A first-hand account of receiving repetitive transcranial magnetic stimulation

Repetitive transcranial magnetic stimulation (rTMS) is widely considered to be a non-invasive neurostimulation technique that is generally painless and lacks the cognitive side effects of electroconvulsive therapy (ECT). There is ample evidence for its use in unipolar depression. While there is more research looking at high-frequency left frontal stimulation, which is intended to relieve melancholic symptoms through activation of neurons, low-frequency right frontal rTMS is intended to dampen symptoms such as rumination and anxiety and overall has similar efficacy (Berlow et al., 2020). rTMS has also been used effectively in a variety of conditions that include bipolar depression, post-traumatic stress disorder and smoking cessation (Cirillo et al., 2019; Gold et al., 2019; Zangen et al., 2021). For outpatients, Medicare currently reimburses for an acute course of 35 sessions (see items 14216, 14217, 14219 and 14220), typically one session each weekday for 7 weeks, while inpatient treatment schedules may be accelerated and covered by private health funds.

Having experienced a major depressive episode of about 6 months duration (see Berger, 2022a, 2022b), I was feeling rather hopeless at the prospect of the depression lifting completely. I had tried a few different medication combinations and psychotherapy with only moderate effect on physical symptoms, ongoing difficulties with distress tolerance and worsening social anxiety. I decided I would probably try rTMS and scoured the Internet for research and patient experiences. While patient message boards were full of conflicting experiences and bizarre potential side effects, I could not find a single in-depth account of the patient experience of rTMS either as a case study or in patient forums. I hope to be able to give an account that will be useful for those looking to refer patients for rTMS, those who perform rTMS and for patients looking to understand what having rTMS is like. While my experience is not necessarily what everyone experiences, I hope that it will help others to better understand what it is like to have rTMS.

I had opted for outpatient rTMS to minimise disruption to my home and work life, and was referred by my psychiatrist to an rTMS psychiatrist. The journey began with an assessment much like any other visit to a new psychiatrist with extra focus on rTMS contraindications and risks such as history of brain tumours, metal implants, epilepsy and migraines. As a migraineur, I was warned that headaches may occur in the first few sessions of rTMS and usually resolve with ongoing treatment but that migraines could be triggered or exacerbated. Fortunately, I only experienced very mild headaches at the treatment site and not after every treatment. I did have some increase in aura without headache, but this was mild and transient.

My first session included brain mapping prior to the treatment session to find my resting motor threshold (RMT). I received quite a jolt with the first pulse, along with stimulation of my retina causing a blue phosphene and deep pain in my eye (this resolved quickly and has not had any lasting effect, but it was very distressing at the time). At this stage, my body was instantly conditioned for pain, so while it certainly became more tolerable with lower power, I could not help jumping slightly with many of the pulses during brain mapping.

Once brain mapping was complete, I had my first treatment of right frontal rTMS at 120% of my motor threshold. I can only describe the sensation as something between a small electric shock and a small but powerful thumping. Many people find it to be much gentler than I do and describe it as similar to tapping a pencil eraser on the scalp. This was in fact painful for the first 10 minutes of the 30-minute treatment session, but I was able to eventually lean into the sensation and relax. I have since not experienced pain with treatments and can even find the rhythmic thumping relaxing. Since my first treatment, I have experienced a noticeable shift in my general sense of well-being as well as a reduction in rumination and anxiety that continues even on non-treatment days. I noticed my depression lifting significantly at around 2 weeks and that it was gone by 4 weeks. My social interactions improved, with smiling becoming much more genuine and the effects of positive interactions holding past the interaction itself, as well as a significant reduction in social anxiety. While I still had suicidal ideation early in treatment, it became much easier to acknowledge that suicide is not what I actually want and that my life is good in many ways. By 4 weeks, I had none at all.

During treatment, I frequently experienced stimulation of my masseter muscle, resulting in jaw clinching and requiring use of a bite block to protect my teeth. This is, to my knowledge, not a common experience and the effects of occasional masseter stimulation are generally relieved by holding the mouth slightly open. I strongly recommend availability of a small bite block such as folded gauze to improve comfort if this occurs. I also found that having the treatment room lights dimmed reduced how noticeable the occasional phosphene was.

Overall, my impression of rTMS and the variety of patient experiences is that we are working with a complex and delicate organ that differs slightly in every individual. Some patients have reported on forums a variety of neurological symptoms or severe pain during or after treatment. We should not discount experiences that do not align with our expectations. Minute anatomical differences may partially account for the efficacy or lack thereof of rTMS in any given individual as well as side effects. While we know much more about the brain now than we used to, we still have a long way to go.

As a result of my experience, I have decided to become rTMS certified myself in order to be able to provide this potentially life-changing treatment to others. I would certainly recommend rTMS to patients who do not respond to adequate antidepressant trials or for whatever reason medication is contraindicated. It is also important to have psychotherapy with any treatment, if the patient is able to engage in psychotherapy. Under current Medicare Benefits Scheme requirements for rTMS, both of these are necessary for Medicare rebate (see items 14216, 14217, 14219 and 14220). My experience of rTMS has been overall positive despite side effects. I have had significant benefit from low-frequency right frontal rTMS, particularly for ruminative and anxiety symptoms, and look forward to more research being done on this approach.