Repetitive Transcranial Magnetic Stimulation is a noninvasive treatment that uses a magnetic field to stimulate nerve cells in the dorsolateral prefrontal cortex, to relieve symptoms of depression. For more information, please review the e-brochure. If you have any questions or are interested in receiving this treatment, please email sepa.tms@gmail.com

1. Repetitive
Transcranial
Magnetic
Stimulation
A Clinically Proven Treatment for
Major Depression
Now Available at
Southeastern Psychiatric
Associates
1093 N. Main Street
Randolph, MA 02368
(781) 963-7775

2. rTMS vs. Medication for Treatment
Resistant Major Depressive Disorder
Treatment resistant major depression, defined as
three or more failed medication trials, is a serious
clinical issue. In multiple controlled studies, patients
who have already failed several medication trials
responded significantly better to rTMS than sham
treatment. In the STAR-D trial, the antidepressant
remission rate dropped significantly with each failed
medication. As shown in the following chart, once a
patient has failed three medication trials, rTMS is
almost three times as likely as a fourth medication to
produce remission. 1
In observational studies, up to 58% of patients are
responders and 37% remitters. The effect is durable
but, as major depression tends to be a chronic illness,
eventually many patients do require follow-up
treatments. Well over 80% of the time these follow-up
treatments are successful, and often the treatment
course is significantly shorter. 2
Side effects include mild headaches, site pain, muscle
tension or twitching, and GI upset. There is a low
incidence of seizures, with an estimated seizure risk of
0.003% per treatment, or 0.1% of patients. The
discontinuation rate tends to be approximately 10%,
as compared with a 20%-30% rate for medication
trials.

3. What is Repetitive
Transcranial Magnetic
Stimulation (rTMS)?
Repetitive Transcranial Magnetic Stimulation is an
entirely new approach to treating patients with
treatment resistant major depression. Research
shows that rTMS outperforms an additional
medication trial in these patients.
The treatment involves the use of brief, highly
focused magnetic pulses to stimulate the left
dorsolateral prefrontal cortex, designated with a “*”
in the diagram below. This region is part of a cortical
network, which acts to regulate and inhibit negative
affect originating from limbic structures.
The mechanism of action of rTMS is uncertain, but it
is thought to induce higher levels of electrical
activity, leading to durable changes via long-term
potentiation and increased neural plasticity.

4. rTMS Treatment Procedure
The patient is seated comfortably in the treatment
chair and remains awake and alert throughout the
procedure. The Patient may watch television, use a
tablet, or converse with a friend. In the initial
session, the psychiatrist determines the patient’s
motor threshold and treatment location. The
patient’s head remains free, resting on a head
rest, while the treatment coil is placed in contact
with the forehead. The treatment lasts 37.5
minutes, and involves 75 trains of pulses. Each
train consists of 40 pulses over 4 seconds, or 10
Hz. There is then a 26 second rest period before
the next pulse train. The experience is similar to
having someone tap firmly on the forehead with
their finger. Muscle twitching around the eye is
common, but generally well tolerated. Due to the
loud noise produced by the electromagnetic coil,
patients are required to wear disposable earplugs.
At the end of the session, the patient may
immediately resume normal activities, drive, and
return to work.

5. rTMS vs. ECTrTMS vs. ECT
Some Contraindications of rTMS
Therapy
Repetitive Transcranial Magnetic Therapy
should not be used on individuals under the
age of 18; pregnant women; epileptic
individuals; those with a family history of
convulsions; individuals with severe heart
disease; individuals with non-removable
magnetic sensitive metal objects in their
heads or near the magnetic coil; or individuals
with pacemakers; implantable cardioverter
defibrillators; vagus nerve stimulators; or
ferromagnetic ocular implants.
rTMS ECT
Seizure
Induced
No Yes
Anesthesia
Required
No Yes
Current
Reaches Deep
Structures
No Yes
Psychosocial
Impact
Can drive from
treatments and
can work the
same day
Can’t drive from
treatments or
work the same
day
Direction of
Induced
Current
Tangential Radial
After-Effects
None.
Pro-cognitive
Mild memory loss

6. For more information or
to refer a patient, please
contact
Miriam Isreb
TMS Coordinator
Southeastern Psychiatric
Associates
Phone: 781-963-7775
Fax: 781-963-7776
Email: sepa.tms@gmail.com
References: 1. Avery, David H., Keithe E. Isenberg,
Shirlene M. Sampson, Philip G. Janicak, Sarah H. Lisanby,
Daniel F. Maixner, Colleen Loo, Michael E. Thase, Mark A.
Demitrack, and Mark S. George. "Transcranial Magnetic
Stimulation in the Acute Treatment of Major Depressive
Disorder." J. Clin. Psychiatry The Journal of Clinical
Psychiatry 69.3 (2008): 441-51. Web. 2. Carpenter, L. et
al. “Transcranial Magnetic Stimulation (TMS) for Major
Depression: A multisite, naturalistic, observational study
of acute treatment outcomes in clinical practice” (2012).
3. Herwig U. et al. Biol. Psychiatry. (2001): 50(1): 58-61.
4. http://www.slideshare.net/lcadymd/magnets-not-
drugs-tms-immh-san-antonio-2014