What are the side effects and risks of rTMS?
Compared to traditional anti-depressant medications which have systemic effects throughout the body, rTMS is very safe and well-tolerated. Side effects can include:
- headaches, usually mild and dull, which respond to simple analgesics i.e. acetaminophen or Aspirin
- scalp discomfort and tightness sensations at the site of stimulation
- tingling and spasms in scalp and facial muscles-can be addressed by modifying technique
- lightheadedness and possibly brief fainting sensation
The major risk factor in rTMS is the induction of a seizure through brain stimulation. This is considered to be a very low probability event, in the order of 1/1000 patients or 0.1%.
It is also possible that a client with Bipolar Disorder can be "switched" from a depressed state to a manic or hypomanic state through rTMS, and we recommend the use of mood stabilizers in this population during the course of treatment.
Why is rTMS not covered by BC's Medical Services Plan?
Despite being approved by Health Canada and being available since 2002, TMS treatments have never been formally funded by BC's government. The provincial government reviewed rTMS as a health technology for the treatment of Major Depression in the spring of 2016, and thereafter decided not to allow further public support for this service. This is in contrast to Medicare plans in other provinces such as Quebec and Saskatchewan which provide full public funding for rTMS. It is also in contrast to Medicare funding for rTMS in the United States, where there is an extensive combination of private and public clinics. TMS is a safe, effective, and strongly-recommended treatment for Major Depression according to the highly-respected Canadian Network for Mood and Anxiety guidelines (2016) which state:
More than 30 systematic reviews and meta-analyses have been conducted on rTMS in depression, with most studies involving patients with some degree of treatment resistance (i.e., having failed at least 1 or 2 antidepressant trials). Overall, rTMS is considered a first-line treatment for MDD for patients who have failed at least 1 antidepressant treatment.
Why does a medical doctor need to refer me to BrainStim Healthcare?
Having a medical doctor refer you is required because the initial consultation is MSP-covered only if a referral is made, and because your doctor will oversee your mental and physical health care during the course of rTMS.
Click here for our referral form
What is the likelihood that my condition will respond to rTMS?
The scientific literature for treating Major Depression suggests that 2/3 to 3/4 of those who undergo rTMS will have significant improvements in symptoms, and many will see a benefit in their functioning and quality of life.
Why do I need to stay on my medications during the rTMS course?
Stopping medication(s) or reducing dosages may confound the effects of rTMS. Studies in which patients had rTMS along with medications seemed to overall show higher effectiveness, compared to patients in studies which involved "washing out" (i.e. stopping) their medications prior to the rTMS course. Your TMS psychiatrist will advise you if there are any medications that do need to be changed, stopped or not taken just before each treatment session.
What is the "standard" rTMS treatment course at BrainStim Healthcare?
The "standard" FDA-approved (USA) rTMS treatment course consists of clusters of high frequency pulses over 20-30 treatments in a four to six week period, five days per week, 19 minutes per treatment session. This protocol has been derived from well-established pivotal studies in the United States that is widely used by TMS clinics. Low frequency pulse rTMS may sometimes be used as an alternative and has equal evidence for efficacy in depression compared to high frequency treatment (see CANMAT guidelines, 2016, Canadian Journal of Psychiatry).
What about using new rTMS protocols such as theta burst rTMS, bilateral rTMS, or deep rTMS?
There are newer rTMS protocols that deviate from the standard treatment technique as described above. Currently, these are still undergoing investigation and are not considered more effective than standard protocol rTMS approved in the United States by the Food and Drug Administration. At this time, the standard protocol simply has far more published evidence for efficacy than any other alternative, and this is our starting point at BrainStim Healthcare.
What is accelerated rTMS?
Accelerated rTMS is also under active investigation and involves doing rTMS sessions more than once in a day (rather than once daily), or doing rTMS six to seven days per week instead of five. Evidence so far indicates that this is a safe approach. In certain situations, Brainstim Healthcare has adopted accelerated rTMS as it can potentially shorten the overall course of treatment, leading to faster resolution of your symptoms.
What is brain mapping and motor threshold assessment? Why is that important?
Brain mapping occurs in the first TMS session, during which your TMS psychiatrist will work with the technician in locating the precise brain areas to be stimulated by the electromagnetic coil. Finding the motor threshold involves locating the motor strip of the brain's cortex, and reducing the intensity of the coil until the threshold is found which gives a minimal contraction of the muscles of the thumb/fingers.
The motor threshold is important in determining what stimulation intensity settings to use during active rTMS treatment. Successful brain mapping typically allows the targeting of the dorsolateral prefrontal cortex for depression or PTSD, and the primary motor cortex itself for many pain conditions. Motor threshold will likely be re-measured throughout the rTMS treatment course as it can change with time.
If I have a seizure disorder, can I still receive rTMS?
We generally don't recommend rTMS for those with an active seizure disorder (i.e. epilepsy), due to the risk of provoking a seizure during the rTMS treatment session. However, those with a known seizure disorder or history of seizures will be reviewed on a case by case basis, and certain forms of rTMS may be considered safer to employ compared standard protocol rTMS
What if I have a condition that does not allow me to sit still in the rTMS chair?
We try to make it as comfortable as possible throughout the treatment session. It is important for your head to remain quite still when the coil is applied on your scalp, since moving the head will cause the coil to miss the targeted brain site and make the treatment less effective. Your neck will be supported to enhance comfort in the TMS chair. If you have a medical or pain-related condition that makes it difficult to sit and hold still, it may not be possible to undergo rTMS.
How do I get to the clinic? Is there parking?
BrainStim Healthcare is located within a larger private health clinic called the Chakra Health Centre. It is centrally located near Broadway and Fir St. in Vancouver, and readily accessible by transit. There is no designated parking for clients at this time, although this may change in the future. There is a number of one-to-two hour free street parking spots nearby, as well as metered street parking on West 7th Avenue and elsewhere.
Terraces On 7th/Seymour Medical Clinic
1530 - 1538 W 7th Avenue
Vancouver, BC V6J 1S3
(604) 681 7311
Additional Parking Information
Can I book rTMS appointments for the evening as I work during the day?
We are not currently offering evening appointments. We will try to book an appointment for you in the daytime that will take into account your schedule as much as feasible. Generally, you will have a fixed appointment time over the 4-6 week rTMS course because we have to coordinate your treatment time with other clients' time, and it can be easier to remember.
How do I pay for my treatment? What are the methods of payment?
You will be asked to pay for an initial six-session block of rTMS treatment, which is non-refundable as it includes motor-threshold testing, secures your appointments, and allows us to coordinate other clients' appointments and ensure appropriate staffing levels. After this, you will pay for week-long blocks of treatment if you are attending daily for an intense protocol, or per-treatment if you are attending periodically for maintenance. We will accept credit card, debit, e-transfer, cash, or bank draft made out to "BrainStim Healthcare Associates Ltd"
Can I get a letter of support for my insurer for reimbursement through extended health benefits?
Once you have paid to secure your appointments, your TMS psychiatrist can provide you with a letter of support or other documentation that can assist you in applying for reimbursement for the cost of your treatment. Our understanding is that some extended health plans have provided coverage for rTMS on a case-by-case basis, and we are happy to support you in pursuing this however we can.
When can I start seeing benefits during my treatment course?
This will vary with different individuals, and sometimes those close to you may see some initial benefits before you do! The TMS psychiatrist will monitor your progress, adjust the settings or technique as necessary, and do a brief but formal assessment with the aid of validated scales every week or two. Generally, clients with depression will begin responding after two weeks of treatment, while others may not see benefit until the fourth week. For those who experience moderate improvement by four weeks, another two weeks is often recommended to obtain further benefits. For those who have shown no improvement by the end of four weeks, there is still a small chance (up to 10%) for significant benefits with a further two weeks of treatment. In this group, the TMS psychiatrist will discuss the options to optimize further response if continuing until week six, with the client deciding based on cost-benefit analysis.
Due to the wider range of clinical variables and presentations in the pain population, it can be somewhat more challenging to predict the overall rate of improvement and case-by-case discussion of this is encouraged.
Can I have an extended treatment series of five days per week beyond six weeks? Is it safe?
Though not typical, there may be circumstances for prescribing rTMS beyond six weeks, and doing so is considered safe for the person undergoing the treatment.
How sustained is the rTMS effect if I successfully respond to it?
When you respond to rTMS, it should still be completed to the full course in order to consolidate the therapeutic effect. Once a TMS series is stopped, it is quite variable how long you will remain well. The scientific literature for Major Depression indicates that more than 50% of patients will remain well over a 6-12 month period. Your chances of remaining well may be higher if you receive maintenance or continuation rTMS, and some may benefit from a "mini-series" of rTMS treatments at a later date. There will be quite a few clients who will remain well for years after treatment stops, but there is no good way to predict at this time who will respond to rTMS, and who will have a sustained response once rTMS stops.
What is maintenance or continuation rTMS?
These terms are regarded as interchangeable, and refers to decreasing the frequency of the rTMS sessions once a person has successfully responded to a series of five days a week. There is no current standard for how often rTMS needs to be given in order to remain well, but cutting back to two to three sessions per week at first, then to a single weekly session, then a session every two to four weeks has been one method to taper a course of rTMS. Some clients find that they remain well with an indefinite but low-frequency maintenance program such as one treatment per month, or several treatments every few months to a year.
Can adolescents, seniors, and pregnant or post-partum women benefit from rTMS?
There can certainly be potential benefits for such clients with unique treatment needs. Please click here to read about this in more detail.
I have received ECT in the past. Can rTMS benefit me?
If you have received a full course of contemporary electroconvulsive therapy (ECT), particularly bilateral ECT, you will be less likely to respond to a course of rTMS although benefits may still occur. If you have received ECT with success, but experienced cognitive side effects and therefore do not wish to have ECT again, then rTMS can be a viable option since there appears to be no associated memory impairment.
I would like to refer someone who cannot provide informed consent but has someone who can legally give substitute consent. Can rTMS be done?
At BrainStim Healthcare, our client needs to be the one signing the consent form, even if another person has legal authority. We require our clients to be able to give informed, voluntary consent.