Expert Witness Journal Issue 64 December 2025 - Flipbook - Page 67
over electroconvulsive therapy (ECT). TMS is
approved by the UK’s National Institute for Health
and Care Excellence (NICE) for TRD and holds
FDA clearance in the United States for both MDD
and Obsessive-Compulsive Disorder (OCD). 3 Its
mechanism is believed to involve the induction
of neuroplastic changes, including long-term
potentiation (LTP) and long-term depression (LTD),
e昀昀ectively ‘retuning’ dysfunctional neural networks
that are characteristically hypoactive or hyperactive
in conditions like depression and OCD.4
trauma if they are cognitively incapacitated by their
depression.
•
The Distinct Advantages of Deep TMS in
a Medicolegal Context
1.
Overcoming Pharmacological Limitations:
Psychotropic medications, while foundational,
operate on a system-wide basis, leading to a
high burden of side e昀昀ects such as weight gain,
sexual dysfunction, emotional blunting, and
gastrointestinal distress. These often contribute to
poor adherence and subsequent treatment failure,
creating a vicious cycle of hopelessness for the
patient and complicating the clinical picture for
the expert.5 Furthermore, the pharmacokinetic and
pharmacodynamic variations between individuals
mean that 昀椀nding an e昀昀ective agent is often a
protracted process of trial and error, which can
extend over many years in a claimant’s history.
•
3. A Demonstrated E昀케cacy in Treatment-Resistant
Populations:
The most compelling argument for Deep TMS is its
proven e昀케cacy in those for whom other treatments
have categorically failed. Large-scale, randomised
controlled trials and subsequent meta-analyses
have consistently shown that Deep TMS leads to
signi昀椀cantly higher response and remission rates
compared to sham treatment in patients with TRD.9
Many patients who have spent years, or even decades,
cycling through ine昀昀ective treatments experience a
signi昀椀cant and meaningful reduction in symptom
burden. For instance, a multi-centre study published
in World Psychiatry demonstrated that over a third
of patients with TRD achieved remission after a sixweek course of Deep TMS, a remarkable outcome
in this challenging population.10 This data provides
the robust, evidence-based foundation upon which
medicolegal opinions can be con昀椀dently built.
The Deep TMS Advantage: Deep TMS o昀昀ers
a targeted, non-systemic approach. It directly
modulates the malfunctioning neural
networks implicated in the disorder without
exposing the entire body to pharmaceutical
agents. Consequently, it is not associated
with the systemic side e昀昀ects that so often
impair quality of life and adherence. The
most common adverse e昀昀ects are transient,
mild scalp discomfort or headache, which
typically resolve early in the treatment
course.6 This favourable side-e昀昀ect pro昀椀le
makes it a viable option for patients who
are intolerant to medications, a common
scenario in longstanding medicolegal cases.
It provides a clear, distinct therapeutic
pathway when pharmacology has been
exhausted or rejected.
The Synergistic Potential: Deep TMS as
Part of a Combined Treatment Strategy
The most forward-thinking clinical paradigm is
not to view Deep TMS as a mere replacement for
other therapies, but as a powerful component of
an integrated, personalised treatment plan. The
sequence can be conceptualised as ‘Neuromodulation
---Pharmacological Optimisation---Psychotherapy’.
2. Complementing and Enhancing Psychological
Interventions:
Psychological therapies are cornerstone treatments
for trauma-based disorders, but their e昀케cacy can
be limited in severe, treatment-resistant cases.
Profound neurovegetative symptoms (e.g., anergia,
poor concentration), emotional numbing, and high
levels of cognitive distortion can impede a patient’s
ability to engage meaningfully and proactively
in therapy. A patient cannot e昀昀ectively process
EXPERT WITNESS JOURNAL
The Deep TMS Advantage: There is growing
evidence that Deep TMS can create a
‘neuroplastic window’. By priming and
normalising the brain circuits involved in
mood regulation, executive function, and
fear extinction (e.g., the prefrontal-amygdala
circuit), it can enhance cognitive capacity
and emotional resilience.7 This can, in turn,
make patients more receptive and engaged in
concurrent psychotherapy. The combination
of Deep TMS (addressing the underlying
neurobiological de昀椀cit) with trauma-focused
psychotherapy (addressing maladaptive
cognitive and behavioural patterns) can
be synergistic, leading to more robust and
durable recovery than either modality
alone.8 For the expert, this means that Deep
TMS should not be seen as a competitor to
psychotherapy, but as a potential catalyst
for its success in previously non-responding
claimants.
1.
64
Deep TMS as the Initial Catalyst: Deep TMS can
be used to break the cycle of treatment resistance,
alleviating core depressive symptoms such as
anhedonia and psychomotor retardation. By
DECEMBER/JANUARY 2025-2026
