Transcranial Magnetic StimulationPresented by: Lisa Harpur, MD MSc PhD FRCPCPsychiatrist, Rockyview General HospitalCalgary Zone Clinical Medical Lead, rTMS

Photo by Eric Wassermann, M.D. / Public domain

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Burden of Depression

Burden of Depression

The Technology

The Technology

rTMS is a safe, non-invasive neuromodulation procedure that works by directly stimulating areas of the brain that are either underactive or overactive

Uses high-strength pulsed magnetic fields to stimulate a specific area of the cerebral cortex

This Photo by Unknown Author is licensed under CC BY-NC-ND

THE HISTORY

Choosing the rTMSPatient• Diagnosis of depression• The Depression is episodic NOT chronic

lifelong depression• Patients who have not responded to at least

two trials of medications• Patients who are not able to tolerate

medications

Choosing the rTMSPatient• Patient’s depression is < 3 years• Patient has responded to rTMS in the past

and has a recurrence• Patient is motivated to come for daily

treatment

Exclusionary Criteria• Ferro-magnetic material anywhere in head and neck

• No cochlear implants• No implanted brain stimulators• No electrodes, aneurysm clips, plates or screws

• Increased intracranial pressure • Large infarctions

• Seizure Disorders

• Current Suicidal Ideation with intent and plan

What is the Treatment Like?

• rTMS at RockyviewGeneral Hospital

What to Expect with rTMS

Risks and Side Effects

• Seizure 1/10,000• Facial Muscle Twitch During

Procedure• Discomfort at Site• Headache

This Photo by Unknown Author is licensed under CC BY-ND

Parameters of rTMS

• Treatment depends on:• Location• Intensity• Frequency• Duration

How Does rTMS Work?

The Impact

• Reduction:• 1/3 of patients achieve full

remission • 1/3 of patients achieve partial

response (40-60% improvement)• 1/3 patients state no

improvement

• Remember: These patients are already considered to have “treatment resistant” depression!

Improving Outcomes

Improving Outcomes,By Avoiding

• Drugs that will lower seizure threshold• Conditions that lower seizure threshold

• Sleep deprivation (not chronic insomnia)

• Active substance use, including alcohol• Cannabis, Cannabis oil, weed, marijuana• History of seizures or syncopal episodes• Benzodiazepines• Anti-epileptic medication

Improving Outcomes,By Avoiding

• Sleep medication • Hypnotics• Zopiclone, Eszopiclone

• Chronic, long-standing depression• “I’ve been depressed my whole

life”• Psychosis associated with depression• Schizophrenia• Personality Disorders

Referral Process

• Alberta Referral Directory has referral form

• Complete Referral Form and fax it to Access Mental Health at 403-943-9044

• Access MH will fax it to Rockyview General Hospital rTMS Clinic (Triage site)

Referral Process

• Referring Doctor will receive a letter from RGH

• If there is more information required

• If the patient has been declined

• If the patient has been referred to FMC or RGH (2 sites in Calgary offering treatment)

• Once the patient has been accepted and has started treatment

Questions about rTMS Program?

References

• Anderson, R.J., Hoy, K.E., Daskalakis, Z.J., Fitzgerald, P.B. (2016). Repetitive transcranial magnetic stimulation for treatment resistant depression: re-establishing connection. Clinical Neurophysiology, 127, 3394-3405.

• Barker, A., Jalinous, R., & Freeston, I. (1985). Non-invasive magnetic stimulation of human motor cortex [letter]. Lancet, 1, 1106-07.

• Blumberger, D.M., Vila-Rodriguez, F., Thorpe, K.E., Feffer, K., Noda, Y., Giacobbe, P., Knyahnytska, Y., Kennedy, S.H., Lam, R.W., Daskalakis, Z.J., Downar, J.(2018). Effectiveness of theta burst versus high-frequency repetitive transcranial magnetic stimulation in patients with depression (THREE-D): a randomized non-inferiority trial. The Lancet, 391(April 28), 1683-92.

• Canadian Network for Mood & Anxiety Disorders (CANMAT). Clinical Guidelines for the Management of Adults with Major Depressive Disorder Can J of Psychiatry 2016; 61(9):561-575.

• Chung, S., Hoy, K., & Fitzgerald, P. (2015). Theta-burst stimulation. A new form of TMS treatment for depression? Depression and Anxiety, 32, 182-92.

References

• Demas, M. (2016). Provincial Clinical Knowledge Topic – TrancranialMagnetic Stimulation, Adult – Inpatient, Ambulatory.

• Drysdale, A.T., et al. (2017). Resting-state connectivity biomarkers define neurophysiological subtypes of depression. Nature Medicine, 23(1), 28-

• George M, Wassermann E, Kimbrell T, Little J, et.al. Mood Improvement following daily left prefrontal repetitive transcranial magnetic stimulation in patients with depression a placebo-controlled crossover trial. AM J Psychiatry 1997:154:1752-1756.

• Holtzheimer, P. & McDonald, W. (Eds.) (2014). A Clinical Guide to Transcranial Magnetic Stimulation. New York: Oxford University Press.

• Huang, Y., Edwards, M., Rounis, E., Bhatia, K., & Rothwell, J. (2005). Theta burst stimulation of the human motor cortex. Neuron, 45, 201-6.

References

• Lanocha, K. (2018). Transcranial magnetic stimulation therapy for treatment-resistant depression. In, R. Bermudes, K. Lanocha, & P. Janicak (Eds.), Transcranial Magnetic Stimulation, Clinical Applications for Psychiatric practice. Arlington, VA: American Psychiatric Association. (1-24).

• Liston, C., Chen A.C., Zibley, B.D., Drysdale, A.T., Gordon, R., Leucher, B., Voss, H.U., Casey, B.J., Etkin, A., & Dubin, M. (2014). Default mode network mechanisms of transcranial magnetic stimulation in depression. Biological Psychiatry, 76,517-526.

• National Institute for Health and Care Excellence. Repetitive Transcranial Magnetic Stimulation for Depression. London (UK): NICE; Updated December 2015. (Clinical Guideline 542)

• Nguyen, K. & Gordon, L. (2015). Cost-effectiveness of repetitive transcranial magnetic stimulation versus antidepressant therapy for treatment-resistant depression. Value in Health, 18, 597-604.

• Pascual-Leone, A., Rubio, B., Pallardo, F., & Catala, M. (1996). Rapid-rate transcranial magnetic stimulation of left dorsolateral prefrontal cortex in drug-resistant depression. The Lancet, 348, 233-237.

References

• Patten, S.B. & Beck, C.A. (2004). Major depression and mental health care utilization in Canada: 1994 to 2000. Canadian Journal of Psychiatry, 49 (5), 303-309.

• Perera, T., George, M., Grammer, G., Janicak, P., Pascual-Leone, A., & Wirecki, T. (2016). The clinical tms society consensus review and treatment recommendations for tms therapy for major depressive disorder. Brain Stimulation, 9, 336-346.

• Philip, N.S., Barredo, J., Aiken, E., & Carpenter, LL. (2018). Neuroimaging mechanisms of therapeutic transcranial magnetic stimulation for major depressive disorder. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 3, 211-222.

• Rehm, J. & Shield, K.D. (2019). Global Burden of Disease and the impact of mental and addictive disorders. Current Psychiatry Reports, 21(10), 1-7.

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