Safe, painless, effective and virtually without side effects. Characteristics of rTMS (Repetitive Transcranial Magnetic Stimulation), a fairly new treatment in the ETZ (Elisabeth-TweeSteden Hospital) for people with depression, for whom medication does not work well.
In an rTMS treatment, the healthcare professional places a magnetic coil on the patient’s head. That coil delivers a series of short magnetic pulses to the prefrontal cortex, the brain region involved in regulating emotions. With rTMS one tries to positively influence the activity of that brain region.
Welcome addition
This makes rTMS a welcome addition to the list of treatment options for depression, something that Iris Dalhuisen, researcher in training at Radboudumc in Nijmegen, also noted. “Normally, depression treatment consists of talk therapy and/or medication,” she explains. “If that doesn’t work, medication will be prescribed again.” When that does not work either, electrocovulsive therapy (ECT) is often followed, in which the patient – who is now suffering from severe depression – is given electroshocks. This is a very effective treatment, which at the same time can cause memory loss as one of the possible side effects.
Positive results
“An rTMS treatment has the advantage that it functions as a good intermediate step, is an excellent alternative to the use of medication and is not as taxing as ECT,” says Dalhuisen, who is involved as coordinator in the DETECT study at Radboudumc. neuroCare Group Netherlands, Pro Persona and the ETZ. That study – which started in the summer of 2019 – looks at the effect of rTMS on depressive symptoms in comparison with the usual medication treatment with antidepressants. An rTMS treatment shows positive results when it comes to tackling depressive disorders. In combination with cognitive behavioral therapy (CBT), about sixty percent recover. The treatment has recently been on the rise within the ETZ. “We treat many patients with rTMS and see that the therapy has taken off in our hospital in the last two years. For example, we are scheduling more and more patients for rTMS treatment,” says Dieuwertje de Waardt, psychiatrist and principal researcher at ETZ.
Bird’s eye view
A high score for the rTMS treatment, which since 2017 is only reimbursed if there is treatment-resistant depression (if medication and/or talk therapy do not work). Before that happens, patients are often six months further. “An important part of the study is looking at the moment when rTMS comes into the picture,” explains De Waardt. “So after how many times to prescribe medication, it is good to use rTMS in the treatment guideline.” Officially, rTMS has not yet been included in the treatment guideline, which dates back to 2013. It states that there is insufficient evidence for the effectiveness of the treatment. The existing information on rTMS and the results of the DETECT study ultimately contribute to the mission to demonstrate the effectiveness of the treatment.
eight weeks
During the study, patients with major depressive disorder – who have been treated unsuccessfully with antidepressants at least twice and who had no previous exposure to rTMS and/or ECT – will be treated for eight weeks with either rTMS and CBT or medication. After registration by the attending physician, an intake interview follows, after which a drawing of lots determines in which treatment group (rTMS + CBT group or medication switch group) the patient ends up. When the patient ends up in the rTMS group, he immediately starts the rTMS treatment, which consists of twenty-five thirty-minute sessions and at least one CBT session per week spread over eight weeks. Patients from the medication switch group receive a proposal for new medication and CBT during those eight weeks. After the treatment phase – which ends with four concluding consultations for both groups – they still have the opportunity to undergo the rTMS treatment.
Well tolerated
The treatment takes place in the specially equipped rTMS treatment room at the ETZ Elisabeth location in Tilburg. There the patient takes place in a comfortable treatment chair, after which the administration of the magnetic pulses begins. The magnetic waves can pass through the skull without any risk and without any problems. “Patients can tolerate the treatment very well because the side effects are minimal,” Dalhuisen says. “We mainly see mild headaches during or after treatment.” Although rTMS is generally experienced as painless, the treatment is not completely numb. “Most patients do not find it bothersome at all, while others are more sensitive to physical sensations and therefore find it more annoying. Usually one notices that after a number of treatments, habituation occurs, which makes it very tolerable,” says De Waardt.
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