Frequently Asked Questions - For Physicians

How can I describe rTMS to my patients?

rTMS is a relatively new treatment for major depression, approved by Health Canada since 2002. It is also being explored as a treatment for several other kinds of neurological and psychiatric disorders. Unlike medications or therapy, rTMS treats these disorders by stimulating the brain’s neurons directly. It does this using pulsed magnetic fields that are as strong as the one in an MRI scanner, but focused into an area the size of a toonie. The pulses are applied non-invasively through a magnetic coil held against the scalp. By applying repeated pulses of magnetic stimulation over time, rTMS can gradually increase or decrease the activity in the region of the brain underneath the magnetic coil. In major depression, and many other kinds of psychiatric and neurological illnesses, there are parts of the brain that are abnormally underactive or overactive. Over a series of treatment sessions, rTMS can correct these abnormalities to restore normal patterns of brain activity, and thereby treat the illness.

What kinds of disorders can be treated with rTMS?

So far, the strongest evidence base for rTMS is in the treatment of major depressive episodes. Patients with unipolar depression, bipolar depression, and postpartum depression may all benefit from the technique. Efficacy rates have been improving steadily over the last two decades, and the most recent generation of studies are achieving response (>50% reduction in symptoms) in 50-60% of patients and remission in 30-35% of patients with medically refractory depression. We are also seeing encouraging results in refractory eating disorders (particularly bulimia nervosa), impulse-control disorders, obsessive-compulsive disorder, PTSD and certain patients with neuropathic pain. However, these indications should still be considered investigational for the time being.

At what point should I consider making a referral for rTMS?

It is useful to think of rTMS as an intermediate option for treating depression: to be considered after unsuccessful trials of medication and/or therapy. In general, the remission rates for rTMS begin to exceed the remission rates for additional antidepressant trials after 1-2 failed attempts at pharmacotherapy. Thus, it would be reasonable to refer patients for rTMS if they have failed to improve with 1-2 or more medication trials of adequate dose and duration. Patients unable or unwilling to tolerate medication may also be suitable.

Who is a good candidate for rTMS?

Good candidates for rTMS have unipolar or bipolar depression as a primary diagnosis, and have a history of episodic rather than chronic lifelong depression, have had remediable life stressors (for example, divorce or loss of loved one) at least somewhat optimized prior to treatment, are sufficiently motivated and reliable to adhere to the schedule of treatments, and reside within easy commuting distance of the clinic. Ideally, a plan for psychiatric follow-up (medications, individual or group therapy) should be arranged prior to or during the course of treatment, to reduce the risk of relapse.

What management steps should I consider during rTMS?

Patients do not need to stop or start taking medications prior to beginning treatment, but should maintain a stable regimen and consistent adherence. We routinely advise against any changes to the medication regimen for 4 weeks before and during rTMS treatment. The issue is that concurrent medication changes will confound the interpretation of response or nonresponse to rTMS. rTMS responders usually continue to respond to rTMS in future episodes, and nonresponders do not. For this reason, it is useful to have unambiguous information on whether the rTMS treatment was associated with a successful or an unsuccessful outcome.

How do I make a referral?

On the Referrals tab of this website you will find an online form that can be completed and submitted electronically. Alternatively, you can print the completed form and fax it to us at 1-888-400-7094. Our clinic will contact your patient to schedule an appointment. We aim to maintain wait times of less than 10 days from the receipt of the referral to the initial assessment appointment. Suitable candidates can begin treatment within 1-2 weeks of assessment.

Whom should I contact for further information?

For further information please review the background material in the other sections of this website, and in the event of further questions please get in touch with our clinic at 1-888-400-7094.

Can I schedule a visit to observe an rTMS treatment session?

We are pleased to arrange for interested physicians, whether psychiatrists or general practitioners to visit the clinic and observe rTMS treatment. Please contact us at 1-888-400-7094 to make an appointment.

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