A total of 522 psychiatrists from 30 provinces and autonomous regions in China completing the questionnaire, of which 268 (51.3%) were male and 254 (48.7%) were female, with a mean age of 38.7 ± 8.5 years. Demographic characteristics of the psychiatrists are shown in Table 1. The proportions of specialty hospitals and psychiatric departments in general hospitals were 72.2% and 27.8%, respectively. A total of 230 psychiatrists (44.1%) received formal training in rTMS theory, and 149 psychiatrists (28.5%) applied rTMS in their clinical practice. A total of 451 psychiatrists (86.4%) reported having access to rTMS within their clinical departments, and 71 psychiatrists (13.6%) reported that they did not have access or were unsure about access.
Knowledge about rTMS
As shown in Table 2, the psychiatrists were asked whether they knew about the FDA’s approval of rTMS for treatment-resistant depression; 379 psychiatrists (72.6%) answered “yes,” and 143 (27.4%) answered “no.” We then performed binary logistic regression analysis to identify sociodemographic characteristics and relevant factors that were associated with knowledge about rTMS. In the univariate logistic regression analysis, several factors were independently associated with knowledge about rTMS, including age, having a senior professional title, working more years, having an onsite clinical rTMS program in their hospital, receiving formal theory education, and receiving professional training (Table 2).
Multivariate logistic regression analysis showed that working for more than 20 years and receiving formal training in rTMS theory facilitated knowledge about the FDA’s approval of rTMS for treatment-refractory depression. Compared with respondents who were employed for 1-10 years, respondents who were employed for > 20 years were more likely to know about FDA approval (OR = 2.09, 95% CI = 1.23-3.59, p < 0.01). Receiving formal training in rTMS theory was associated with more knowledge about rTMS (OR = 3.50, 95% CI = 2.25-5.43).
A total of 51.9% of the respondents knew most or all indications for rTMS. Less than 50% of the respondents knew most or all principles of rTMS, parameter settings, adverse reactions, and contraindications (40.2%, 27.4%, and 41.4%, respectively; Table 3). We then performed multiple linear regression analysis to investigate the effects of age, gender, years of education, educational background, professional title, attributes of departments and hospitals, and receiving training in rTMS theory and application on psychiatrists’ knowledge about rTMS. In the model of comprehensive knowledge about rTMS, three variables (onsite clinical rTMS program in the hospital, having received training in rTMS theory, and having received training in rTMS application) were significant (all p < 0.001; Table 4), which explained 44.5% of the variance of knowledge about rTMS (adjusted R2 = 0.445, p < 0.001). These results indicate that theoretical training in rTMS was vital for the psychiatrists’ knowledge.
Attitudes about rTMS
Table 5 shows the psychiatrists’ attitudes about rTMS. We first asked whether the psychiatrists would recommend rTMS alone for patients with refractory mental disorders. Only 27 of the 522 respondents answered that they would strongly recommend this approach. This low likelihood had several reasons. First, the psychiatrists reported that rTMS has no effect or limited effect on mental disease (51.1%). Second, a slow onset of rTMS efficacy may delay treatment (51.1%). Third, the cost of rTMS is not covered by medical insurance in most parts of the country, which would place a financial burden on patients (29.8%). Fourth, some of the psychiatrists did not know how to design a treatment plan because of their lack of knowledge about rTMS (27.7%). The psychiatrists were then asked whether they would recommend rTMS as a combination therapy with other interventions to treat mental disorders. Only 53 of the 522 respondents (10.2%) answered that they would strongly recommend rTMS as an adjunct therapy to treat refractory mental disorders. The following reasons were given for not recommending rTMS. First, the psychiatrists reported that rTMS has no effect or limited effect on mental disease (66.7%). Second, a slow onset of TMS efficacy may delay treatment (50.0%). Third, some of the psychiatrists did not know how to design a treatment plan because of their lack of knowledge about rTMS (33.3%). Fourth, the cost of rTMS is not covered by medical insurance in most parts of the country, which would place a financial burden on patients (16.7%). The psychiatrists were then asked about their attitudes about continuing rTMS education, and nearly 100.0% of the respondents had a positive attitude. A total of 294 respondents (56.0%) reported that they would pursue continuing education training in rTMS certainly in the future (Table 5).
Recommendations for rTMS
To accelerate the clinical application of rTMS, we also asked the psychiatrists for their recommendations about rTMS. The results are shown in Table 6. A total of 86.4% of the respondents reported an urgent need to expand the scope of medical insurance reimbursement to include the cost of rTMS. A total of 371 respondents (71.1%) indicated the need to enhance the intensity of scientific research and optimize treatment plans for rTMS. A total of 77.0% of the respondents reported that formal training in rTMS theory and practice is also needed among psychiatrists to achieve standardized use. A total of 372 of the 522 respondents (71.3%) suggested formulating treatment specifications for rTMS. A total of 72.0% of the respondents recommended that rTMS should be popularized among patients.