Berenson-Allen Center for Noninvasive Brain Stimulation (CNBS)
Optimizing and applying noninvasive brain stimulation to health care and research

Patient Care

At CNBS we use TMS for diagnostic and therapeutic applications. Diagnostic applications include studies of:

• Central motor conduction time
• Cortical excitability
• Noninvasive determination of hemispheric dominance for language
• Noninvasive cortical mapping

In addition, our clinical program offers noninvasive brain stimulation for treatment of neuropsychiatric disorders, chronic pain, and the neurorehabilitation of hand function and language after stroke. Regarding these therapeutic applications, we encourage you to ask questions, do some research, and discuss the information with your physicians and family before determining whether rTMS is right for you. TMS can help some patients, but it is not right for everyone and does not work for everyone. It is important to know that magnetic stimulation devices have been approved by the U.S. Food and Drug Administration for peripheral nerve stimulation use, but not for therapeutic applications of any disease. Therefore, rTMS treatment is offered either in the setting of clinical research trials or as an ‘off-label application’ of an approved device. If you want to learn more about rTMS treatment you can contact us at 617-667 0203 (tel); 617-975 5322 (fax) or TMSlab@bidmc.harvard.edu .

Most of the experience with rTMS treatment is in its application for the treatment of depression. The following paragraphs provide answers to some of the most frequently-asked questions about the use of rTMS for treatment of depression

Is rTMS Effective for the Treatment of Depression?

Numerous research studies have shown that rTMS can influence mood in patients with depression if stimulation is applied with the appropriate stimulation parameters and to the appropriate part of the brain. Several lines of research indicate that the severity of the depression is related to the degree of left prefrontal dysfunction, and that normalization of the prefrontal dysfunction might be linked with clinical improvement of the depressive symptomatology.

What are some advantages of rTMS?

• Few side effects
• Quick onset of therapeutic effect (usually one to two weeks)
• Painless procedure
• Non-invasive
• No anesthesia required
• Outpatient therapy

Am I eligible?

Your eligibility will be determined after your initial neurological and psychiatric evaluations. We will be using the following inclusion and exclusion criteria in determining your eligibility and to prevent exposing you to unwarranted risks.

• You must be at least 18 years old.
• You have been diagnosed with depression. A referral from your psychiatrist will also be needed to receive rTMS therapy.
• You do not have a history of epilepsy.
• You have not tolerated or responded well to other medical treatments for your depression in the past.
• We believe that you are a suitable candidate for rTMS and will derive a benefit from it. We base this assessment on the results of our evaluation. We will also review results of other tests in certain circumstances, including EEG, SPECT, or MRI.
• We believe that the potential benefits outweigh the possible adverse effects and risks of rTMS.
• You do not have any of the following contradictions for rTMS:
  • Metal anywhere in the head, excluding the mouth. This includes shrapnel, and screws and clips from surgical procedures unless the physical properties of the metal object are known.
  • Cardiac pacemakers or electrodes inside the heart, unless the specific type of device is known and certification from the manufacturers documents that it can be safely exposed to magnetic stimulation.
  • Implanted medication pumps, unless the specific type is known and certification from the manufacturers documents that it can be safely exposed to magnetic stimulation.
  • Serious heart disease, unless the treating cardiologist can certify that the potential clinical benefit in improving the depression outweighs the risk that a possible seizure might pose to the cardiac disease.
  • Increased intracranial pressure can pose a life-threatening risk to the patient in case of a possible seizure induced by rTMS.
  • Pregnancy represents a relative contraindication as no sufficient safety data exist. If you are a woman of child-bearing potential we will generally obtain a pregnancy test prior to pursuing rTMS.

How will rTMS be applied?

rTMS is administered by a physician or a trained technician under the supervision of a physician. We use a device called a magnetic stimulator. A magnetic stimulator is a machine that can store electricity and discharge it quickly into a coil of electrical wire that is encased in plastic. This coil of wire looks like a thick plastic spoon and it is held resting over the patient’s scalp. As the current flows through the coil, a magnetic field is generated that penetrates the patient’s scalp and skull and creates a flow of in the brain. None of this is painful. rTMS is non-invasive and requires no anesthesia. 

Stimulation is applied in daily sessions. The total number of daily sessions may vary but generally a first course of rTMS will encompass at least 10 daily sessions over 2 weeks. During each session, the patient is exposed to several trains of repetitive stimuli. The number of stimuli per second and the duration of each train of stimuli may vary. However, in any case, in each rTMS session, up to 1600 stimuli are applied over nearly 30 min.

What is the procedure like?

Your first visit will consist of initial consultations with a neurologist and a psychiatrist who will discuss the procedure with you and determine if rTMS is right for you. You will be encouraged to ask additional questions. The rTMS procedure is painless, non-invasive and requires no anesthesia. You will be fully conscious during your treatment sessions. The only equipment used during the procedure is the rTMS machine and a hand-held device, which will be held close to your scalp. You may feel a tingling or tapping sensation on your head, or your scalp muscles may feel a little tense during and after your procedure. This is normal and some patients may experience mild discomfort, such as headache or neck pains, but this will typically pass after a few hours or with Tylenol. You will also be asked to wear earplugs to reduce the noise from the sound of the machine. As compared to other forms of treatment, such as medication or electroconvulsive therapy, rTMS has been shown to have very few or minimal side effects.

Who will be involved in my treatment?

All physicians and technicians working at CNBS have been educated in all aspects of rTMS. Neurologists, neurophysiologists and psychiatrists working closely together with your primary psychiatrist and with you will make all decisions about your TMS treatment. The stimulation will be applied only by personnel licensed by the Beth Israel Deaconess Medical Center for the application of TMS. While our staff is highly qualified and well trained, the outcome of your rTMS therapy depends also on factors that we cannot control. We recommend you consult your own psychiatrist, who is familiar with your depressive illness, your medical history, and will continue to care for you after your treatments. We will work closely with you and your psychiatrist to provide you with a high level of quality care and comprehensive results.

How often will I receive rTMS?

rTMS therapy generally consists of two stages: Acute treatment and maintenance treatment. Depending on your response, acute treatment usually involves 10 to 20 consecutive treatment sessions over a two- to four-week period. After your initial acute treatment, maintenance treatment sessions may be recommended. Doctors will discuss this with you during your follow-up evaluations and will determine whether you would likely benefit from maintenance.

How long will the procedure and appointments take?

Your initial neurological and psychiatric evaluations will take approximately one hour each. At that time, the doctors will review your medical history, explain the procedures, answer questions, and determine if you are a suitable candidate for rTMS therapy.
Each treatment session will take approximately one hour each day for 10 to 20 days over 2 to 4 weeks. You will see a physician periodically for a brief evaluation. In addition, at the end of each week of sessions you will have a more detailed neurologic evaluation and a follow-up psychiatric evaluation taking approximately one hour each.

What kind of results can I expect?

The majority of patients receiving rTMS for depression experience a significant improvement with minimal or no side effects. However, the degree of improvement varies from patient to patient. Patients who respond to rTMS derive a benefit that is roughly equivalent to electro-convulsive therapy. TMS does not require anesthesia and generally has fewer side-effects than electro-convulsive therapy, but some patients who do not respond to rTMS can still benefit from ECT.

What are the risks of rTMS?

A series of adverse effects from rTMS have been identified. The risk of such adverse effects depends greatly on the form of stimulation used. At the Laboratory for Magnetic Brain Stimulation at Beth Israel Deaconess Medical Center, clinicians strictly follow all currently recommended safety precautions in order to minimize the risks or rTMS. Nevertheless, the risks may include:

• Up to 20 in every 100 patients undergoing rTMS experience headaches or neck pain, which are believed to be due to excessive muscle tension. In the case of such an event acetaminophen (Tylenol®) generally resolves the discomfort.
• rTMS produces a loud clicking sound when the current is passed through the stimulation coil. This loud click can result in ringing in the ear and short-term decreased hearing if no protection is used. In order to prevent this potential adverse effect earplugs are used at our laboratory. Animal and human studies have demonstrated that ear plugs can effectively prevent the risk of hearing disturbance due to TMS.
• rTMS in the presence of electrodes for EMG or EEG recording can result in overheating of the electrodes and induce skin burns. This risk is only present when the stimulation coil is held exactly on top of the electrodes. No such electrodes will be used during rTMS at our laboratory.
• rTMS can induce a convulsion even in the absence of brain lesions, epilepsy, or other risk factors for seizures. The overall risk for this complication is thought to be about 1 in 1000 studies. Nevertheless, this is a very concerning complication and the clinicians will follow all precautions that are recommended by the International Society for Transcranial Stimulation to make the risk as small as possible. It is important to note that experiencing a seizure induced by rTMS has never led to the development of epilepsy or posed any risk for subsequent unprovoked seizures. Seizures induced by rTMS would occur during the rTMS or immediately after. Seizures induced by rTMS are not expected to occur hours or days after the rTMS.
• rTMS could induce short-term changes in memory, attention, and other cognitive functions. This is a theoretical risk, as none of the safety studies conducted has found such side effects.
• Finally, even though rTMS has been used in several laboratories worldwide for over 10 years, it remains an experimental procedure for its use in depression and it is possible that unexpected complications could occur.

Is the cost of rTMS covered by insurance companies?

Beth Israel Deaconess Medical Center and the CNBS believe that providing quality patient care at an affordable cost for our patients is important. Unfortunately, although there has been significant research, the use of rTMS for depression is not approved by the FDA and is still considered and ‘off-label’ use of rTMS. rTMS is not covered under most health insurances or Medicare. Therefore, the cost of the rTMS will be charged directly to you. However, we will work closely with you to provide you with information that you may present to your insurance company to try to recuperate some of the cost of rTMS.