The Clinical TMS Society Consensus Review and Treatment: Recommendations for TMS Therapy for Major Depressive Disorder

Prefrontal Transcranial Magnetic Stimulation (TMS) therapy repeated daily over 4–6 weeks (20–30 sessions) is US Food and Drug Administration (FDA) approved for treating Major Depressive Disorder in adults who have not responded to prior antidepressant medications. In 2011, leading TMS clinical providers and researchers created the Clinical TMS Society (cTMSs) (, Greenwich, CT, USA), incorporated in 2013.

Taylor JJ, Williams NR, George MS. Beyond Neural Cubism: Promoting a Multidimensional View of Brain Disorders by Enhancing the Integration of Neurology and Psychiatry in Education. Acad Med. 2015 May ; 90(5): 581–586

Cubism was an influential early-20th-century art movement characterized by angular, disjointed imagery. The two-dimensional appearance of Cubist figures and objects is created through juxtaposition of angles. The authors posit that the constrained perspectives found in Cubism may also be found in the clinical classification of brain disorders. Neurological disorders are often separated from psychiatric disorders as if they stemmed from different organ systems. Maintaining two isolated clinical disciplines fractionalizes the brain in the same way that Pablo Picasso fractionalized figures and objects in his Cubist art. This Neural Cubism perpetuates a clinical divide that does not reflect the scope and depth of neuroscience. All brain disorders are complex and multidimensional, with aberrant circuitry and resultant psychopharmacology manifesting as altered behavior, affect, mood, or cognition. Trainees should receive a multidimensional education based on modern neuroscience, not a partial education based on clinical precedent. The authors briefly outline the rationale for increasing the integration of neurology and psychiatry and discuss a nested model with which clinical neuroscientists (neurologists and psychiatrists) can approach and treat brain disorders.

Williams NR, Taylor JJ, Kerns S, Short EB, Kantor EM, George MS. Interventional Psychiatry: Why Now? J Clin Psychiatry. 2014 August ; 75(8): 895–897

Interventional psychiatry offers substantial therapeutic benefits in some neuropsychiatric disorders and enormous potential in treating others. However, as interventional diagnostics and therapeutics require specialized knowledge and skill foreign to many psychiatrists, the emerging subspecialty of interventional psychiatry must be more formally integrated into the continuum of psychiatric training to ensure both safe application and continued growth. By establishing training paradigms for interventional psychiatry, academic medical centers can help fill this knowledge gap. The cultivation of a properly trained cohort of interventional psychiatrists will better meet the challenges of treatment-resistant psychiatric illness through safe and ethical practice, while facilitating a more informed development and integration of novel neuromodulation techniques.

A Clinical Guide To Transcranial Magnetic Stimulation Edited by Paul E. Holtzheimer and William McDonald -Oxford University Press 2014 (ISBN-13: 978-0199926480)

This resource serves as a reference tool for clinicians in the administration of transcranial magnetic stimulation (TMS) for neuropsychiatric disorders, and it focuses on the clinical applications of TMS and offers detailed information on the safe and effective administration of TMS with consideration of the neurophysiological effects particularly in relation to safety, targeting specific cortical areas and practical issues such as the length of treatment sessions and the durability of the TMS response. It also covers the evidenced based literature and utilizes this literature to inform specific recommendations on the use of rTMS in a clinical setting, while also addressing the efficacy and safety of TMS for neuropsychiatric disorders, including its use in special populations, such as the elderly. Finally, it outlines setting up a TMS service and includes practical issues such as considerations for the qualifications of the person administering the treatment, the use of concomitant medications, what equipment is necessary to have in the treatment room, and monitoring the outcomes to treatment.

Beam, W., Borckardt, J.J., Reeves, S.T., George, M.S. (2009) An Efficient and Accurate New method for locating the F3 position for prefrontal TMS applications”

The International 10-20 system is a method for standardized placement of electroencephalogram (EEG) electrodes. The 10-20 system correlates external skull locations with the underlying cortical areas. This system accounts for variability in patient skull size by using certain percentages of the circumference and distances between four basic anatomical landmarks. This 10-20 system has recently been used in transcranial magnetic stimulation (TMS) research for locating specific cortical areas. In the treatment of depression (and some types of pain), the desired placement of the TMS coil is often above the left dorsalateral prefrontal cortex (DLPFC) which corresponds to the F3 location given by the 10-20 system. However, for an administrator with little experience with the 10-20 system, the numerous measurements and calculations can be excessively time-consuming. Additionally, with more measurements comes more opportunity for human error. For this reason we have developed a new, simpler and faster way to find the F3 position using only three skull measurements. In this paper, we describe and illustrate the application of the new F3 location system, provide the formulas used in the calculation of the F3 position, and summarize data from 10 healthy adults. After using both the International 10-20 system and this new method, it appears that the new method is sufficiently accurate; however, future investigations may be warranted to conduct more in dept analyses of the method’s utility and potential limitations. This system requires less time and training to find the optimal position for prefrontal coil placement and it saves considerable time compared to the 10-20 EEG system.

Paulus W, Classen J, Cohen LG, Large CH, Di Lazzaro V, Nitsche M, Pascual-Leone A, Rosenow F, Rothwell JC, Ziemann U. (2008) State of the Art: Pharmacologic Effects on Cortical Excitability Measures Tested by Transcranial Magnetic Stimulation. Brain Stimulation (2008) 1, 151–63

The combination of brain stimulation techniques like transcranial magnetic stimulation (TMS) with CNS active drugs in humans now offers a unique opportunity to explore the physiologic effects of these substances in vivo in the human brain. Motor threshold, motor evoked potential size, motor evoked potential intensity curves, cortical silent period, short-interval intracortical inhibition, intracortical facilitation, short-interval intracortical facilitation, long-interval intracortical inhibition and short latency afferent inhibition represent the repertoire for investigating drug effects on motor cortical excitability by TMS. Here we present an updated overview on the pharmacophysiologic mechanisms with special emphasis on methodologic pitfalls and possible future developments or requirements.

The Oxford Handbook Of Transcranial Magnetic Simulation Edited by Eric Wassermann, Charles Epstein, and Ulf Ziemann -Oxford University Press 2008 (ISBN-13: 978-0198568926)

Since becoming commercially available in 1985, transcranial magnetic stimulation (TMS) has emerged as an important tool in several areas of neuroscience. Originally envisioned as a way to measure the responsiveness and conduction speed of neurons and synapses in the brain and spinal cord, TMS has also become an important tool for changing the activity of brain neurons and the functions they subserve and an important adjunct to brain imaging and mapping techniques. Along with transcranial electrical stimulation techniques, TMS has diffused far beyond the borders of clinical neurophysiology and into cognitive, perceptual, behavioural, and therapeutic investigation and attracted a highly diverse group of users and would-be users. The Oxford Handbook of Transcranial Stimulation provides an authoritative review of the scientific and technical background required to understand transcranial stimulation techniques and a wide-ranging survey of their burgeoning application in neurophysiology, perception, cognition, emotion, and clinical practice.

Transcranial Magnetic Stimulation In Clinical Psychiatry Edited by Mark S. George and Robert H. Belmaker -American Psychiatric Publishing 2007 (ISBN-13: 978-1585621972)

As understanding evolves about how different brain regions are involved in carrying out everyday tasks—and in causing brain diseases when they go awry—this book describes a new technology that allows physicians to focally stimulate the brain in awake adults through a non-invasive procedure. Transcranial Magnetic Stimulation in Clinical Psychiatry is an accessible and authoritative review of TMS, a procedure that is showing promise as a treatment in several disorders. Its authors explain how the procedure works, then the latest findings in a wide range of situations—notably in depression, but also in other conditions ranging from migraine to stroke recovery.

George, M.S., Nahas, Z., Kozel, F.A., Li, X., Denslow, S., Yamanaka, K., Mishory, A., Foust, M.J., Bohning, D.E. (2002) Mechanisms and State of the Art of Transcranial Magnetic Stimulation The Journal of ECT 18(4):170–181

In 1985, Barker et al. built a transcranial magnetic stimulation (TMS) device with enough power to stimulate dorsal roots in the spine. They quickly realized that this machine could likely also noninvasively stimulate the superficial cortex in humans. They waited a while before using their device over a human head, fearing that the TMS pulse might magnetically “erase the hard-drive” of the human brain. Almost 10 years later, in 1994, an editorial in this journal concerned whether TMS might evolve into a potential antidepressant treatment. In the intervening years, there has been an explosion of basic and clinical research with and about TMS. Studies are now uncovering the mechanisms by which TMS affects the brain. It does not “erase the hard-drive” of the brain, and it has many demonstrated research and clinical uses. This article reviews the major recent advances with this interesting noninvasive technique for stimulating the brain, critically reviewing the data on whether TMS has anticonvulsant effects or modulates cortical-limbic loops.