Expert Witness Journal Issue 64 December 2025 - Flipbook - Page 66
Beyond the Pill: The Medicolegal
Signi昀椀cance of Deep TMS in Managing
Treatment-Resistant Psychiatric Disorders
by Dr Behrouz Nabavi, MD, MSc, FRCPsych, Section 12 Approved
reports, in昀氀uencing substantial awards for lifelong
care and loss of amenity.
Abstract
In medicolegal practice, experts frequently encounter
claimants with psychiatric injuries – most commonly
Major Depressive Disorder (MDD), Post-Traumatic
Stress Disorder (PTSD), GAD (Generalized Anxiety
Disorder), and Obsessive-Compulsive Disorder
(OCD) – who have derived inadequate bene昀椀t
from 昀椀rst-line treatments. This ‘treatment-resistant’
population often presents a complex challenge in
both prognosis and the quanti昀椀cation of future care
needs. This article introduces Deep Transcranial
Magnetic Stimulation (Deep TMS) as a validated,
non-invasive neuromodulation therapy that is
revolutionising outcomes for such individuals. We
will explore its mechanism of action, evidence base,
and distinct advantages over pharmacological and
psychological interventions, arguing for its inclusion
as a standard consideration in modern medicolegal
reporting and future care plans. Its ability to alter
the neurobiological substrate of trauma-related
disorders positions it not merely as an alternative,
but as a foundational intervention that can rede昀椀ne
recovery trajectories and settlement valuations.
For the medicolegal expert, this presents a
profound dilemma. Is the claimant’s condition truly
intractable? Or have all reasonable and modern
treatment options been explored? The advent of
advanced neuromodulation techniques, particularly
Deep Transcranial Magnetic Stimulation (Deep
TMS), demands a re-evaluation of what constitutes a
‘reasonable’ treatment pathway. This article aims to
equip medicolegal professionals with a foundational
understanding of Deep TMS, highlighting its
role as a pivotal, evidence-based intervention
that can fundamentally alter the prognosis and,
consequently, the accurate valuation of a case.
What is Deep TMS? A Primer on the
Technology and Mechanism
Transcranial Magnetic Stimulation is a non-invasive
brain stimulation technique that uses pulsed
magnetic 昀椀elds to induce electrical currents in
targeted cortical and subcortical brain regions. It is
based on the principle of electromagnetic induction,
昀椀rst described by Faraday, allowing for direct, noninvasive modulation of neuronal activity. While
conventional TMS devices primarily stimulate the
super昀椀cial cortex, Deep TMS utilises a patented
H-Coil helmet design. This unique engineering
allows the magnetic 昀椀elds to penetrate deeper and
broader neural circuits, modulating key structures
implicated in psychiatric disorders, such as the
dorsolateral and ventrolateral prefrontal cortices,
the anterior cingulate cortex, and the insula.2
Introduction: The Therapeutic Impasse in
Medicolegal Cases
The landscape of personal injury and clinical
negligence often features claimants with enduring
psychiatric sequelae stemming from their trauma.
Despite guideline-concordant care involving multiple
antidepressant trials and psychological therapies
such as Cognitive Behavioural Therapy (CBT) or
Eye Movement Desensitisation and Reprocessing
(EMDR), a signi昀椀cant proportion – estimated at
30% for MDD – do not achieve remission.1 This
state of Treatment-Resistant Depression (TRD),
typically de昀椀ned as a failure to respond to at least
two adequate antidepressant trials, can lead to
a perception of permanent disability and a poor
long-term prognosis. The clinical narrative often
becomes one of chronicity and managed decline,
which is subsequently re昀氀ected in medicolegal
EXPERT WITNESS JOURNAL
The procedure is conducted while the patient is
awake and seated, requiring no anaesthesia or
sedation. A typical acute treatment course involves
daily sessions (20-30 minutes each), 昀椀ve days a
week, for 4-6 weeks. The patient can resume their
normal activities immediately thereafter, with no
recovery period – a signi昀椀cant practical advantage
63
DECEMBER/JANUARY 2025-2026
