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A 35-year-old man had been suffering from clinical depression for five years. He was brought to psychiatrist Sanjay Chugh’s clinic in Greater Kailash, Delhi, for treatment. Dr Chugh suggested repetitive transmagnetic stimulation (rTMS) but the family was apprehensive. Dr Chugh reassured them that there would be no side effects. “My brother experienced no side effects during the treatment except a mild tapping sensation on his head and he reported no side effects after either," said the patient’s sister.

Repetitive transmagnetic stimulation is a form of therapy where the brain is non-invasively stimulated with a magnetic coil. The treatment uses our knowledge of various regions of the brain and how they play a role in mind and body functioning. Dr Chugh says that usually “a rTMS session lasts 30 minutes and does not require anaesthesia. The patient has an electromagnetic coil held against his or her forehead near an area of the brain involved in mood regulation. Then, short electromagnetic pulses are administered through the coil". The magnetic pulses stimulate nerve cells in the targeted brain region. The magnetic field generated by the rTMS machine is about the same strength as that of a magnetic resonance imaging (MRI) scan. Dr Chugh finds the therapy effective and uses it to treat depression, schizophrenia, obsessive-compulsive disorders and auditory hallucinations, migraine, addiction, paralysis after stroke and fibromyalgia.

In India, there are doctors who are using it to treat everything from clinical depression to attention deficit disorder (ADD) and stroke. But the US FDA (Food and Drug Administration) has only approved it for patients with depression, with an additional caveat that only those patients with depression who haven’t responded to medicines can be prescribed rTMS. Globally 35% of patients who seek treatment for depression don’t respond to medicines.

A Cochrane review by Z. Hao and colleagues published in May reviewed 19 published trials on rTMS and its ability to treat stroke to see if rTMS was indeed helping in improving people’s functional abilities after stroke. The review found there wasn’t sufficient evidence to show that rTMS was useful in improving stroke victims’ use of their limbs. Another Cochrane review by J.L. Rodriguez-Martin and colleagues published in January 2009 found no difference in the ability of rTMS to show impact in the treatment of depression compared with medication and other therapies. It may be that more and differently designed studies are needed to confirm the usefulness of this therapy. The fact that it has passed the stringent process of gaining US FDA approval indicates that rTMS is a therapy that can safely be used for the treatment of major depression. The cost of 10 rTMS sessions is about 50,000 and at least 10 sessions are required depending on the illness. In India, using rTMS for non-FDA approved uses like stroke or ADD is legal because we do not have a government regulatory body to approve machines. The mandate of the Drugs Controller General of India, the US FDA counterpart in India, is to approve medicines, not therapeutic machines like rTMS.

Another similar, though experimental form of brain stimulation therapy, available at some psychiatric clinics is transcranial direct current stimulation (tDCS). It is non-invasive like rTMS and uses direct currents from a battery to stimulate the brain. Unlike rTMS, it is not US FDA approved as yet. Experimental though it may be, Anjali Chhabria, psychiatrist and founder of Mindtemple, a mental wellness clinic in Mumbai, and Dr Chugh both find it useful.

An 18-year-old boy, one of Dr Chhabria’s patients, recently underwent tDCS. His mother said he suffered from ADD and had been on medication. But the medicines weren’t helping and when Dr Chhabria suggested tDCS (about 25,000 for 10 sessions), the parents agreed and the boy underwent two treatments with 10 sessions each for two months. After the second treatment, the mother said she found a distinct improvement in her son’s ability to concentrate. When asked about side effects, she said apart from a slight tingling sensation, her son didn’t feel a thing and was playing video games on his laptop throughout the sessions.

The mother said that while the treatment was successful, she believes the fact that the doctor was reassuring and expressed concern throughout the time her son was undergoing treatment made a positive impact on her child’s experience. In India, because of the sheer volume of patients, doctors often have no time to talk to and reassure their patients. Farokh Udwadia, professor emeritus of medicine, Grant Medical College, JJ Hospital, Mumbai, and a pioneering physician of critical care in India, writes in his book, The Forgotten Art of Healingand Other Essays, “The art of medicine is the art of healing, not just treating, not even just curing. And it is only when art and science join hands that healing is best accomplished."

If you are trying to find a doctor who administers rTMS or tDCS, look for one who pays heed to Dr Udwadia’s words. Dr Chugh and Dr Chhabria both advise that treating a patient with rTMS requires extensive training. So carefully survey and look for a psychiatrist whose technical abilities and bedside manners are evenly matched. These two factors will decide if new treatments like rTMS and tDCS work or don’t work.

Sujata Kelkar Shetty, PhD, writes on public health issues and is a research scientist trained at the National Institutes of Health in Bethesda, US.

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