rTMS

MagnaCentre™

Repetitive Transcranial Magnetic Stimulation (rTMS) treatment for depression and obsessive-compulsive disorder

In September 2014, Professor Craig (MagnaCentre™) formed a partnership with the Nightingale Hospital to deliver state of the art repetitive Transcranial Magnetic Stimulation (rTMS) treatment to patients with resistant depression. This partnership led to the first hospital based rTMS service in the UK, and the only service in the UK to offer H-Coil™ technology.

What is rTMS?

Repetitive Transcranial Magnetic Stimulation (rTMS) is an evidence based, non-pharmacological treatment for depression. The basic principle of rTMS is to target short magnetic pulses over the scalp to produce electrical currents in specific brain regions that regulate mood.

In December 2015, NICE concluded that transcranial magnetic stimulation for depression is safe enough and works well enough for use in the NHS. NICE reviewed 7 studies involving over 6,000 patients. Overall, the studies showed that the treatment improved depressive symptoms and quality of life, and in some cases allowed patients to stop taking antidepressants.

rTMS is routinely used in many leading international hospitals (for example, Johns Hopkins Hospital, USA) and is increasingly used in Scandinavian and other European countries. When indicated, it is now covered by several of the major healthcare insurers in the UK (for example, AXA Health, Bupa and Cigna).

Who may be suitable for rTMS?

Approximately one third of patients with depression and two thirds of patients with OCD do not respond to standard treatment. In this situation, rTMS is a significant treatment option.
Those who cannot tolerate the side effects of medication, such as weight gain, sexual dysfunction and sleep problems.
Those who do not want to have ECT.
Women with postnatal depression who wish to breastfeed and avoid transmission of medication.

Benefits of rTMS

Effective in treating the debilitating effects of depression and/or OCD
A long lasting treatment with minimal side effects
Well tolerated by most people
Unlike ECT, it does not require anaesthesia or lead to memory loss
Daily activities can be resumed immediately after each session
You can drive straight after treatment

Side effects of rTMS

rTMS is a safe procedure when the published safety guidelines are adhered to. These are comprehensively followed at the Nightingale Hospital. rTMS is extremely well tolerated by most people but can cause some minor, short term side effects, including:

Headaches
Scalp discomfort at the site of stimulation
Tingling, spasms or twitching of facial muscles
Light-headedness
Discomfort from noise during treatment
Seizures are a rare side effect of rTMS.

Treatment pathway and cost of rTMS

The standard evidence-based protocol for depression, using an H1 coil, delivers 20 treatment sessions, each lasting 20 minutes, 5 days per week over 4 weeks, at £225 per session. In some cases an accelerated protocol using intermittent theta burst stimulation (iTBS) is recommended. This delivers 5 treatment sessions per day, each lasting 3 minutes, 3 days per week over 2 weeks, at [PRICE TO BE CONFIRMED] per session.

The standard evidence-based protocol for OCD, using an H7 coil, delivers 29 daily treatment sessions, each lasting 20 minutes, over 6 weeks, at £200 per session.

The Helmet ('H') Coils

The rTMS service at the Nightingale Hospital operates using Helmet ('H') coils, developed following research at the National Institute of Mental Health (USA). These coils may produce antidepressant effects of greater magnitude than other coils, due to stimulation of deeper and more widespread prefrontal reward mediating neural pathways (Roth Y, et al. Brain Stimulation 2014; 7: 194-205). H-coils use the same stimulator hardware, and the patient undergoes an identical procedure in the clinic as for rTMS using a conventional Figure of 8 coil. The primary difference is the geometry of the coil placed on the patient's head.

Width: the standard Figure of 8 coil uses a highly focused stimulation field that can be hit or miss when it comes to targeting the relevant brain circuitry. H-coils supply a wider field, designed to stimulate important brain regions more consistently. Depth: H-coils induce an effective field at a depth of approximately 3 cm below the skull, compared with less than 1.5 cm for the standard Figure of 8 coil. It has been proposed that this deeper penetration leads to greater effectiveness.

The first head-to-head randomised controlled study comparing placebo, Figure of 8 and H-coil rTMS reported that response was significantly better in the H1-coil group than in the Figure of 8 group (OR 2.33; 95% CI 1.04 to 5.21; P = 0.040). The HAM-D17 score was lowered by 59% in the H1-coil group, 41% in the Figure of 8 group (P = 0.048) and 17% in the control group (P < 0.001 vs H1-coil; P = 0.003 vs Figure of 8).

What happens during treatment?

You will be taken to our dedicated treatment room by your nurse or therapist and seated in a comfortable chair. Any paperwork will be completed.
Before your first treatment begins, your nurse will determine the precise location for the H-coil on your head and calculate the optimum intensity of magnetic energy for you.
The electromagnetic coil is switched on and off repeatedly to produce stimulating pulses. This results in a tapping or clicking sound that usually lasts a few seconds, followed by a pause. You will also feel a tapping sensation on your forehead.
During the course of treatment, the amount of stimulation may be adjusted depending on your response.
Throughout sessions you will remain awake and alert.
You should be able to resume your daily activities immediately after your session.

What are the results of rTMS?

A multi-centre study of 212 patients with depression compared rTMS using the H-coil with sham (placebo) treatment and demonstrated significantly higher remission rates after 5 weeks of deep TMS (Levkovitz Y, et al. World Psychiatry 2015; 14: 64-73). [Chart: remission after 5 weeks with deep TMS versus sham.]

When is rTMS not suitable?

For those with co morbid neurological disorders, a history of epilepsy and/or previous neurosurgery

For those with metal plates in the head or brain, pacemakers or other electronic implants, inner ear implants, metal or magnetic objects in the brain, or medication pumps

Age below 18 years