Conventional Repetitive Transcranial Magnetic Stimulation for Depression: A Step-by-Step Protocol

Repetitive Transcranial Magnetic Stimulation (rTMS) is a non-invasive approach for brain stimulation, with proven effectiveness and efficacy to treat Major Depressive Disorder (MDD), particularly for episodes that do not respond to antidepressant medication. A structured patient-centered Transcranial Magnetic Stimulation (TMS) protocol, focused on precision, comfort, and safety, should be provided in TMS clinics treating MDD. The procedure begins with the patient seated comfortably in a reclining chair, equipped with head and foot support. A pillow is placed around the patient's neck to ensure head stability and comfort throughout the session. A lycra cap is placed on the patient's head, and the treatment area is marked on the cap to ensure the correct placement of the electromagnetic coil. Two main strategies, relying on the head landmarks for each individual patient, have been widely used to identify the treatment area: the 5 cm rule and the Beam F3 method. To initiate the treatment, the coil is positioned on the treatment target to deliver a series of electromagnetic pulses. Patients hear a clicking sound and feel a light tapping sensation on the scalp. For acoustic protection, earplugs are provided before the session begins. The stimulation itself typically causes no discomfort, and patients can resume their normal daily activities after the session. However, driving is discouraged immediately after treatment sessions. The rTMS protocol to treat MDD consists of 20 to 30 daily sessions over four to six weeks, monitored by regular consultations with a psychiatrist, to track progress and adjust if needed. Maintenance sessions may follow to sustain clinical benefits. This step-by-step protocol ensures comfort, consistency, and effective treatment delivery for patients undergoing rTMS therapy.