Repetitive Transcranial Magnetic Stimulation (rTMS) is a form of brain stimulation that uses focused magnetic field pulses to induce electrical currents in neural tissue non-invasively, via an inductor coil positioned against the scalp.
Intensity, frequency, and site | • Stimulate at 110%-120% of resting motor threshold (70%-80% for theta-burst stimulation) • Select stimulation frequency and site |
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Treatment course | • Perform stimulation 5 times weekly (Level 1) • Deliver initial course until symptom remission is achieved, up to 20 sessions (4 weeks) (Level 1) • Extend course to 30 sessions (6 weeks) in responders who have not achieved symptom remission (Level 3) |
Maintenance course | • Use rTMS as needed to maintain response (Level 3) |
First line | • High-frequency rTMS to left DLPFC • Low-frequency rTMS to right DLPFC |
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Second line | • Bilateral rTMS to DLPFC (left high-frequency and right low-frequency) (Level 1) • Low-frequency rTMS to right DLPFC (in non-responders to high-frequency left DLPFC-rTMS), OR high-frequency rTMS to left DLPFC (in non-responders to low-frequency right DLPFC-rTMS) (Level 1) TBS protocols (Level 3): • Intermittent TBS to left DLPFC • Left intermittent and right continuous TBS to DLPFC • Intermittent TBS to bilateral DMPFC |
Third line | • High-frequency rTMS to bilateral DMPFC (Level 3) |
20
sessions (i.e. - 4 weeks) should be attempted before declaring treatment failure, with extension to 25 to 30 sessions if improvements occur.Neurostimulation | Overall Recommendation | Acute Efficacy | Maintenance Efficacy | Safety and Tolerability |
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rTMS | • First line (for patients who have failed at least 1 antidepressant) | Level 1 | Level 3 | Level 1 |
ECT | • Second line • First line in some acute clinical situations | Level 1 | Level 1 | Level 1 |
tDCS | • Third line | Level 2 | Level 3 | Level 2 |
Vagal Nerve Stimulation (VNS) | • Third line | Level 3 | Level 2 | Level 2 |
DBS | • Investigational | Level 3 | Level 3 | Level 3 |
MST | • Investigational | Level 3 | Not known | Level 3 |