Transcranial Magnetic StimulationFor a printable version of this collection click here TMS.pdf
Transcranial Magnetic Stimulation Adjunctive treatment with repetitive transcranial magnetic stimulation (rTMS) improved depressive symptoms in patients with medication-resistant depression. Methods: Fifty-four patients suffering from a severe and drug-resistant major depressive episode without psychotic features were enrolled in the study. All patients had a Hamilton Rating Scale for Depression (HAM-D) score of ≥26. Patients were considered drug-resistant if they showed a lack of improvement with ≥2 different antidepressant treatments. During the trial, 20 patients were receiving venlafaxine, 16 receiving fluvoxamine, 10 receiving sertraline, and 8 imipramine. All drugs were maintained at a stable dosage during the trial. Patients younger than 18 years and older than 75 years were excluded from the study. Participants were randomly assigned to receive 10 sessions of either sham or active rTMS over a 2-week period. Subjects assigned to receive the active stimulation were treated with either 80% or 100% motor threshold (MT) intensity. Assessment was performed using HAM-D and the Clinical Global Impression Severity (CGI-S) and Global Improvement scales (CGI-I), administered at baseline (with the exception of CGI-I) and weekly thereafter for 5 weeks. Response was defined as a ≥50% decrease in the HAM-D score from baseline, and remission was defined as a HAM-D total score of ≤8 for ≥3 consecutive weeks. Results: Fifty-two of the 54 enrolled patients completed the entire protocol. No dropouts were due to adverse effects. In the 80% MT group, 5 of 18 patients (28%) were responders, all of whom demonstrated a sustained remission of the episode. In the 100% MT group, 11 of 18 (61%) were responders, with 9 of these patients showing complete remission. In the sham group, 1 patient of 16 (6%) was a responder, but did not fulfill the criteria for complete remission of the episode. A significant difference was found between the 100% MT and sham groups (p=0.0008), while no significant difference was found between the 80% MT and sham groups. There was a marginally significant difference between the 2 active groups (p=0.04). A reduction in HAM-D scores over time was found in all 3 groups, with a significant advantage favoring the 100% MT stimulation group over the sham group (p=0.04). The significance increased over time (p <0.0001) for the HAM-D scores. There was also a significant difference between the 100% and the 80% MT groups (p=0.021) and between the 80% MT and sham groups (p=0.0004).
TMS Ineffective in Schizophrenia In a small trial of repetitive transcranial magnetic stimulation in 18 patients with schizophrenia, active treatment was not more effective than sham stimulation. Patients received a randomly assigned 10-day course of active or sham treatment over the left temporoparietal cortex (80% motor threshold, 1Hz, 5 trains of 1 min each). All patients were improved at the end of treatment with no significant differences between groups in Positive and Negative Syndrome Scale or Clinical Global Impression scores.
Adjunctive rTMS in Severe Depression Repetitive transcranial magnetic stimulation (rTMS) in combination with amitriptyline (Elavil) resulted in rapid response in patients with severe depression. Methods: Subjects were 46 patients with severe depression defind as a score of ³22 on the 17-item Hamilton Depression Rating Scale (mean score, 30) with a mean episode duration of 2 years. Antidepressants, taken by most patients at enrollment, were discontinued and amitriptyline started and titrated to a maximum dosage of 150 mg/day. After 1 week, patients began a randomized course of either real or sham rTMS. Patients in both groups underwent 20 sessions over 4 weeks. Real rTMS was delivered at 5 Hz at 120% motor threshold intensity. Response was defined as a >50% reduction in the HAM-D score and remission as a final score of £7 points. Results: After 4 weeks, rTMS was associated with a significantly higher response rate than sham treatment (95% vs 46%, p<0.001) as well as a higher rate of remission (54% vs 12%, p<0.002). Patients receiving rTMS responded rapidly, with significant differences from the control group after as little as 1 week. Routine clinical assessment of 23 patients 3 weeks post-treatment showed that the benefits of rTMS persisted, while the placebo effect associated with sham treatment did not. Adverse effects of real and sham rTMS included headache, neck pain, and pain and burning in the scalp. Discussion: Earlier studies suggested the optimal rate of rTMS to achieve antidepressant effects is between 3 and 5 Hz. Although this study used a high motor threshold intensity, no patient experienced seizures. Editor’s Note: Additional information on rTMS along with a list of centers that provide the treatment can be found at the International Society of Transcranial Stimulation website at www.ists.unibe.ch.
rTMS as Maintenance in Bipolar Depression Preliminary observations suggest repetitive transcranial magnetic stimulation (rTMS) may be effective as adjunctive maintenance treatment in bipolar depression. Continued treatment was offered to 7 patients who had participated in a controlled trial of daily acute rTMS. Prior mood stabilizing and antidepressant medications, which had been ineffective against depression, were withdrawn during the controlled trial but reinstated during the maintenance phase. Patients received weekly rTMS delivered over the left prefrontal cortex. A 2-week cycle of daily treatments was resumed if the patient experienced a relapse, which was defined as a Hamilton Rating Scale for Depression (HAM-D) score of >20 for 2 consecutive weeks. Patients with >3 relapses during the year were withdrawn from treatment. At the start of the acute study, patients had an average HAM-D score of 34 that was reduced to 12 at the beginning of maintenance therapy. Over the year of maintenance rTMS, no headache, memory or cognitive problems, mania relapse, or other adverse effects were reported. Maintenance treatment was unsuccessful in 4 patients who were withdrawn from treatment after 13–38 weeks (mean, 24 weeks). Of the remaining 3 patients (all female) 2 remained well throughout the year: a woman with a 40-year history of bipolar depression with episodes occurring every 3 months for the previous 12 years; and another whose annual seasonal episode of depression did not recur during maintenance rTMS. Relapse occurred in 1 patient who had not respond to sham rTMS during the clinical trial but improved within the first few days of active rTMS. She responded promptly to acute rTMS during the maintenance phase. Discussion: Although these cases suggest weekly rTMS is safe and well tolerated and may be helpful in the maintenance treatment of bipolar depression, the number of patients was small and the descriptive nature of the data, the lack of a control group, and the resumption of previous pharmacotherapy limit the applicability. Randomized controlled trials are needed to confirm these reports and to determine optimal stimulation parameters.
rTMS for Posttraumatic Stress Disorder High-frequency repetitive transcranial magnetic stimulation reduced anxiety and core symptoms of PTSD in a preliminary controlled trial. Background: Previous imaging studies have demonstrated structural and functional abnormalities involving limbic and paralimbic structures in the prefrontal cortex of patients with PTSD. This study was undertaken to evaluate the effects of rTMS delivered to the right dorsolateral prefrontal cortex. Methods: Patients were 29 adults with PTSD secondary to combat; accidents; sexual abuse; assault; or bereavement. The precipitating stress had occurred an average of 5 years in the past. Most patients were taking multiple medications, often antidepressants and benzodiazepines, and in a few cases mood stabilizers or an antipsychotic agent. Patients were randomly assigned to either high-frequency (10 Hz) rTMS, slow-frequency (1 Hz) rTMS, or sham treatment and underwent 20-min sessions on 10 consecutive working days. Outcomes were rated with the 17-item, self-report PTSD Checklist and the 8-item, clinician-rated Treatment Outcome PTSD Scale at 5, 10, and 24 days. Hamilton Rating Scales for Anxiety and Depression were also used. Results: Slow-frequency and sham treatment did not produce significant improvement on any outcome measure. In the patients receiving high-frequency rTMS, scores on the PTSD Checklist decreased by 29% and clinician-rated PTSD symptoms decreased by 39%. Patients experienced significant declines in all symptom domains (i.e., re-experiencing, avoidance, hyperarousal). Anxiety scores also decreased significantly with high-frequency rTMS, and depression improved to a lesser degree. Positive effects were still evident 2 weeks after the last treatment. Some patients reported additional benefits, such as improved sleep and increased calmness. The treatments were generally well tolerated; headache was the most frequently reported adverse effect and occurred after 8% of sessions.
Slow Magnetic Stimulation for Depression In a placebo-controlled study, slow right prefrontal repetitive transcranial magnetic stimulation (rTMS) improved medication resistant depression. Background: Research has shown positive effects of rTMS but protocols have varied widely regarding frequency and brain region stimulated. High-frequency rTMS (>1 Hz) has been used in most studies but a few reports suggest efficacy for slow rTMS. Methods: Subjects (n=12; 11 females) with DSM-IV major depression that had been unresponsive to ³2 antidepressant trials were enrolled and randomized to receive a 2-week course of either 10 real or sham rTMS sessions. Treatments were administered at slow frequency (1 Hz) to the right cerebral cortex and previous pharmacotherapy with the exception of benzodiazepines and mood stabilizers was continued. The Hamilton Rating Scale for Depression (HAM-D) was administered at baseline and after 1 and 2 weeks. Response was defined as a ³50% reduction in HAM-D score. Results: Average HAM-D scores decreased by 48% with rTMS and by 30% with sham treatment, from baseline means of 22 and 18, respectively. Response criteria were met by 4 of the 7 patients receiving rTMS (57%) and by 2 of the 5 receiving sham treatment (40%). Final Hamilton scores of <10 points were achieved by 4 patients receiving the active treatment (57%) and by 1 sham-treated patient (20%). Two patients in the sham group crossed over to active treatment and had an average 45% decrease in HAM-D score. No adverse events were reported but most patients relapsed within a few months after treatment was discontinued. Discussion: Slow frequency rTMS offers a noninvasive method of brain stimulation that could become an intermediate treatment step between pharmacotherapy and ECT. However, since relapse rates were high, further studies are needed to investigate maintenance programs.
MRI Stimulation for Bipolar Depression A controlled study was carried out after improvements were observed in 2 patients who underwent echo-planar magnetic resonance spectroscopic imaging (EP-MRSI) as part of a clinical trial of other treatments for bipolar disorder. EP-MRSI is similar to repetitive transcranial magnetic stimulation (rTMS), another type of brain stimulation that has shown varied but generally modest efficacy in depression, but uses a different waveform. Methods: Study participants, who had bipolar I or II disorder, were enrolled in clinical trials of other treatments and were not aware that EP-MRSI was being investigated. Active EP-MRSI was administered to 30 patients with bipolar disorder (including 19 who were receiving lithium, divalproex (Depakote), or other anticonvulsants and 11 who were unmedicated) and to 14 healthy comparison subjects. Sham EP-MRSI was administered to 10 patients with bipolar disorder (2 unmedicated). Participants rated their depressive symptoms on the treatment day (after undergoing a scan) on a 7-point scale with 3 representing very much better and –3 very much worse. Results: Of the 30 patients with bipolar disorder who received active treatment, 23 rated their depression as improved by at least 1 point after EP-MRSI. All 11 unmedicated patients and 12 of the 19 medicated patients improved. A single patient reported worsening and 6 reported no change in symptoms. Of those who received sham EP-MRSI, 3 reported improvement of depression and 2 reported worsening while 4 of the healthy controls rated their mood as improved. No adverse effects were observed. Discussion: More than 10,000 MRI and echo-planar scans using other technology have been completed at the institution conducting this research, without any observation of an antidepressant effect. This suggests the positive results are specific to the EP-MRSI examination used. EP-MRSI and rTMS both expose the brain to electrical and magnetic fields, but EP-MRSI fields are 100 to 1000 times weaker. The disparity in field strength and in the localization of the fields between EP-MRSI and rTMS suggest the 2 treatments have different mechanisms of action. Further investigation into shared and differing characteristics of the 2 treatments may help identify mechanisms useful for treating depression.
Bilateral TMS in Refractory Depression Serial bilateral repetitive transcranial magnetic stimulation was not more effective in a small group of patients with treatment-resistant depression than historically reported response rates for unilateral administration.1 Background: In patients with depression, both left- and right-sided TMS have produced clinical improvement. This study was undertaken to determine if bilateral treatment might provide better results than unilateral treatment. Methods: Study subjects were 10 consecutively referred outpatients with Hamilton Rating Scale for Depression (HAM-D) scores of ³16 despite antidepressant therapy. Participants underwent 9–10 sessions of bilateral TMS (administered to the left and right sides serially) over a 2-week period. Depressive symptoms and cognition were assessed at baseline and at the beginning of every other session. Results: All participants completed at least 7 sessions, with 7 patients completing at least 9. In an intent-to-treat analysis, 4 of the 10 subjects experienced a ³50% decrease in HAM-D score within 2 weeks, and mean scores decreased from 22 at baseline to 16 after TMS completion. No adverse events were reported and no patient had a change in cognitive status. Discussion: Bilateral TMS did not appear to have an advantage over unilateral treatment,2,3 but based on the possible theoretical advantage and the apparent safety, controlled studies with adequate samples appear warranted.
rTMS vs ECT for Nonpsychotic Depression Repetitive transcranial magnetic stimulation and ECT were equally effective in the acute treatment of drug-resistant nonpsychotic major depression.1 Methods: Study subjects were 40 patients with moderate-to-severe nonpsychotic depression who were referred for ECT after nonresponse to at least 1 adequate course of antidepressant drug therapy. Participants were randomized to receive either rTMS or ECT; 33% of patients in each group had previously received ECT. Both inpatients and outpatients were included in the study, and benzodiazepines were the only drugs permitted during treatment. TMS was administered over the left dorsolateral prefrontal cortex at 90% motor threshold, 5 times per week for 4 weeks. ECT treatments, unilateral in 13 patients and bilateral in 7, were continued until the patient responded or the treating psychiatrist expected no further improvement. ECT patients received a mean of 10 treatments, but all completed ³6 sessions. Clinical response was defined as a ³50% decrease in the Hamilton Rating Scale for Depression (HAM-D) score or a final score of £10, and a Global Assessment of Function (GAF) rating of ³60. Baseline HAM-D scores were similar in the ECT and rTMS groups (26 and 24, respectively), but GAF scores were significantly lower in the ECT group (40 vs 49), probably because this group included higher proportions of older patients and inpatients. Results: Response occurred in 11 of 20 patients receiving rTMS (55%) and in 12 of 20 patients receiving ECT (60%). The magnitude of change in HAM-D score was similar in the 2 groups, and 6 patients in each group had final HAM-D scores of <9. Secondary outcome measures, including Mini-Mental State Examination scores, also did not differ between groups. Adverse effects (e.g., headache, sleep disturbance) were mild in the rTMS group, but were not recorded in the ECT group. Discussion: Previously these authors found ECT superior to rTMS in psychotic depression.2 The apparent equivalent efficacy in resistant nonpsychotic depression is limited to the acute period; long-term effects of rTMS are unknown.
TMS Ineffective in Tourette's A placebo-controlled crossover trial of repetitive transcranial magnetic stimulation was ineffective in Tourette's syndrome. The 16 patients enrolled in the study received 2 days each of real and sham TMS. No improvements were found in motor or vocal tics or in obsessions and compulsions in the 12 patients who completed the protocol.
Executive Function After Transcranial Stimulation Repetitive transcranial magnetic stimulation (rTMS) improved executive function, but did not significantly improve depression in a group of patients with treatment-refractory depression. Methods: After a medication washout, study subjects, aged 48–78 years, were randomized to undergo 5 sessions of either active rTMS (n=9) or sham rTMS (n=10). Patients underwent neuropsychological and psychiatric testing before and a mean of 3 days after treatment. Results: Scores on the Hamilton Depression Rating Scale improved in both groups (mean decrease, 7 points), with no difference between active and sham rTMS. There were no significant changes in either group on the language, memory, or visuospatial tests of neuropsychological function. However, subjects who received active rTMS showed significant improvement on the Trail Making Test–B, a measure of executive function, compared with baseline values (p<0.05). The change was independent of education or severity depression.
Transcranial Magnetic Stimulation vs ECT A few preliminary studies have reported favorable results with repetitive transcranial magnetic stimulation (TMS) in comparison with ECT in patients with severe depression. The aim of this study was to extend prior findings. Methods: Study subjects were 22 patients judged to be candidates for ECT. Patients had chronic severe depression, with a mean of 6 prior hospitalizations and multiple antidepressant drug trials. Before randomization, most patients underwent a brief medication washout (mean duration, 4 days). TMS was administered 5 days/week for 2–4 weeks and bitemporal ECT was administered 3 times/week for 1–4 weeks. Clinical response was defined as a ³50% reduction in the Hamilton Rating Scale for Depression (HAM-D) score, with a final score of £8. Adjunctive anxiolytics were used sparingly, and 3 patients received temporary rescue antipsychotic medication. Results: Response rates were comparable in the 2 groups; 6 of 13 patients (46%) in the TMS group and 5 of 9 patients (56%) in the ECT group had HAM-D reductions of ³50% (mean decreases 55% and 64%, respectively). On average, patients in both groups were rated as "much improved" on the Clinical Global Impression-Improvement scale. No serious adverse events were associated with either treatment. Side effects of TMS were mild and included facial twitching, localized discomfort, warmth, and erythema at the treatment site. One patient had moderate pain at the treatment site, which was controlled with a topical anesthetic. No cases of treatment-emergent mania occurred in either group. Discussion: These results are consistent with previous reports of TMS efficacy in severe depression, suggesting that TMS may be useful as an intermediate strategy between drug therapy and ECT or as an adjunct to either. The present trial differs from previous investigations in its use of a relatively aggressive TMS protocol, bitemporal ECT, and minimal rescue medications.
Transcranial Magnetic Stimulation for OCD In a small trial, repetitive transcranial magnetic stimulation (rTMS) was not more effective than placebo in improving symptoms of OCD.1 Methods: Subjects were 18 outpatients (mean age, 35 years) who met DSM-IV criteria for OCD; 13 patients were receiving pharmacotherapy. Subjects were randomly assigned to receive either low-frequency rTMS or sham treatment 3 times per week for 6 weeks. Assessments were performed weekly for 10 weeks following treatment, using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Hamilton Rating Scale for Depression (HAM-D). Results: Subjects in the rTMS group experienced greater reductions in obsessions than those treated with the sham procedure, 13% and 5%, respectively. However, compared with baseline values, neither the real nor the sham treatment had an effect on the Y-BOCS or the HAM-D scores at 10 weeks that was significant. Two patients in the active treatment group who had checking compulsions and 1 patient in the sham group with sexual/religious obsessions had >40% decreases in Y-BOCS scores and were considered responders. Conclusion: Although right prefrontal rTMS has been reported to reduce compulsions for up to 8 hours after a single treatment in patients with OCD,2 multiple treatments do not produce significant improvement.
Magnetic Brain Stimulation for Psychiatric Disorders Repetitive transcranial magnetic stimulation (rTMS) is known to be effective for refractory depression and is under investigation for treating symptoms of schizophrenia, OCD, and Parkinson's disease. In addition, the technique appears to facilitate performance on some cognitive tasks, according to News Focus in Science. The results of recent clinical trials, showing efficacy of rTMS in refractory depression, have led to the approval of rTMS for treatment of major depression by the Canadian Health Ministry; and the FDA is considering its approval in the U.S. The therapeutic potential is a recently recognized aspect of rTMS, which was first introduced as a research tool in 1985. Stimulation is applied by passing electric current through a coil on the scalp, creating a perpendicular magnetic field that generates electrical current in the brain tissue lying immediately below the coil. A single burst of strong current can interrupt neural communication locally, creating a "temporary lesion," which allows researchers to test the localization of various brain functions. In contrast, repeated low-intensity, low-frequency stimulation can temporarily depress brain activity, and increase excitability at higher frequencies. The mechanism for these responses and their relationship to different stimulation frequencies is unknown. In clinical trials, the treatment is typically applied for 20–30 min/day for 2–4 weeks. In contrast to ECT, which induces seizures and radically disrupts brain activity, rTMS as used in depression protocols acts only on the left prefrontal cortex. This brain region is less active in patients with depression and, neuroimaging studies show, can be made more active with rTMS. The technique is not believed to be a milder form of ECT, but to act in a completely different way. By stimulating one part of a neural circuit, investigators believe they are affecting the limbic system. By a similar rationale, researchers believe that by using neuroimaging techniques, they will be able to identify areas where a given circuit involved in a particular disease rises to the surface of the brain and then apply treatment to the site. This approach was used to identify and treat an area in the temporoparietal cortex to reduce auditory hallucinations in schizophrenia. The rTMS technique appears to be safe when used at mild intensities, but further safety data are needed because the mechanisms of the technique are so poorly understood. When applied to target areas of the brain, rTMS has been shown to speed word recall and movement. Study subjects were able to solve analogy puzzles more rapidly after application of rTMS to the prefrontal cortex.
Safety of Repetitive TMS In a preliminary controlled trial, repetitive transcranial magnetic stimulation (rTMS) did not cause adverse effects on cognition, EEG, or hearing.1 Efficacy results of the study have been published elsewhere.2 Background: A study of single-exposure TMS found the treatment to have a negative effect on neuropsychologic function,3 but several small studies of rTMS have found that the treatments improved both mood and cognitive functioning in patients with major depression.4-6 It could not be determined whether improvement in cognition was secondary to the mood effects of treatment, or if improved mood could mask deteriorations in cognitive function. Transient hearing loss has been described in patients exposed to the noise artifacts of rTMS, and there have been concerns about brain kindling resulting from multiple treatments. Methods: Study subjects were 18 patients, aged 33–78 years (mean, 48 years), with a DSM-IV major depressive episode. Patients were randomly assigned to 2 weeks of either real or sham rTMS, administered on 5 consecutive days each week. After blinded treatment, all patients were offered continued open rTMS, to a maximum of 4 weeks of total exposure. A total of 12 patients received 4 weeks of active rTMS. Patients’ frontal lobe function, visual and verbal memory, attention, and general mental status were assessed at baseline and every 2 weeks. Auditory threshold and EEG readings were also obtained every 2 weeks. Because of concerns about impaired driving fitness, the investigators checked patients' orientation, reaction time, and psychomotor function before and after the first treatment. Results: No measure of cognitive function deteriorated during treatment, and rTMS did not affect driving fitness tests. Assessments of auditory threshold did not show any clinically significant changes. However, slight increases in 2 patients suggests that prolonged exposure may cause increases in some patients. Mild, clinically non-significant EEG abnormalities occurred in 2 patients—a single occurrence in a sham-treated patient and abnormalities that resolved over 9 months in an rTMS-treated patient.
TMS-Induced Switching into Mania In 2 patients with bipolar depression, transcranial magnetic stimulation induced episodes of mania.1 TMS appears to have some advantages over direct electrical stimulation of the CNS, including greater safety, fewer adverse effects, and the ability to stimulate specific regions. Several studies support the use of TMS in depression,2,3 but few data are available about its use in treating mania.4 A 46-year-old woman with a 15-year history of bipolar affective disorder was hospitalized for a depressive episode. Her regular medications were 800 mg/day valproic acid and 5 mg/day haloperidol. After admission, haloperidol was stopped and TMS treatments were started 5 times/week for 4 weeks. By the end of the third week, she experienced progressively worsening manic symptoms. After the course of TMS was completed, haloperidol was restarted and her manic symptoms resolved within 1 month. A 54-year-old man experiencing an 18-month-long ongoing depressive episode was started on TMS 5 times/week for 4 weeks. He had a history of a single previous depressive episode and 3 spontaneously remitting hypomanic episodes. Within 5 days after completing the treatments, he began experiencing manic symptoms. Despite treatment with 800 mg/day valproic acid, the manic episode lasted 2 months. Discussion: The findings in these 2 patients suggest that TMS, like antidepressants, can induce a switch from depression to mania, especially in patients with bipolar disorder. Further research is needed to understand the nature of the switch.
TMS for Depression Transcranial magnetic stimulation was more effective than a sham procedure in relieving depression in a 2-week trial. Methods: Study subjects were 30 patients (19 women) who met DSM-IV criteria for either major depression (n=21) or bipolar disorder, depressive phase (n=9). Most of the patients had not responded to antidepressants, and 7 patients had received prior ECT, but had experienced serious side effects or failed to respond. The duration of the current depressive episode was 2 years (mean). Patients were randomly assigned to 2 weeks of either high-frequency (20 Hz; n=10) or low-frequency (5 Hz; n=10) TMS, consisting of 20 min of left prefrontal stimulation every weekday morning, or sham treatment (n=10). The 10 subjects receiving sham treatment had the device applied in such a way that the skin and scalp muscles were stimulated in a fashion similar to active treatment, but significant magnetic fields did not reach the brain. Treatment response was defined as a ³ 50% improvement in scores on the 21-item Hamilton Rating Scale for Depression (HAM-D). Results: TMS resulted in significantly better response than sham treatment; 9 of 20 patients who received TMS responded, compared with none of the sham-treated patients. Two TMS patients withdrew early in treatment because of inability to tolerate the pain of stimulation. TMS appeared to be more effective in women (8 of the 9 responders) and in patients with bipolar disorder (5 of the 9 responders). Response did not differ significantly between the high- and low-frequency groups. Secondary outcome measurements, including tests of anxiety and global improvement, were less conclusive but tended to support TMS as well. Headache, a known side effect of TMS, occurred in 10 patients and was responsive to acetaminophen. No patient experienced cognitive or memory problems, seizures, or mania. Discussion: The TMS device generates a small but powerful magnetic field on the scalp that passes through the skull and induces a weaker focal current in the brain. Unlike ECT, it does not require anesthesia or induce seizures. A follow-up study of this cohort, to determine long-term safety and efficacy, and a 1-year trial of intermittent TMS as maintenance treatment for bipolar disorder are currently underway.
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