TMS is prescribed and supervised by a psychiatrist and delivered by an appropriately trained clinician.  The patient rests comfortably in a reclining chair and hears a series of clicks as the magnetic pulses are generated. There is no anaesthetic, seizure or loss of consciousness involved.

TMS has several variables that can be individually tailored and modified according to response, such as the site, intensity, and number of pulses per treatment, or the frequency and number of sessions.  The most common course is five times per week for around five weeks.

During long-standing depression, the brain circuits responsible for positive emotion and thinking become less active, and therefore weaker and less likely to fire – much like muscles that shrink from underuse.  Meanwhile the circuits behind feelings of anxiety and melancholy are reinforced, becoming stronger and more ‘trigger-happy’.  Put simply, active circuits sprout new connections and become primed to fire again.  This is why depression tends to fuel its own course and take on a life of its own.

The effects spread through the associated connections of the brain involved with the regulation of mood, such as the hypothalamus and the amygdala.  Actual physical changes can be visualised with positron emission tomography and functional MRI.  Over time, depression is effectively written into the patient’s brain as positive experiences become more elusive, and success with psychotherapy or medication ever more difficult.

TMS works to reverse this process by inducing electrical activity through the circuits rendered dormant by depression.  The receptors and cells are stimulated to come ‘back online’, and studies have shown that DNA is switched on and new connections formed – a process called neuroplasticity.  The key area is the dorsolateral prefrontal cortex of the left hemisphere, which in turn suppresses overactivity in the hypothalamus and the amygdala.

Studies of the brain after TMS have shown also changes in the GABA and glutamate systems, and increased dopamine in the striatum.  The benefits then pass through the rest of the body, as has been shown through decreased salivary cortisol concentrations – an important marker of the stress response. The end result is correcting the neurocognitive vicious circle set in motion by depression, which is reflected in improved mood and thinking of TMS patients.

The side effects of TMS are mild and few; its delivery is swift and without discomfort, and patients can return to work immediately afterwards.  No medication is involved so there is no interference with other treatments, or concern about transfer into breastmilk.

TMS is non-invasive, with no anaesthetic, injections, or loss of consciousness involved.  Antidepressants, psychotherapy and ECT can be safely combined with a course of TMS.

Since TMS works through a different mechanism than antidepressants, ECT or psychotherapy, it may bring relief where these other methods have failed.

TMS has been most thoroughly studied with treatment-resistant depression, which is depression that has defied two full courses of different classes of antidepressant.  This category of depression is the most refractory and difficult to treat, yet here TMS has shown remarkably positive results.

Around half of these patients improve with TMS treatment, and around one third achieve full remission.  The proportion of positive outcomes has increased over recent years, which suggests TMS treatment protocols continue to improve.

TMS also is suitable for patients’ suffering depression associated with bipolar disorder, where response rates are similar to unipolar depression.

TMS is supported by 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.

TMS at Neurocentrix is accredited by the Australian Council of Healthcare Standards (ACHS) and the psychiatrists supervising the treatment have the appropriate credentialing and expertise, with continuing professional education to remain at the forefront of best-practice.

TMS effects last over 12 months for most patients that respond.  Overall, the durability of effect after 12 months is 64-90%.  When symptoms return after remission, most (84% in one study) recover with a second round of TMS and an antidepressant

Since TMS is a relatively new treatment, there is currently little data for treating pregnant women, children or adolescents.  However, there is no neurophysiological basis for suspecting any particular risk, and no reports of harm in the literature.  Ultimately the decision will need to be made in discussion with a psychiatrist.

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.

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 of TMS on the cortex. TMS is also being used as cognitive enhancement for the early stages of dementia.

Seizures with TMS are very rare, occurring 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.

Just like antidepressants, TMS can potentially ‘go too far’ and bring about a manic or hypomanic episode, especially in patients with pre-existing bipolar disorder.  This adverse effect is rare and reduced further when patients are taking a mood stabiliser.

ECT involves the delivery of an electrical current into the brain to induce a seizure, and accordingly ECT requires an anaesthetic and muscle relaxant.  Confusion, disorientation, and muscle aches are relatively common following ECT, and the patient cannot drive or return to work.

TMS does not deliver an electrical current directly but induces electrical activity by a nearby magnetic field.  TMS can be seen as ‘ECT-lite’, a gentler, indirect approach that nevertheless achieves comparable clinical benefits.  Since ECT and TMS work by different mechanisms, patients who have responded poorly to one may have success with the other.

Neurocentrix is involved in several clinical trials for treatment-resistant depression, involving agents such as ketamine and praxis.  After assessment, patients may choose to participate in one of these research studies, which comes with the benefits of close monitoring, additional imaging, and access to cutting-edge treatment.