tTMU (rTMS) therapy is a system that activates the brain's natural electricity by creating a magnetic field without directly electrifying the brain.
Memory Center is one of the first health institutions in Turkey to apply Repetitive Transcranial Magnetic Stimulation (tTMU) therapy for psychiatric purposes. Repetitive Transcranial Magnetic Stimulation (tTMU - repetitive Transcranial Magnetic Stimulation) Treatment is still successfully applied in our hospitals and polyclinics with the experience we have brought from the past. As one of the first institutions to apply TMU treatment, our hospital is considered a reference in this field.
Technological advances in the last 15 years have led to the development of devices to measure and modify the cellular electrical current in the brain. One of these devices is the Transcranial Magnetic Stimulation (TMU) system.
What is TMU?
In the application of TMU, a strong but short magnetic field is created from the outside, changing brain activity and creating a therapeutic effect. Transcranial magnetic stimulation (TMU) is a noninvasive method that stimulates neurons in the brain. Through rapidly changing magnetic fields (electromagnetic induction), weak electrical currents induced in the tissues lead to stimulation. In this way, brain activity can be triggered or modulated without the need for surgery or external electrodes. By mapping the way the brain works, the TMU method is a powerful tool for diagnosis and research in neuroscience.
Repeated transcranial magnetic stimulation (tTMU) has shown promise in the treatment of a range of disorders such as depression and anxiety disorders. As a result, it is a good alternative to ECT in its current state.
In which disorders is tTMU effective?
TMU is not recommended as a first-line treatment. Transcranial Magnetic Stimulation (TMU) is recommended as an option for the treatment of depression that has not responded to medication in the 'guideline' approved by the FDA in 2008 and published by the APA in 2010. It is typically used only in patients with depression who have not improved with standard treatments or in patients who may consider electroconvulsive therapy but want to try another alternative. Patients with prolonged depression or who have not improved with standard treatments may be candidates for this procedure. TTMU is an important option in treatment-resistant psychiatric cases. It deserves attention as a promising treatment for schizophrenia with negative symptoms, hallucinatory states, addiction, OCD and other resistant psychiatric disorders that do not improve adequately with standard treatments. The important thing is that the physician can listen to the voice of the clinician within the physician and make a decision for the patient to progress one step further on the path to remission.
Responsibility for treatment is not only about the treatments that have been given, but also about the potential treatments that are available as options. On the other hand, determining the tTMU protocol and considering the safety screen are important considerations for the physician. In the 'guideline' approved by the FDA in 2008 and published by the APA in 2010, TMU is recommended as an option for the treatment of depression that has not responded to a medication. It is typically used only in patients with depression who have not improved with standard treatments or in patients who may consider electroconvulsive therapy but want to try another alternative.
TMU can also be used in cases where the use of medication is restricted, for example in pregnancy, nursing mothers and cardiac patients, and in this respect, it provides great convenience to the patient and the physician.
What is Deep TMS (Deep TMU)?
Deep TMS (Deep TMU): It is a TMU application that can affect the deep structures of the brain. Thanks to the features of the head used, stimulation can be given to different brain regions in different diseases. There are study findings that it is effective in Obsessive Compulsive Disorder, Adult Attention Deficit Hyperactivity Disorder and some other psychiatric diseases and its use is becoming increasingly widespread.
In which cases is Deep TMS (Deep TMU) applied?
The use of Deep TMS (Deep TMU) in Depression and Bipolar Disorder is FDA and CE approved and is widely used primarily in the treatment of depression in the USA, Canada, Australia, Germany, Belgium, Italy and other European and South American countries.
Deep TMS is also used to treat
- Alcohol use disorder
- Alzheimer's Disease
- Cocaine addiction
- Multiple sclerosis - to relieve fatigue,
- Neuropathic pain
- Obsessive compulsive disorder,
- Autism - in increasing communication skills,
- Parkinson's disease
- Cigarette addiction
- It is also CE approved for resistant neuro-psychiatric disorders such as schizophrenia-negative symptoms, and the results of clinical trials are positive and its use in treatment is becoming increasingly widespread.
What is tTMU/rTMS with neuronavigation?
Neuronavigation is an application that allows the treatment to be applied to the exact point in the brain and thus increases the effectiveness of the treatment.
- Patients first undergo brain MRI scans and the images are transferred to the navigation device
- The point in the patient's brain where the treatment will be applied is determined by a specialist.
- The neuronavigation device ensures that brain stimulation (transcranial magnetic stimulation) is delivered to this exact point.
- Neuronavigation device is available in our institution.
Does TMU /tTMU have an effect on the brain?
TMU interferes with the electrical conduction of the cells in the brain. Considering that the brain works with electrical and chemical conduction, this intervention has the effect of activating the natural processes of the brain that are not working adequately. The treatment effect is created by creating a strong but short magnetic field without external electric current. Thus, a change called "neuronal depolarization" occurs in the targeted area of the brain.
How is TMU /tTMU different from electroconvulsive therapy (ECT)?
ECT is applied by direct electric current to the brain. It needs to be performed in a hospital environment and under general anesthesia. TMU treatment, on the other hand, can be applied on an outpatient basis and does not require anesthesia or analgesics. Most of the time, the patient does not feel any negative effects other than a mild headache and slight discomfort at the site of stimulation.
How long is a TMU/tTMU (TMS/rTMS) session?
The duration of the session is determined according to the individual needs of the patient. For a period of 5 to 30 minutes, the frequency and intensity determined are applied with the frequency and intensity determined.
In which diseases is TMU/tTMU (TMS/rTMS) effective?
Currently, the primary recommended treatment areas are Treatment-Resistant Depression, Schizophrenia and Obsessive-Compulsive Disorder and Schizophrenia mental disorders. It is noted that it can be used in pregnancy, nursing mothers and cardiac patients and that it is superior to drug treatment. (Arch. Gec-Psychiatry. 1999;56:300-311)
In which cases is TMU used in neurology?
It is currently used for experimental purposes in speech disorders, epilepsy, Parkinson's and some strokes. Research is ongoing.
How is TMU/tTMU used in children?
Scientific studies on its use in autism and hyperactivity are ongoing.
How is TMU/tTMU applied?
After a psychiatric evaluation followed by functional imaging of the brain with functional MRI or Quantitative EEG, it is recommended to determine the appropriate area according to the diagnosis considered and apply it to that area. In depression, a coil is usually placed on the left frontal forehead. Rhythmic stimuli are given. It is applied in 10 to 30 minute sessions for not less than 20 sessions. No preliminary preparation is required except that the hair must be clean.
What are the benefits of TMU/ tTMU (TMS/rTMS)?
- Based on highly effective clinical trial results, the success rate of tTMU treatment is higher than pharmacotherapy and lower than electroconvulsive therapy.
- It has few or no side effects. The most severe side effect is a mild headache.
- Quick onset of therapeutic effect (typically within 1 week).
- No direct intervention in the body. So no invasive intervention is required.
- It does not require anesthesia.
- The patient is treated as an outpatient.
- It has superior targeting power to specific neuronal circuits.
- Requires only 2 to 4 weeks of treatment.
- Provides therapeutic benefit in treatment-resistant individuals.
- Patients do not need to stop taking medication for tTMU application.
- A reduction in depression symptoms is typically achieved in a proportion of those who do not respond to treatment.
- It is equally effective in treating patients with major depressive disorder and bipolar disorder.
- Treatment parameters are determined individually for each patient.
- Protocols are based on the specific diagnosis of each individual patient and allow for the most effective course of treatment.
- Patients are kept informed of their progress on depression and anxiety rating scales throughout the course of treatment.
- The treatment parameters and outcomes from all tTMU procedures performed in our hospital are tracked using a specially developed software program. This allows the medical staff to track each patient's progress in treatment and provide feedback on the results on an individual basis.
- As with any effective treatment modality, the degree of improvement varies from person to person. An initial pre-procedure consultation with a medical doctor at our hospital helps to determine a range of possible outcomes based on the intensity of the person's depression, medical history and expectations.
When does TMU treatment produce a response?
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Typically, improvement is seen within one to two weeks of starting treatment.
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Most patients tend to notice therapeutic benefit in the second week of treatment.
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Late responders may require additional sessions in the third week to achieve significant reductions in symptoms of depression.
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On average, patients enter maintenance therapy after about 8-12 months. This timeframe varies for each patient.
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On average, maintenance therapy includes half the number of tTMU sessions initially completed.
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We strongly encourage patients who feel that their symptoms of depression are recurring to contact us immediately. You will be contacted as soon as possible.
What are the immediate and short-term risks of tTMU?
Seizures
The primary safety concern with tTMU is the risk of inducing seizures. Although this risk is primarily associated with tTMU, single-pulse stimulation has been reported to cause seizures in patients with large cerebral infarcts, contusions or other structural brain lesions. Seizure activity is highly unlikely to occur if the conditions are in accordance with established safety guidelines (Wassermann 1998).
Cardiovascular effects
No significant changes in blood pressure and heart rate were reported during and after tTMU administration (Foerster et al. 1997).
Auditory function
In a study of 12 depressed subjects who received tTMU for four weeks, no significant change in hearing threshold was observed for four weeks after the study (Loo et al. 2001).
Headache
TMU application can lead to local pain from direct stimulation of the muscles under the coil and stimulation of the nerves in the face and scalp. The procedure is generally more painful at higher intensity and frequency. Approximately 5% to 20% of subjects experience tension-type headaches after tTMU sessions (George et al. 1999).
What are the side effects of TMU/tTMU (TMS/rTMS)
Compared to other brain stimulation methods, tTMU can be considered relatively safe because it is noninvasive. The main problems are involuntary induced seizures, local pain during the procedure, changes in auditory performance due to the noise generated by the coil with the passage of the electric current, ligament pain and potential changes in cognitive function.
Most of these side effects are immediate and of short duration. There was no evidence of any long-term neuronal damage attributable to tTMU in animal studies. In a safety study, tTMU had no significant effect on sleep EEG in therapeutic parameters (Graf et al. 2001).
Is tTMU used in the treatment of depression in the elderly?
Late-life depression is an important issue in treatment resistance. Treatment-resistant depression is more common in the elderly, and combination or augmentation therapies carry greater risks of drug interactions. There are limited number of TMU studies in this patient group. In the only study conducted in Turkey on the use of TMS in the treatment of depression in the elderly, an average of 18 sessions of TMS was applied to the left DLPFC area simultaneously with antidepressant treatment in 65 elderly patients with treatment-resistant depression with an average age of 66.6 years. As a result of the treatment, partial improvement was achieved in 38 of 65 patients and complete improvement was achieved in 19 of 65 patients. In this study, there were no patients with worsening of depression symptoms and no serious side effects or cognitive deterioration were reported (Hızlı Sayar et al. 2013).
tTMU Procedure Description
- tTMU therapy is applied to areas of the brain thought to be affected by depression and other mood disorders.
- With tTMU it is possible to selectively modulate or alter activity in certain areas of the brain.
- tTMU produces a number of positive effects on the brain (e.g. stimulatory or suppressive effects) that have been shown to be effective in treating a variety of conditions and diseases, including depression
- The treatment affects electrical activity in the brain through a pulsed magnetic field. A magnetic field is created by delivering short, current pulses through a metal coil in the shape of an octagon, (see picture below).
- The plastic-coated metal coil is held close to the scalp so that the magnetic field is focused on specific areas of the cortex or brain surface.
- The magnetic field generated in tTMU painlessly and safely penetrates the skull and scalp and induces a current in specific neurons (brain cells).
- Because the magnetic stimulation is delivered at regular intervals, it is called repeated TMU or tTMU.
- The stimulation parameters, such as the number of stimuli, the stimulus strength and duration, and the length of the stimulation interval, can all vary. The ability to vary the parameters while directly targeting specific brain cells suggests that tTMU has a highly valuable therapeutic potential. It is also possible to tailor the treatment to each patient's needs.
- The validity of tTMU therapy has been thoroughly tested in clinical trials and medical research studies. It has been approved for use in Canada since 2002.
- In peer-reviewed articles in various medical journals, tTMU therapy has shown promise in the treatment of Parkinson's disease, auditory Hallucinations, Schizophrenia, Obsessive Compulsive Disorder, Tinnitus, Eating Disorders, Migraine headaches, Pain Management and other mood disorders.
- In peer-reviewed articles in various medical journals, tTMU therapy has shown promise in the treatment of Parkinson's disease, auditory hallucinations, Schizophrenia, Obsessive Compulsive Disorder, Tinnitus, Eating Disorders, Migraine headaches, Pain Management and other mood disorders.
Response rate of patients receiving tTMU therapy (CANADA Mind Care Centers table)
- MindCare Centers have clinically treated over 300 patients with tTMU therapy.
- Clinical data showed that more than two-thirds of patients responded significantly to tTMU therapy.
- Typically, "responders" achieved at least a 75% reduction in depression symptoms.
- Response statistics of MindCare Centers
- Non-respondents 32.6
- Respondents 62.4
- Unknown 5.1
- Determined by Beck Depression Inventory, Hamilton-7 Index, Hamilton-Anxiety Scale and Patient Feedback.
Benefit Duration
- Typically, improvement is seen within one to two weeks of starting treatment.
- Most patients tend to notice therapeutic benefit in the second week of treatment.
- Late responders may require an additional session in the third week to achieve significant reductions in symptoms of depression.
- On average, patients enter maintenance therapy after about 8-12 months. This timeframe varies for each patient.
- On average, maintenance therapy includes half of the number of tTMU sessions initially completed.
We encourage patients who feel that their depression symptoms are recurring to contact us immediately. NPISTANBUL staff will make every effort to arrange an appointment as soon as possible.
At NPISTANBUL Hospital, this treatment has so far been considered to be applied to people with the following disease states in treatment-resistant cases.
NOTE : In CANADA, it can be used as the first option in cases that are not resistant to treatment. However, in NPISTANBUL, tTMU treatment is applied with approval in cases resistant to other treatments.
Areas of Use for Diseases in CANADA:
- Anxiety
- Auditory Hallucination (Schizophrenia)
- Depression
- Eating Disorders - Bulimia
- Epilepsy and Seizures
- Migraine headaches
- Obsessive Compulsive Disorder (OCD) Disease states
- Tinnitus
The story of tTMU
1831 Faraday discovers the principle of mutual induction. Faraday's law is based on the transformation of electric " energy into magnetic fields, and likewise magnetic fields into electric energy.
1896 D'arsonval went further and placed a magnetic (power) coil inside the head of a subject. The subjects reported seeing "magneto-phosphenes" (sparks) and experiencing dizziness and syncope.
1902 Pollacsek and Beer of Vienna, Austria, who were granted a patent for the treatment of depression, sent vibrations inside the skull through an electromagnetic coil placed on the skull. These early discoveries represent the historical constructs that have shaped today's modern version of the tTMU, although use at high intensity or frequency was not authorized.
1959 Klein proves that a frog muscle is stimulated by a magnetic field. The first magnetic stimulation of human nerves is performed by Bickford and Fremming.
1970 More research was carried out using different magnetic stimuli to study the production of phosphenes. As mentioned, these stimuli were inadequate in terms of magnetic pulse intensity and duration, magnetic field shape and focality, and fast frequency handling capability. Furthermore, it is not known whether phosphene production is the result of occipital cortex stimulation or direct retinal stimulation.
1985 Anthony Barker of the University of Sheffield, UK, develops the first effective, modern Transcranial Magnetic Stimulation (TMU) device. In addition to the stimulation previously discovered with the frog, researchers could now induce finger or foot movement by placing a coil over the motor cortex. This TMU device could generate an evoked potential in specific neurons in the brain. However, these initial TMU studies were limited to functional brain imaging. The non-invasive and painless nature of the procedure allowed previous researchers to use TMU devices to study and map brain regions involved in memory, vision and muscle control. Technological advances in magnetic stimulation devices made it possible to apply more and faster stimuli to specific brain regions.
1993 The first open studies of the use of TMU in the treatment of depression begin. Hoflich et al. suggest that TMU applied along the vertex has antidepressant effects. Initially, the first clinical use of TMU devices included diagnoses of multiple sclerosis and motor neuron disease. Previous researchers had not thought to stimulate the frontal cortex or regions associated with mood disorders.
2002 tTMU therapy is approved for clinical use in Canada by Health Canada.
2006 tTMU research has been ongoing for more than 20 years in many parts of the world, including Canada, the U.S.A., the United Kingdom, Germany, Israel and Japan. More recently, tTMU has been used to investigate sensory and cognitive aspects of cortical processing. Recent research has suggested that tTMU has valuable therapeutic potential in the treatment of many other diseases and disorders besides depression, due to its capacity to selectively increase or decrease the excitability of neurons in different brain regions. This technological development is the most important breakthrough in neuropsychiatry in the last 50 years.
Case descriptions (taken from Mind Care CANADA)
The tTMU treatment I received at MindCare Center was very successful. My depression lifted. My test results showed that I am in remission. I feel MUCH better. tTMU treatment has worked much better than any medication I have ever taken. The staff at the Center are amazing and very supportive. I would have no hesitation in recommending MindCare to any relative or friend."
E.O., California
"I was on antidepressant medication from 1991 until April 2005. Although I tried many of the available medications, none of them worked consistently, and all of them had challenging side effects at times. In April 2005, I started receiving tTMU treatment for my depression at the MindCare Center. After only seven treatments, I was able to completely stop taking antidepressants. One year after treatment, I am still not taking antidepressants and I feel great. I would recommend this treatment to anyone who has had similar experiences with antidepressant medication."
H.F., Utah
"I have a 25-year history of depression. Five years ago I became resistant to medication and my life spiraled out of control. My doctor had heard about tTMU treatment and recommended I try it. I didn't qualify for a local research study, so I applied to MindCare Centers in Vancouver. Within two weeks I felt better and was back at work and with my family."
C.H., Washington
"For the past ten years, I have been under psychiatric treatment for anxiety and depression. I have tried many medications, including combinations of drugs, many of which did not work or provided only short-term relief. Thanks to this treatment, I have experienced a significant improvement and I am hopeful for the coming months. I would especially recommend this treatment for people with refractory depression."
B.L.S.,TBritlsh Columbia
"I struggled with depression for four years. As a result, I was on a lot of antidepressants at maximum doses. It seemed to be working, but my capacity to work was halved. My depression relapsed and two years ago I had ECT, which was quite effective, but I lost my memory for six months - I didn't do well in my research post at UBC. It relapsed again. I heard about tTMU treatment and asked my doctor about it. He had some doubts about it. I went ahead with the treatment and within a month - I experienced a dramatic improvement, I felt happy (many people I met in the clinic had the same experience). I felt revitalized. Now I'm on 50% of my previous doses of medication and I can do my job effectively. My goal is to be medication-free."
J.G., Vancouver
"I went to the tTMU clinic (MindCare) in Vancouver, which has a really professional approach. Two independent doctors recommended this clinic to me. I found the staff to be very professional. Health Canada approved the procedure much earlier than the U.S. FDA, which is unusual. I would not hesitate to recommend this place to others..."
J.M., Maryland
"I had been on various antidepressants for the last 12 years. Even the most helpful ones had unwanted side effects, I felt disconnected from my emotions... The last one I was on caused me to gain about ten kilos, and the weight gain made me even more depressed! After a week of treatment, I started to feel better. By the end of the third week, I reduced my use of antidepressants and gradually stopped taking them altogether. For years now, I finally feel open-minded and sociable, and I lost ten kilos without dieting!"
S.W., Toronto
"When I came to the MindCare Centre, I had been suffering from major depression for about a year. I was forced to take a medical leave, I was on the verge of losing my job and my marriage. I was even considering suicide as a last resort if the tTMU treatment didn't work. But surprisingly, after two days of treatment, I started to feel better. By the end of the first week, my depressive symptoms had disappeared. I can say I came back to life. My family and friends were also very relieved. Six years ago, I had ECT as a last treatment option. Although I got results, it was invasive and coercive and caused significant short-term memory problems. Compared to that, tTMU is non-invasive and easy. I had no side effects at all. I owe a debt of gratitude to the extraordinarily experienced, warm and supportive staff. This treatment has given life new meaning for me. I hope other people with depression will learn about tTMU and realize the beauty of life again."
S.B., Seattle
"I have suffered from severe depression since November 2001. I have been on all kinds of medications for years (Paxil, Celexa, Lexapro, Effexor XR, just to name a few), but nothing got better, I was suicidal, and I was hospitalized twice on my own accord. That didn't help either. However, in May 2005, I went to the MindCare Clinic in Toronto for tTMU treatment. For ten days (excluding weekends), I received repeated, mild magnetic shock therapy to the brain for one hour a day. I thought that this would not work either, as I had not had any results from any treatment for four and a half years. But I was wrong. It worked surprisingly well. About three weeks after the treatment I felt much better. Within a few months I was completely out of depression. I am still on Effexor XR, but at a lower dose. I plan to gradually wean myself off it completely by next year. In July this year, I am planning to go to another MindCare Clinic (this time in Vancouver) for a second tTMU treatment. This is not because I am depressed, but simply because those who have had one treatment are recommended at least one follow-up treatment. I feel really good, I haven't had any memory loss, seizures or anything like that. I would recommend this procedure to anyone with severe depression who feels hopeless. It really works. Anyone who has any questions about the procedure can contact me. Thank you..."
A.B., Costa Rica FAQ
