Transcranial Magnetic Stimulation (tTMS)

Transcranial Magnetic Stimulation (TMS) is a method that stimulates the brain’s natural electrical activity by generating a magnetic field without directly applying electricity to the brain. NP ISTANBUL is one of the first healthcare institutions in Turkey to administer this treatment for psychiatric purposes. Repetitive Transcranial Magnetic Stimulation (rTMS) treatment has been successfully administered at our hospital and outpatient clinics for many years. Our institution is one of the first healthcare centers in Turkey to have implemented TMS treatment and is recognized as a leader in this field
. Thanks to technological advancements over the past 15 years, devices such as TMU—which can measure and modify electrical activity in the brain—have been developed, and this treatment method is now used as an effective option for treating psychiatric disorders.

What Is TMS?

In TMS treatment, a strong but brief external magnetic field is applied to modify brain activity and produce a therapeutic effect. Transcranial magnetic stimulation (TMS) is a noninvasive method that stimulates neurons in the brain. Weak electric currents induced in tissues through rapidly changing magnetic fields (electromagnetic induction) lead to stimulation. In this way, brain activity can be triggered or modulated without the need for surgery or external electrodes. The TMS method, which maps the brain’s functioning, is a powerful tool for diagnosis and research in neurology.

Repetitive transcranial magnetic stimulation (rTMS) shows promise in the treatment of a range of disorders, such as depression and anxiety disorders. As a result, it is a viable alternative to ECT in its current form.

For Which Conditions Is TMU Effective?

TMU is not recommended as a first-line treatment. The 2010 “guideline” published by the APA, which was based on the FDA’s 2008 approval, recommends the use of Transcranial Magnetic Stimulation (TMU) as an option for treating depression that has not responded to medication. It is typically used in patients with depression who have not shown improvement with standard treatments alone, or in patients who might consider electroconvulsive therapy but wish to try another alternative. Patients with long-standing depression or those who have not improved with standard treatments may be candidates for this procedure. tTMU is an important option for treatment-resistant psychiatric cases. It deserves attention as a promising treatment for patients who have not achieved sufficient improvement with standard treatments, including those with negative-symptom schizophrenia, hallucinatory states, substance use disorders, OCD, and other treatment-resistant psychiatric disorders. What matters is that the physician, by listening to the clinician within, can make a decision to help the patient take another step toward remission.

Treatment responsibility extends not only to the treatments currently being administered but also to potential treatments that are available as options. On the other hand, determining the tTMU protocol and considering safety precautions are important considerations for the physician. The 2010 “guideline” published by the APA—based on the FDA’s 2008 approval—recommends TMU as an option for treating depression that has not responded to medication. It is typically used in patients with depression who have not shown improvement with standard treatments alone, or in patients for whom electroconvulsive therapy (ECT) is a consideration but who wish to try another alternative.

TMU can also be safely used in situations where medication use is restricted—for example, during pregnancy, in breastfeeding mothers, and in patients with heart disease—and in this regard, it offers significant convenience to both patients and physicians.

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 enables magnetic stimuli to be precisely directed to targeted brain regions. The treatment delivers effective results, particularly in the management of neurological and psychiatric disorders. The advantages of neuronavigation-guided tTMU/rTMS are as follows:

Precise Targeting: By delivering magnetic stimuli to specific regions of the brain, it enhances the therapeutic effect.

Personalized Treatment: Neuronavigation technology enables the creation of individualized treatment plans tailored to each patient’s brain structure.

High Efficacy: By focusing on the correct areas of the brain, it provides more noticeable improvements in symptoms.

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

What Is the Difference Between TMU/tTMU and Electroconvulsive Therapy (ECT)?

Transcranial Magnetic Stimulation (TMU/tTMU) and Electroconvulsive Therapy (ECT) are both methods used to treat neurological and psychiatric disorders, but there are significant differences between them:

Method of Administration: TMU/tTMU modulates brain cell activity using magnetic fields and is non-invasive. ECT, on the other hand, triggers brief seizures by applying an electric current to the brain.

Anesthesia Requirements: TMU/tTMU does not require anesthesia, and the patient remains awake during the procedure. ECT, on the other hand, requires the patient to be under general anesthesia.

Side Effects: TMU/tTMU is generally limited to short-term side effects such as mild headaches or slight discomfort. ECT, on the other hand, can lead to more serious side effects such as memory loss and cognitive impairment.

Treatment Duration: TMU/tTMU sessions typically consist of short, repeated treatment sessions. ECT sessions may be fewer in number but produce a more intense effect.

Indications: While TMU/tTMU is primarily used for conditions such as depression, anxiety, and OCD, ECT is used specifically for cases of major depression or in patients who do not respond to other treatments.

For Which Conditions Is TMU/tTMU (TMS/rTMS) Effective?

TMU/tTMU (Transcranial Magnetic Stimulation / Repetitive Transcranial Magnetic Stimulation) is an effective treatment method, particularly for neurological and psychiatric disorders. It is effective for the following conditions:

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

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

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

Bipolar Disorder: It is used to alleviate symptoms during depressive episodes of bipolar disorder.

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

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 undergoing treatment for ringing in the ears (tinnitus).

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

TMU/tTMU offers a non-surgical, non-invasive, and safe option for the treatment of these conditions.

In Which Neurological Conditions Is TMU Used?

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

Parkinson’s Disease: It can be used to alleviate motor symptoms and improve mobility.

Post-Stroke Rehabilitation: It can help patients who have suffered a stroke regain their motor functions.

Chronic Pain: It can be effective in managing 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: By balancing muscle tone, it provides benefits in the treatment of muscle control disorders such as dystonia and spasticity.

TMU offers an effective, non-invasive treatment option for managing symptoms and improving patients’ quality of life in neurological disorders.

How Is TMU/tTMU Used in Children?

Transcranial Magnetic Stimulation (TMU) and Repetitive Transcranial Magnetic Stimulation (tTMU) have a limited but promising scope of application in the treatment of certain neurological and psychiatric disorders in children. Its use in children generally requires a careful evaluation process, and treatment is based on protocols that have been more extensively tested in adults. Some conditions for which TMU/tTMU is used in children include:

Attention-Deficit/Hyperactivity Disorder (ADHD): TMS may help manage ADHD symptoms, but further clinical research is needed.

Obsessive-Compulsive Disorder (OCD): TMU is thought to be effective in treating OCD in children, particularly in cases resistant to medication.

Autism Spectrum Disorder (ASD): TMU offers the potential to improve social interaction and cognitive functioning in children with autism, although research in this area is still in its early stages.

Depression and Anxiety Disorders: TMU has shown promising results in the treatment of treatment-resistant depression and anxiety disorders in children.

TMU/tTMU treatment in children is generally administered by specialist physicians following a careful evaluation and tailored to the child’s specific needs. Further research is needed regarding the safety and efficacy of the treatment; therefore, such treatments are used only in a limited number of cases in the pediatric population.

How Is TMU/tTMU Administered?

Following a psychiatric evaluation and subsequent imaging of the brain’s functional activity using functional MRI or quantitative EEG, it is recommended to identify the area deemed appropriate based on the suspected diagnosis and apply the treatment to that region. For depression, a coil is generally placed in the left anterior frontal region. Rhythmic pulses are delivered. Treatment is administered in sessions lasting 10 to 30 minutes, with a minimum of 20 sessions. No special preparation is required other than having clean hair.

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 that of pharmacotherapy and lower than that of electroconvulsive therapy.

• It has few or no side effects. The most severe side effect is a mild headache.
• It produces a rapid onset of therapeutic effect (typically within 1 week).
• It does not involve direct intervention in the body. In other words, it does not require an invasive procedure.
• It does not require anesthesia.
• The patient is treated on an outpatient basis.
• It has superior targeting capabilities for specific neural circuits.
• It requires only 2 to 4 weeks of treatment.
• It provides therapeutic benefits for treatment-resistant patients.
• Patients do not need to stop taking their medications for tTMU treatment.
• A reduction in depression symptoms is typically achieved in patients who do not respond to treatment.
• It provides equally effective results 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 patient’s specific diagnosis and allow for the most effective course of treatment.
• Patients are kept informed of their progress, as recorded on depression and anxiety assessment scales, throughout the course of treatment.
• The treatment parameters applied at our hospital and the results obtained from all tTMU procedures are tracked using specially developed software. This allows the medical staff to monitor each patient’s progress during treatment and provide individualized feedback on the results.
• As with any effective treatment modality, the degree of improvement varies from person to person. At our hospital, a pre-procedure consultation with a physician helps determine the likely range of outcomes based on the individual’s depression severity, medical history, and expectations.

What Are the Side Effects of 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: This is the most common side effect; it is usually mild and resolves shortly after treatment.

Discomfort in the Treatment Area: Mild discomfort or a tingling sensation on the skin may occur in the area where the magnetic stimulation is applied.

Muscle Twitching: Temporary twitching may occur in the facial or head muscles during the procedure.

Dizziness: Some patients may experience brief dizziness after treatment.

Risk of Epileptic Seizures: Although very rare, the risk of seizures is a concern, particularly for patients with a history of epilepsy.

These side effects are mostly mild and resolve quickly after treatment. When the treatment plan is tailored to the individual and administered by a specialized team, the side effects of TMU/tTMU are minimal.

tTMU Procedure Description

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

• TMU treatment is applied to brain regions believed to be involved in depression and other mood disorders.
• Thanks to tTMU, it is possible to selectively modulate or alter activity in certain regions of the brain.
• tTMU produces a number of positive effects on the brain that have been shown to be effective in the treatment of various conditions and diseases, in addition to depression (e.g., excitatory or inhibitory effects).
• The treatment affects electrical activity in the brain through a pulsed magnetic field. A magnetic field is generated by delivering short, pulsed currents through a figure-eight-shaped metal coil (see the image 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 the brain’s surface.
• The magnetic field generated by tTMU penetrates the skull and scalp painlessly and safely, inducing a current in specific neurons (brain cells).
• Because the magnetic stimulation is delivered at regular intervals, it is referred to as repetitive TMU or tTMU.
• Stimulation parameters—such as the number of pulses, pulse intensity and duration, and the interval between pulses—are fully adjustable. The ability to adjust these parameters while directly targeting specific brain cells suggests that tTMU has significant therapeutic potential. Furthermore, the treatment can be tailored to the needs of each individual patient.
• The validity of tTMU treatment has been comprehensively tested in clinical trials and medical research studies. Its use has been approved in Canada since 2002.
• Peer-reviewed articles published in various medical journals have noted that tTMU therapy shows 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 published in various medical journals have indicated that tTMU therapy shows 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 tTMU Therapy (Canada Mind Care Centers Table)

According to research conducted by Canada Mind Care Centers, the response rate among patients receiving Transcranial Magnetic Stimulation (TMS) therapy has yielded promising results, particularly for conditions such as treatment-resistant depression. Clinical data from these centers provide detailed information on the effectiveness of TMS therapy and the rates of symptom improvement among patients. The response rate among patients undergoing tTMS therapy may vary depending on the type of condition being treated, the frequency of sessions, and the individual’s biological factors; however, high success rates have generally been reported;

• MindCare Centers have administered tTMU therapy to over 300 patients on a clinical basis.
• Clinical data has shown that more than two-thirds of patients responded significantly to tTMU treatment.
• Typically, “responders” experienced at least a 75% reduction in depression symptoms.
• MindCare Centers’ Response Statistics
• Non-responders: 32.6%
• Responders: 62.4%
• Unknown: 5.1%
• Determined using the Beck Depression Inventory, the Hamilton-7 Index, the Hamilton Anxiety Scale, and patient feedback.

Duration of Benefit

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

• Typically, improvement is observed within one to two weeks of starting treatment.
• Most patients tend to notice therapeutic benefits by the second week of treatment.
• To achieve significant reductions in depression symptoms, additional sessions may be required for late responders during the third week.
• On average, patients begin maintenance therapy approximately 8–12 months later. This timeframe varies by patient.
• On average, maintenance therapy consists of half the number of tTMU sessions completed initially.
• We ask that patients who feel their depression symptoms are recurring contact us without delay. NPİSTANBUL staff will make every effort to schedule an appointment as soon as possible.
• At NPİSTANBUL Hospital, this treatment has been considered for use in treatment-resistant cases involving the following conditions to date.

In Canada, it can be used as a first-line treatment for cases that are not treatment-resistant. However, at NP İSTANBUL, tTMU therapy is administered with approval specifically for cases resistant to other treatments.

Indications for Use in Canada

In Canada, Transcranial Magnetic Stimulation (TMS) therapy is widely used in the treatment of various neurological and psychiatric disorders. TMS is offered to patients as a non-invasive method at many healthcare centers and clinics across Canada, and this treatment approach is preferred to alleviate symptoms and improve quality of life. The treatment’s applications continue to expand based on clinical studies and individual patient needs;

• Anxiety,
• Auditory Hallucinations (Schizophrenia),
• Depression,
• Eating Disorders – Bulimia,
• Epilepsy and Seizures,
• Migraine-Type Headaches,
• Obsessive-Compulsive Disorder (OCD),
• Tinnitus.

The History of tTMU

In 1831, Faraday discovered the principle of mutual induction. Faraday’s law is based on the principle that electrical energy can be converted into magnetic fields, and magnetic fields can be converted into electrical energy.

1896 D’Arsonval took this a step further and placed a magnetic (power) coil inside a subject’s head. The subjects reported seeing “magneto-phosphenes” (sparks) and experiencing dizziness and syncope.

In 1902, Pollacsek and Beer of Vienna, Austria—who were granted a patent for the treatment of depression—transmitted vibrations into the skull via an electromagnetic coil placed on the skull. These early discoveries represent the historical foundations that shaped the modern version of tTMU; however, their use at high intensities or frequencies was not permitted.

1959 Klein demonstrated that a frog’s muscle could be stimulated by a magnetic field. The first magnetic stimulation of human nerves was performed by Bickford and Fremming.

In 1970, further research was conducted using various magnetic stimuli to investigate the production of phosphenes. As mentioned, these stimuli were inadequate in terms of magnetic pulse intensity and duration, magnetic field shape and focality, and the capacity to use high frequencies. Furthermore, it is unknown whether phosphenes result from occipital cortex stimulation or direct retinal stimulation.

In 1985, Anthony Barker of the University of Sheffield in England developed the first effective, modern Transcranial Magnetic Stimulation (TMS) device. In addition to the stimulation previously discovered in frogs, researchers were now able to induce movement in a finger or foot by placing a coil over the motor cortex. This TMI device could generate an evoked potential in specific neurons in the brain. However, these early TMI studies were limited to functional brain imaging. Because the procedure is noninvasive and painless, earlier researchers were able to use TMU devices to examine 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.

In 1993, the first open-label studies on the use of TMS in the treatment of depression began. Hoflich et al. suggested that TMS applied along the vertex had antidepressant effects. Initially, the first clinical use of TMS devices involved the diagnosis of multiple sclerosis and motor neuron diseases. Early researchers did not consider stimulating the frontal cortex or regions associated with mood disorders.

In 2002, Health Canada approved the clinical use of tTMS in Canada.

Since 2006, tTMU research has been ongoing for over 20 years in many parts of the world, including Canada, the U.S., the United Kingdom, Germany, Israel, and Japan. More recently, tTMU has been used to investigate the emotional and cognitive aspects of cortical processes. In current research, it has been suggested that, due to tTMU’s ability to selectively increase or decrease the excitability of neurons in different brain regions, it holds valuable therapeutic potential for the treatment of many other diseases and disorders beyond depression. This technological advancement is the most significant breakthrough in neuropsychiatry in the last 50 years.

Case Reports (Courtesy of Mind Care, Canada)

The tTMU treatment I received at the MindCare Center was quite successful. My depression is gone. My test results showed that I am in remission. I feel MUCH better. The tTMU treatment has produced much better results than any medication I’ve taken so far. The staff at the Center is amazing and very supportive. I wouldn’t hesitate to recommend MindCare to any of my relatives or friends.”

E.O., California

"I had been taking antidepressants from 1991 until April 2005. Although I tried many of the available medications, I never experienced sustained relief from any of them. In addition, each one had side effects that were sometimes difficult to manage. In April 2005, I began receiving tTMU treatment for my depression at the MindCare Center. Even though I’ve only had seven sessions so far, I’ve been able to completely stop taking antidepressants. It’s been a year since my treatment ended, and I’m still not taking any antidepressants—I feel great. I recommend this treatment to anyone who has had similar experiences with antidepressant medications."

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 of tTMU therapy and recommended that I try it. I didn’t qualify for the local research study, so I reached out to MindCare Centers in Vancouver. Within two weeks, I felt better and was able to return to my job and my family."

C.H., Washington

"For the past ten years, I’ve been receiving psychiatric treatment for anxiety and depression. During that time, I tried many medications, including various combinations. Most of them didn’t work or only provided short-term relief. Thanks to this treatment, I’ve experienced a marked improvement, and I’m 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. As a result, I was taking a variety of antidepressants at maximum doses. It seemed to be working, but my ability to work had been cut in half. My depression worsened again, and I underwent ECT two years ago. Although it was quite effective, I lost my memory for six months—I was unable to succeed in my research position at UBC. It relapsed again. I heard about tTMU therapy and asked my doctor about it. He had some reservations about it. I continued with the treatment, and within a month—I experienced a dramatic improvement; I felt happy. (Many people I spoke with at the clinic had had the same experience.) I felt rejuvenated. Now I’m taking only 50% of my previous medication dosage and am able to work effectively. My goal is to stop taking medication altogether.”

J.G., Vancouver

"I went to the tTMU outpatient clinic (MindCare) in Vancouver. They have a truly professional approach there. Two different doctors, independently of one another, recommended this clinic to me. I found the staff to be very professional. Health Canada approved this method long before the U.S. FDA did, which is quite unusual. I have no hesitation in recommending this place to others…"

J.M., Maryland

"I had been taking various antidepressants for the past 12 years. Even the most effective ones had unwanted side effects; it felt like I’d lost touch with my emotions… The last medication I took caused me to gain about ten kilos, and gaining weight made me even more depressed! After just one week of treatment, I started to feel better. By the end of the third week, I started tapering off my antidepressants and eventually stopped taking them altogether. For the first time in years, I finally feel open-minded and sociable. Plus, 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 leave of absence from work; 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 just two days of treatment, I started to feel better. By the end of the first week, his depressive symptoms had disappeared. He can say he has returned to life. His family and friends were also greatly relieved. Six years ago, he had undergone ECT as a last resort. Although it produced results, it was invasive and stressful, and it caused significant short-term memory problems. In comparison, tTMU is far from invasive—it’s a simple procedure. It caused no side effects for him. He is grateful to the exceptionally experienced, warm, and supportive staff. Thanks to this treatment, life has regained its meaning for him. He hopes other people with depression will learn about tTMU and rediscover the beauty of life.”

S.B., Seattle

"I have been suffering from severe depression since November 2001. For years, I tried every kind of medication (Paxil, Celexa, Lexapro, Effexor XR—to name just a few), but nothing helped; I was suicidal and voluntarily checked myself into the hospital twice. That didn’t help either.However, in May 2005, I sought tTMU treatment at the MindCare Clinic in Toronto. For ten days (excluding weekends), I received one hour of repeated, low-intensity magnetic brain stimulation therapy each day. Since I hadn’t seen results from any treatment in four and a half years, I thought this wouldn’t work either. But I was wrong. Surprisingly, it helped. About three weeks after the treatment, I felt much better. Within a few months, I had completely recovered from depression. I’m still taking Effexor XR, but at a lower dose. I plan to gradually wean myself off it completely by next year. This July, I’m planning to apply to another MindCare Clinic (this time in Vancouver) to undergo a second tTMU treatment. The reason isn’t that I’m depressed—it’s simply because those who’ve undergone the treatment are recommended to have at least one follow-up session. I really feel great. I haven’t experienced any memory loss, seizures, or anything like that. I can wholeheartedly recommend this procedure to patients with severe depression who feel hopeless. It really works. Anyone with questions about the procedure can contact me. Thank you...”

A.B., Costa Rica FAQ