+ What is repetitive transcranial magnetic stimulation (rTMS)?
rTMS is a Health Canada-approved treatment for major depression and is also being studied as a treatment for other psychiatric and neurological disorders.
Unlike medications or psychotherapy, rTMS works by directly stimulating areas of the brain that are underactive or overactive, gradually returning them to healthy patterns of activity. To stimulate the brain, rTMS uses powerful, focused magnetic field pulses that are applied using a magnetic coil placed against the scalp, over the target brain region.
When applied repeatedly, these pulses can strengthen or weaken the connections between neurons, known as synapses. The long-lasting changes in neural connections can achieve lasting changes in brain activity, reversing the abnormal patterns associated with depression. More information about rTMS and its use in treating depression is available in the other sections of the website.
+ Who is eligible for treatment at the UHN rTMS Clinic?
The most common use of rTMS is for treating depression that has not responded to medications and psychotherapy. If you have a diagnosis of major depression, and you have tried at least 1-2 different antidepressant medications without improvement, or if you have been unable to tolerate at least 2 different antidepressant medications, then it may be worth considering rTMS.
rTMS is also being studied as a treatment for depression in bipolar disorder, as well as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), addictions, and eating disorders. The UHN rTMS clinic sometimes does conduct studies of rTMS for these illnesses, but cannot guarantee being able to offer treatment for illnesses other than major depression.
People who have major depression as well as other illnesses (such as PTSD, OCD, anxiety disorders) are eligible for treatment and can seek referral to the UHN rTMS clinic.
+ Who is not eligible for treatment at the UHN rTMS Clinic?
The UHN rTMS clinic does not currently offer treatment for neurological conditions, chronic pain, tinnitus, auditory hallucinations, or psychotic illnesses (such as schizophrenia).
Patients with a history of seizures or a diagnosis of epilepsy are not normally eligible for rTMS, since seizure is one of the rare but serious side effects of rTMS treatment.
Patients with a history of stroke, brain surgery, traumatic brain injury, or other neurological illnesses affecting the brain may not be eligible for treatment at the UHN rTMS clinic.
+ How do I get an intake appointment for rTMS?
The first step in seeking rTMS treatment is to have your doctor refer you for assessment, using the 1-page form here. Under OHIP rules, the referral must come from a physician, so please do not submit the form yourself. Once the referral is received, the clinic will contact you to schedule an intake appointment. If you do not hear from the clinic, you can always contact us via email or by telephone at (416) 603 - 5667 to check if the referral has been received. Due to high demand, it may be several weeks before we are able to offer you an appointment.
Prior to the intake appointment, you will receive a form to describe your symptoms and medical history. Please be sure to complete all sections of this form before you come to your intake appointment and bring the completed form with you, to avoid delays in being seen.
At the intake appointment, the doctor will review your history and then discuss whether rTMS is likely to be helpful for you. You will also have a chance to discuss the nature, risks and benefits of rTMS and to ask any questions you may have about the treatment. At the end of this appointment, if you are eligible, you may be offered a course of rTMS treatment.
+ What is involved in a course of rTMS treatment?
Due to high demand, it may be a few weeks between the time of your initial assessment and the time of your first treatment session.
A full course of treatment requires 20-30 sessions of rTMS in order to achieve maximum effect. rTMS is given on weekdays, Monday to Friday, so a course of treatment requires 4-6 weeks. Treatment visits last between 15 and 60 minutes, depending on the type of treatment being offered. The clinic is open from 9am to 5pm on weekdays. Unfortunately we are not able to offer treatment outside these hours of operation.
After the course of treatment, we will offer 1-3 follow-up appointments to see whether rTMS has helped you. Depending on the outcome, we may offer additional treatment recommendations during these follow-up appointments.
+ Are there any activity restrictions during rTMS treatment?
There are no activity restrictions during the course of rTMS. Most people do not require any recovery period after completing a session of rTMS, and may continue their daily activities as usual. There are no restrictions on driving before or after rTMS treatments. You do not need to bring anyone with you to your rTMS sessions, although some people prefer to have a spouse, relative, or friend accompany them for the first few treatments. If you are working, you do not need to stop working to undergo rTMS so long as your schedule can accommodate the treatment visits.
+ What are the potential benefits of rTMS in depression?
Outcome results from our clinic for patients with major depression have been published in the scientific literature. (Learn More)
In general, at the UHN clinic we have found that with a course of 20-30 sessions, about 1 in 3 patients achieves remission from depression. Another 1 in 3 patients achieves a partial response, with 40-60% improvement in symptoms. The remaining 1 in 3 patients report little to no noticeable improvement in symptoms.
If rTMS is successful, the effects generally last about 4-12 months before beginning to wear off. Booster sessions are possible, and are usually effective. The number of booster sessions required depends on how much the symptoms have returned, but is usually from 5-20 sessions. Booster sessions do not necessarily need to be given 5 days a week, and can be given 1, 2, or 3 days a week to accommodate work or other responsibilities, if required.
+ Is rTMS painful?
The most common side effect with rTMS is pain during the stimulation session itself. In addition to stimulating the brain, the magnetic pulses of rTMS can also stimulate the nerves in the areas of scalp, forehead, or face near the stimulation coil. This creates an unpleasant sensation similar to static electricity.
In research studies, patients usually rate the pain at about 6/10 intensity near the beginning of the course of treatment, and about 3/10 by the end of the course of treatment (on a scale where 10 is the maximum tolerable pain). About 2-4% of patients find that the pain is too intense to tolerate. Over the counter pain remedies such as ibuprofen (Advil) or acetaminophen (Tylenol) can be helpful for the first few sessions. A minority of people report fatigue or a mild headache in the hours after the treatment session is over.
A minority of people (2-4%) may get more severe, migraine-like headaches during the course of treatment, and these sometimes persist for 1-2 weeks even after the treatment course is over. These headaches are more common in people who have a history of migraines.
+ What are the potential risks of rTMS?
For the majority of people, there are no serious risks to rTMS.
A small number of people (3-5%) may feel faint, or may briefly faint, during the first one or two sessions.
Much rarer risks include hypomania (a high-energy, hyperactive state similar to the opposite of depression) or thoughts of self-harm (although not actual acts of self-harm) in less than 1% of cases.
The most serious known risk with rTMS is the induction of a seizure during brain stimulation, reported in approximately 1 in 10 000 cases. For comparison, the risk of seizure on most antidepressant medications is about 1-5 in 1 000 cases.
Despite the risk of a seizure during actual stimulation, there is no evidence that rTMS can cause the more general condition of epilepsy, in which seizures occur spontaneously outside of stimulation sessions. In fact, inhibitory forms of rTMS have been studied as a treatment for epilepsy.
+ What are the advantages of rTMS compared to other treatments?
rTMS has the advantage of few side effects, other than transient pain at the stimulation site, in the majority of people.
For those who have not responded to medication, or who have not been able to tolerate the side effects of medication, and for those who are uncomfortable with undergoing ECT, rTMS can be an attractive option.
+ What are the disadvantages of rTMS compared to other treatments?
The main disadvantage of rTMS is that it requires daily hospital visits for treatment. For people who live far from the clinic, or are working full-time, or have full-time responsibilities as a parent or caregiver, it can be quite inconvenient to come to the hospital every weekday for several weeks. For this reason, most people choose to try medications first, and turn to rTMS if the medications are ineffective or hard to tolerate.
Another disadvantage is that rTMS is not a permanent treatment. Typically, the effects of rTMS will last for 6-12 months before booster sessions are needed. To reduce the risk of relapsing, we strongly encourage patients to use the time after treatment to pursue a course of psychotherapy (for example, Mindfulness-Based Cognitive Therapy), address major life stressors, and consult with a specialist regarding medications.
+ What happens after the rTMS treatment is complete?
We offer 1-3 follow-up appointments over the 3-6 months after treatment. These follow-up appointments are an opportunity to evaluate symptoms, review progress, arrange follow-up medication or psychotherapy for responders, and arrange other options for nonresponders.
We strongly recommend that patients who complete rTMS enroll in a course of therapy to help prevent relapse. Usually, for patients with depression, we recommend enrollment in Mindfulness-Based Cognitive Therapy or Mindfulness-Based Stress Reduction, although other therapies may also be helpful.
Unfortunately, due to the volume of patients undergoing treatment, we are not able to offer long-term follow-up after rTMS is complete. We are also not able to offer management of medications during or after treatment. In the event of relapse after successful treatment, we do offer the possibility of booster or maintenance rTMS treatments. These additional treatments are usually effective if rTMS has been successful in the past.
+ What are the costs associated with rTMS?
rTMS is not currently a funded procedure under OHIP. However, the UHN rTMS Clinic does not currently charge patients for treatment. The clinic has a number of research studies underway at any given time, and research funds are available to cover the full cost of treatment for participants in these studies. The majority of people who are good candidates for rTMS can be offered participation in one of the studies currently underway.
For those people who prefer not to participate in a study, there is the option to pay for the treatment privately or through an insurer through the Altum rTMS Clinic (Learn More). Please be advised that a portion of the revenues from the Altum clinic are used to support rTMS research at UHN.
+ Where else can I obtain rTMS treatment aside from the UHN rTMS Clinic?
There are now a growing number of rTMS clinics accepting referrals in many areas of Canada. A map of Canadian rTMS clinics can be found here: www.rtmscanada.ca
+ How can I get an appointment to discuss having rTMS treatment at UHN?
To request an appointment for an initial assessment, please have your doctor refer you for assessment, using the 1-page form on this website, here. Under OHIP rules, the referral must come from a physician, so please do not submit the form yourself. Once the referral is received, the clinic will contact you to schedule an intake appointment. If you do not hear from the clinic, you can always contact us via email or by telephone at (416) 603 - 5667 to check if the referral has been received. Due to high demand, it may be several weeks before we are able to offer you an appointment.