Repetitive transcranial magnetic stimulation in Malta : a revolutionary therapy for psychiatric and neurological disorders

Severe depression is one of the most common psychological disabilities, with a global point prevalence of 4.7%. The World Health Organisation predicts it to be the leading cause of disease burden by 2030. With 350 million depressed people, depression is a debilitating condition where only a third of treated patients achieve remission after the first antidepressant treatment. Up to 34% of the patients are treatment resistant, whereas another 15% respond partially, following standard doses of antidepressants for 6 weeks or more. Failure to respond to two consecutive antidepressants leads to greater reductions in remission rates. Recurrence rates, despite specialised care, are 60% and 85% after 5 and 15 years post-recovery respectively. Inadequate efficacy, adverse effects, and sensitivity to current treatments call for more effective and tolerable treatment options. With over 20 years of research, repetitive transcranial magnetic stimulation (rTMS) is a non-invasive treatment that alters brain activity and cortical excitability permanently, making it an effective antidepressant treatment beyond the conventional ones, including electroconvulsive therapy (ECT) in some studies. Furthermore, rTMS is safe, natural, painless, fast acting and approved by the Food and Drug Administration (FDA) and the National Institute for Health and Care Excellence (NICE). It has virtually no side effects and only one absolute contraindication (epilepsy). Experience of its use in Malta has shown improvement in diminishing the key symptoms of depression, decreased suicidal ideation and a decrease in other psychiatric and neurological symptoms within hours of the first sessions. Besides providing immediate relief and hope for patients and relatives, this improvement has many clinical and future management implications. Research is now underway to apply this novel technology and its variants to other physical and psychological disorders. KEYwORDS Treatment resistant depression; repetitive transcranial magnetic stimulation; intermittent theta burst stimulation; transcranial direct current stimulation BASIC PRINCIPLES AND HISTORY Repetitive transcranial magnetic stimulation (rTMS) is a safe, painless, effective, natural, evidence-based treatment for patients suffering from severe unipolar affective disorder/depression who are treatment resistant and/ or treatment intolerant, i.e. they are generally labelled as suffering from treatment-resistant severe/major depression (TRD) (Carpenter et al., 2012; Connolly et al., 2012). Others find rTMS appealing as they may be sceptical of conventional treatment. Revolutionary in its approach to treating TRD, rTMS is the brainchild of Baker and his colleagues who have been experimenting with single pulse TMS in Sheffield, UK since the 1980s (Hotlzheimer and Mc Donald, 2014). The UK team pioneered stimulating the human brain’s cortex after being inspired by Galvani and Aldini’s eighteenth century experiments on electrically stimulating the peripheral muscles of dead animals and humans respectively. Their objective at the time was to map the cortex and elicit a corresponding short-lived motor stimulation of peripheral muscles (Baker, Jalinous and Freeston, 1985). Technological developments subsequently produced repetitive pulse TMS which was shown to have long lasting effects on the cortex that