Transcranial Magnetic Stimulation (TMS)

Transcranial Magnetic Stimulation (TMS) therapy is a method that stimulates the brain's natural electrical activity by creating a magnetic field without directly delivering electricity to the brain. NP İSTANBUL is one of the first healthcare institutions in Turkey to apply this treatment for psychiatric purposes. Repetitive Transcranial Magnetic Stimulation (rTMS) therapy has been successfully applied in our hospital and outpatient clinics with years of experience. 
Our institution is one of the pioneering health centers to first apply TMS therapy in Turkey and is accepted as a reference in this field. Thanks to technological advancements over the past 15 years, devices such as TMS, which can measure and alter electrical activity in the brain, have been developed, and this treatment method is used as an effective option in the treatment of psychiatric disorders.

What is TMS?

In TMS application, brain activity is modified by creating a strong but short magnetic field from the outside, producing a therapeutic effect. Transcranial magnetic stimulation (TMS) is a non-invasive method that stimulates neurons in the brain. Through rapidly changing magnetic fields (electromagnetic induction), weak electrical currents induced in tissues lead to stimulation. In this way, brain activity can be triggered or modulated without the need for surgery or external electrodes. Mapping the way the brain functions, the TMS method is a powerful tool in neurology for diagnosis and research.

Repetitive transcranial magnetic stimulation (rTMS) holds promise in the treatment of a range of disorders such as depression and anxiety disorders. Consequently, in its current state, it is a good alternative to ECT.

In Which Diseases is TMS Effective?

TMS is not recommended as a first-line treatment. In the 2008 FDA approval and the 2010 guideline published by the APA, the application of Transcranial Magnetic Stimulation (TMS) is suggested as an option in the treatment of depression that has not responded to pharmacotherapy. It is typically used only in patients with depression who have not achieved remission with standard treatments, or in patients for whom electroconvulsive therapy could be considered but who wish to try another alternative. Patients with prolonged depression or depression unresponsive to standard treatments may be candidates for this procedure. rTMS is an important option in treatment-resistant psychiatric cases. It deserves attention as a promising treatment for patients who do not achieve adequate improvement with standard treatments, for negative-symptom schizophrenia, hallucinatory states, addiction, OCD, and other treatment-resistant psychiatric disorders. The important thing is for the physician to listen to the clinician within and be able to make a decision for the patient to progress another step on the road to remission.

Treatment responsibility is not only related to the treatments performed, but also encompasses potential treatments that exist as options to be performed. On the other hand, determining the rTMS protocol and considering the safety screening are important points for the physician to heed. In the 2008 FDA approval and the 2010 guideline published by the APA, the application of TMS is suggested as an option in the treatment of depression that has not responded to pharmacotherapy. It is typically used only in patients with depression who have not achieved remission with standard treatments, or in patients for whom electroconvulsive therapy could be considered but who wish to try another alternative.

TMS can also be easily used in situations where drug use is restricted  such as; during pregnancy, in breastfeeding mothers, and in cardiac patients, and in this respect, it provides great convenience for both the patient and the physician.

What is Neuronavigation-guided tTMU/rTMS?

Neuronavigation-guided Repetitive Transcranial Magnetic Stimulation (tTMU/rTMS), is an advanced treatment method used in conjunction with brain mapping technology. This technique allows magnetic stimuli to be directed precisely to targeted brain regions. The treatment offers effective results, particularly in the management of neurological and psychiatric disorders. The advantages of neuronavigation-guided tTMU/rTMS are:

Precise Targeting: Enhances the therapeutic effect by delivering accurate magnetic impulses to specific regions of the brain.

Personalized Treatment: Neuronavigation technology allows individual treatment planning tailored to each patient's brain structure.

High Efficacy: More pronounced improvements in symptoms are achieved thanks to focusing on the correct regions of the brain.

Non-invasive and Safe: It is a painless treatment method that does not require surgical intervention.

What is the Difference Between TMS / rTMS and Electroconvulsive Therapy (ECT)?

Transcranial Magnetic Stimulation (TMS/rTMS) and Electroconvulsive Therapy (ECT) are both methods used in the treatment of neurological and psychiatric diseases, but there are significant differences between them:

Method of Application: TMS/rTMS modulates brain cell activity using magnetic fields and is non-invasive. ECT, on the other hand, triggers short-term seizures by applying electric current to the brain.

Necessity of Anesthesia: TMS/rTMS does not require anesthesia during the procedure, and the patient remains awake. ECT requires the procedure to be performed under general anesthesia.

Side Effects: TMS/rTMS is generally limited to short-term side effects such as mild headache or mild discomfort. ECT, however, can lead to more serious side effects such as memory loss and cognitive impairment.

Duration of Treatment: TMS/rTMS sessions typically consist of short-term and repetitive treatment sessions. ECT sessions may be fewer in number but produce a more intense effect.

Areas of Use: While TMS/rTMS is preferred more for conditions such as depression, anxiety, and OCD, ECT is used particularly in severe cases of depression or in patients unresponsive to other treatments.

In Which Diseases is TMS / rTMS (TMS/rTMS) Effective?

TMS/rTMS (Transcranial Magnetic Stimulation / Repetitive Transcranial Magnetic Stimulation) is an effective treatment method, particularly in neurological and psychiatric disorders. The diseases in which it is effective are as follows:

Depression: It yields effective results, particularly in treatment-resistant major depression cases.

Anxiety Disorders: It alleviates symptoms of conditions such as generalized anxiety disorder and social anxiety.

Obsessive-Compulsive Disorder (OCD): It helps reduce repetitive thoughts and behaviors in OCD patients.

Bipolar Disorder: It is used to alleviate symptoms during periods of bipolar depression.

Schizophrenia: It can help reduce negative symptoms and auditory hallucinations in schizophrenia patients.

Chronic Pain: It can be used in the management of chronic pain syndromes such as fibromyalgia.

Migraine: It is effective in reducing the frequency and severity of migraine attacks.

Tinnitus: Positive results have been observed in some patients in the treatment of ringing in the ears (tinnitus).

Neurological Disorders: It can also be effective in the management of Parkinson's disease, post-stroke rehabilitation, and neuropathic pain.

TMS/rTMS offers a non-surgical, non-invasive, and safe option in the treatment of these disorders.

In Which Conditions is TMS Used in Neurology?

Transcranial Magnetic Stimulation (TMS) is also used as an effective method in the treatment of neurological diseases. The conditions in which TMS is used in neurology are:

Parkinson's Disease: It can be used to alleviate motor symptoms and increase mobility.

Post-Stroke Rehabilitation: It can help stroke patients regain motor functions.

Chronic Pain: It can be effective in the management of chronic pain syndromes, particularly neuropathic pain and fibromyalgia.

Tinnitus: It can help reduce symptoms in patients with ringing in the ears.

Migraine: It can be used to reduce the frequency and severity of migraine attacks.

Dystonia and Spasticity: It provides benefits in the treatment of muscle control disorders such as dystonia and spasticity by balancing muscle tone.

TMS offers an effective option as a non-invasive treatment in neurological diseases to manage symptoms and improve patients' quality of life.

How is TMS/rTMS Used in Children?

Transcranial Magnetic Stimulation (TMS) and Repetitive Transcranial Magnetic Stimulation (rTMS) have a limited yet promising field of use in the treatment of certain neurological and psychiatric disorders in children. Their use in children generally requires a careful evaluation process, and the application is based more on treatment protocols tested in adults. Some conditions in which TMS/rTMS is used in children are:

Attention Deficit Hyperactivity Disorder (ADHD): TMS may assist in managing ADHD symptoms, but further clinical research is required.

Obsessive-Compulsive Disorder (OCD): It is thought that TMS may be effective in treating OCD in children, particularly in cases resistant to pharmacotherapy.

Autism Spectrum Disorder (ASD): TMS offers the potential to improve social interaction and cognitive functions in autistic children, but research in this area is still in the early stages.

Depression and Anxiety Disorders: TMS shows promising results in the treatment of treatment-resistant depression and anxiety disorders in children.

TMS/rTMS treatment in children is generally administered by specialist physicians after a careful evaluation and according to the child's specific needs. Further research is needed regarding the safety and efficacy of the treatment, which is why such treatments are applied in a limited number of pediatric populations.

How is TMS/rTMS Administered?

Following a psychiatric evaluation and subsequent functional imaging of the brain with functional MRI or Quantitative EEG, it is recommended to determine the area deemed appropriate according to the suspected diagnosis and apply it to that region. In depression, the coil is generally placed over the left prefrontal region. Rhythmic stimuli are administered. It is applied in sessions lasting 10 to 30 minutes, for no fewer than 20 sessions. No special preparation is required other than having clean hair.

What are the Benefits of TMS / rTMS (TMS/rTMS)?

 Based on highly effective clinical research results, the success rate of rTMS treatment is greater than pharmacotherapy and less than electroconvulsive therapy.

• It has few or zero side effects. The most severe side effect is a mild headache.
• It demonstrates a rapid-onset therapeutic effect (typically within 1 week).
• The body is not directly intervened with. That means it does not require an invasive procedure.
• It does not require anesthesia.
• The patient is treated on an outpatient basis.
• It possesses superior targeting power for specific neuronal circuits.
• It requires only 2 to 4 weeks of treatment.
• It provides therapeutic benefit in treatment-resistant individuals.
• Patients do not need to stop taking medications for rTMS application.
• A reduction of typically around 75% is achieved in the depression symptoms of non-responders.
• It provides equal therapeutic efficacy in the treatment of patients with major depressive disorder and bipolar disorder.
• Treatment parameters are determined individually for each patient.
• Protocols are based on each individual patient's specific diagnosis, allowing for the most effective course of treatment.
• Patients are informed of the progress recorded on depression and anxiety rating scales throughout the course of treatment.
• The treatment parameters applied in our hospital and the results obtained from all rTMS procedures have been tracked using a specially developed software program. This allows the medical staff to track each patient's progress in treatment and provide feedback on a case-by-case basis.
• As with any effective treatment modality, the degree of recovery varies from person to person. An initial pre-procedure consultation with a medical doctor at our hospital helps determine the range of possible outcomes based on the individual's depression severity, medical history, and expectations.

What are the Side Effects of TMS / rTMS (TMS/rTMS)?

Transcranial Magnetic Stimulation (TMS) and Repetitive Transcranial Magnetic Stimulation (rTMS) are generally considered safe and non-invasive treatment methods. However, like other medical treatments, they may cause some side effects. These are usually mild and temporary;

Headache: It is the most common side effect, usually of mild severity and resolving shortly after treatment.

Discomfort at the Treatment Site: A mild discomfort or tingling sensation in the skin may occur in the area where the magnetic stimulation is applied.

Muscle Twitching: Temporary twitching of facial or scalp muscles may be observed during the procedure.

Dizziness: Some patients may experience short-term dizziness after treatment.

Risk of Epileptic Seizure: Although very rare, the risk of seizure is a condition that requires attention, especially for patients with a history of epilepsy.

These side effects are mostly mild and disappear rapidly after treatment. When the treatment plan is adjusted individually and administered by an expert team, the side effects of TMS/rTMS are kept to a minimum.

rTMS Procedure Description

The Transcranial Magnetic Stimulation (TMS) procedure is a non-invasive treatment method applied using magnetic fields to modulate brain functions. This method is used particularly in the treatment of various neurological and psychiatric disorders such as depression, anxiety, and obsessive-compulsive disorder. TMS can affect the activity of nerve cells by sending magnetic pulses to targeted regions in the brain, thereby contributing to the reduction of symptoms. This innovative technique offers a safe and effective treatment option that can be applied without the need for surgical intervention;

• rTMS treatment is applied to brain regions thought to be affected by depression and other mood disorders.
• Thanks to rTMS, it is possible to selectively modulate or alter activity in certain regions of the brain.
• rTMS produces a series of positive effects on the brain—such as excitatory or inhibitory effects—which have been shown to be effective in the treatment of various conditions and diseases in addition to depression.
• The treatment affects electrical activity in the brain through pulsed magnetic fields. A magnetic field is created by delivering short current pulses via a figure-eight metal coil (see the image below).
• The plastic-coated metal coil is held close to the scalp, thus focusing the magnetic field onto specific areas of the cortex or the surface of the brain.
• The magnetic field generated in rTMS penetrates the skull and scalp in a painless and safe manner, inducing a current in specific neurons (brain cells).
• Because magnetic stimulation is delivered at regular intervals, it is called repetitive TMS or rTMS.
• Stimulation parameters, such as the number of pulses, stimulation strength and duration, and the length of the pulse interval, can be entirely varied. The power to alter parameters while directly targeting specific brain cells suggests that rTMS has highly valuable therapeutic potential. Furthermore, it is possible to tailor the treatment to each patient's needs.
• The validity of rTMS treatment has been tested in a versatile manner in clinical trials and medical research studies. It has been approved for use in Canada since 2002.
• Peer-reviewed articles in various medical journals have stated that rTMS treatment holds promise in the treatment of Parkinson's disease, auditory hallucinations, schizophrenia, obsessive-compulsive disorder, tinnitus, eating disorders, migraine-type headaches, pain management, and other mood disorders.
• Peer-reviewed articles in various medical journals have stated that rTMS treatment holds promise in the treatment of Parkinson's disease, auditory hallucinations, schizophrenia, obsessive-compulsive disorder, tinnitus, eating disorders, migraine-type headaches, pain management, and other mood disorders.

Response Rate of Patients Receiving rTMS Therapy (Canada Mind Care Centres Table)

According to research conducted by Canada Mind Care Centres, the response rate of patients receiving Transcranial Magnetic Stimulation (TMS) therapy has revealed promising results, particularly in conditions such as treatment-resistant depression. Clinical data from these centres provide detailed information on the efficacy of TMS treatment and the rates of improvement in patients' symptoms. The proportion of patients responding to TMS therapy may vary depending on the type of disease being treated, session frequency, and individual biological factors, but high success rates have generally been reported;

• MindCare Centres administered rTMS therapy to over 300 patients on a clinical basis.
• It was demonstrated with clinical data that more than two-thirds of the patients responded significantly to rTMS treatment.
• A reduction of at least 75% was typically achieved in the depression symptoms of "responders".
• MindCare Centres Response Statistics
• Non-responders 32.6%
• Responders 62.4%
• Unknown 5.1%
• Determined via Beck Depression Inventory, Hamilton-7 Index, Hamilton Anxiety Rating Scale, and Patient Feedback.

Duration of Benefit

Although the duration of benefit from Transcranial Magnetic Stimulation (TMS) treatment varies from person to person, it generally depends on the treatment protocol and the type of disease. In TMS treatment applied for psychiatric disorders such as depression, most patients begin to see positive results within a few weeks. However, the lasting effects of the treatment may vary depending on personal factors, the number of sessions, and post-treatment lifestyle. While some patients experience long-term benefits, maintenance treatments may be required for others. In general, the effects of TMS can continue for weeks or even months after treatment, but it is important to evaluate the treatment process individually;

• Typically, improvement is observed within one to two weeks after initiating treatment.
• Most patients tend to notice the therapeutic benefit by the second week of treatment.
• To achieve significant reductions in depression symptoms, additional sessions in the third week may be required for slow responders.
• On average, patients enter maintenance therapy after approximately 8-12 months. This timeframe varies for each patient.
• On average, maintenance therapy involves half the number of rTMS sessions initially completed.
• We ask patients who feel that their depression symptoms are recurring to contact us without delay. NPİSTANBUL staff will make the necessary effort to secure an appointment as soon as possible.
• At NPİSTANBUL Hospital, this treatment has been considered for administration in treatment-resistant cases for individuals with the following disease conditions to date.

In Canada, it can be used as a first-line option in non-treatment-resistant cases. However, at NP İSTANBUL, rTMS treatment is administered with approval in cases resistant to other treatments.

Areas of Use Related to Diseases in Canada

In Canada, Transcranial Magnetic Stimulation (TMS) therapy is widely used in the treatment of various neurological and psychiatric diseases. TMS is offered to patients as a non-invasive method in many health centres and clinics across Canada, and this treatment approach is preferred to alleviate disease symptoms and improve quality of life. The areas of use for the treatment continue to expand based on clinical studies and individual patient needs;

• Anxiety,
• Auditory Hallucination (Schizophrenia),
• Depression,
• Eating Disorders – Bulimia,
• Epilepsy and Seizures,
• Migraine-type headaches,
• Obsessive-Compulsive Disorder (OCD) disease conditions,
• Tinnitus.

History of rTMS

1831 Faraday discovered the principle of mutual induction. Faraday's law is based on the principle of converting electrical energy into magnetic fields, and likewise magnetic fields into electrical energy.

1896 D'arsonval went a step further and placed a magnetic (power) coil inside a subject's head. Subjects reported seeing "magnetophospenes" (flarks of light) and experiencing dizziness and syncope.

1902 Pollacsek and Beer from Vienna, Austria, patented for the treatment of depression, sent vibrations into the skull via an electromagnetic coil placed over the skull. These early discoveries represent the historical framework that shaped today's modern version of rTMS, whereas use at high intensity or frequency was not permitted.

1959 Klein proved that a frog muscle was stimulated by means of a magnetic field. The first magnetic stimulation of human nerves was performed by Bickford and Fremming.

1970 Further research was conducted using different magnetic stimuli to study phosphene production. As mentioned, these stimuli were inadequate in terms of magnetic pulse intensity and duration, magnetic field shape and focality, and the capacity to use rapid frequencies. Furthermore, it is unknown whether phosphene production was a result of occipital cortex stimulation or direct retinal stimulation.

1985 Anthony Barker from the University of Sheffield, England, developed the first effective, modern Transcranial Magnetic Stimulation (TMS) device. In addition to the stimulation previously discovered in the frog, researchers could now induce movement in a hand finger or foot by placing a coil over the motor cortex. This TMS device was capable of producing an evoked potential in specific neurons in the brain. However, these initial TMS studies were limited to functional brain imaging. The non-invasive and painless nature of the procedure allowed earlier researchers to study and map brain regions involved in memory, vision, and muscle control using TMS devices. Technological advancements recorded in magnetic stimulation devices created the opportunity to apply greater and faster stimuli to specific brain regions.

1993 The first open studies on the use of TMS in the treatment of depression were initiated. Höflich et al. suggested that TMS applied along the vertex had antidepressant effects. Initially, the early clinical use of TMS devices included diagnoses of multiple sclerosis and motor neuron disease. Earlier researchers did not think to stimulate the frontal cortex or regions associated with mood disorders.

2002 The clinical use of rTMS treatment was approved by Health Canada in Canada.

2006 rTMS research has been ongoing for over 20 years in many parts of the world, such as Canada, the USA, the UK, Germany, Israel, and Japan. More recently, rTMS application has been utilized to investigate sensory and cognitive aspects of cortical processing. Current research has suggested that because of rTMS's capacity to selectively increase or decrease the excitability of neurons in different brain regions, it has valuable therapeutic potential in the treatment of many other diseases and disorders besides depression. This technological development is the most important discovery in neuropsychiatry in the last 50 years.

Case Reports (Excerpted from Canada Mind Care)

The rTMS treatment I received at MindCare Centre was quite successful. My depression cleared up. My test results showed I was in remission. I feel SO much better. The rTMS treatment yielded much better results than any medications I had taken before. The staff at the Centre are wonderful and very supportive. I would not hesitate to recommend MindCare to any relative or friend."

E.O., California

"I had been taking antidepressant medication from 1991 until April 2005. Although I tried many of the available medications, I never obtained sustained benefit from any of them. Moreover, each of them had challenging side effects at times. In April 2005, I began receiving rTMS treatment for my depression at MindCare Centre. Even though I had only seven treatments, I was able to stop taking antidepressants altogether. A year after the treatment, I am still not taking antidepressants and I feel wonderful. I recommend this treatment to anyone having similar experiences with antidepressant medications."

H.F., Utah

"I have a 25-year history of depression. Five years ago, I became resistant to medications, and my life spiraled out of control. My doctor had heard of rTMS treatment and recommended I try it. I did not qualify for the local research study, so I applied to MindCare Centres in Vancouver. Within two weeks, I felt I was improving; I got my job and family back."

C.H., Washington

"For the past ten years, I had been receiving psychiatric treatment for anxiety and depression. Meanwhile, I tried many medications, including drug combinations. Most of the medications did not work or provided only short-term relief. Thanks to this treatment, I experienced significant improvement and am hopeful for the months ahead. I especially recommend this treatment to those with refractory (treatment-resistant) depression."

B.L.S., British Columbia

"I struggled with depression for four years. Consequently, I was taking a lot of antidepressants at maximum doses. It seemed to be working on the surface, but my working capacity was reduced by half. My depression worsened again, and two years ago I underwent ECT. Although this was quite effective, I lost my memory for a period of 6 months—I could not succeed in my research position at UBC. It relapsed again. I heard about rTMS treatment and asked my doctor. He had some doubts about it. I went ahead with the treatment, and within a month—I experienced a dramatic recovery, I felt happy. (Many people I met at the clinic had experienced the same thing). I felt revitalized. Now I am using 50% of my previous medication doses and am able to do my job effectively. My goal is to use no medication at all."

J.G., Vancouver

"I went to the rTMS clinic (MindCare) in Vancouver. A truly professional approach prevails there. Two independent doctors recommended this clinic to me. I found the staff to be very professional. Health Canada approved this method long before the U.S. FDA, which is unusual. I would not hesitate to recommend this place to others..."

J.M., Maryland

"I had been using various antidepressants for the past 12 years. Even the ones that worked best had unwanted side effects; it felt as though I was disconnected from my emotions… The last medication I used caused me to gain about twenty pounds, and having gained weight made me even more depressed! After one week of treatment, I began to feel better. By the end of the third week, I reduced my antidepressant use and gradually stopped using them altogether. For the first time in years, I finally feel open-minded and social. And I lost twenty pounds without dieting!"

S.W., Toronto

"When I came to MindCare Centre, I was suffering from major depression lasting about a year. I was forced to take a leave of absence, and I was on the verge of losing my job and my marriage. I was even considering suicide as a last resort if the rTMS application did not work. However, surprisingly, after two days of treatment, I began to feel well. By the end of the first week, my depressive symptoms disappeared. I can say I came back to life. My family and friends were also greatly relieved. Six years ago, I had undergone ECT as a last treatment option. Although I got results, it was invasive and grueling, and it caused significant short-term memory problems. Compared to that, rTMS is far from invasive, an easy application. It caused no side effects for me. I owe a debt of gratitude to the exceptionally experienced, warm, and supportive staff. Thanks to this treatment, life has regained meaning for me. I hope other depression patients also become aware of rTMS and rediscover the beauties of life".

S.B., Seattle

"I have been suffering from severe depression since November 2001. I used all kinds of medications for years (Paxil, Celexa, Lexapro, Effexor XR, just to name a few), yet nothing got better; I was suicidal and hospitalized twice voluntarily. That didn't help either. However, in May 2005, I applied to the MindCare Clinic in Toronto to receive rTMS treatment. For ten days (excluding weekends), one hour a day, I received repeated, mild brain-directed magnetic shock treatment. Since I hadn't gotten results from any treatment for four and a half years, I thought this wouldn't work either. But I was wrong. Surprisingly, it did me good. About three weeks after the treatment, I felt much better. Within a few months, I completely emerged from depression. I am still using Effexor XR, but at a lower dose. I plan to taper it off completely by next year. In July of this year, I am thinking of applying to another MindCare Clinic (this time in Vancouver) to receive a second rTMS treatment. The reason for this is not that I am depressed, but because at least one follow-up treatment is recommended for those who have received one treatment. I really feel well. I did not experience memory loss, seizures, or anything like that. I wholeheartedly recommend this procedure to severe depression patients who feel hopeless. It really works. Those with questions about the procedure can contact me. Thank you..."

A.B., Costa Rica