, 3].

Specifically, inhibition of the left DLPFC suppresses hypothalamic and amygdala overactivity modulates the GABA and glutamate systems and increases dopamine in the striatum. These effects are seen physiologically in decreased salivary cortisol.

The end result is normalisation of negative feedback loops active in depression, which is reflected in improved psychological and cognitive functioning of TMS patients [1, 2].

How is TMS Treatment Delivered?

TMS is an outpatient treatment prescribed and supervised by a psychiatrist. The treatment is delivered by an appropriately trained clinician, usually a psychiatric nurse.

Unlike ECT, there is no anaesthetic, seizure or loss of consciousness involved.

TMS consists of several variables that can be tailored to individual patients and modified with time such as the site, intensity and number of pulses per treatment or the frequency and number of sessions. The most common course is 5 times per week for around 5 weeks.

Patients with metal implants or electronic devices must be carefully assessed, as with MRI.

Advantages of TMS

TMS is non-invasive, delivered quickly and generally without discomfort. Patients can drive or return to work straight afterwards.

Side effects are minimal and there is no need to stop other treatments – both antidepressants and psychotherapy can be safely continued during a course of TMS [2].

Effectiveness of TMS

Over 40 randomised-controlled trials have proven the benefit of TMS in treatment-resistant depression.

Among patients with two failed antidepressant trials, around 50% respond to TMS and have reduced symptoms long-term.

Positive results have increased in recent years, which suggests that treatment protocols continue to improve. TMS also is suitable for patients with bipolar depression where response rates are similar to unipolar depression.

For very severe or psychotic depression, ECT remains the treatment of choice [3, 4, 5, 7].

TMS as a First Line for Depression

TMS is increasingly chosen as a first-line treatment for depression. With intolerable side effects at only 1-2%, patients have an improved chance of completing the course and thereby achieving remission with their first treatment.

Overall, 2 in 3 patients receiving TMS will have improved symptoms without intolerable side effects.

TMS may also be safely used concurrently with an antidepressant, so patients hoping for rapid relief of their symptoms may be prescribed both.

TMS as first-line is especially warranted for depressed patients among the elderly, women who are pregnant or breastfeeding [4, 5].

Does the Benefit of TMS Last?

TMS effects last over 12 months for most patients that respond. Overall, the durability of effect after 12 months is around 80%.

When symptoms return after remission, most recover with a second round of TMS and an antidepressant.

Professional Bodies Supporting TMS

TMS is supported by the major psychiatric professional bodies internationally.

These include:

  • RANZCP Position Statement: rTMS is an effective and evidence-based treatment for depression.
  • Guidelines prepared by European experts: Level A (definite efficacy) for the antidepressant effect of HF-rTMS of the left dorsolateral prefrontal cortex (DLPFC).
  • Clinical TMS Society: Daily left prefrontal TMS has substantial evidence of efficacy and safety for treating the acute phase of depression in patients who are treatment resistant or intolerant.
  • Guidelines of the Canadian Network for Mood and Anxiety Treatments: Level I evidence that rTMS is suitable first-line treatment for treatment-resistant MDD.
  • Sax Institute: Most systematic reviews found that TMS was better than sham for major depression.

Psychiatrists supervising TMS at NeuroCentrix have the appropriate neurostimiluation expertise with continuing professional education to remain at the forefront of best practice.

Side Effects

TMS has been studied extensively for over thirty years and only minimal side effects have been identified.

There can be some discomfort where the magnet is positioned, or occasionally a headache. Some passing tiredness may also occur.

Such side effects usually fade after the first two weeks of treatment and less than 2% of patients discontinue [2, 3, 6].

Seizures with TMS occur around once every 30,000 sessions.

Patients are evaluated for risk factors before treatment such as neurological conditions, alcohol or substance abuse, and medications that lower seizure threshold.

There is no evidence that TMS increases risk of future seizures [9].

Unlike ECT, clinical trials have found no cognitive side effects with TMS. In fact, cognitive impairment is likely to improve, both through resolution of the depression and the stimulating effect on the cortex.

Research studies are also investigating TMS for cognitive enhancement in the early stages of dementia [9, 7].

Can TMS Trigger Mania?

Just like antidepressants, TMS can potentially induce mania especially in patients with pre-existing bipolar disorder. This adverse effect is very rare and may be reduced with the concurrent use of a mood stabliser [9].

TMS for Other Conditions

The success of TMS in treating depression has led to rapid expansion to other areas.

Patients with bipolar depression have achieved similar response rates with TMS as unipolar patients, and now exciting results are emerging for TMS in a variety of other conditions.

TMS treatment has shown promising results in reducing the symptoms of:

As a relatively new treatment, the evidence base for TMS in these areas is only expected to grow. Importantly, any side effects remain minimal and no safety issues have been identified in research to date.

We welcome referrals for an assessment to gauge your patient’s suitability for TMS treatment in Noble Park.

What Else Does NeuroCentrix Offer?

NeuroCentrix is involved in several clinical trials for treatment-resistant depression. After assessment, patients may choose to participate in one of these research studies which comes with the benefits of close monitoring and access to new and novel treatments.

References

  1. Taïb, S., Arbus, C., Sauvaget, A., Sporer, M., Schmitt, L., & Yrondi, A. (2018). How Does Repetitive Transcranial Magnetic Stimulation Influence the Brain in Depressive Disorders?: A Review of Neuroimaging Magnetic Resonance Imaging Studies. The Journal of ECT, 34(2), 79- 86. https://doi.org/10.1097/yct.0000000000000477
  2. Berlim, M. T., Van den Eynde, F., & Daskalakis, Z. J. (2013). A systematic review and meta-analysis on the efficacy and acceptability of bilateral repetitive transcranial magnetic stimulation (rTMS) for treating major depression. Psychological Medicine, 43(11), 2245-2254. https://doi.org/10.1017/S0033291712002802
  3. Terao Y, Ugawa Y. Basic mechanisms of TMS. J Clin Neurophysiol. 2002 Aug;19(4):322-43. https://doi.org/10.1097/00004691-200208000-00006. PMID: 12436088.
  4. Fitzgerald PB, Daskalakis ZJ. (2016) A practical guide to the use of repetitive transcranial magnetic stimulation in the treatment of depression. Brain Stimulation 5: 287-296.
  5. Fitzgerald PB, Daskalakis ZJ. (2011) The effects of repetitive transcranial magnetic stimulation in the treatment of depression. Expert Rev. Med. Devices 8: 85–95.
  6. O’Reardon JP, Solvason HB, Janicak PG, et al. (2007) Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biological Psychiatry 62: 1208–1216.
  7. Lefaucheur JP, André-Obadia N, Antal A, et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clin Neurophysiol 2014;125(11):2150–206.
  8. Perera T, George M, Grammer G, Janicak P, Pascual-Leone A, Wirecki T. The Clinical TMS Society consensus review and treatment recommendations for TMS therapy for major depressive disorder. Brain Stimul 2016;9(3):336–46.
  9. RANZCP Position Statement 79, November 2018. https://www.ranzcp.org/news-policy/policy-and-advocacy/position-statements/repetitive-transcranial-magnetic-stimulation.
  10. Milev RV, Giacobbe P, Kennedy SH, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical guidelines for the management of adults with major depressive disorder: Section 4. Neurostimulation treatments. Can J Psychiatry 2016;61(9):561–75.
  11. Malhi et al. RANZCP clinical practice guidelines for mood disorders. Med J Aust. 2018 Mar 5;208(4):175-180.
  12. Gaynes et al. What Did STAR D Teach Us? Results From a Large-Scale, Practical, Clinical Trial for Patients With Depression. Psychiatric services, Nov 2009 Vol 60 No. 11.
  13. Brunoni AR, Chaimani A, Moffa AH, et al. (2017) Repetitive transcranial magnetic stimulation for the acute treatment of major depressive episodes: a systematic review with network meta-analysis. JAMA psychiatry 74: 143-152.
  14. Rush AJ et al. “Acute and longer-term outcomes in depressed outpatient requiring one or several treatment steps: A STAR*D report”. The American Journal of Psychiatry. 2006. 163(11):1905-1917.
  15. Schoisswohl, S., Agrawal, K., Simoes, J. et al. RTMS parameters in tinnitus trials: a systematic review. Sci Rep 9, 12190 (2019).
  16. Hamid P, Malik BH, Hussain ML. Noninvasive Transcranial Magnetic Stimulation (TMS) in Chronic Refractory Pain: A Systematic Review. Cureus. 2019;11(10):e6019.
  17. Matto et al. Repetitive transcranial magnetic stimulation in chronic tension-type headache: a pilot study. IJMR 2019 Jul 150: 73-80.
  18. Cohen H, Kaplan Z, Kotler M, et al. Repetitive transcranial magnetic stimulation of the right dorsolateral prefrontal cortex in posttraumatic stress disorder: A double-blind, placebo-controlled study. Am J Psychiatry 2004;161(3):515–24.
  19. A multi-site, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: durability of benefit over a 1-year follow-up period. Dunner DL, Aaronson ST, Sackeim HA, Janicak PG, Carpenter LL, Boyadjis T, Brock DG, Bonneh-Barkay D, Cook IA, Lanocha K, Solvason HB, Demitrack MA.
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