rTMS not Effective for Depression

Dr Shock
May 8, 2008


Rapid Transcranial Magnetic Stimulation (rTMS) to the left prefrontal cortex is not more effective than sham rTMS for depression. This was the result of a recent published randomized controlled trial with 4 month follow-up.

rTMS is a non-invasive method to stimulate the brain. Weak electric currents are induced in the cortex of the brain by rapidly changing magnetic fields (electromagnetic induction). This way, brain activity can be triggered with minimal discomfort, no need for anesthesia, and no cognitive side-effects. Side effects of rTMS are: discomfort or pain from the stimulation of the scalp and associated nerves and muscles on the overlying skin and hearing from the loud click made by the TMS pulses.

The most recent Cochrane review concluded that there is no strong evidence for benefit from using transcranial magnetic stimulation to treat depression, although the small sample sizes do not exclude the possibility of benefit. Since then (2002) 8 randomized controlled trials were published about rTMS and depression, you can read about these trials here.

After the review only one other randomized sham controlled trial was published about rTMS for depression.

Considering the outcome on the time point at week 4, Dr Shock is not very impressed by the results. For significant difference with the primary outcome 6 patients had to be excluded from the analysis. The mean difference between active and sham on the severity scales is in the range of 2-3 points, significant but hardly clinical relevant. Absolute figures on response and remission at week 4 are not given in this article. Remission rate at 6 weeks on the HAMD-17 was 15.5% increasing to 22.6% at week 9 with open labeled therapy. Not very impressive.

Since some previous studies used relatively non-intense stimulation parameters in
the absence of a true placebo condition this trial used an intensive form of rTMS treatment:

Research physicians administered TMS at 110% resting MT (motor threshold) at frequency 10 Hz, in 5-second trains. Twenty trains were given each session with inter-train intervals of 55 seconds. Thus a total of 1000 TMS pulses were given per session and 10 000 per course.

In addition, very few reported meaningful follow-up data, in this study subjects were followed up for 4 months. To prevent unblinding placebo rTMS was delivered in the same way as real rTMS but using a purpose-built sham coil (Magstim Co.,Whitland, UK) that was visually identical to the real coil and made the same clicking sound but did not
deliver a magnetic field to scalp or cortex.

And these are the results:

Overall, Hamilton Depression Rating Scale (HAMD) scores were modestly reduced in both groups but with no significant grouprtime interaction (p=0.09) or group main effect (p=0.85) ; the mean difference in HAMD change scores wasx0.3 (95% CIx3.4 to 2.8). At end-of-treatment time-point, 32% of the real group were responders compared with 10% of the sham group (p=0.06) ; 25% of the real group met the remission criterion compared with 10% of the sham group (p=0.2) ; the mean difference in HAMD change scores was 2.9 (95% CI x0.7 to 6.5). There were no significant differences between the two groups on any secondary outcome measures. Blinding was difficult to maintain for both patients and raters.

In a comment they still want us to believe that rTMS can be promising. In the comment comparison is mad with antidepressants and ECT but these treatments have been studied far more often resulting in not very great advantages but much more evidence and meta analysis with greater power. Moreover, as with other failing treatments in the past rTMS is studied in all kinds of diagnoses. rTMS for Stroke?

A study by a group out of the University of Cologne in Germany has demonstrated that rTMS over the unaffected motor cortex of patients that have had a stroke will make their use of the affected hand more efficient and quicker.

rTMS for Parkinson’s disease and Dystonia?

Most studies to date have shown beneficial effects of rTMS or tDCS on clinical symptoms in Parkinson’s disease (PD) and support the notion of spatial specificity to the effects on motor and nonmotor symptoms. Stimulation parameters have varied widely, however, and some studies are poorly controlled. Studies of rTMS or tDCS in dystonia have provided abundant data on physiology, but few on clinical effects.

Nah, get out of here……….

There is now even deep TMS

This specific technology can excite or inhibit more areas of the brain than conventional TMS. Regular TMS is basically limited the brain’s outer layer, the neocortex, and can only reach about 1 to 2 centimeters into the brain. So it is limited in its ability to affect many brain areas. The new deep tms can stimulate inner brain areas without inducing unbearable electromagnetic fields cortically. This device currently has almost magical properties and it is somewhat difficult to distinguish company hype from real clinical benefit. I’m not sure at this point how selective this targeting technique is. I think it will be fairly difficult to selectively turn on or off specific brain areas without having unintentional effects.

Or cTMS.

Researchers have developed a better way to manipulate a person’s brain functioning. They have created a new type of transcranial magnetic stimulation (TMS) device (called controllable pulse width TMS or cTMS for short) that will allow rectangular pulse shapes of the magnetic fields. This device will enable researchers to control the width of the magnetic pulse that passes through the subjects skull.

Will keep you posted on all this, will it help TMS?. Let me know in the comments what you think?

ResearchBlogging.org
Mogg, A., Pluck, G., Eranti, S., Landau, S., Purvis, R., Brown, R., Curtis, V., Howard, R., Philpot, M., McLoughlin, D. (2008). A randomized controlled trial with 4-month follow-up of adjunctive repetitive transcranial magnetic stimulation of the left prefrontal cortex for depression. Psychological Medicine, 38(03) DOI: 10.1017/S0033291707001663
Ebmeier, K., Herrmann, L. (2008). TMS – the beginning of the end or the end of the beginning?. Psychological Medicine, 38(03) DOI: 10.1017/S0033291707001651

 

9 Responses to “rTMS not Effective for Depression”

  1. [...] blog a lot of posts are about rapid Transcranial Magnetic Stimulation (rTMS), in short Dr Shock is not convinced that rTMS is effective in depression. On Therapeutic Modulation there is an abstract of a recent published study in the Journal of [...]

  2. Cost effectiveness of ECT versus rTMS | Dr Shock MD PhD on July 18th, 2008 at 6:56 am
  3. [...] all the posts about neurostimulation the most popular is about TMS not being effective in depression treatment. It is a extensive review kind of post, the core being a placebo controlled trial comparing TMS [...]

  4. Dr Shock’s popular posts from 2008 and a look ahead for 2009. | Dr Shock MD PhD on December 27th, 2008 at 6:58 am
  5. hello Dr Schock,

    Thanks for Your marvelous blog. I enjoy it very much. As an EBM afficionado I think it is good to be critical on the efficacy of new neurostimulating procedures be it rTMS, cTMS or even more general “new” therapeutic hype such as neurofeedback. We do not want to invest in expensive machinery when it offers nothing more then a mere placebo effect but, on the other hand, therapy rsistent depression being a very serious problem, we would not want to dispatch prematurely people to last resort very expensive interventionist neurosurgical procedures such as NVS and especially DBS treatment if rTMS (or ECT) could eventually in some form be beneficial after all.

    What has always struck me on rTMS is the disparity in reported results. Some centers claim “wonderfull” effects (Pascuall-Leone , Boston) while others overtly find the results less then clinically impressive.

    Could it be that rTMS has become to broad an umbrella and that the new procedures differ to much to be compared with vintage rTMS ? For instance: in most rTMS devices the motor point (hot spot) is looked for and then the coil is advanced 5 cm in a parasagittal plane in order to stimulate BA 46 and 9 (DLPFC). Neuronavigation methods however (on patient NMR mapped referenced landmarks) showed that in 22 testcases this procedure only directed the coil on correct target (DLPFC) in only 7 (30%). Thus 70% received rTMS but in what is supposed to be “off target” cortical networks . That is a substantial difference and could jeopardise the clinical outcome. Maybe we should postpone our judgements until results from neuronavigated rTMS (RCT like) are available. Also a slight twist of the wrist holding the coil can put it off target (subdural or even on bone ..). Seeing neuronavigated rTMS at work has given me more insight in the technical problems that rTMS has to deal with. In older people or people with slifgt corticosubcortical atrophy it is very easy to be off traget alltogether. Robot controlled neuronavigated rTMS can solve those issues.It is indeed more expensive and time consuming but has advantages over neurosurgery. I really look forward to clinical outcome studies (will be presented in France at the beaune Neuromeeting in jan 2009 by groups from Ulm and Paris. Especially in therapy resistent depression. Let’s hope the outcome of what I call “augmented” rTMS is more inspiring !
    Will keep You posted

    Dr. G. Otte

  6. Georges Otte on December 27th, 2008 at 6:08 pm
  7. The hammer on the nail. rTMS is mainly in a premature phase. It is still to be defined in the sense of localization, frequency and apparatus parameters. The only problem is indeed that most positive results are from one research group. To my opinion good research still has to be done. Placebo controlled that is, very interested in the neuromeeting, link?
    Kind regards Dr Shock

  8. Dr Shock on December 27th, 2008 at 8:40 pm
  9. Look at ANT website.

    georges

  10. Georges Otte on December 27th, 2008 at 11:27 pm
  11. Sorry, forgot the correct link.

    http://www.ant-neuro.com/events/neuromeeting2009/

    Greetz

    Georges

  12. Georges Otte on December 28th, 2008 at 10:16 pm
  13. Thanks :0

  14. Dr Shock on December 28th, 2008 at 10:57 pm
  15. I’m very interested in rTMS since I’ve been unable to get into a clinical trial for DBS for over three years. I had an amazing experience while receiving an MRI of my brain, and apparently TMS is based off of what people, like me, have experienced and others have observed of our affect.

    One specific portion while the machine turned on provided relief. The contrast/brightness of my vision was noticeably improved, and I was thinking very oddly, which turned out to be clear thinking which I had forgotten the feeling of. I was able to do math in my head much more quickly and I had a general feeling of content and happiness. The happiness I felt what I can only imagine I used to feel like before my depression got so awful, or possibly how I should be feeling all of the time and that I’ve never truly felt happy in my life.

    When that portion was over, everything went away very quickly and I was excited for the next scanning portion to begin so that I could feel it again. The succeeding portions did offer any of the same feelings or effects, and I was asking the technician to put me back in and he said nobody had ever felt that way about the MRI machine before. I researched and found that I wasn’t the only one who had a relieving experience while having an MRI scan performed. I’m betting that it’s only applicable to a select few people with a specific problem, or possibly only for those who truly have depression, as I’ve read research that the majority of people diagnosed with depression just have chronic stress; additionally, I read an article about how the placebo effect is becoming more and more effective, furthering the suspicion that the majority of people don’t necessarily have depression, by definition. I certainly wasn’t susceptible to the placebo effect with my MRI scan since I went in to be checked for tumors and possible pressure on my frontal lobe; my sensations initiated and stopped as the machine became active and then deactivated and did not return, as hoped, in succeeding rounds of the scan intervals.

    There’s a good chance that people in the control groups are not very aware of themselves–I have an oddly powerful sense of proprioception, know my body very well, and astounded the neuropsychologist with my motorfunctions. There’s also the chance that they aren’t positioning the magnets for TMS in the proper position, orientation, or with the proper calibration. I would love to be part of ongoing research since I’m articulate and can describe my symptoms and sensations with abundant information and provide accompanying hypotheses to physicians so that they can better understand the problem. I think I could fine-tune the location, orientation, and calibration of TMS systems if given the opportunity–”0.5mm to the left…3mm lower…adjust yaw 5 degrees counter-clockwise…decrease power output…increase frequency”, etc. I think it has great potential for a niche of people since not everyone is physiologically the same: like extra ribs, extra chromosomes, missing finger/toe, and so on. As it turns out, I suffer from undocumented side-effects from abundant medications I’ve tried, and am often told “no, that’s not from the medication”…then a few years later, my symptoms become documented as a known side-effect of the medication when all the while I was told “no, you’re wrong because the documentation doesn’t agree with you”.

    It’s unfortunate that I’m not given opportunities to offer my services (beyond a mere clinical trial of “yes/no”) in exchange for some worthwhile treatment. I can be contacted by yahoo mail under my posted name if any researchers are willing to include me in their projects for some in-depth discussion of hypotheses and some stringent and exhaustive trials. I’ll sign all waivers if it means getting an improved version of TMS treatment and furthering the research, guided by my feedback.

  16. Jon8RFC on December 28th, 2009 at 10:20 am
  17. In my own opinion I can say that rTMS is somehow effective in depression in some ways , maybe at least lessens it a bit. .

  18. Gail Holst on July 14th, 2011 at 4:05 pm
  1. [...] blog a lot of posts are about rapid Transcranial Magnetic Stimulation (rTMS), in short Dr Shock is not convinced that rTMS is effective in depression. On Therapeutic Modulation there is an abstract of a recent published study in the Journal of [...]

  2. Cost effectiveness of ECT versus rTMS | Dr Shock MD PhD on July 18th, 2008 at 6:56 am
  3. [...] all the posts about neurostimulation the most popular is about TMS not being effective in depression treatment. It is a extensive review kind of post, the core being a placebo controlled trial comparing TMS [...]

  4. Dr Shock’s popular posts from 2008 and a look ahead for 2009. | Dr Shock MD PhD on December 27th, 2008 at 6:58 am
  5. hello Dr Schock,

    Thanks for Your marvelous blog. I enjoy it very much. As an EBM afficionado I think it is good to be critical on the efficacy of new neurostimulating procedures be it rTMS, cTMS or even more general “new” therapeutic hype such as neurofeedback. We do not want to invest in expensive machinery when it offers nothing more then a mere placebo effect but, on the other hand, therapy rsistent depression being a very serious problem, we would not want to dispatch prematurely people to last resort very expensive interventionist neurosurgical procedures such as NVS and especially DBS treatment if rTMS (or ECT) could eventually in some form be beneficial after all.

    What has always struck me on rTMS is the disparity in reported results. Some centers claim “wonderfull” effects (Pascuall-Leone , Boston) while others overtly find the results less then clinically impressive.

    Could it be that rTMS has become to broad an umbrella and that the new procedures differ to much to be compared with vintage rTMS ? For instance: in most rTMS devices the motor point (hot spot) is looked for and then the coil is advanced 5 cm in a parasagittal plane in order to stimulate BA 46 and 9 (DLPFC). Neuronavigation methods however (on patient NMR mapped referenced landmarks) showed that in 22 testcases this procedure only directed the coil on correct target (DLPFC) in only 7 (30%). Thus 70% received rTMS but in what is supposed to be “off target” cortical networks . That is a substantial difference and could jeopardise the clinical outcome. Maybe we should postpone our judgements until results from neuronavigated rTMS (RCT like) are available. Also a slight twist of the wrist holding the coil can put it off target (subdural or even on bone ..). Seeing neuronavigated rTMS at work has given me more insight in the technical problems that rTMS has to deal with. In older people or people with slifgt corticosubcortical atrophy it is very easy to be off traget alltogether. Robot controlled neuronavigated rTMS can solve those issues.It is indeed more expensive and time consuming but has advantages over neurosurgery. I really look forward to clinical outcome studies (will be presented in France at the beaune Neuromeeting in jan 2009 by groups from Ulm and Paris. Especially in therapy resistent depression. Let’s hope the outcome of what I call “augmented” rTMS is more inspiring !
    Will keep You posted

    Dr. G. Otte

  6. Georges Otte on December 27th, 2008 at 6:08 pm
  7. The hammer on the nail. rTMS is mainly in a premature phase. It is still to be defined in the sense of localization, frequency and apparatus parameters. The only problem is indeed that most positive results are from one research group. To my opinion good research still has to be done. Placebo controlled that is, very interested in the neuromeeting, link?
    Kind regards Dr Shock

  8. Dr Shock on December 27th, 2008 at 8:40 pm
  9. Look at ANT website.

    georges

  10. Georges Otte on December 27th, 2008 at 11:27 pm
  11. Sorry, forgot the correct link.

    http://www.ant-neuro.com/events/neuromeeting2009/

    Greetz

    Georges

  12. Georges Otte on December 28th, 2008 at 10:16 pm
  13. Thanks :0

  14. Dr Shock on December 28th, 2008 at 10:57 pm
  15. I’m very interested in rTMS since I’ve been unable to get into a clinical trial for DBS for over three years. I had an amazing experience while receiving an MRI of my brain, and apparently TMS is based off of what people, like me, have experienced and others have observed of our affect.

    One specific portion while the machine turned on provided relief. The contrast/brightness of my vision was noticeably improved, and I was thinking very oddly, which turned out to be clear thinking which I had forgotten the feeling of. I was able to do math in my head much more quickly and I had a general feeling of content and happiness. The happiness I felt what I can only imagine I used to feel like before my depression got so awful, or possibly how I should be feeling all of the time and that I’ve never truly felt happy in my life.

    When that portion was over, everything went away very quickly and I was excited for the next scanning portion to begin so that I could feel it again. The succeeding portions did offer any of the same feelings or effects, and I was asking the technician to put me back in and he said nobody had ever felt that way about the MRI machine before. I researched and found that I wasn’t the only one who had a relieving experience while having an MRI scan performed. I’m betting that it’s only applicable to a select few people with a specific problem, or possibly only for those who truly have depression, as I’ve read research that the majority of people diagnosed with depression just have chronic stress; additionally, I read an article about how the placebo effect is becoming more and more effective, furthering the suspicion that the majority of people don’t necessarily have depression, by definition. I certainly wasn’t susceptible to the placebo effect with my MRI scan since I went in to be checked for tumors and possible pressure on my frontal lobe; my sensations initiated and stopped as the machine became active and then deactivated and did not return, as hoped, in succeeding rounds of the scan intervals.

    There’s a good chance that people in the control groups are not very aware of themselves–I have an oddly powerful sense of proprioception, know my body very well, and astounded the neuropsychologist with my motorfunctions. There’s also the chance that they aren’t positioning the magnets for TMS in the proper position, orientation, or with the proper calibration. I would love to be part of ongoing research since I’m articulate and can describe my symptoms and sensations with abundant information and provide accompanying hypotheses to physicians so that they can better understand the problem. I think I could fine-tune the location, orientation, and calibration of TMS systems if given the opportunity–”0.5mm to the left…3mm lower…adjust yaw 5 degrees counter-clockwise…decrease power output…increase frequency”, etc. I think it has great potential for a niche of people since not everyone is physiologically the same: like extra ribs, extra chromosomes, missing finger/toe, and so on. As it turns out, I suffer from undocumented side-effects from abundant medications I’ve tried, and am often told “no, that’s not from the medication”…then a few years later, my symptoms become documented as a known side-effect of the medication when all the while I was told “no, you’re wrong because the documentation doesn’t agree with you”.

    It’s unfortunate that I’m not given opportunities to offer my services (beyond a mere clinical trial of “yes/no”) in exchange for some worthwhile treatment. I can be contacted by yahoo mail under my posted name if any researchers are willing to include me in their projects for some in-depth discussion of hypotheses and some stringent and exhaustive trials. I’ll sign all waivers if it means getting an improved version of TMS treatment and furthering the research, guided by my feedback.

  16. Jon8RFC on December 28th, 2009 at 10:20 am
  17. In my own opinion I can say that rTMS is somehow effective in depression in some ways , maybe at least lessens it a bit. .

  18. Gail Holst on July 14th, 2011 at 4:05 pm
  1. [...] blog a lot of posts are about rapid Transcranial Magnetic Stimulation (rTMS), in short Dr Shock is not convinced that rTMS is effective in depression. On Therapeutic Modulation there is an abstract of a recent published study in the Journal of [...]

  2. Cost effectiveness of ECT versus rTMS | Dr Shock MD PhD on July 18th, 2008 at 6:56 am
  3. [...] all the posts about neurostimulation the most popular is about TMS not being effective in depression treatment. It is a extensive review kind of post, the core being a placebo controlled trial comparing TMS [...]

  4. Dr Shock’s popular posts from 2008 and a look ahead for 2009. | Dr Shock MD PhD on December 27th, 2008 at 6:58 am
  5. hello Dr Schock,

    Thanks for Your marvelous blog. I enjoy it very much. As an EBM afficionado I think it is good to be critical on the efficacy of new neurostimulating procedures be it rTMS, cTMS or even more general “new” therapeutic hype such as neurofeedback. We do not want to invest in expensive machinery when it offers nothing more then a mere placebo effect but, on the other hand, therapy rsistent depression being a very serious problem, we would not want to dispatch prematurely people to last resort very expensive interventionist neurosurgical procedures such as NVS and especially DBS treatment if rTMS (or ECT) could eventually in some form be beneficial after all.

    What has always struck me on rTMS is the disparity in reported results. Some centers claim “wonderfull” effects (Pascuall-Leone , Boston) while others overtly find the results less then clinically impressive.

    Could it be that rTMS has become to broad an umbrella and that the new procedures differ to much to be compared with vintage rTMS ? For instance: in most rTMS devices the motor point (hot spot) is looked for and then the coil is advanced 5 cm in a parasagittal plane in order to stimulate BA 46 and 9 (DLPFC). Neuronavigation methods however (on patient NMR mapped referenced landmarks) showed that in 22 testcases this procedure only directed the coil on correct target (DLPFC) in only 7 (30%). Thus 70% received rTMS but in what is supposed to be “off target” cortical networks . That is a substantial difference and could jeopardise the clinical outcome. Maybe we should postpone our judgements until results from neuronavigated rTMS (RCT like) are available. Also a slight twist of the wrist holding the coil can put it off target (subdural or even on bone ..). Seeing neuronavigated rTMS at work has given me more insight in the technical problems that rTMS has to deal with. In older people or people with slifgt corticosubcortical atrophy it is very easy to be off traget alltogether. Robot controlled neuronavigated rTMS can solve those issues.It is indeed more expensive and time consuming but has advantages over neurosurgery. I really look forward to clinical outcome studies (will be presented in France at the beaune Neuromeeting in jan 2009 by groups from Ulm and Paris. Especially in therapy resistent depression. Let’s hope the outcome of what I call “augmented” rTMS is more inspiring !
    Will keep You posted

    Dr. G. Otte

  6. Georges Otte on December 27th, 2008 at 6:08 pm
  7. The hammer on the nail. rTMS is mainly in a premature phase. It is still to be defined in the sense of localization, frequency and apparatus parameters. The only problem is indeed that most positive results are from one research group. To my opinion good research still has to be done. Placebo controlled that is, very interested in the neuromeeting, link?
    Kind regards Dr Shock

  8. Dr Shock on December 27th, 2008 at 8:40 pm
  9. Look at ANT website.

    georges

  10. Georges Otte on December 27th, 2008 at 11:27 pm
  11. Sorry, forgot the correct link.

    http://www.ant-neuro.com/events/neuromeeting2009/

    Greetz

    Georges

  12. Georges Otte on December 28th, 2008 at 10:16 pm
  13. Thanks :0

  14. Dr Shock on December 28th, 2008 at 10:57 pm
  15. I’m very interested in rTMS since I’ve been unable to get into a clinical trial for DBS for over three years. I had an amazing experience while receiving an MRI of my brain, and apparently TMS is based off of what people, like me, have experienced and others have observed of our affect.

    One specific portion while the machine turned on provided relief. The contrast/brightness of my vision was noticeably improved, and I was thinking very oddly, which turned out to be clear thinking which I had forgotten the feeling of. I was able to do math in my head much more quickly and I had a general feeling of content and happiness. The happiness I felt what I can only imagine I used to feel like before my depression got so awful, or possibly how I should be feeling all of the time and that I’ve never truly felt happy in my life.

    When that portion was over, everything went away very quickly and I was excited for the next scanning portion to begin so that I could feel it again. The succeeding portions did offer any of the same feelings or effects, and I was asking the technician to put me back in and he said nobody had ever felt that way about the MRI machine before. I researched and found that I wasn’t the only one who had a relieving experience while having an MRI scan performed. I’m betting that it’s only applicable to a select few people with a specific problem, or possibly only for those who truly have depression, as I’ve read research that the majority of people diagnosed with depression just have chronic stress; additionally, I read an article about how the placebo effect is becoming more and more effective, furthering the suspicion that the majority of people don’t necessarily have depression, by definition. I certainly wasn’t susceptible to the placebo effect with my MRI scan since I went in to be checked for tumors and possible pressure on my frontal lobe; my sensations initiated and stopped as the machine became active and then deactivated and did not return, as hoped, in succeeding rounds of the scan intervals.

    There’s a good chance that people in the control groups are not very aware of themselves–I have an oddly powerful sense of proprioception, know my body very well, and astounded the neuropsychologist with my motorfunctions. There’s also the chance that they aren’t positioning the magnets for TMS in the proper position, orientation, or with the proper calibration. I would love to be part of ongoing research since I’m articulate and can describe my symptoms and sensations with abundant information and provide accompanying hypotheses to physicians so that they can better understand the problem. I think I could fine-tune the location, orientation, and calibration of TMS systems if given the opportunity–”0.5mm to the left…3mm lower…adjust yaw 5 degrees counter-clockwise…decrease power output…increase frequency”, etc. I think it has great potential for a niche of people since not everyone is physiologically the same: like extra ribs, extra chromosomes, missing finger/toe, and so on. As it turns out, I suffer from undocumented side-effects from abundant medications I’ve tried, and am often told “no, that’s not from the medication”…then a few years later, my symptoms become documented as a known side-effect of the medication when all the while I was told “no, you’re wrong because the documentation doesn’t agree with you”.

    It’s unfortunate that I’m not given opportunities to offer my services (beyond a mere clinical trial of “yes/no”) in exchange for some worthwhile treatment. I can be contacted by yahoo mail under my posted name if any researchers are willing to include me in their projects for some in-depth discussion of hypotheses and some stringent and exhaustive trials. I’ll sign all waivers if it means getting an improved version of TMS treatment and furthering the research, guided by my feedback.

  16. Jon8RFC on December 28th, 2009 at 10:20 am
  17. In my own opinion I can say that rTMS is somehow effective in depression in some ways , maybe at least lessens it a bit. .

  18. Gail Holst on July 14th, 2011 at 4:05 pm
  1. [...] blog a lot of posts are about rapid Transcranial Magnetic Stimulation (rTMS), in short Dr Shock is not convinced that rTMS is effective in depression. On Therapeutic Modulation there is an abstract of a recent published study in the Journal of [...]

  2. Cost effectiveness of ECT versus rTMS | Dr Shock MD PhD on July 18th, 2008 at 6:56 am
  3. [...] all the posts about neurostimulation the most popular is about TMS not being effective in depression treatment. It is a extensive review kind of post, the core being a placebo controlled trial comparing TMS [...]

  4. Dr Shock’s popular posts from 2008 and a look ahead for 2009. | Dr Shock MD PhD on December 27th, 2008 at 6:58 am
  5. hello Dr Schock,

    Thanks for Your marvelous blog. I enjoy it very much. As an EBM afficionado I think it is good to be critical on the efficacy of new neurostimulating procedures be it rTMS, cTMS or even more general “new” therapeutic hype such as neurofeedback. We do not want to invest in expensive machinery when it offers nothing more then a mere placebo effect but, on the other hand, therapy rsistent depression being a very serious problem, we would not want to dispatch prematurely people to last resort very expensive interventionist neurosurgical procedures such as NVS and especially DBS treatment if rTMS (or ECT) could eventually in some form be beneficial after all.

    What has always struck me on rTMS is the disparity in reported results. Some centers claim “wonderfull” effects (Pascuall-Leone , Boston) while others overtly find the results less then clinically impressive.

    Could it be that rTMS has become to broad an umbrella and that the new procedures differ to much to be compared with vintage rTMS ? For instance: in most rTMS devices the motor point (hot spot) is looked for and then the coil is advanced 5 cm in a parasagittal plane in order to stimulate BA 46 and 9 (DLPFC). Neuronavigation methods however (on patient NMR mapped referenced landmarks) showed that in 22 testcases this procedure only directed the coil on correct target (DLPFC) in only 7 (30%). Thus 70% received rTMS but in what is supposed to be “off target” cortical networks . That is a substantial difference and could jeopardise the clinical outcome. Maybe we should postpone our judgements until results from neuronavigated rTMS (RCT like) are available. Also a slight twist of the wrist holding the coil can put it off target (subdural or even on bone ..). Seeing neuronavigated rTMS at work has given me more insight in the technical problems that rTMS has to deal with. In older people or people with slifgt corticosubcortical atrophy it is very easy to be off traget alltogether. Robot controlled neuronavigated rTMS can solve those issues.It is indeed more expensive and time consuming but has advantages over neurosurgery. I really look forward to clinical outcome studies (will be presented in France at the beaune Neuromeeting in jan 2009 by groups from Ulm and Paris. Especially in therapy resistent depression. Let’s hope the outcome of what I call “augmented” rTMS is more inspiring !
    Will keep You posted

    Dr. G. Otte

  6. Georges Otte on December 27th, 2008 at 6:08 pm
  7. The hammer on the nail. rTMS is mainly in a premature phase. It is still to be defined in the sense of localization, frequency and apparatus parameters. The only problem is indeed that most positive results are from one research group. To my opinion good research still has to be done. Placebo controlled that is, very interested in the neuromeeting, link?
    Kind regards Dr Shock

  8. Dr Shock on December 27th, 2008 at 8:40 pm
  9. Look at ANT website.

    georges

  10. Georges Otte on December 27th, 2008 at 11:27 pm
  11. Sorry, forgot the correct link.

    http://www.ant-neuro.com/events/neuromeeting2009/

    Greetz

    Georges

  12. Georges Otte on December 28th, 2008 at 10:16 pm
  13. Thanks :0

  14. Dr Shock on December 28th, 2008 at 10:57 pm
  15. I’m very interested in rTMS since I’ve been unable to get into a clinical trial for DBS for over three years. I had an amazing experience while receiving an MRI of my brain, and apparently TMS is based off of what people, like me, have experienced and others have observed of our affect.

    One specific portion while the machine turned on provided relief. The contrast/brightness of my vision was noticeably improved, and I was thinking very oddly, which turned out to be clear thinking which I had forgotten the feeling of. I was able to do math in my head much more quickly and I had a general feeling of content and happiness. The happiness I felt what I can only imagine I used to feel like before my depression got so awful, or possibly how I should be feeling all of the time and that I’ve never truly felt happy in my life.

    When that portion was over, everything went away very quickly and I was excited for the next scanning portion to begin so that I could feel it again. The succeeding portions did offer any of the same feelings or effects, and I was asking the technician to put me back in and he said nobody had ever felt that way about the MRI machine before. I researched and found that I wasn’t the only one who had a relieving experience while having an MRI scan performed. I’m betting that it’s only applicable to a select few people with a specific problem, or possibly only for those who truly have depression, as I’ve read research that the majority of people diagnosed with depression just have chronic stress; additionally, I read an article about how the placebo effect is becoming more and more effective, furthering the suspicion that the majority of people don’t necessarily have depression, by definition. I certainly wasn’t susceptible to the placebo effect with my MRI scan since I went in to be checked for tumors and possible pressure on my frontal lobe; my sensations initiated and stopped as the machine became active and then deactivated and did not return, as hoped, in succeeding rounds of the scan intervals.

    There’s a good chance that people in the control groups are not very aware of themselves–I have an oddly powerful sense of proprioception, know my body very well, and astounded the neuropsychologist with my motorfunctions. There’s also the chance that they aren’t positioning the magnets for TMS in the proper position, orientation, or with the proper calibration. I would love to be part of ongoing research since I’m articulate and can describe my symptoms and sensations with abundant information and provide accompanying hypotheses to physicians so that they can better understand the problem. I think I could fine-tune the location, orientation, and calibration of TMS systems if given the opportunity–”0.5mm to the left…3mm lower…adjust yaw 5 degrees counter-clockwise…decrease power output…increase frequency”, etc. I think it has great potential for a niche of people since not everyone is physiologically the same: like extra ribs, extra chromosomes, missing finger/toe, and so on. As it turns out, I suffer from undocumented side-effects from abundant medications I’ve tried, and am often told “no, that’s not from the medication”…then a few years later, my symptoms become documented as a known side-effect of the medication when all the while I was told “no, you’re wrong because the documentation doesn’t agree with you”.

    It’s unfortunate that I’m not given opportunities to offer my services (beyond a mere clinical trial of “yes/no”) in exchange for some worthwhile treatment. I can be contacted by yahoo mail under my posted name if any researchers are willing to include me in their projects for some in-depth discussion of hypotheses and some stringent and exhaustive trials. I’ll sign all waivers if it means getting an improved version of TMS treatment and furthering the research, guided by my feedback.

  16. Jon8RFC on December 28th, 2009 at 10:20 am
  17. In my own opinion I can say that rTMS is somehow effective in depression in some ways , maybe at least lessens it a bit. .

  18. Gail Holst on July 14th, 2011 at 4:05 pm
  1. [...] blog a lot of posts are about rapid Transcranial Magnetic Stimulation (rTMS), in short Dr Shock is not convinced that rTMS is effective in depression. On Therapeutic Modulation there is an abstract of a recent published study in the Journal of [...]

  2. Cost effectiveness of ECT versus rTMS | Dr Shock MD PhD on July 18th, 2008 at 6:56 am
  3. [...] all the posts about neurostimulation the most popular is about TMS not being effective in depression treatment. It is a extensive review kind of post, the core being a placebo controlled trial comparing TMS [...]

  4. Dr Shock’s popular posts from 2008 and a look ahead for 2009. | Dr Shock MD PhD on December 27th, 2008 at 6:58 am
  5. hello Dr Schock,

    Thanks for Your marvelous blog. I enjoy it very much. As an EBM afficionado I think it is good to be critical on the efficacy of new neurostimulating procedures be it rTMS, cTMS or even more general “new” therapeutic hype such as neurofeedback. We do not want to invest in expensive machinery when it offers nothing more then a mere placebo effect but, on the other hand, therapy rsistent depression being a very serious problem, we would not want to dispatch prematurely people to last resort very expensive interventionist neurosurgical procedures such as NVS and especially DBS treatment if rTMS (or ECT) could eventually in some form be beneficial after all.

    What has always struck me on rTMS is the disparity in reported results. Some centers claim “wonderfull” effects (Pascuall-Leone , Boston) while others overtly find the results less then clinically impressive.

    Could it be that rTMS has become to broad an umbrella and that the new procedures differ to much to be compared with vintage rTMS ? For instance: in most rTMS devices the motor point (hot spot) is looked for and then the coil is advanced 5 cm in a parasagittal plane in order to stimulate BA 46 and 9 (DLPFC). Neuronavigation methods however (on patient NMR mapped referenced landmarks) showed that in 22 testcases this procedure only directed the coil on correct target (DLPFC) in only 7 (30%). Thus 70% received rTMS but in what is supposed to be “off target” cortical networks . That is a substantial difference and could jeopardise the clinical outcome. Maybe we should postpone our judgements until results from neuronavigated rTMS (RCT like) are available. Also a slight twist of the wrist holding the coil can put it off target (subdural or even on bone ..). Seeing neuronavigated rTMS at work has given me more insight in the technical problems that rTMS has to deal with. In older people or people with slifgt corticosubcortical atrophy it is very easy to be off traget alltogether. Robot controlled neuronavigated rTMS can solve those issues.It is indeed more expensive and time consuming but has advantages over neurosurgery. I really look forward to clinical outcome studies (will be presented in France at the beaune Neuromeeting in jan 2009 by groups from Ulm and Paris. Especially in therapy resistent depression. Let’s hope the outcome of what I call “augmented” rTMS is more inspiring !
    Will keep You posted

    Dr. G. Otte

  6. Georges Otte on December 27th, 2008 at 6:08 pm
  7. The hammer on the nail. rTMS is mainly in a premature phase. It is still to be defined in the sense of localization, frequency and apparatus parameters. The only problem is indeed that most positive results are from one research group. To my opinion good research still has to be done. Placebo controlled that is, very interested in the neuromeeting, link?
    Kind regards Dr Shock

  8. Dr Shock on December 27th, 2008 at 8:40 pm
  9. Look at ANT website.

    georges

  10. Georges Otte on December 27th, 2008 at 11:27 pm
  11. Sorry, forgot the correct link.

    http://www.ant-neuro.com/events/neuromeeting2009/

    Greetz

    Georges

  12. Georges Otte on December 28th, 2008 at 10:16 pm
  13. Thanks :0

  14. Dr Shock on December 28th, 2008 at 10:57 pm
  15. I’m very interested in rTMS since I’ve been unable to get into a clinical trial for DBS for over three years. I had an amazing experience while receiving an MRI of my brain, and apparently TMS is based off of what people, like me, have experienced and others have observed of our affect.

    One specific portion while the machine turned on provided relief. The contrast/brightness of my vision was noticeably improved, and I was thinking very oddly, which turned out to be clear thinking which I had forgotten the feeling of. I was able to do math in my head much more quickly and I had a general feeling of content and happiness. The happiness I felt what I can only imagine I used to feel like before my depression got so awful, or possibly how I should be feeling all of the time and that I’ve never truly felt happy in my life.

    When that portion was over, everything went away very quickly and I was excited for the next scanning portion to begin so that I could feel it again. The succeeding portions did offer any of the same feelings or effects, and I was asking the technician to put me back in and he said nobody had ever felt that way about the MRI machine before. I researched and found that I wasn’t the only one who had a relieving experience while having an MRI scan performed. I’m betting that it’s only applicable to a select few people with a specific problem, or possibly only for those who truly have depression, as I’ve read research that the majority of people diagnosed with depression just have chronic stress; additionally, I read an article about how the placebo effect is becoming more and more effective, furthering the suspicion that the majority of people don’t necessarily have depression, by definition. I certainly wasn’t susceptible to the placebo effect with my MRI scan since I went in to be checked for tumors and possible pressure on my frontal lobe; my sensations initiated and stopped as the machine became active and then deactivated and did not return, as hoped, in succeeding rounds of the scan intervals.

    There’s a good chance that people in the control groups are not very aware of themselves–I have an oddly powerful sense of proprioception, know my body very well, and astounded the neuropsychologist with my motorfunctions. There’s also the chance that they aren’t positioning the magnets for TMS in the proper position, orientation, or with the proper calibration. I would love to be part of ongoing research since I’m articulate and can describe my symptoms and sensations with abundant information and provide accompanying hypotheses to physicians so that they can better understand the problem. I think I could fine-tune the location, orientation, and calibration of TMS systems if given the opportunity–”0.5mm to the left…3mm lower…adjust yaw 5 degrees counter-clockwise…decrease power output…increase frequency”, etc. I think it has great potential for a niche of people since not everyone is physiologically the same: like extra ribs, extra chromosomes, missing finger/toe, and so on. As it turns out, I suffer from undocumented side-effects from abundant medications I’ve tried, and am often told “no, that’s not from the medication”…then a few years later, my symptoms become documented as a known side-effect of the medication when all the while I was told “no, you’re wrong because the documentation doesn’t agree with you”.

    It’s unfortunate that I’m not given opportunities to offer my services (beyond a mere clinical trial of “yes/no”) in exchange for some worthwhile treatment. I can be contacted by yahoo mail under my posted name if any researchers are willing to include me in their projects for some in-depth discussion of hypotheses and some stringent and exhaustive trials. I’ll sign all waivers if it means getting an improved version of TMS treatment and furthering the research, guided by my feedback.

  16. Jon8RFC on December 28th, 2009 at 10:20 am
  17. In my own opinion I can say that rTMS is somehow effective in depression in some ways , maybe at least lessens it a bit. .

  18. Gail Holst on July 14th, 2011 at 4:05 pm
  1. [...] blog a lot of posts are about rapid Transcranial Magnetic Stimulation (rTMS), in short Dr Shock is not convinced that rTMS is effective in depression. On Therapeutic Modulation there is an abstract of a recent published study in the Journal of [...]

  2. Cost effectiveness of ECT versus rTMS | Dr Shock MD PhD on July 18th, 2008 at 6:56 am
  3. [...] all the posts about neurostimulation the most popular is about TMS not being effective in depression treatment. It is a extensive review kind of post, the core being a placebo controlled trial comparing TMS [...]

  4. Dr Shock’s popular posts from 2008 and a look ahead for 2009. | Dr Shock MD PhD on December 27th, 2008 at 6:58 am
  5. hello Dr Schock,

    Thanks for Your marvelous blog. I enjoy it very much. As an EBM afficionado I think it is good to be critical on the efficacy of new neurostimulating procedures be it rTMS, cTMS or even more general “new” therapeutic hype such as neurofeedback. We do not want to invest in expensive machinery when it offers nothing more then a mere placebo effect but, on the other hand, therapy rsistent depression being a very serious problem, we would not want to dispatch prematurely people to last resort very expensive interventionist neurosurgical procedures such as NVS and especially DBS treatment if rTMS (or ECT) could eventually in some form be beneficial after all.

    What has always struck me on rTMS is the disparity in reported results. Some centers claim “wonderfull” effects (Pascuall-Leone , Boston) while others overtly find the results less then clinically impressive.

    Could it be that rTMS has become to broad an umbrella and that the new procedures differ to much to be compared with vintage rTMS ? For instance: in most rTMS devices the motor point (hot spot) is looked for and then the coil is advanced 5 cm in a parasagittal plane in order to stimulate BA 46 and 9 (DLPFC). Neuronavigation methods however (on patient NMR mapped referenced landmarks) showed that in 22 testcases this procedure only directed the coil on correct target (DLPFC) in only 7 (30%). Thus 70% received rTMS but in what is supposed to be “off target” cortical networks . That is a substantial difference and could jeopardise the clinical outcome. Maybe we should postpone our judgements until results from neuronavigated rTMS (RCT like) are available. Also a slight twist of the wrist holding the coil can put it off target (subdural or even on bone ..). Seeing neuronavigated rTMS at work has given me more insight in the technical problems that rTMS has to deal with. In older people or people with slifgt corticosubcortical atrophy it is very easy to be off traget alltogether. Robot controlled neuronavigated rTMS can solve those issues.It is indeed more expensive and time consuming but has advantages over neurosurgery. I really look forward to clinical outcome studies (will be presented in France at the beaune Neuromeeting in jan 2009 by groups from Ulm and Paris. Especially in therapy resistent depression. Let’s hope the outcome of what I call “augmented” rTMS is more inspiring !
    Will keep You posted

    Dr. G. Otte

  6. Georges Otte on December 27th, 2008 at 6:08 pm
  7. The hammer on the nail. rTMS is mainly in a premature phase. It is still to be defined in the sense of localization, frequency and apparatus parameters. The only problem is indeed that most positive results are from one research group. To my opinion good research still has to be done. Placebo controlled that is, very interested in the neuromeeting, link?
    Kind regards Dr Shock

  8. Dr Shock on December 27th, 2008 at 8:40 pm
  9. Look at ANT website.

    georges

  10. Georges Otte on December 27th, 2008 at 11:27 pm
  11. Sorry, forgot the correct link.

    http://www.ant-neuro.com/events/neuromeeting2009/

    Greetz

    Georges

  12. Georges Otte on December 28th, 2008 at 10:16 pm
  13. Thanks :0

  14. Dr Shock on December 28th, 2008 at 10:57 pm
  15. I’m very interested in rTMS since I’ve been unable to get into a clinical trial for DBS for over three years. I had an amazing experience while receiving an MRI of my brain, and apparently TMS is based off of what people, like me, have experienced and others have observed of our affect.

    One specific portion while the machine turned on provided relief. The contrast/brightness of my vision was noticeably improved, and I was thinking very oddly, which turned out to be clear thinking which I had forgotten the feeling of. I was able to do math in my head much more quickly and I had a general feeling of content and happiness. The happiness I felt what I can only imagine I used to feel like before my depression got so awful, or possibly how I should be feeling all of the time and that I’ve never truly felt happy in my life.

    When that portion was over, everything went away very quickly and I was excited for the next scanning portion to begin so that I could feel it again. The succeeding portions did offer any of the same feelings or effects, and I was asking the technician to put me back in and he said nobody had ever felt that way about the MRI machine before. I researched and found that I wasn’t the only one who had a relieving experience while having an MRI scan performed. I’m betting that it’s only applicable to a select few people with a specific problem, or possibly only for those who truly have depression, as I’ve read research that the majority of people diagnosed with depression just have chronic stress; additionally, I read an article about how the placebo effect is becoming more and more effective, furthering the suspicion that the majority of people don’t necessarily have depression, by definition. I certainly wasn’t susceptible to the placebo effect with my MRI scan since I went in to be checked for tumors and possible pressure on my frontal lobe; my sensations initiated and stopped as the machine became active and then deactivated and did not return, as hoped, in succeeding rounds of the scan intervals.

    There’s a good chance that people in the control groups are not very aware of themselves–I have an oddly powerful sense of proprioception, know my body very well, and astounded the neuropsychologist with my motorfunctions. There’s also the chance that they aren’t positioning the magnets for TMS in the proper position, orientation, or with the proper calibration. I would love to be part of ongoing research since I’m articulate and can describe my symptoms and sensations with abundant information and provide accompanying hypotheses to physicians so that they can better understand the problem. I think I could fine-tune the location, orientation, and calibration of TMS systems if given the opportunity–”0.5mm to the left…3mm lower…adjust yaw 5 degrees counter-clockwise…decrease power output…increase frequency”, etc. I think it has great potential for a niche of people since not everyone is physiologically the same: like extra ribs, extra chromosomes, missing finger/toe, and so on. As it turns out, I suffer from undocumented side-effects from abundant medications I’ve tried, and am often told “no, that’s not from the medication”…then a few years later, my symptoms become documented as a known side-effect of the medication when all the while I was told “no, you’re wrong because the documentation doesn’t agree with you”.

    It’s unfortunate that I’m not given opportunities to offer my services (beyond a mere clinical trial of “yes/no”) in exchange for some worthwhile treatment. I can be contacted by yahoo mail under my posted name if any researchers are willing to include me in their projects for some in-depth discussion of hypotheses and some stringent and exhaustive trials. I’ll sign all waivers if it means getting an improved version of TMS treatment and furthering the research, guided by my feedback.

  16. Jon8RFC on December 28th, 2009 at 10:20 am
  17. In my own opinion I can say that rTMS is somehow effective in depression in some ways , maybe at least lessens it a bit. .

  18. Gail Holst on July 14th, 2011 at 4:05 pm
  1. [...] blog a lot of posts are about rapid Transcranial Magnetic Stimulation (rTMS), in short Dr Shock is not convinced that rTMS is effective in depression. On Therapeutic Modulation there is an abstract of a recent published study in the Journal of [...]

  2. Cost effectiveness of ECT versus rTMS | Dr Shock MD PhD on July 18th, 2008 at 6:56 am
  3. [...] all the posts about neurostimulation the most popular is about TMS not being effective in depression treatment. It is a extensive review kind of post, the core being a placebo controlled trial comparing TMS [...]

  4. Dr Shock’s popular posts from 2008 and a look ahead for 2009. | Dr Shock MD PhD on December 27th, 2008 at 6:58 am
  5. hello Dr Schock,

    Thanks for Your marvelous blog. I enjoy it very much. As an EBM afficionado I think it is good to be critical on the efficacy of new neurostimulating procedures be it rTMS, cTMS or even more general “new” therapeutic hype such as neurofeedback. We do not want to invest in expensive machinery when it offers nothing more then a mere placebo effect but, on the other hand, therapy rsistent depression being a very serious problem, we would not want to dispatch prematurely people to last resort very expensive interventionist neurosurgical procedures such as NVS and especially DBS treatment if rTMS (or ECT) could eventually in some form be beneficial after all.

    What has always struck me on rTMS is the disparity in reported results. Some centers claim “wonderfull” effects (Pascuall-Leone , Boston) while others overtly find the results less then clinically impressive.

    Could it be that rTMS has become to broad an umbrella and that the new procedures differ to much to be compared with vintage rTMS ? For instance: in most rTMS devices the motor point (hot spot) is looked for and then the coil is advanced 5 cm in a parasagittal plane in order to stimulate BA 46 and 9 (DLPFC). Neuronavigation methods however (on patient NMR mapped referenced landmarks) showed that in 22 testcases this procedure only directed the coil on correct target (DLPFC) in only 7 (30%). Thus 70% received rTMS but in what is supposed to be “off target” cortical networks . That is a substantial difference and could jeopardise the clinical outcome. Maybe we should postpone our judgements until results from neuronavigated rTMS (RCT like) are available. Also a slight twist of the wrist holding the coil can put it off target (subdural or even on bone ..). Seeing neuronavigated rTMS at work has given me more insight in the technical problems that rTMS has to deal with. In older people or people with slifgt corticosubcortical atrophy it is very easy to be off traget alltogether. Robot controlled neuronavigated rTMS can solve those issues.It is indeed more expensive and time consuming but has advantages over neurosurgery. I really look forward to clinical outcome studies (will be presented in France at the beaune Neuromeeting in jan 2009 by groups from Ulm and Paris. Especially in therapy resistent depression. Let’s hope the outcome of what I call “augmented” rTMS is more inspiring !
    Will keep You posted

    Dr. G. Otte

  6. Georges Otte on December 27th, 2008 at 6:08 pm
  7. The hammer on the nail. rTMS is mainly in a premature phase. It is still to be defined in the sense of localization, frequency and apparatus parameters. The only problem is indeed that most positive results are from one research group. To my opinion good research still has to be done. Placebo controlled that is, very interested in the neuromeeting, link?
    Kind regards Dr Shock

  8. Dr Shock on December 27th, 2008 at 8:40 pm
  9. Look at ANT website.

    georges

  10. Georges Otte on December 27th, 2008 at 11:27 pm
  11. Sorry, forgot the correct link.

    http://www.ant-neuro.com/events/neuromeeting2009/

    Greetz

    Georges

  12. Georges Otte on December 28th, 2008 at 10:16 pm
  13. Thanks :0

  14. Dr Shock on December 28th, 2008 at 10:57 pm
  15. I’m very interested in rTMS since I’ve been unable to get into a clinical trial for DBS for over three years. I had an amazing experience while receiving an MRI of my brain, and apparently TMS is based off of what people, like me, have experienced and others have observed of our affect.

    One specific portion while the machine turned on provided relief. The contrast/brightness of my vision was noticeably improved, and I was thinking very oddly, which turned out to be clear thinking which I had forgotten the feeling of. I was able to do math in my head much more quickly and I had a general feeling of content and happiness. The happiness I felt what I can only imagine I used to feel like before my depression got so awful, or possibly how I should be feeling all of the time and that I’ve never truly felt happy in my life.

    When that portion was over, everything went away very quickly and I was excited for the next scanning portion to begin so that I could feel it again. The succeeding portions did offer any of the same feelings or effects, and I was asking the technician to put me back in and he said nobody had ever felt that way about the MRI machine before. I researched and found that I wasn’t the only one who had a relieving experience while having an MRI scan performed. I’m betting that it’s only applicable to a select few people with a specific problem, or possibly only for those who truly have depression, as I’ve read research that the majority of people diagnosed with depression just have chronic stress; additionally, I read an article about how the placebo effect is becoming more and more effective, furthering the suspicion that the majority of people don’t necessarily have depression, by definition. I certainly wasn’t susceptible to the placebo effect with my MRI scan since I went in to be checked for tumors and possible pressure on my frontal lobe; my sensations initiated and stopped as the machine became active and then deactivated and did not return, as hoped, in succeeding rounds of the scan intervals.

    There’s a good chance that people in the control groups are not very aware of themselves–I have an oddly powerful sense of proprioception, know my body very well, and astounded the neuropsychologist with my motorfunctions. There’s also the chance that they aren’t positioning the magnets for TMS in the proper position, orientation, or with the proper calibration. I would love to be part of ongoing research since I’m articulate and can describe my symptoms and sensations with abundant information and provide accompanying hypotheses to physicians so that they can better understand the problem. I think I could fine-tune the location, orientation, and calibration of TMS systems if given the opportunity–”0.5mm to the left…3mm lower…adjust yaw 5 degrees counter-clockwise…decrease power output…increase frequency”, etc. I think it has great potential for a niche of people since not everyone is physiologically the same: like extra ribs, extra chromosomes, missing finger/toe, and so on. As it turns out, I suffer from undocumented side-effects from abundant medications I’ve tried, and am often told “no, that’s not from the medication”…then a few years later, my symptoms become documented as a known side-effect of the medication when all the while I was told “no, you’re wrong because the documentation doesn’t agree with you”.

    It’s unfortunate that I’m not given opportunities to offer my services (beyond a mere clinical trial of “yes/no”) in exchange for some worthwhile treatment. I can be contacted by yahoo mail under my posted name if any researchers are willing to include me in their projects for some in-depth discussion of hypotheses and some stringent and exhaustive trials. I’ll sign all waivers if it means getting an improved version of TMS treatment and furthering the research, guided by my feedback.

  16. Jon8RFC on December 28th, 2009 at 10:20 am
  17. In my own opinion I can say that rTMS is somehow effective in depression in some ways , maybe at least lessens it a bit. .

  18. Gail Holst on July 14th, 2011 at 4:05 pm
  1. [...] blog a lot of posts are about rapid Transcranial Magnetic Stimulation (rTMS), in short Dr Shock is not convinced that rTMS is effective in depression. On Therapeutic Modulation there is an abstract of a recent published study in the Journal of [...]

  2. Cost effectiveness of ECT versus rTMS | Dr Shock MD PhD on July 18th, 2008 at 6:56 am
  3. [...] all the posts about neurostimulation the most popular is about TMS not being effective in depression treatment. It is a extensive review kind of post, the core being a placebo controlled trial comparing TMS [...]

  4. Dr Shock’s popular posts from 2008 and a look ahead for 2009. | Dr Shock MD PhD on December 27th, 2008 at 6:58 am
  5. hello Dr Schock,

    Thanks for Your marvelous blog. I enjoy it very much. As an EBM afficionado I think it is good to be critical on the efficacy of new neurostimulating procedures be it rTMS, cTMS or even more general “new” therapeutic hype such as neurofeedback. We do not want to invest in expensive machinery when it offers nothing more then a mere placebo effect but, on the other hand, therapy rsistent depression being a very serious problem, we would not want to dispatch prematurely people to last resort very expensive interventionist neurosurgical procedures such as NVS and especially DBS treatment if rTMS (or ECT) could eventually in some form be beneficial after all.

    What has always struck me on rTMS is the disparity in reported results. Some centers claim “wonderfull” effects (Pascuall-Leone , Boston) while others overtly find the results less then clinically impressive.

    Could it be that rTMS has become to broad an umbrella and that the new procedures differ to much to be compared with vintage rTMS ? For instance: in most rTMS devices the motor point (hot spot) is looked for and then the coil is advanced 5 cm in a parasagittal plane in order to stimulate BA 46 and 9 (DLPFC). Neuronavigation methods however (on patient NMR mapped referenced landmarks) showed that in 22 testcases this procedure only directed the coil on correct target (DLPFC) in only 7 (30%). Thus 70% received rTMS but in what is supposed to be “off target” cortical networks . That is a substantial difference and could jeopardise the clinical outcome. Maybe we should postpone our judgements until results from neuronavigated rTMS (RCT like) are available. Also a slight twist of the wrist holding the coil can put it off target (subdural or even on bone ..). Seeing neuronavigated rTMS at work has given me more insight in the technical problems that rTMS has to deal with. In older people or people with slifgt corticosubcortical atrophy it is very easy to be off traget alltogether. Robot controlled neuronavigated rTMS can solve those issues.It is indeed more expensive and time consuming but has advantages over neurosurgery. I really look forward to clinical outcome studies (will be presented in France at the beaune Neuromeeting in jan 2009 by groups from Ulm and Paris. Especially in therapy resistent depression. Let’s hope the outcome of what I call “augmented” rTMS is more inspiring !
    Will keep You posted

    Dr. G. Otte

  6. Georges Otte on December 27th, 2008 at 6:08 pm
  7. The hammer on the nail. rTMS is mainly in a premature phase. It is still to be defined in the sense of localization, frequency and apparatus parameters. The only problem is indeed that most positive results are from one research group. To my opinion good research still has to be done. Placebo controlled that is, very interested in the neuromeeting, link?
    Kind regards Dr Shock

  8. Dr Shock on December 27th, 2008 at 8:40 pm
  9. Look at ANT website.

    georges

  10. Georges Otte on December 27th, 2008 at 11:27 pm
  11. Sorry, forgot the correct link.

    http://www.ant-neuro.com/events/neuromeeting2009/

    Greetz

    Georges

  12. Georges Otte on December 28th, 2008 at 10:16 pm
  13. Thanks :0

  14. Dr Shock on December 28th, 2008 at 10:57 pm
  15. I’m very interested in rTMS since I’ve been unable to get into a clinical trial for DBS for over three years. I had an amazing experience while receiving an MRI of my brain, and apparently TMS is based off of what people, like me, have experienced and others have observed of our affect.

    One specific portion while the machine turned on provided relief. The contrast/brightness of my vision was noticeably improved, and I was thinking very oddly, which turned out to be clear thinking which I had forgotten the feeling of. I was able to do math in my head much more quickly and I had a general feeling of content and happiness. The happiness I felt what I can only imagine I used to feel like before my depression got so awful, or possibly how I should be feeling all of the time and that I’ve never truly felt happy in my life.

    When that portion was over, everything went away very quickly and I was excited for the next scanning portion to begin so that I could feel it again. The succeeding portions did offer any of the same feelings or effects, and I was asking the technician to put me back in and he said nobody had ever felt that way about the MRI machine before. I researched and found that I wasn’t the only one who had a relieving experience while having an MRI scan performed. I’m betting that it’s only applicable to a select few people with a specific problem, or possibly only for those who truly have depression, as I’ve read research that the majority of people diagnosed with depression just have chronic stress; additionally, I read an article about how the placebo effect is becoming more and more effective, furthering the suspicion that the majority of people don’t necessarily have depression, by definition. I certainly wasn’t susceptible to the placebo effect with my MRI scan since I went in to be checked for tumors and possible pressure on my frontal lobe; my sensations initiated and stopped as the machine became active and then deactivated and did not return, as hoped, in succeeding rounds of the scan intervals.

    There’s a good chance that people in the control groups are not very aware of themselves–I have an oddly powerful sense of proprioception, know my body very well, and astounded the neuropsychologist with my motorfunctions. There’s also the chance that they aren’t positioning the magnets for TMS in the proper position, orientation, or with the proper calibration. I would love to be part of ongoing research since I’m articulate and can describe my symptoms and sensations with abundant information and provide accompanying hypotheses to physicians so that they can better understand the problem. I think I could fine-tune the location, orientation, and calibration of TMS systems if given the opportunity–”0.5mm to the left…3mm lower…adjust yaw 5 degrees counter-clockwise…decrease power output…increase frequency”, etc. I think it has great potential for a niche of people since not everyone is physiologically the same: like extra ribs, extra chromosomes, missing finger/toe, and so on. As it turns out, I suffer from undocumented side-effects from abundant medications I’ve tried, and am often told “no, that’s not from the medication”…then a few years later, my symptoms become documented as a known side-effect of the medication when all the while I was told “no, you’re wrong because the documentation doesn’t agree with you”.

    It’s unfortunate that I’m not given opportunities to offer my services (beyond a mere clinical trial of “yes/no”) in exchange for some worthwhile treatment. I can be contacted by yahoo mail under my posted name if any researchers are willing to include me in their projects for some in-depth discussion of hypotheses and some stringent and exhaustive trials. I’ll sign all waivers if it means getting an improved version of TMS treatment and furthering the research, guided by my feedback.

  16. Jon8RFC on December 28th, 2009 at 10:20 am
  17. In my own opinion I can say that rTMS is somehow effective in depression in some ways , maybe at least lessens it a bit. .

  18. Gail Holst on July 14th, 2011 at 4:05 pm
  1. [...] blog a lot of posts are about rapid Transcranial Magnetic Stimulation (rTMS), in short Dr Shock is not convinced that rTMS is effective in depression. On Therapeutic Modulation there is an abstract of a recent published study in the Journal of [...]

  2. Cost effectiveness of ECT versus rTMS | Dr Shock MD PhD on July 18th, 2008 at 6:56 am
  3. [...] all the posts about neurostimulation the most popular is about TMS not being effective in depression treatment. It is a extensive review kind of post, the core being a placebo controlled trial comparing TMS [...]

  4. Dr Shock’s popular posts from 2008 and a look ahead for 2009. | Dr Shock MD PhD on December 27th, 2008 at 6:58 am
  5. hello Dr Schock,

    Thanks for Your marvelous blog. I enjoy it very much. As an EBM afficionado I think it is good to be critical on the efficacy of new neurostimulating procedures be it rTMS, cTMS or even more general “new” therapeutic hype such as neurofeedback. We do not want to invest in expensive machinery when it offers nothing more then a mere placebo effect but, on the other hand, therapy rsistent depression being a very serious problem, we would not want to dispatch prematurely people to last resort very expensive interventionist neurosurgical procedures such as NVS and especially DBS treatment if rTMS (or ECT) could eventually in some form be beneficial after all.

    What has always struck me on rTMS is the disparity in reported results. Some centers claim “wonderfull” effects (Pascuall-Leone , Boston) while others overtly find the results less then clinically impressive.

    Could it be that rTMS has become to broad an umbrella and that the new procedures differ to much to be compared with vintage rTMS ? For instance: in most rTMS devices the motor point (hot spot) is looked for and then the coil is advanced 5 cm in a parasagittal plane in order to stimulate BA 46 and 9 (DLPFC). Neuronavigation methods however (on patient NMR mapped referenced landmarks) showed that in 22 testcases this procedure only directed the coil on correct target (DLPFC) in only 7 (30%). Thus 70% received rTMS but in what is supposed to be “off target” cortical networks . That is a substantial difference and could jeopardise the clinical outcome. Maybe we should postpone our judgements until results from neuronavigated rTMS (RCT like) are available. Also a slight twist of the wrist holding the coil can put it off target (subdural or even on bone ..). Seeing neuronavigated rTMS at work has given me more insight in the technical problems that rTMS has to deal with. In older people or people with slifgt corticosubcortical atrophy it is very easy to be off traget alltogether. Robot controlled neuronavigated rTMS can solve those issues.It is indeed more expensive and time consuming but has advantages over neurosurgery. I really look forward to clinical outcome studies (will be presented in France at the beaune Neuromeeting in jan 2009 by groups from Ulm and Paris. Especially in therapy resistent depression. Let’s hope the outcome of what I call “augmented” rTMS is more inspiring !
    Will keep You posted

    Dr. G. Otte

  6. Georges Otte on December 27th, 2008 at 6:08 pm
  7. The hammer on the nail. rTMS is mainly in a premature phase. It is still to be defined in the sense of localization, frequency and apparatus parameters. The only problem is indeed that most positive results are from one research group. To my opinion good research still has to be done. Placebo controlled that is, very interested in the neuromeeting, link?
    Kind regards Dr Shock

  8. Dr Shock on December 27th, 2008 at 8:40 pm
  9. Look at ANT website.

    georges

  10. Georges Otte on December 27th, 2008 at 11:27 pm
  11. Sorry, forgot the correct link.

    http://www.ant-neuro.com/events/neuromeeting2009/

    Greetz

    Georges

  12. Georges Otte on December 28th, 2008 at 10:16 pm
  13. Thanks :0

  14. Dr Shock on December 28th, 2008 at 10:57 pm
  15. I’m very interested in rTMS since I’ve been unable to get into a clinical trial for DBS for over three years. I had an amazing experience while receiving an MRI of my brain, and apparently TMS is based off of what people, like me, have experienced and others have observed of our affect.

    One specific portion while the machine turned on provided relief. The contrast/brightness of my vision was noticeably improved, and I was thinking very oddly, which turned out to be clear thinking which I had forgotten the feeling of. I was able to do math in my head much more quickly and I had a general feeling of content and happiness. The happiness I felt what I can only imagine I used to feel like before my depression got so awful, or possibly how I should be feeling all of the time and that I’ve never truly felt happy in my life.

    When that portion was over, everything went away very quickly and I was excited for the next scanning portion to begin so that I could feel it again. The succeeding portions did offer any of the same feelings or effects, and I was asking the technician to put me back in and he said nobody had ever felt that way about the MRI machine before. I researched and found that I wasn’t the only one who had a relieving experience while having an MRI scan performed. I’m betting that it’s only applicable to a select few people with a specific problem, or possibly only for those who truly have depression, as I’ve read research that the majority of people diagnosed with depression just have chronic stress; additionally, I read an article about how the placebo effect is becoming more and more effective, furthering the suspicion that the majority of people don’t necessarily have depression, by definition. I certainly wasn’t susceptible to the placebo effect with my MRI scan since I went in to be checked for tumors and possible pressure on my frontal lobe; my sensations initiated and stopped as the machine became active and then deactivated and did not return, as hoped, in succeeding rounds of the scan intervals.

    There’s a good chance that people in the control groups are not very aware of themselves–I have an oddly powerful sense of proprioception, know my body very well, and astounded the neuropsychologist with my motorfunctions. There’s also the chance that they aren’t positioning the magnets for TMS in the proper position, orientation, or with the proper calibration. I would love to be part of ongoing research since I’m articulate and can describe my symptoms and sensations with abundant information and provide accompanying hypotheses to physicians so that they can better understand the problem. I think I could fine-tune the location, orientation, and calibration of TMS systems if given the opportunity–”0.5mm to the left…3mm lower…adjust yaw 5 degrees counter-clockwise…decrease power output…increase frequency”, etc. I think it has great potential for a niche of people since not everyone is physiologically the same: like extra ribs, extra chromosomes, missing finger/toe, and so on. As it turns out, I suffer from undocumented side-effects from abundant medications I’ve tried, and am often told “no, that’s not from the medication”…then a few years later, my symptoms become documented as a known side-effect of the medication when all the while I was told “no, you’re wrong because the documentation doesn’t agree with you”.

    It’s unfortunate that I’m not given opportunities to offer my services (beyond a mere clinical trial of “yes/no”) in exchange for some worthwhile treatment. I can be contacted by yahoo mail under my posted name if any researchers are willing to include me in their projects for some in-depth discussion of hypotheses and some stringent and exhaustive trials. I’ll sign all waivers if it means getting an improved version of TMS treatment and furthering the research, guided by my feedback.

  16. Jon8RFC on December 28th, 2009 at 10:20 am
  17. In my own opinion I can say that rTMS is somehow effective in depression in some ways , maybe at least lessens it a bit. .

  18. Gail Holst on July 14th, 2011 at 4:05 pm

Leave a Reply

%d bloggers like this: