UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Technique for performing transcranial magnetic stimulation (TMS)

Author
Paul E Holtzheimer, MD
Section Editor
Peter P Roy-Byrne, MD
Deputy Editor
David Solomon, MD

INTRODUCTION

Many patients with unipolar major depression do not respond to standard treatment with pharmacotherapy and psychotherapy [1,2] and are thus candidates for noninvasive neuromodulation procedures, including repetitive transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT) [3-5]. Although ECT is more efficacious than repetitive TMS [6,7], patients may prefer repetitive TMS because it is better tolerated and unlike ECT, TMS does not require general anesthesia and induction of seizures.

This topic reviews the technique for performing TMS to treat unipolar major depression in adults; the indications, efficacy, and safety of TMS are discussed elsewhere. Other neuromodulation procedures, including ECT, magnetic seizure therapy, focal electrically administered seizure therapy, transcranial direct current stimulation, transcranial low voltage pulsed electromagnetic fields, cranial electrical stimulation, vagus nerve stimulation, deep brain stimulation, direct cortical stimulation, and ablative neurosurgery, are also discussed separately, as is choosing treatment for treatment resistant depression and treatment refractory depression:

(See "Unipolar depression in adults: Indications, efficacy, and safety of transcranial magnetic stimulation (TMS)".)

(See "Depression in adults: Overview of neuromodulation procedures".)

(See "Overview of electroconvulsive therapy (ECT) for adults".)

              
To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Aug 04, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 2006; 163:1905.
  2. Holtzheimer PE, Mayberg HS. Stuck in a rut: rethinking depression and its treatment. Trends Neurosci 2011; 34:1.
  3. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder, third edition. Am J Psychiatry 2010; 167 (supplement):1.
  4. American Psychiatric Association: Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition, 2010. http://psychiatryonline.org/guidelines.aspx (Accessed on April 17, 2012).
  5. Kennedy SH, Milev R, Giacobbe P, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. IV. Neurostimulation therapies. J Affect Disord 2009; 117 Suppl 1:S44.
  6. Eranti S, Mogg A, Pluck G, et al. A randomized, controlled trial with 6-month follow-up of repetitive transcranial magnetic stimulation and electroconvulsive therapy for severe depression. Am J Psychiatry 2007; 164:73.
  7. Fitzgerald PB. Repetitive transcranial magnetic stimulation is not as effective as electroconvulsive therapy for major depression. Evid Based Ment Health 2007; 10:78.
  8. George MS, Lisanby SH, Avery D, et al. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Arch Gen Psychiatry 2010; 67:507.
  9. Allan C, Kalu UG, Sexton CE, Ebmeier KP. Transcranial stimulation in depression. Br J Psychiatry 2012; 200:10.
  10. Perera T, George MS, Grammer G, et al. The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder. Brain Stimul 2016; 9:336.
  11. 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; 125:2150.
  12. George MS, Post RM. Daily left prefrontal repetitive transcranial magnetic stimulation for acute treatment of medication-resistant depression. Am J Psychiatry 2011; 168:356.
  13. Lisanby SH. Update on magnetic seizure therapy: a novel form of convulsive therapy. J ECT 2002; 18:182.
  14. Fitzgerald PB, Daskalakis ZJ. A practical guide to the use of repetitive transcranial magnetic stimulation in the treatment of depression. Brain Stimul 2012; 5:287.
  15. Baeken C, De Raedt R. Neurobiological mechanisms of repetitive transcranial magnetic stimulation on the underlying neurocircuitry in unipolar depression. Dialogues Clin Neurosci 2011; 13:139.
  16. Fitzgerald PB, Hoy KE, Herring SE, et al. A double blind randomized trial of unilateral left and bilateral prefrontal cortex transcranial magnetic stimulation in treatment resistant major depression. J Affect Disord 2012; 139:193.
  17. Bakker N, Shahab S, Giacobbe P, et al. rTMS of the dorsomedial prefrontal cortex for major depression: safety, tolerability, effectiveness, and outcome predictors for 10 Hz versus intermittent theta-burst stimulation. Brain Stimul 2015; 8:208.
  18. Downar J, Blumberger DM, Daskalakis ZJ. Repetitive transcranial magnetic stimulation: an emerging treatment for medication-resistant depression. CMAJ 2016; 188:1175.
  19. 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; 61:561.
  20. Schutter DJ. Quantitative review of the efficacy of slow-frequency magnetic brain stimulation in major depressive disorder. Psychol Med 2010; 40:1789.
  21. Berlim MT, Van den Eynde F, Jeff Daskalakis Z. Clinically meaningful efficacy and acceptability of low-frequency repetitive transcranial magnetic stimulation (rTMS) for treating primary major depression: a meta-analysis of randomized, double-blind and sham-controlled trials. Neuropsychopharmacology 2013; 38:543.
  22. Berlim MT, van den Eynde F, Tovar-Perdomo S, Daskalakis ZJ. Response, remission and drop-out rates following high-frequency repetitive transcranial magnetic stimulation (rTMS) for treating major depression: a systematic review and meta-analysis of randomized, double-blind and sham-controlled trials. Psychol Med 2014; 44:225.
  23. Chen J, Zhou C, Wu B, et al. Left versus right repetitive transcranial magnetic stimulation in treating major depression: a meta-analysis of randomised controlled trials. Psychiatry Res 2013; 210:1260.
  24. Avery DH, Isenberg KE, Sampson SM, et al. Transcranial magnetic stimulation in the acute treatment of major depressive disorder: clinical response in an open-label extension trial. J Clin Psychiatry 2008; 69:441.
  25. McDonald WM, Durkalski V, Ball ER, et al. Improving the antidepressant efficacy of transcranial magnetic stimulation: maximizing the number of stimulations and treatment location in treatment-resistant depression. Depress Anxiety 2011; 28:973.
  26. Turnier-Shea Y, Bruno R, Pridmore S. Daily and spaced treatment with transcranial magnetic stimulation in major depression: a pilot study. Aust N Z J Psychiatry 2006; 40:759.
  27. Galletly C, Gill S, Clarke P, et al. A randomized trial comparing repetitive transcranial magnetic stimulation given 3 days/week and 5 days/week for the treatment of major depression: is efficacy related to the duration of treatment or the number of treatments? Psychol Med 2012; 42:981.
  28. Padberg F, George MS. Repetitive transcranial magnetic stimulation of the prefrontal cortex in depression. Exp Neurol 2009; 219:2.
  29. Schönfeldt-Lecuona C, Lefaucheur JP, Cardenas-Morales L, et al. The value of neuronavigated rTMS for the treatment of depression. Neurophysiol Clin 2010; 40:37.
  30. Connolly KR, Helmer A, Cristancho MA, et al. Effectiveness of transcranial magnetic stimulation in clinical practice post-FDA approval in the United States: results observed with the first 100 consecutive cases of depression at an academic medical center. J Clin Psychiatry 2012; 73:e567.
  31. Rossi S, Hallett M, Rossini PM, et al. Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clin Neurophysiol 2009; 120:2008.
  32. Rumi DO, Gattaz WF, Rigonatti SP, et al. Transcranial magnetic stimulation accelerates the antidepressant effect of amitriptyline in severe depression: a double-blind placebo-controlled study. Biol Psychiatry 2005; 57:162.
  33. Ray S, Nizamie SH, Akhtar S, et al. Efficacy of adjunctive high frequency repetitive transcranial magnetic stimulation of left prefrontal cortex in depression: a randomized sham controlled study. J Affect Disord 2011; 128:153.
  34. Mufti MA, Holtzheimer PE 3rd, Epstein CM, et al. Bupropion decreases resting motor threshold: a case report. Brain Stimul 2010; 3:177.
  35. Richieri R, Guedj E, Michel P, et al. Maintenance transcranial magnetic stimulation reduces depression relapse: a propensity-adjusted analysis. J Affect Disord 2013; 151:129.
  36. Fitzgerald PB, Grace N, Hoy KE, et al. An open label trial of clustered maintenance rTMS for patients with refractory depression. Brain Stimul 2013; 6:292.
  37. O'Reardon JP, Blumner KH, Peshek AD, et al. Long-term maintenance therapy for major depressive disorder with rTMS. J Clin Psychiatry 2005; 66:1524.
  38. Levkovitz Y, Roth Y, Harel EV, et al. A randomized controlled feasibility and safety study of deep transcranial magnetic stimulation. Clin Neurophysiol 2007; 118:2730.
  39. Zangen A, Roth Y, Voller B, Hallett M. Transcranial magnetic stimulation of deep brain regions: evidence for efficacy of the H-coil. Clin Neurophysiol 2005; 116:775.
  40. Bersani FS, Minichino A, Enticott PG, et al. Deep transcranial magnetic stimulation as a treatment for psychiatric disorders: a comprehensive review. Eur Psychiatry 2013; 28:30.
  41. Levkovitz Y, Harel EV, Roth Y, et al. Deep transcranial magnetic stimulation over the prefrontal cortex: evaluation of antidepressant and cognitive effects in depressive patients. Brain Stimul 2009; 2:188.
  42. Levkovitz Y, Isserles M, Padberg F, et al. Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial. World Psychiatry 2015; 14:64.
  43. Brunoni AR, Chaimani A, Moffa AH, et al. Repetitive Transcranial Magnetic Stimulation for the Acute Treatment of Major Depressive Episodes: A Systematic Review With Network Meta-analysis. JAMA Psychiatry 2017; 74:143.
  44. Rosa MA, Lisanby SH. Somatic treatments for mood disorders. Neuropsychopharmacology 2012; 37:102.
  45. Loo CK, Mitchell PB, McFarquhar TF, et al. A sham-controlled trial of the efficacy and safety of twice-daily rTMS in major depression. Psychol Med 2007; 37:341.
  46. Theleritis C, Sakkas P, Paparrigopoulos T, et al. Two Versus One High-Frequency Repetitive Transcranial Magnetic Stimulation Session per Day for Treatment-Resistant Depression: A Randomized Sham-Controlled Trial. J ECT 2017.
  47. Holtzheimer PE 3rd, McDonald WM, Mufti M, et al. Accelerated repetitive transcranial magnetic stimulation for treatment-resistant depression. Depress Anxiety 2010; 27:960.
  48. Hadley D, Anderson BS, Borckardt JJ, et al. Safety, tolerability, and effectiveness of high doses of adjunctive daily left prefrontal repetitive transcranial magnetic stimulation for treatment-resistant depression in a clinical setting. J ECT 2011; 27:18.
  49. Berlim MT, McGirr A, Rodrigues Dos Santos N, et al. Efficacy of theta burst stimulation (TBS) for major depression: An exploratory meta-analysis of randomized and sham-controlled trials. J Psychiatr Res 2017; 90:102.
  50. Berlim MT, Van den Eynde F, Daskalakis ZJ. A systematic review and meta-analysis on the efficacy and acceptability of bilateral repetitive transcranial magnetic stimulation (rTMS) for treating major depression. Psychol Med 2013; 43:2245.
  51. Chen JJ, Liu Z, Zhu D, et al. Bilateral vs. unilateral repetitive transcranial magnetic stimulation in treating major depression: a meta-analysis of randomized controlled trials. Psychiatry Res 2014; 219:51.