Repeated Transcranial Magnetic Stimulation continues to be researched for schizophrenia.  Initial studies have not given clear evidence of benefit yet.  Since ECT is known to be of some benefit for schizophrenia, it is not surprising that rTMS is proving to be useful.  Because rTMS is far easier to use and almost without side-effects, it would be great if it does prove of benefit for this disorder.  

Actually, rTMS has already been much better researched with many double-blind studies especially for depression, but also for schizophrenia and Parkinson's disease, than was ever the case for gabapentin or topirimate for Bipolar Disorder.  Yet, thousands of psychiatrists were quick to prescribe those drugs without a single double-blind study, while they still consider rTMS experimental.  The main difference is that insurance companies still refuse to pay for rTMS and the equipment is very expensive, whereas insurance companies never care about what medication is being prescribed.  In fact, gabapentin, topirimate, and rTMS have all been approved by the FDA for use on humans, but none of them has been specifically approved for the treatment of psychiatric illness.  Also, the side-effects of gabapentin and topirimate are much, much more common and potentially much more severe.

Strange, isn't it.  The very safe and apparently effective treatment isn't being used because its "experimental," while the much less safe and totally unresearched medicines are given to tens of thousands with the U.S. government paying for the treatment in most cases.  Sort of schizophrenic behavior on the part of psychiatrists.

Left Prefrontol rTMS No Benefit for Schizophrenia in Small Study: In a DB PC study of high-frequency left prefrontal repetitive transcranial magnetic stimulation (rTMS) for 22 chronic hospitalized schizophrenia patients, 2 weeks (10 sessions) of real vs. sham rTMS. ( 20 trains of 5-second 10-Hz stimulation at 100 percent motor threshold, 30 seconds apart) found no benefit for symptoms as measured by the PANSS, MMSE, and hormonal testing. Left prefrontal repetitive transcranial magnetic stimulation in schizophrenia. Holi MM, Eronen M, et al. Helsinki University, Finland. Schizophr Bull. 2004;30(2):429-34 

Auditory Hallucinations Decreased by rTMS in Larger Study: Fifty right-handed patients experiencing auditory hallucinations at least 5 times per day were randomly allocated to receive either rTMS or sham stimulation. A total of 132 minutes of rTMS was administered over 9 days at 90% motor threshold using a in a DB sham-controlled study. Hallucination Change Score was more improved for rTMS relative to sham stimulation (p = .008) as was the Clinical Global Impressions Scale (p = .0004). Hallucination frequency was significantly decreased during rTMS relative to sham stimulation (p = .0014). There was no evidence of neurocognitive impairment associated with rTMS.  Temporoparietal Transcranial Magnetic Stimulation for Auditory Hallucinations: Safety, Efficacy and Moderators in a Fifty Patient Sample. Hoffman RE, Gueorguieva R, et al. Biol Psychiatry. 2005 Jun 2

Auditory Hallucinations Improved Only in Loudness: In a DB PC study of 33 patients with treatment-resistant auditory hallucinations, temporoparietal rTMS for 10 consecutive weekdays, for 15 minutes at 1 Hz and 90% of the resting motor threshold did not result in a greater therapeutic effect than sham on any measure except for the loudness of hallucinations where there was a significant reduction in the active versus the sham group over time. A Double-Blind Sham-Controlled Trial of Repetitive Transcranial Magnetic Stimulation in the Treatment of Refractory Auditory Hallucinations. Fitzgerald PB, et al. Monash University, Melbourne, Victoria, Australia. J Clin Psychopharmacol. 2005 Aug;25(4):358-362

Auditory Hallucinations: Temporoparietal rTMS Helped Schizophrenia with Hallucinations: Repetitive transcranial magnetic stimulation (rTMS) on the right temporoparietal cortex did better than left-sided of sham stimulation in 39 schizophrenic patients with treatment-refractory auditory hallucinations. rTMS was applied to the TP3 or 4 brain regions with the aid of the electroencephalography 10-20 international system at 1Hz for 20 min per day for 10 treatment days. A double blind study showing that two weeks of daily repetitive TMS over the left or right temporoparietal cortex reduces symptoms in patients with schizophrenia who are having treatment-refractory auditory hallucinations. Lee SH, Kim W, et al. Inje University of Korea, Koyang, South Korea. Neurosci Lett. 2005 Mar 16;376(3):177-81. 

Auditory Hallucinations Reduced by Temporoparietal rTMS: Repetitive transcranial magnetic stimulation (rTMS) at 1 Hz reduces cortical activation, and recent results have shown that 1-Hz left temporoparietal rTMS may reduce AVH. Ten right-handed schizophrenia patients with resistant AVH received 5 days of active rTMS and 5 days of sham rTMS (2,000 stimulations per day at 90% of motor threshold) over the left temporoparietal cortex in a double-blind crossover design with a 1-week washout period in between. AVH were improved (56%) by 5 days active rTMS, whereas no variation was observed after sham. Seven patients were responders to active treatment, five of whom maintained improvement for at least 2 months. Slow transcranial magnetic stimulation can rapidly reduce resistant auditory hallucinations in schizophrenia. Poulet E, Brunelin J, et al. Institut Federatif des Neurosciences de Lyon, France. Biol Psychiatry. 2005 Jan 15;57(2):188-91

Visual Hallucinations Treated in Single Case: A French schizophrenic patient who killed his mother thinking she was the devil continued to suffer from auditory hallucinations of God and the Devil despite a variety of anti-psychotic medications.  He received a course of rTMS: 10 sessions of 1-Hz stimulations near Wernicke's area. After rTMS, the patient's hallucinations grew less intrusive and he no longer required isolation.  Left temporoparietal transcranial magnetic stimulation in treatment-resistant schizophrenia with verbal hallucinations. Franck N, Poulet E, Terra JL, Dalery J, d'Amato T. Psychiatry Res.2003 Aug 30;120(1):107-9

No Benefit Left TP rTMS: In a small study of 18 patients, both the rTMS and sham patients showed equal improvement. rTMS was 10 sessions at 80% motor threshold 5 trains of 1 minute at 1 Hz. J Psychiatr Res. 2005 May 7

Yale Study Finds Left Temporopariety Slow rTMS Helps Auditory Hallucinations: A sham controlled study of 24 schizophrenic patients with medication resistant auditory hallucinations were treated for 9 days at 90% of motor threshold. Neuroimaging studies suggest that auditory hallucinations of speech arise, at least in part, from activation of brain areas underlying speech perception. One-hertz rTMS produces sustained reductions in cortical activation. Auditory hallucinations were robustly improved with rTMS, especially the frequency and attentional salience of the hallucinations. Duration of benefit ranged widely, with 52% of patients improved for at least 15 weeks. Transcranial magnetic stimulation of left temporoparietal cortex and medication-resistant auditory hallucinations. Hoffman RE, Hawkins KA, Gueorguieva R, Boutros NN, Rachid F, Carroll K, Krystal JH. Arch Gen Psychiatry. 2003 Jan;60(1):49-56

Left prefrontol fast rTMS Helped Schizophrenics in Small DB: 12 schizophrenic patients were treated with left prefrontal rTMS for 10 sessions using a DB sham controlled corssover design with 2 weeks of each treatment. Those getting the real treatment did significantly better (p<.05) for BPRS scores although anxiety and depression were not affected. The rTMS was 20 2s 20 Hz stimulations at 80% motor threshold over 20 min, dorsolateral preforntal cortex. Hannover, Germany. High frequency repetitive transcranial magnetic stimulation (rTMS) of the dorsolateral prefrontal cortex in schizophrenic patients. Rollnik JD, Huber TJ, Mogk H, Siggelkow S, Kropp S, Dengler R, Emrich HM, Schneider U. Neuroreport. 2000 Dec 18;11(18):4013-5

Right prefrontal slow rTMS did Not Help Schizophrenics in DB: 35 patients in a sham controlled study found no benefit. Right prefrontal slow repetitive transcranial magnetic stimulation in schizophrenia: a double-blind sham-controlled pilot study. Haifa. Klein E, Kolsky Y, Puyerovsky M, Koren D, Chistyakov A, Feinsod M. Biol Psychiatry. 1999 Nov 15;46(10):1451-4; An earlier open trial by the same group of 10 schizophrenics, 7 of whom reported decreased anxiety, had led the team to conduct the DB study. Depress Anxiety. 1998;7(2):65-8

rTMS No Benefit for Schizophrenia in Very Small Study: In a DB, controlled study of 22 schizophrenic patients, 2 weeks (10 sessions) of real vs. sham rTMS at 20 trains of 5-second 10-Hz stimulation at 100 percent motor threshold, 30 seconds apart found no evidence of benefit. Left prefrontal repetitive transcranial magnetic stimulation in schizophrenia. Holi MM, Eronen M, Toivonen K, Toivonen P, Marttunen M, Naukkarinen H. Helsinki University, Finland. Schizophr Bull. 2004;30(2):429-34

Other Possible Uses of rTMS

Besides being best researched as a treatment for depression, rTMS has evidence that it can benefit schizophrenia, Parkinson's disease, and possible Motor Conversion Syndrome.

Parkinson's Disease Helped by Motor Cortex fast rTMS in DB: In an Egyptian study of 36 unmedicated Parkinson's patients using a sham procedure as a control and half the patients receiving a suprathreshold 5-Hz, 2000 pulses once a day for 10 consecutive days (20,000 stimulations). Total motor section of Unified Parkinson's Disease Rating Scale (UPDRS), walking speed, and self-assessment scale were performed for each patient before rTMS and after the first, fifth, 10th sessions, and then after 1 month. Evaluation of these measures was performed blindly without knowing the type of rTMS. The rTMS group show considerable improvement (P = 0.0001, 0.001, and 0.002), while the sham group only had improvement in the self-assessment measure. Therapeutic effect of repetitive transcranial magnetic stimulation on motor function in Parkinson's disease patients. Khedr EM, Farweez HM, Islam H. Eur J Neurol. 2003 Sep;10(5):567-72

Parkinson's Patients Worse After SMA rTMS: 10 patients in a sham controlled crossover study of rTMS to the supplementary motor area (SMA) found two patients unable to tolerate the treatment.  There was evidence of subclinical deterioration in complex motor tasks. NYU. Repetitive transcranial magnetic stimulation to SMA worsens complex movements in Parkinson's disease. Boylan LS, Pullman SL, Lisanby SH, Spicknall KE, Sackeim HA. Clin Neurophysiol. 2001 Feb;112(2):259-64.

No Benefit Very Slow rTMS to Motor or Occipital Cortex in DB: 85 Parkinson's patients received 0.2 Hz rTMS at 110% of motor threshold receiving 100 stimuli per treatment with eight weekly treatments (800 stimulations) to motor cortex or occipital cortex or a sham controlled. Univ. Toyko.  0.2-Hz repetitive transcranial magnetic stimulation has no add-on effects as compared to a realistic sham stimulation in Parkinson's disease. Okabe S, Ugawa Y, Kanazawa I; Effectiveness of rTMS on Parkinson's Disease Study Group.  Mov Disord. 2003 Apr;18(4):382-8

Parkinson's Helped by fast rTMS to Motor Cortex in Small Controlled Study: 9 patients treated with 2250 stimulations at 5 Hz 90% motor threshold rTMS divided into 15 trains at intervals of ten second.  Control patients were treated on their less affected side.  Those treated on their move affected side showed a 46% improvement vs. 21%. Leipzig. Contralateral and ipsilateral repetitive transcranial magnetic stimulation in Parkinson patients. de Groot M, Hermann W, Steffen J, Wagner A, Grahmann F. Nervenarzt. 2001 Dec;72(12):932-8

Parkinson's Helped by Prefrontal Slow rTMS in Small DB: 18 patients with half getting sham control. Weekly for 2 months 0.2 Hz at 700 volt 60 stimulations given, 30 each frontal cortex. Kurume Univ. Japan. Therapeutic effect and mechanism of repetitive transcranial magnetic stimulation in Parkinson's disease. Shimamoto H, Takasaki K, Shigemori M, Imaizumi T, Ayabe M, Shoji H. J Neurol. 2001 Sep;248 Suppl 3:III48-52

rTMS Helps Cognitive Functioning in Depressed: A Univ of Illinois, Chicago, study of 15 severe depressed patients treated for 3 weeks found not a deterioration in cognitive funcitoning, such as occur with ECT and some medications, but a modest but statistically significant improvement in performance was noted in working memory-executive function, objective memory and fine motor speed domains over the rTMS treatment period. Neurocognitive effects of repetitive transcranial magnetic stimulation in severe major depression. Martis B, Alam D, Dowd SM, Hill SK, Sharma RP, Rosen C, Pliskin N, Martin E, Carson V, Janicak PG. Clin Neurophysiol. 2003 Jun;114(6):1125-32