rTMS vs cTBS for Anxiety | TMS Doctor Answers TMS Questions

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At Florida TMS Clinic we treat depression differently. We use TMS or Transcranial Magnetic Stimulation. TMS is an effective, proven treatment for depression that is FDA approved and covered by insurance. TMS is safe and has no systemic side effects. While antidepressant medications and psychotherapy can be helpful for some, many others don't respond to medications and therapy. Some others may not be able to tolerate the side effects of medications. TMS therapy is a drug-free alternative treatment for depression. We love what we do! We enjoy seeing our patients blossom throughout their treatment course with TMS therapy.
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Disclaimer: Although I am a psychiatrist, this is not professional advice as I am not familiar with the specifics of your unique situation; please contact a psychiatrist in your area with more questions. This disclaimer is added to my answers on social media after consulting with the American Psychiatric Association.
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[@gauravmehta6102]

Does rtms harm the neurons or kill them? Or does it cause any harm to the brain? Please clarify. Thanks

[@Ryan-cb9bw]

Are 1hz and cTBS less painful for the patient than 10hz rTMS and 50hz iTBS? Do you ever exceed 120% MT for low frequency stimulation, what % of MT do you typically start at? For high frequency stimulation, most clinicians I've spoken to prefer to ramp up the % of MT by around 5% every 1-2 days until they reach 120% MT to give time for the patient's scalp to release endogenous opioids and reduce the small risk of inducing mania from excessive high frequency stimulation. I have yet to find any cases suggesting low frequency stimulation induced mania.

[@floridatmsclinic1239]

I see three questions here.
First question. Low-frequency TMS is generally more comfortable and less painful than high-frequency TMS. I can’t say the same about cTBS because you still use high frequency. It is just continuous. Maybe the pain is the same but quick comfort because of the anxiolytic effect.
Second question. No, I don’t exceed 120% MT. There are safety charts that we follow. More work will need to be done to justify the safety of above 120% MT.
Third question. I start at 90% MT and taper up by 5% every session until 120% by around the 7th session. The main reason for the radial increase is to improve patients’ tolerance. This is clearly documented in the pivotal trials for TMS. Other theories you heard sound like anecdotal opinions.
I am not sure I came across low-frequency right-sided TMS inducing mania. You make a good point here. You provoked my curiosity. Thanks!
It will take a couple of weeks for the next videos to come out.

[@qeegrtms3211]

Shortly after intermittent theta burst stimulation for depression I've noticed my mood improves and anxiety decreases for a couple hours but then later in the day I get an abnormal (worse than baseline) amount of anxiety and insomnia. As treatment has progressed it seems like this period of improvement has slowly lengthened from a couple hours to now about 48 hours. Problem is I've only got 3 sessions left. Is this normal? Will these ups and downs sort themselves out or do I need to fight with insurance to try to get more than 36 sessions? We never got to 120% of MT because it would cause me so much anxiety until my brain adjusted to it. Is there any chance BlueCross would cover more sessions this year? I've hit my out of pocket max so they may not like that. I was feeling great the past 2 days (less so yesterday) and now today I'm only slightly better than I was before TMS but have increased anxiety and terrible insomnia last night.

[@floridatmsclinic1239]

Please check out a reply to another question that is somewhat similar to this. I will copy-paste the question and answer here.
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Question:
If I have depression AND OCD but I already did TMS for depression (50 hertz, left DLPFC, 36 sessions), will Blue Cross Blue Shield approve me for more TMS without appeal if it's for OCD this time or do I have to wait 2-6 months? Left DLPFC stimulation helped a little with both depression and OCD but we never got to 120% of the motor threshold due to all the anxiety it would induce for 24-72 hours after treatment. It's been 2 weeks since I finished TMS and the short lived positive effects have diminished a lot so it might be that I didn't get sufficient dosage?
Answer:
Interesting question. If I had a patient with a similar dilemma i.e. MDD + Anxiety + OCD, and I did high frequency left DLPFC, which caused more anxiety. First, I would switch to the conventional 10Hz rTMS over 50 Hz iTBS. But then, I would do one of three things: 1. Add low-frequency right-sided TMS after the high frequency left DLPFC treatment. 2. Switch altogether to just low-frequency right DLPFC. 3. Refer out to H7 coil or DB80 coil with OCD protocol. I would pick #1 if the patient was primarily depressed, #2 if the patient was primarily anxious, #3 if the patient was primarily obsessed. BCBS will probably wash their hands off the case as soon as possible because of the “lack of response” reported with the initial treatment. Wait for the video in two weeks to hear more thoughts on why I prefer 10Hz rTMS over 50Hz iTBS for anxious depression.
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