Depression and Anxiety-Related Concerns – Neurostimulation Procedures Provincial Program

Repetitive Transcranial Magnetic Stimulation (rTMS)

TRD, depression that is unresponsive to conventional treatment (e.g., psychotherapy and/or medication), affects approximately one-third of individuals with major depressive disorder in Canada. Without the appropriate treatment, individuals experiencing TRD are at an increased risk of functional impairment, health care utilization, suicide and death.

Health Canada first approved the use of rTMS in 2002. The treatment is a safe, non-invasive brain stimulation treatment that uses powerful, focused magnetic fields to stimulate brain areas responsible for regulating thought, emotion and behaviour. For treating TRD, the Canadian Network for Mood and Anxiety Treatment (CANMAT) recommends rTMS as a first line of treatment. In addition to being well tolerated and having few side effects, the treatment does not require anesthesia. The 2021 Ontario Health Technology Advisory Committee’s (OHTAC) Report on rTMS reported that “Compared with sham treatment, most rTMS modalities led to lower depression scores and better response and remission rates. There was no difference in response or remission rates when comparing rTMS modalities with each other.”

Program Approach

The MHA CoE has prioritized developing and implementing a provincial rTMS program, including organizational and clinical expectations, performance measures, data collection processes, oversight and regional pathways, and training and implementation supports. The goal is to ensure consistent access to high‑quality, standardized rTMS treatment for depression across Ontario, integrated within the broader continuum of depression care.

Referrals

Referrals must be completed by a physician, nurse practitioner or psychiatrist.

When assessing an individual for rTMS, the treating clinician should consider recommending evidence-based psychotherapy, such as a referral to Ontario Structured Psychotherapy (OSP) program, for those who have not previously accessed psychotherapy, if clinically indicated.

Individuals must receive a clinical assessment to determine eligibility for rTMS treatment based on the following inclusion and exclusion criteria:

Inclusion Criteria

• Adults aged 18 and older experiencing unipolar TRD. Consideration should be given to the level of treatment resistance and probability of achieving remission.

Exclusion Criteria

Clinical judgement must be used to determine suitability for rTMS treatment. Evidence suggests rTMS is unsuitable for individuals with the following:

• severe depressive disorder with features of psychosis
• current seizure disorder
• ferromagnetic or metal hardware implanted in the head and/or neck (e.g., cochlear implants, aneurysm clips, plates)
• implanted cardiac defibrillators and pacemakers; may be suitable at some centres (e.g., centres with appropriate cardiac resources) based on clinician judgement

Generally, rTMS is not recommended for inpatients given the established efficacy of ECT for inpatients with severe depression.

Find rTMS Networks

The program is coordinated by 10 networks across the province, who work with different organizations across their regions to offer services.

To learn more about the networks and how to get assessed, visit their websites:

Central Region (Mississauga to Huntsville and Orangeville to Markham)

• Waypoint Centre for Mental Health Care
• CarePoint Health
• Canadian Mental Health Association – York and South Simcoe

Toronto Region (City of Toronto)

• Centre for Addiction and Mental Health

West Region (Waterloo to Windsor and Tobermory to Niagara Falls)

• St. Joseph's Healthcare Hamilton
• St. Joseph’s Health Care London

East Region (Scarborough to Deep River to Hawkesbury)

• The Royal Ottawa Mental Health Centre
• Ontario Shores Centre for Mental Health Sciences

North East Region (Parry Sound to Sault Ste. Marie to the Hudson Bay and James Bay Coasts)

• Health Sciences North

North West Region (Thunder Bay to Kenora to the Hudson Bay Coast)

• St. Joseph’s Care Group

Electroconvulsive Therapy (ECT)

ECT is a therapeutic procedure that entails the induction of a seizure by applying an electrical stimulus to the brain.

ECT, combined with rTMS, in a stepped care pathway, presents the most effective means to address TRD in Ontario from a cost and client management perspective.

ECT services were scaled back during the COVID-19 pandemic, reducing treatment volumes. The provincial neurostimulation program continues to monitor ECT activity and will expand its focus to ECT, including the development of the program expectations.