Abstract
Keywords
Transcranial magnetic stimulation (TMS) is attracting considerable interest as a treatment for psychiatric illness, particularly depression (e.g. [1–4]). In the procedure, a current is passed around an insulated coil held in contact with the head, causing a magnetic field to pass into the first few mm of cortex. Unfortunately, there are no published data on the experience and opinions of recipients of TMS concerning the treatment. This area is worth exploring because consumer satisfaction is recognized as an increasingly important outcome measure and because ‘physical treatments’ in psychiatry have not always been well regarded by patients and the community generally. Electroconvulsive therapy (ECT), for example, remains controversial in many quarters. We aimed to ascertain patient experience, knowledge and attitudes in relation to TMS, and to make comparisons with other treatments TMS recipients had been given.
Method
Survey
A 60-item instrument was constructed by the authors. Several items were adapted from an instrument that the first author had developed for studies of ECT (described in Walter et al. [5]). The survey covered demographic features (e.g. age, gender, relationship status, occupation), experience with TMS (e.g. fears, provision of information, perceived effectiveness, side-effects, comparisons with other treatments), knowledge (e.g. about the nature and technical aspects of TMS) and attitudes (e.g. whether TMS is humane or cruel and whether recipients would recommend it to others). The vast majority of survey items (n = 55, 92%) offered a set choice of responses; five questions (8%) were open. Subjects were not prompted by the interviewer for responses.
Subjects
Following ethics committee approval from the Royal Hobart Hospital, Tasmania, Australia, all persons who received TMS at that hospital between 1 November 1996 (when the treatment was first given) and 31 October 1999 were identified. The patients were all suffering from a DSM-IV major depressive episode [6] and had failed to respond to adequate trials of medication. All patients had received antidepressants; some had also been treated with antipsychotics, anxiolytics and mood stabilizers. In addition, they were all right handed, free of epilepsy and intracranial metal objects and in at least fair general health. The patients were sent a complete description of the study and, if they agreed to participate, were interviewed by telephone by one of the authors (JM) who had not been involved in the treatment of any subjects.
Details of transcranial magnetic stimulation treatment
All patients had been treated at 100% of motor threshold with a Magstim Super Rapid stimulator (Magstim, Dysed, Wales) and a 70-mm double coil held over the left prefrontal cortex, 5 cm anterior to the point at which the motor threshold was determined. About half the patients were treated with 10 Hz stimulation in 5 s trains and the other half with 20 Hz stimulation in 2 s trains. Between 20 and 30 trains of stimulation were given daily, 5 days per week. A standard course of treatment was 10–15 sessions.
Statistical analysis
Because this is mainly a descriptive study with relatively small numbers, few statistics were applied to the data; χ2 was used when comparing subgroups. Only differences significant at p < 0.05 are reported. Percentages are rounded to the nearest unity.
Results
Sample
Sixty-four subjects were identified. Forty-eight (75%) were subsequently interviewed. Of the 16 patients who did not participate in the study, 12 declined to be interviewed, three could not be located and one had died, having suicided 9 months after his last TMS treatment. On average, interviewed patients were 49 years old (range = 23–79). Onethird (n = 16) were male, almost half (n = 22, 46%) were married, 19 (40%) were in employment and only one (2%) lived in supported accommodation. The vast majority (n = 44, 92%) were currently being treated by a psychiatrist or other mental health professional. The same proportion (n = 44, 92%) were presently on psychotropic medication. About two-thirds of patients (n = 31, 65%) had had ECT at some stage.
Almost two-thirds (n = 31, 65%) of persons interviewed had had one course of TMS; eight (16%) had two courses, three (6%) had three courses, and six (13%) had more than three courses. Twenty-seven (56%) of the interviewees had received at least one course of TMS as an inpatient; 21 (44%) had received TMS only as an outpatient. There were similar proportions of patients who had had their last TMS treatment 1 year prior to the interview (n = 18, 38%), 1–2 years previously (n = 15, 31%) and more than 2 years beforehand (n = 15, 31%). According to information in the case notes, there were no differences between the 48 patients interviewed and the 16 not interviewed in age, gender, number of TMS courses, inpatient/outpatient status during TMS and time of the last TMS course.
Experience of transcranial magnetic stimulation
Forty-two patients (88%) believed they had received adequate information from health professionals about TMS before having the treatment. Most (n = 44, 92%) believed they could have refused TMS if they had chosen. All stated (correctly) that they had received TMS for depression.
Three-quarters of interviewees (n = 36, 75%) said they were not fearful of TMS before the first treatment; nine patients (19%) indicated they had been ‘a little’ fearful, and two (4%) recalled being very fearful. By comparison, during the TMS course 45 patients (94%) stated they were not fearful of TMS, three (6%) were ‘a little fearful’ and none were very fearful. Most patients (n = 42, 88%) said that TMS was less frightening than ‘having something done at the dentist’; five patients (10%) rated the two experiences the same in this regard. One rated TMS as the more frightening experience.
Thirty patients (63%) considered TMS had been helpful; of these, 23 (77%) stated that TMS had helped ‘a lot’. Fourteen patients (29%) believed there had been no improvement in their condition with the treatment. One patient thought TMS had made him worse. Three patients (6%) were unsure whether TMS had helped or not.
When asked what was ‘the worst’: the illness, TMS, ECT (if they had it) or psychotropic medication, the vast majority of respondents (n = 46, 96%) stated the illness was worst; one considered ECT was worst and one stated the medication was worst. No patients nominated TMS as the worst. Information about the patients' experience of sideeffects with TMS, ECT and psychotropic medication is presented in Table 1. Other adverse events reported with TMS, in response to an open question, were tiredness (n = 6, 12%), a brief episode of derealization (n = 1, 2%) and a sensation of pins and needles as the magnetic field was applied (n = 1, 2%). Two patients (4%) mentioned they had felt fleetingly ‘elated’ with TMS treatment. No patients volunteered experiencing scalp pain or discomfort at the time of TMS stimulation, a side-effect described in some centres [Loo C: personal communication], although it is possible that some patient reports of ‘headache’ (Table 1) might have been referring to that phenomenon.
Comparison between transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT) and psychotropic medication: recalled side-effects and attitudes toward treatment
Described less commonly with TMS than ECT were muscle aches (χ2 = 19.34, df = 1, p < 0.0001), nausea or vomiting (χ2 = 12.3, df = 1, p < 0.001), confusion (χ2 = 22.96, df = 1, p < 0.0001) and memory impairment (χ2 = 42.62, df = 1, p < 0.0001). There were no significant differences between TMS and ECT in reported frequency of headaches.
The vast majority of patients (n = 43, 90%) rated TMS as more acceptable than having, or the prospect of having, ECT; two respondents (4%) considered TMS less acceptable than ECT, a further two (4%) rated the two treatments as equally acceptable and one respondent did not know.
The various aspects of TMS were generally considered ‘not upsetting at all’ by respondents. However, the following were rated as ‘very upsetting’ by some patients: waiting for the treatment (n = 6, 12%), having a magnetic field applied (n = 1, 2%), developing a headache (n = 1, 2%), and the ‘whole experience’ of TMS (n = 3, 6%).
A majority of patients had informed only immediate family (n = 8, 17%) or other relatives or close friends (n = 19, 40%) about their TMS treatment. A minority (n = 21, 43%) had told others. About one-fifth (n = 9, 19%) had attempted to actively conceal the history of TMS treatment.
Knowledge
Most interviewees (n = 32, 67%) correctly stated that TMS had been used in psychiatry for less than 20 years. The vast majority of interviewees (n = 43, 90%) also chose the correct option to the question ‘What do you think TMS is?’ (‘A treatment in which a magnetic field is used’). However, one respondent considered TMS a form of ‘brain washing’ and four respondents (8%) did not know. Most patients displayed good knowledge about the disorders for which TMS is usually used. Forty-seven (98%) mentioned depression. Few thought that schizophrenia (n = 10, 21%), mania (n = 8, 17%) or other disorders (n = 4, 8%) are common indications. Only three (6%) believed that TMS is used to ‘to control unacceptable behaviour’. Most patients (n = 46, 96%) believed that patients who have TMS are usually given an explanation of the treatment by their doctor and then give their agreement; two (4%) believed patients are usually given the treatment against their will. Most interviewees (n = 44, 92%) believed that TMS is a safe treatment; one did not believe TMS is safe and three (6%) did not know. Most patients did not believe TMS leads to permanent damage (n = 42, 88%) and did not consider it more dangerous than medication (n = 42, 88%).
Attitudes
Information about patient attitudes towards TMS, ECT and psychotropic medication is presented in Table 1. There were no significant differences in attitudes between TMS and medication. Compared with ECT, TMS was less frequently rated cruel (χ2 = 13.42, df = 1, p < 0.001), unsophisticated (χ2 = 19.84, df = 1, p < 0.0001) and a treatment that should be outlawed (χ2 = 7.35, df = 1, p < 0.01). Forty-four patients (92%) would agree to TMS if recommended in future; about two-thirds (n = 32, 67%) would agree to it immediately and one-quarter (n = 12, 25%) if other treatments did not work. Forty-two patients (87%) would recommend TMS to family or friends if it had been advised by a doctor, either immediately or if other treatments did not work. About two-thirds (n = 31, 65%) believed TMS should be given to adolescents if indicated; one-third (n = 16, 33%) were unsure.
Few differences emerged when patients were dichotomized into those who believed TMS had helped ‘a lot’ versus the rest, and the two groups compared with regard to their responses to a variety of questions. Patients who believed TMS had helped a lot were more likely to say they would agree to TMS immediately in future (χ2 = 8.18, df = 1, p < 0.01) and were also more likely to have had more than one course of TMS (χ2 = 5.42, df = 1, p < 0.05). There were no differences between the two groups according to patient gender, age (< 50 years and ≥?50 years), presence of side-effects with TMS, and whether or not patients had had ECT.
Discussion
This is the first study describing the experience, knowledge and attitudes of recipients of TMS regarding the treatment. The results suggest that patients have generally very positive views about TMS. Strongly negative opinions were uncommon. The vast majority of patients found TMS to be an acceptable treatment, less aversive than the illness for which it was prescribed, and in many ways preferable to ECT.
The study has several shortcomings. First, it is a retrospective survey and essentially descriptive. Second, a comparison group was not included because of the difficulty of finding a treatment experience that resembles TMS. We were able to partly obviate this by asking subjects to compare the experience of TMS with that of ECT and psychotropic medication. Third, the instrument was adapted from one used to assess attitudes to ECT; although this was done to facilitate comparison of treatments, it is possible that an instrument developed de novo for TMS would have been more sensitive in eliciting data about that treatment. Fourth, the sample was derived from a single site; the findings may not necessarily generalize to other settings. In particular, TMS stimulus characteristics can vary markedly across centres; different TMS settings might account for very different subjective experiences. Finally, making distinctions based on a patient's perceptions, between the illness and its treatment (TMS, ECT or medication), and between the side-effects of treatment (TMS, ECT or medication) and possible somatic features of the underlying disorder, has limitations [5].
Despite the above considerations, there are reasons to have confidence in the data. First, the response rate (75%) was satisfactory and there was no suggestion that interviewees differed from those not interviewed. Second, there was a very low rate (0.3%) of missing data. Third, the opinions expressed about TMS would have reflected, as much as possible, ‘true’ views and experiences, not contaminated by negative media accounts of the treatment; as far as we are aware, TMS, being a new treatment, has to date escaped an assault by the media.
The finding that TMS was generally preferred to ECT is, perhaps, not surprising. Unlike ECT, TMS is not administered under a general anaesthetic, does not produce a seizure and has not been subject to negative media portrayals. However, it is worth noting that although TMS was favoured over ECT, views about ECT were nevertheless often fairly positive. For example, the majority of interviewees considered ECT to be a humane and legitimate treatment. This finding is consistent with most studies of patient attitudes towards ECT (e.g. [7,8]). which have elicited mainly favourable opinions.
In conclusion, reports (e.g. [9,10]) generally suggest TMS can have a beneficial effect on depressive symptoms and is associated with few adverse events. More studies are required to further evaluate the treatment's efficacy and safety. In the interim, when TMS is being considered as a treatment option, it will be reassuring for potential recipients, their families and health professionals that the patients we interviewed endorsed the treatment. It is important to replicate our findings in other settings, particularly when the treatment is further refined.
Footnotes
Acknowledgements
We thank Joseph Rey, Colleen Loo, Karryn Koster, Brett Daniels and Alison Bowling for their advice, and the patients for participating in the survey.