1
|
Rakesh G, Cordero P, Khanal R, Himelhoch SS, Rush CR. Optimally combining transcranial magnetic stimulation with antidepressants in major depressive disorder: A systematic review and Meta-analysis. J Affect Disord 2024; 358:432-439. [PMID: 38740269 DOI: 10.1016/j.jad.2024.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 04/12/2024] [Accepted: 05/06/2024] [Indexed: 05/16/2024]
Abstract
There is a critical knowledge gap in optimally combining transcranial magnetic stimulation (TMS) and antidepressants to treat patients with major depressive disorder (MDD). TMS is effective in treating MDD in patients who have failed at least one antidepressant trial, with accelerated protocols showing faster remission in treatment-resistant depression (TRD). Although clinicians routinely augment antidepressants with TMS, there is a knowledge gap in stopping versus continuing antidepressants or the dosing strategies when starting or tapering TMS. These considerations are important when considering maintenance TMS (delivered alone or in combination with suitable antidepressants) to maintain remission in MDD after the index course of TMS. As the first step towards filling this knowledge gap, we reviewed randomized controlled trials (RCTs) and open-label trials from 2 databases (PubMed/Medline and EMBASE) that compared active TMS combined with a pre-specified antidepressant dosed in the same manner for adults with MDD versus sham TMS combined with the same antidepressant as in the active arm. All studies were published between January 1, 2000, and December 31, 2023. We excluded case reports, case series, and clinical studies that augmented TMS with antidepressants and vice versa. We found 10 RCTs (n = 654 participants) and performed a meta-analysis. This showed active TMS combined with pre-specified antidepressants had greater efficacy for MDD treatment than sham TMS combined with the same antidepressants as in the active arm (Hedge's g = 1; 95 % CI [0.27, 1.73]). The review and meta-analysis indicate greater short-term efficacy in combining antidepressants with TMS from the get-go in MDD. Given the increasing role of accelerated TMS protocols in expediting remission in MDD and the results of our meta-analysis, we advocate for RCTs examining the short-term and long-term effects of various antidepressant classes on these TMS protocols in MDD. This can also optimize and individualize maintenance TMS protocols to prevent relapse in MDD.
Collapse
Affiliation(s)
- Gopalkumar Rakesh
- Department of Psychiatry, College of Medicine, University of Kentucky, Lexington, KY, United States of America.
| | - Patrick Cordero
- Department of Psychiatry and Behavioral Health, The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Rebika Khanal
- University of Kentucky College of Medicine, Lexington, KY, United States of America
| | - Seth S Himelhoch
- Department of Psychiatry, College of Medicine, University of Kentucky, Lexington, KY, United States of America
| | - Craig R Rush
- Department of Behavioral Sciences, College of Medicine, University of Kentucky, Lexington, KY, United States of America
| |
Collapse
|
2
|
Wang WL, Wang SY, Hung HY, Chen MH, Juan CH, Li CT. Safety of transcranial magnetic stimulation in unipolar depression: A systematic review and meta-analysis of randomized-controlled trials. J Affect Disord 2022; 301:400-425. [PMID: 35032510 DOI: 10.1016/j.jad.2022.01.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND To study the safety and patients' tolerance of transcranial magnetic stimulation (TMS), we conducted a systematic review and meta-analysis of the major depressive disorder population. METHODS Our study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the literature published before April 30th, 2021 and performed a random-effects meta-analyses which included drop-out due to adverse events, serious adverse events and other non-serious adverse events as primary and secondary outcomes. RESULTS A total of 53 randomized sham-controlled trials with 3,273 participants were included. There was no increased risk of drop-out due to an adverse event (active TMS intervention group=3.3%, sham TMS intervention group=2.3%, odds ratio = 1.30, 95% CI= 0.78-2.16, P = 0.31) or a serious adverse event (active TMS intervention group=0.9%, sham TMS intervention group=1.5%, odds ratio = 0.67, 95% CI= 0.29-1.55, P = 0.35). Our findings suggest that TMS intervention may significantly increase the risk of non-serious adverse events including: headaches (active TMS intervention group=22.6%, sham TMS intervention group=16.2%, odds ratio = 1.48, 95% CI= 1.15-1.91, P = 0.002), discomfort (active TMS intervention group=10.9%, sham TMS intervention group=5.0%, odds ratio 1.98, 95% CI= 1.22-3.21, P = 0.006) and pain (active TMS intervention group=23.8%, sham TMS intervention group=5.2%, odds ratio= 8.09, 95% CI= 4.71-13.90, P < 0.001) at the stimulation site, but these non-serious events were mostly mild and transient after TMS treatment. CONCLUSIONS These findings provide evidence for the safety and patients' tolerance of transcranial magnetic stimulation technique as an alternative monotherapy or as an add-on treatment for major depressive disorder.
Collapse
Affiliation(s)
- Wei-Li Wang
- Department of Psychiatry, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan; Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; Master of Public Health Degree Program, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Shen-Yi Wang
- Department of Psychiatry, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Hao-Yuan Hung
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan; Department of Pharmacy Practice, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Mu-Hong Chen
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Psychiatry, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Chi-Hung Juan
- Institute of Cognitive Neuroscience, National Central University, Jhongli, Taiwan
| | - Cheng-Ta Li
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Pharmacy Practice, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Division of Psychiatry, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan; Institute of Cognitive Neuroscience, National Central University, Jhongli, Taiwan; Institute of Brain Science, National Yang-Ming Chiao-Tung University, Taipei, Taiwan; Institute of Brain Science and Brain Research Center, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan.
| |
Collapse
|
3
|
Miuli A, Sepede G, Stigliano G, Mosca A, Di Carlo F, d’Andrea G, Lalli A, Spano MC, Pettorruso M, Martinotti G, di Giannantonio M. Hypomanic/manic switch after transcranial magnetic stimulation in mood disorders: A systematic review and meta-analysis. World J Psychiatry 2021; 11:477-490. [PMID: 34513609 PMCID: PMC8394688 DOI: 10.5498/wjp.v11.i8.477] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/24/2021] [Accepted: 07/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nowadays there is an increasing use of transcranial magnetic stimulation (TMS) both in neurological and psychiatric fields. After Food and Drug Administration approval of TMS for the therapy of treatment-resistant depression, TMS has been widely used in the context of mood disorders (MD). However, growing reports regarding the possibility of developing hypomanic/manic switch (HMS) have generated concern regarding its use in MDs.
AIM To investigate the actual risk of developing HMS due to TMS in the treatment of MD.
METHODS We led our research on PubMed, Scopus and Web of Science on March 22, 2020, in accordance to the PRISMA guidelines for systematic review. Only double blind/single blind studies, written in English and focused on the TMS treatment of MD, were included. A meta-analysis of repetitive TMS protocol studies including HMS was conducted using RevMan 5.4 software. The assessment of Risk of Bias was done using Cochrane risk of bias tool. This protocol was registered on PROSPERO with the CRD42020175811 code.
RESULTS Twenty-five studies were included in our meta-analysis: Twenty-one double blind randomized controlled trials (RCT) and four single blind-RCT (no. of subjects involved in active stimulation = 576; no. of subjects involved in sham protocol = 487). The most frequently treated pathology was major depressive episode/major depressive disorder, followed by resistant depression, bipolar depression and other MD. The majority of the studies used a repetitive TMS protocol, and the left dorsolateral prefrontal cortex was the main target area. Side effects were reported in eight studies and HMS (described as greater energy, insomnia, irritability, anxiety, suicidal attempt) in four studies. When comparing active TMS vs sham treatment, the risk of developing HMS was not significantly different between conditions.
CONCLUSION Applying the most usual protocols and the appropriate precautionary measures, TMS seems not to be related to HMS development.
Collapse
Affiliation(s)
- Andrea Miuli
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d'Annunzio” University of Chieti, Chieti 66100, Italy
| | - Gianna Sepede
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d'Annunzio” University of Chieti, Chieti 66100, Italy
| | - Gianfranco Stigliano
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d'Annunzio” University of Chieti, Chieti 66100, Italy
| | - Alessio Mosca
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d'Annunzio” University of Chieti, Chieti 66100, Italy
| | - Francesco Di Carlo
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d'Annunzio” University of Chieti, Chieti 66100, Italy
| | - Giacomo d’Andrea
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d'Annunzio” University of Chieti, Chieti 66100, Italy
| | - Aliseo Lalli
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d'Annunzio” University of Chieti, Chieti 66100, Italy
| | - Maria Chiara Spano
- Department of Psychiatry Affective Neuropsychiatry, Sahlgrenska University Hospital, Göteborg 40530, Sweden
| | - Mauro Pettorruso
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d'Annunzio” University of Chieti, Chieti 66100, Italy
| | - Giovanni Martinotti
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d'Annunzio” University of Chieti, Chieti 66100, Italy
- Department of Pharmacy, Clinical Science, University of Hertfordshire, Herts AL10 9AB, Italy
| | - Massimo di Giannantonio
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d'Annunzio” University of Chieti, Chieti 66100, Italy
| |
Collapse
|
4
|
Homan S, Muscat W, Joanlanne A, Marousis N, Cecere G, Hofmann L, Ji E, Neumeier M, Vetter S, Seifritz E, Dierks T, Homan P. Treatment effect variability in brain stimulation across psychiatric disorders: A meta-analysis of variance. Neurosci Biobehav Rev 2021; 124:54-62. [PMID: 33482243 DOI: 10.1016/j.neubiorev.2020.11.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/26/2020] [Accepted: 11/29/2020] [Indexed: 02/07/2023]
Abstract
Noninvasive brain stimulation methods such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) are promising add-on treatments for a number of psychiatric conditions. Yet, some of the initial excitement is wearing off. Randomized controlled trials (RCT) have found inconsistent results. This inconsistency is suspected to be the consequence of variation in treatment effects and solvable by identifying responders in RCTs and individualizing treatment. However, is there enough evidence from RCTs that patients respond differently to treatment? This question can be addressed by comparing the variability in the active stimulation group with the variability in the sham group. We searched MEDLINE/PubMed and included all double-blinded, sham-controlled RCTs and crossover trials that used TMS or tDCS in adults with a unipolar or bipolar depression, bipolar disorder, schizophrenia spectrum disorder, or obsessive compulsive disorder. In accordance with the PRISMA guidelines to ensure data quality and validity, we extracted a measure of variability of the primary outcome. A total of 130 studies with 5748 patients were considered in the analysis. We calculated variance-weighted variability ratios for each comparison of active stimulation vs sham and entered them into a random-effects model. We hypothesized that treatment effect variability in TMS or tDCS would be reflected by increased variability after active compared with sham stimulation, or in other words, a variability ratio greater than one. Across diagnoses, we found only a minimal increase in variability after active stimulation compared with sham that did not reach statistical significance (variability ratio = 1.03; 95% CI, 0.97, 1.08, P = 0.358). In conclusion, this study found little evidence for treatment effect variability in brain stimulation, suggesting that the need for personalized or stratified medicine is still an open question.
Collapse
Affiliation(s)
- Stephanie Homan
- University Hospital of Psychiatry Zurich, Zurich, Switzerland; University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland.
| | - Whitney Muscat
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA; Division of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, New York, NY, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
| | - Andrea Joanlanne
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA; Division of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, New York, NY, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
| | | | - Giacomo Cecere
- University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Lena Hofmann
- University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Ellen Ji
- University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Maria Neumeier
- University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Stefan Vetter
- University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Erich Seifritz
- University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Thomas Dierks
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Philipp Homan
- University Hospital of Psychiatry Zurich, Zurich, Switzerland; Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA; Division of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, New York, NY, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.
| |
Collapse
|
5
|
Hobot J, Klincewicz M, Sandberg K, Wierzchoń M. Causal Inferences in Repetitive Transcranial Magnetic Stimulation Research: Challenges and Perspectives. Front Hum Neurosci 2021; 14:586448. [PMID: 33584220 PMCID: PMC7873895 DOI: 10.3389/fnhum.2020.586448] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022] Open
Abstract
Transcranial magnetic stimulation (TMS) is used to make inferences about relationships between brain areas and their functions because, in contrast to neuroimaging tools, it modulates neuronal activity. The central aim of this article is to critically evaluate to what extent it is possible to draw causal inferences from repetitive TMS (rTMS) data. To that end, we describe the logical limitations of inferences based on rTMS experiments. The presented analysis suggests that rTMS alone does not provide the sort of premises that are sufficient to warrant strong inferences about the direct causal properties of targeted brain structures. Overcoming these limitations demands a close look at the designs of rTMS studies, especially the methodological and theoretical conditions which are necessary for the functional decomposition of the relations between brain areas and cognitive functions. The main points of this article are that TMS-based inferences are limited in that stimulation-related causal effects are not equivalent to structure-related causal effects due to TMS side effects, the electric field distribution, and the sensitivity of neuroimaging and behavioral methods in detecting structure-related effects and disentangling them from confounds. Moreover, the postulated causal effects can be based on indirect (network) effects. A few suggestions on how to manage some of these limitations are presented. We discuss the benefits of combining rTMS with neuroimaging in experimental reasoning and we address the restrictions and requirements of rTMS control conditions. The use of neuroimaging and control conditions allows stronger inferences to be gained, but the strength of the inferences that can be drawn depends on the individual experiment's designs. Moreover, in some cases, TMS might not be an appropriate method of answering causality-related questions or the hypotheses have to account for the limitations of this technique. We hope this summary and formalization of the reasoning behind rTMS research can be of use not only for scientists and clinicians who intend to interpret rTMS results causally but also for philosophers interested in causal inferences based on brain stimulation research.
Collapse
Affiliation(s)
- Justyna Hobot
- Consciousness Lab, Psychology Institute, Jagiellonian University, Krakow, Poland
- Center of Functionally Integrative Neuroscience, Aarhus University, Aarhus, Denmark
| | - Michał Klincewicz
- Cognitive Science, Institute of Philosophy, Jagiellonian University, Krakow, Poland
- Department of Cognitive Science and Artificial Intelligence, Tilburg University, Tilburg, Netherlands
| | - Kristian Sandberg
- Center of Functionally Integrative Neuroscience, Aarhus University, Aarhus, Denmark
- Center of Functionally Integrative Neuroscience, Aarhus University Hospital, Aarhus, Denmark
| | - Michał Wierzchoń
- Consciousness Lab, Psychology Institute, Jagiellonian University, Krakow, Poland
| |
Collapse
|
6
|
Maneeton B, Maneeton N, Woottiluk P, Likhitsathian S. Repetitive Transcranial Magnetic Stimulation Combined with Antidepressants for the First Episode of Major Depressive Disorder. Curr Neuropharmacol 2020; 18:852-860. [PMID: 32091338 PMCID: PMC7569318 DOI: 10.2174/1570159x18666200221113134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/11/2020] [Accepted: 02/19/2020] [Indexed: 12/20/2022] Open
Abstract
Objectives The aims of this study were to systematically review the efficacy, acceptability, and tolerability of repetitive transcranial magnetic stimulation (rTMS) combined with antidepressants in the treatment of the first major depressive disorder (MDD) episode. Materials and Methods The primary efficacious outcome was the pooled mean-endpoint scores of the Hamilton Depression Rating Scale (HAMD). Rates of response, remission rate, overall discontinuation and discontinuation due to adverse events were also evaluated. Search in the Scopus, PubMed, CINAHL, and Cochrane Controlled Trials Register databases for interesting outcomes was carried out in March 2018. Results A total of 108 randomized patients of two randomized controlled trials were included in this study. The pooled mean- endpoint scores of the HAMD in one, two, and four weeks for rTMS plus antidepressants (citalopram or paroxetine) were greater than that of sham plus the antidepressants. The pooled rates of overall discontinuation and discontinuation rates due to adverse events were not different between the two groups. Conclusion According to a piece of limited evidence, the high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) could accelerate the antidepressant effect of SSRIs in young patients with a first-episode major depressive disorder. However, the acceptability and tolerability of HF-rTMS in the treatment of such patients are no better than an antidepressant alone. However, further well-defined and large sample-size studies of HF-rTMS combined with an antidepressant in MDD should be carried out to warrant these results.
Collapse
Affiliation(s)
- Benchalak Maneeton
- Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Narong Maneeton
- Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pakapan Woottiluk
- Psychiatric Nursing Division, Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand
| | | |
Collapse
|
7
|
Wang YM, Li N, Yang LL, Song M, Shi L, Chen WH, Li SX, Wang XY, Lu L. Randomized controlled trial of repetitive transcranial magnetic stimulation combined with paroxetine for the treatment of patients with first-episode major depressive disorder. Psychiatry Res 2017; 254:18-23. [PMID: 28441583 DOI: 10.1016/j.psychres.2017.04.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 12/19/2016] [Accepted: 04/01/2017] [Indexed: 12/28/2022]
Abstract
Repetitive transcranial magnetic stimulation (rTMS) has been introduced as a new and effective treatment option for major depression. This paper examined the effectiveness of rTMS on first episode depressed patients when combined with antidepressant drugs. A random sample of forty-three first-episode depressed patients received active or sham rTMS to the left dorsolateral prefrontal cortex, and concomitantly took paroxetine for 4 weeks, and paroxetine monotherapy for 4 weeks afterwards. Response was defined as a ≥50% decrease on the total Hamilton Depression Rating Scale (HDRS) from the baseline, and remission was defined as an HDRS total residual score <8. The dosage of paroxetine was the average dose per day in each week. Repeated-measures ANOVA revealed a significant improvement in the HDRS with active compared with sham rTMS from the end of the 1st week to the 4th week. At the end of the 4th week, response rate was 95.5% with active and 71.4% with sham rTMS, remission rate was 68.2% with active and 38.1% with sham rTMS, while these significant differences disappeared at the endpoint of the study. These findings indicate that rTMS at 10-Hz accelerated the onset of action and augmented the response to paroxetine for first-episode depressed patients.
Collapse
Affiliation(s)
- Yu-Mei Wang
- Institute of Mental Health, Brain Aging and Cognitive Neuroscience Laboratory, Hebei Medical University, Shijiazhuang 050030, China
| | - Ning Li
- Institute of Mental Health, Brain Aging and Cognitive Neuroscience Laboratory, Hebei Medical University, Shijiazhuang 050030, China
| | - Lin-Lin Yang
- Institute of Mental Health, Brain Aging and Cognitive Neuroscience Laboratory, Hebei Medical University, Shijiazhuang 050030, China
| | - Mei Song
- Institute of Mental Health, Brain Aging and Cognitive Neuroscience Laboratory, Hebei Medical University, Shijiazhuang 050030, China
| | - Le Shi
- National Institute on Drug Dependence, Peking University, Beijing 100191, China; Institute of Mental Health/Peking University Sixth Hospital and Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing 100191, China
| | - Wen-Hao Chen
- Institute of Mental Health/Peking University Sixth Hospital and Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing 100191, China
| | - Su-Xia Li
- National Institute on Drug Dependence, Peking University, Beijing 100191, China.
| | - Xue-Yi Wang
- Institute of Mental Health, Brain Aging and Cognitive Neuroscience Laboratory, Hebei Medical University, Shijiazhuang 050030, China.
| | - Lin Lu
- National Institute on Drug Dependence, Peking University, Beijing 100191, China; Institute of Mental Health/Peking University Sixth Hospital and Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing 100191, China
| |
Collapse
|
8
|
Beuzon G, Timour Q, Saoud M. Predictors of response to repetitive transcranial magnetic stimulation (rTMS) in the treatment of major depressive disorder. Encephale 2016; 43:3-9. [PMID: 28034451 DOI: 10.1016/j.encep.2016.11.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/28/2016] [Accepted: 11/16/2016] [Indexed: 01/01/2023]
Abstract
Repetitive transcranial magnetic stimulation (rTMS), based on the principle of electromagnetic induction, consists of applying series of magnetic impulses to the cerebral cortex so as to modulate neurone activity in a target zone. This technique, still experimental, could prove promising in the field of psychiatry, in particular for the treatment of major depressive disorder. It is important for the clinician to be able to assess the response potential of a given patient to rTMS, and this among other things requires relevant predictive factors to be available. This review of the literature aims to determine and analyse reported predictive factors for therapeutic response to rTMS treatment in major depressive disorder. Different parameters are studied, in particular age, the severity of the depressive episode, psychological dimensions, genetic factors, cerebral blood flows via cerebral imagery, and neuronavigation. The factors found to be associated with better therapeutic response were young age, low level of severity of the depressive episode, motor threshold intensity over 100%, more than 1000 stimulations per session, more than 10 days treatment, L/L genotype on the 5-HTTLPR transporter gene, C/C homozygosity on the promotor regions of the 5-HT1A receptor gene, Val/Val homozygosity on the BDNF gene, cordance analyses by EEG, and finally the accurate localisation provided by neuronavigation. The authors conclude that investigations in larger patient samples are required in the future, and that the work already achieved should provide lines of approach for the coming experimental studies.
Collapse
Affiliation(s)
- G Beuzon
- Pharmacologie médicale, EA 4312 neurocardiologie, physiopathologie des troubles du rythme cardiaque, hôpital Louis-Pradel, unité 50, 28, avenue du Doyen-Lépine, 69677 Bron, France.
| | - Q Timour
- Pharmacologie médicale, EA 4612 neurocardiologie, physiopathologie des troubles du rythme cardiaque hôpital Louis-Pradel, unité 50, 28, avenue du Doyen-Lépine, 69677 Bron, France.
| | - M Saoud
- Unité de recherche EA4615, PsyR, université Claude-Bernard-Lyon 1, 27-29, boulevard du 11-Novembre-1918, 69622 Lyon, France; Service de psychiatrie adultes liaison consultation, hospices civils de Lyon, 59, boulevard Pinel, 69500 Bron, France.
| |
Collapse
|
9
|
Kedzior KK, Reitz SK, Azorina V, Loo C. Durability of the antidepressant effect of the high-frequency repetitive transcranial magnetic stimulation (rTMS) In the absence of maintenance treatment in major depression: a systematic review and meta-analysis of 16 double-blind, randomized, sham-controlled trials. Depress Anxiety 2015; 32:193-203. [PMID: 25683231 DOI: 10.1002/da.22339] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 10/30/2014] [Accepted: 11/11/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The aim of the current meta-analysis was to investigate predictors of the durability of the antidepressant effect of high-frequency (>1 Hz) repetitive transcranial magnetic stimulation (rTMS) of the left dorsolateral prefrontal cortex in the absence of active maintenance treatment. METHODS Following a systematic literature search of Medline and PsycInfo, N = 16 double-blind, parallel-design, randomized-controlled trials (RCTs) with high-frequency rTMS and inactive sham were included in the current meta-analysis. The effect size (Cohen's d) was the standardized mean difference in depression scores between sham and rTMS groups (baseline -follow-up). Meta-analysis was conducted according to a random-effects model with inverse-variance weights. RESULTS Most RCTs reported only short follow-up phases of 2 weeks (range of 1-16 weeks). The antidepressant effect was observed during follow-up (in the absence of maintenance treatment) compared to baseline (overall mean weighted d = -.48, 95% confidence interval: -.70, -.25, P < .001, N = 16 RCTs with 495 patients). Such an antidepressant effect during follow-up was higher in RCTs with patients who were less severely ill, unipolar, nonpsychotic, treatment-resistant, and on antidepressants (either started with rTMS or continued at stable doses during acute treatment phases). The effect sizes were lower in RCTs with longer (8-16 weeks) compared to shorter (1-4 weeks) follow-up periods. The risk of publication bias was low. CONCLUSIONS High-frequency rTMS has only a small antidepressant effect during follow-up after short acute treatment (5-15 sessions) in the absence of active maintenance treatment. This effect depends on illness severity, decreases over time, and appears to be enhanced by antidepressants.
Collapse
Affiliation(s)
- Karina Karolina Kedzior
- Institute of Psychology and Transfer, University of Bremen, Bremen, Germany; Bremen International Graduate School of Social Sciences (BIGSSS), Jacobs University Bremen, Bremen, Germany
| | | | | | | |
Collapse
|
10
|
Brunelin J, Jalenques I, Trojak B, Attal J, Szekely D, Gay A, Januel D, Haffen E, Schott-Pethelaz AM, Brault C, Poulet E. The Efficacy and Safety of Low Frequency Repetitive Transcranial Magnetic Stimulation for Treatment-resistant Depression: The Results From a Large Multicenter French RCT. Brain Stimul 2014; 7:855-63. [DOI: 10.1016/j.brs.2014.07.040] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 07/18/2014] [Accepted: 07/31/2014] [Indexed: 02/07/2023] Open
|
11
|
Kedzior KK, Reitz SK. Short-term efficacy of repetitive transcranial magnetic stimulation (rTMS) in depression- reanalysis of data from meta-analyses up to 2010. BMC Psychol 2014; 2:39. [PMID: 25685354 PMCID: PMC4317138 DOI: 10.1186/s40359-014-0039-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 09/23/2014] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND According to a narrative review of 13 meta-analyses (published up to 2010), repetitive transcranial magnetic stimulation (rTMS) has a moderate, short-term antidepressant effect in the treatment of major depression. The aim of the current study was to reanalyse the data from these 13 meta-analyses with a uniform meta-analytical procedure and to investigate predictors of such an antidepressant response. METHODS A total of 40 double-blind, randomised, sham-controlled trials with parallel designs, utilising rTMS of the dorsolateral prefrontal cortex in the treatment of major depression, was included in the current meta-analysis. The studies were conducted in 15 countries on 1583 patients and published between 1997-2008. Depression severity was measured using the Hamilton Depression Rating Scale, Beck Depression Inventory, or Montgomery Åsberg Depression Rating Scale at baseline and after the last rTMS. A random-effects model with the inverse-variance weights was used to compute the overall mean weighted effect size, Cohen's d. RESULTS There was a significant and moderate reduction in depression scores from baseline to final, favouring rTMS over sham (overall d = -.54, 95% CI: -.68, -.41, N = 40 studies). Predictors of such a response were investigated in the largest group of studies (N = 32) with high-frequency (>1 Hz) left (HFL) rTMS. The antidepressant effect of HFL rTMS was present univariately in studies with patients receiving antidepressants (at stable doses or started concurrently with rTMS), with treatment-resistance, and with unipolar (or bipolar) depression without psychotic features. Univariate meta-regressions showed that depression scores were significantly lower after HFL rTMS in studies with higher proportion of female patients. There was little evidence for publication bias in the current analysis. CONCLUSIONS Daily rTMS (with any parameters) has a moderate, short-term antidepressant effect in studies published up to 2008. The clinical efficacy of HFL rTMS may be better in female patients not controlling for any other study parameters.
Collapse
Affiliation(s)
- Karina Karolina Kedzior
- Bremen International Graduate School of Social Sciences (BIGSSS), Jacobs University Bremen, Campus Ring 1, 28759 Bremen, Germany
| | - Sarah Kim Reitz
- Bremen International Graduate School of Social Sciences (BIGSSS), Jacobs University Bremen, Campus Ring 1, 28759 Bremen, Germany
| |
Collapse
|
12
|
Kedzior KK, Azorina V, Reitz SK. More female patients and fewer stimuli per session are associated with the short-term antidepressant properties of repetitive transcranial magnetic stimulation (rTMS): a meta-analysis of 54 sham-controlled studies published between 1997-2013. Neuropsychiatr Dis Treat 2014; 10:727-56. [PMID: 24855360 PMCID: PMC4019615 DOI: 10.2147/ndt.s58405] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) of the dorsolateral prefrontal cortex (DLPFC) appears to have short-term antidepressant properties. The aim of the current study was to update our previous meta-analysis and to investigate factors associated with the antidepressant properties of rTMS. METHOD Following a systematic literature search conducted in Medline and PsycInfo, N=14 sham-controlled, parallel design studies (published after 2008 to August 2013) that had utilized rTMS of the DLPFC in major depression were included in the current meta-analysis. The sensitivity and moderator analyses also included data from N=40 studies (published in 1997-2008) from our previous meta-analysis. The effect size (Cohen's d) in each study was the standardized difference in mean depression scores (on Hamilton Depression Rating Scale, Beck Depression Inventory, Montgomery Åsberg Depression Rating Scale) from baseline to final (after last session) in rTMS compared to sham groups. RESULTS According to a random-effects model with inverse-variance weights, depression scores were significantly reduced after rTMS compared to sham in studies published from 2008-2013 based on N=659 patients (overall mean weighted d=-0.42, 95% confidence interval: -0.66, -0.18, P=0.001). Combining studies from our past and current meta-analyses (published in 1997-2013; N=54) revealed that depression was significantly reduced after left-fast (>1 Hz), right-slow (≤1 Hz), and bilateral (or sequential) rTMS of DLPFC compared to sham. Significant antidepressant properties of rTMS were observed in studies with patients who were treatment resistant, unipolar (or bipolar), non-psychotic, medication-free (or started on antidepressants concurrently with rTMS). According to univariate meta-regressions, depression scores were significantly lower in studies with more female patients and fewer stimuli per session. There was little evidence that publication bias occurred in the analysis. CONCLUSION According to this study, the largest meta-analysis to date, short-term antidepressant properties of rTMS are independent of concurrent antidepressants and might depend on sex and the number of stimuli per session.
Collapse
Affiliation(s)
| | - Valeriya Azorina
- School of Engineering and Science, Jacobs University Bremen, Bremen, Germany
| | - Sarah Kim Reitz
- School of Humanities and Social Sciences, Jacobs University Bremen, Bremen, Germany
| |
Collapse
|
13
|
Bauer M, Pfennig A, Severus E, Whybrow PC, Angst J, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders. World J Biol Psychiatry 2013; 14:334-85. [PMID: 23879318 DOI: 10.3109/15622975.2013.804195] [Citation(s) in RCA: 373] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES This 2013 update of the practice guidelines for the biological treatment of unipolar depressive disorders was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal has been to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. The guidelines are intended for use by all physicians seeing and treating patients with these conditions. METHODS The 2013 update was conducted by a systematic update literature search and appraisal. All recommendations were approved by the Guidelines Task Force. RESULTS This first part of the guidelines (Part 1) covers disease definition, classification, epidemiology, and course of unipolar depressive disorders, as well as the management of the acute and continuation phase treatment. It is primarily concerned with the biological treatment (including antidepressants, other psychopharmacological medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of adults. CONCLUSIONS To date, there is a variety of evidence-based antidepressant treatment options available. Nevertheless there is still a substantial proportion of patients not achieving full remission. In addition, somatic and psychiatric comorbidities and other special circumstances need to be more thoroughly investigated. Therefore, further high-quality informative randomized controlled trials are urgently needed.
Collapse
Affiliation(s)
- Michael Bauer
- Department of Psychiatry and Psychotherapy, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany.
| | | | | | | | | | | | | |
Collapse
|
14
|
Ullrich H, Kranaster L, Sigges E, Andrich J, Sartorius A. Ultra-high-frequency left prefrontal transcranial magnetic stimulation as augmentation in severely ill patients with depression: a naturalistic sham-controlled, double-blind, randomized trial. Neuropsychobiology 2013; 66:141-8. [PMID: 22948250 DOI: 10.1159/000339561] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 05/21/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIM Repetitive transcranial magnetic stimulation (rTMS) is supposed to be not as effective in severe depression as it is in medium depression. We evaluated the treatment response to an ultra-high-frequency (UHF; 30 Hz) approach, which was used to maximize the rTMS efficacy in severely ill patients. METHODS 43 severely depressed patients were included in the randomized, double-blind study and received either rTMS with 30 Hz over the left dorsolateral prefrontal cortex or sham condition for 3 weeks as an add-on therapy to stable antidepressant medication. Hamilton Depression Rating Scale (HDRS) and cognitive performance were evaluated before and after the intervention. RESULTS In the active UHF group, the HRDS score was reduced by about 7.2, whereas the sham condition showed a smaller reduction of the HDRS score with 3.9. However, lithium as a covariant was responsible for the outcome difference, not the group of stimulation. No adverse events were reported. Comparing the differences of both groups in the pre- and post-study performance in a trail-making test, a group effect for the UHF group that was not influenced by the lithium intake was observed. CONCLUSION A 30-Hz left prefrontal rTMS in severely depressed patients was safe and no adverse events occurred. Due to a strong effect of lithium as a covariate, we could not demonstrate favorable antidepressant effects of the UHF stimulation compared to sham. However, we found an improvement of processing speed performance in the UHF group, which covaried with improvement of psychomotor retardation.
Collapse
Affiliation(s)
- Heiko Ullrich
- Department of Psychiatry and Psychotherapy, Kreisklinikum Siegen GmbH, Siegen, Germany
| | | | | | | | | |
Collapse
|
15
|
Mishra BR, Sarkar S, Praharaj SK, Mehta VS, Diwedi S, Nizamie SH. Repetitive transcranial magnetic stimulation in psychiatry. Ann Indian Acad Neurol 2012; 14:245-51. [PMID: 22346010 PMCID: PMC3271460 DOI: 10.4103/0972-2327.91935] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 03/25/2011] [Accepted: 10/14/2011] [Indexed: 11/29/2022] Open
Abstract
Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive and relatively painless tool that has been used to study various cognitive functions as well as to understand the brain–behavior relationship in normal individuals as well as in those with various neuropsychiatric disorders. It has also been used as a therapeutic tool in various neuropsychiatric disorders because of its ability to specifically modulate distinct brain areas. Studies have shown that repeated stimulation at low frequency produces long-lasting inhibition, which is called as long-term depression, whereas repeated high-frequency stimulation can produce excitation through long-term potentiation. This paper reviews the current status of rTMS as an investigative and therapeutic modality in various neuropsychiatric disorders. It has been used to study the cortical and subcortical functions, neural plasticity and brain mapping in normal individuals and in various neuropsychiatric disorders. rTMS has been most promising in the treatment of depression, with an overall milder adverse effect profile compared with electroconvulsive therapy. In other neuropsychiatric disorders such as schizophrenia, mania, epilepsy and substance abuse, it has been found to be useful, although further studies are required to establish therapeutic efficacy. It appears to be ineffective in the treatment of obsessive compulsive disorder. There is a paucity of studies of efficacy and safety of rTMS in pediatric and geriatric population. Although it appears safe, further research is required to optimize its efficacy and reduce the side-effects. Magnetic seizure therapy, which involves producing seizures akin to electroconvulsive therapy, appears to be of comparable efficacy in the treatment of depression with less cognitive adverse effects.
Collapse
Affiliation(s)
- Biswa Ranjan Mishra
- Department of Psychiatry, M.K.C.G. Medical College, Berhampur, Orissa, India
| | | | | | | | | | | |
Collapse
|
16
|
Cho SS, Yoon EJ, Lee JM, Kim SE. Repetitive transcranial magnetic stimulation of the left dorsolateral prefrontal cortex improves probabilistic category learning. Brain Topogr 2012; 25:443-9. [PMID: 22842936 DOI: 10.1007/s10548-012-0242-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 07/16/2012] [Indexed: 10/28/2022]
Abstract
Traditionally, it has been thought that probabilistic category learning, one of the implicit memory functions, is dependent on the basal ganglia. However, there is growing evidence indicating the involvement of the dorsolateral prefrontal cortex (DLPFC) in probabilistic category learning. In order to identify the causal role of DLPFC in probabilistic category learning, we investigated whether repetitive transcranial magnetic stimulation (rTMS) over the left DLPFC influences the learning ability in healthy subjects using the weather prediction task (WPT). Application of 10 Hz rTMS over the left DLPFC induced significant improvement in the total hit rate during the total trials of the WPT, compared with sham stimulation. Specifically, the improvement was significant in the early and late learning blocks of the WPT, but not in the intermediate block of learning. These results indicate that the left DLPFC may play an important role in probabilistic category learning, possibly by influencing not only on embodied information application in late stage of the learning but also on memory encoding for working memory demands in early stage of the learning via frontostriatal and frontohippocampal circuits, respectively. They also may lend support to the possibility that rTMS can improve implicit learning ability in patients with basal ganglia disorders.
Collapse
|
17
|
Abstract
Given the limitations of evidence for treatment options that are consistently effective for TRD and the possibility that TRD is in fact a form of depression that has a low probability of resolving, how can clinicians help patients with TRD? Perhaps the most important conceptual shift that needs to take place before treatment can be helpful is to accept TRD as a chronic illness, an illness similar to many others, one that can be effectively managed but that is not, at our present level of knowledge, likely to be cured. An undue focus on remission or even a 50% diminution of symptoms sets unrealistic goals for both patients and therapists and may lead to overtreatment and demoralization. The focus should be less on eliminating depressive symptoms and more on making sense of and learning to function better in spite of them. It is important to acknowledge the difficult nature of the depressive illness, to remove blame from the patient and clinician for not achieving remission, to set realistic expectations, and to help promote better psychosocial functioning even in the face of persisting symptoms. The critical element when implementing such an approach is a judicious balance between maintaining hope for improvement without setting unrealistic expectations. It is important to reemphasize that following a disease management model with acceptance of the reality of a chronic illness is not nihilistic and does not mean the abandonment of hope for improvement. The first step in treating a patient with TRD is to perform a comprehensive assessment of the patient’s past and current treatment history to ensure that evidence-based treatment trials have in fact been undertaken, and if not, such treatment trials should be implemented. If the patient continues to have significant residual symptoms, it is important to determine the impact is of these symptoms on the patient’s quality of life and ability to function. It is also important to evaluate the factors that may be contributing to the persistence of depressive symptoms such as comorbid personality disorders, somatic disorders, substance abuse, and work and interpersonal conflicts. The treatment of patients with TRD needs to move beyond attempts to modify symptoms without taking into consideration and attempting to modify the patient’s personality, coping skills, and social system. Further somatic treatment trials can be undertaken, if desired by the patient and therapist, as a small (5%–15%) percentage of patients may respond and further treatment trials, and this may engender hope. The risk with this approach is that patients and therapists may not work at disease management skills if they believe there may be a resolution of the depression if they could just find the right medication or intervention. Therapists may also feel pressured by patients, families, insurance companies, as well as their own sense of helplessness to escalate treatment in a more and more aggressive manner in an attempt to achieve an elusive remission. A disease management program can provide the therapist and patient with sufficient structure, skills, and goals to encourage ongoing treatment without resorting to unproven measures that may create more side effects and problems. It is particularly important to include the patient’s significant others in the reformulation of the patient’s problem and thereby learn how to manage the illness more effectively. Significant others and family members can be invaluable in providing support for dealing with the difficult process of acquiring a new skill set. Indeed, they spend significantly more time with the patient than does any therapist. Family members are likely to provide this kind of support only if they have been part of the assessment and treatment process. Patients with a wide range of chronic medical illnesses can and do learn to function effectively and to achieve a satisfying quality of life in spite of their illness. There is no reason to think that patients with TRD should not be able to achieve a similar level of illness management, functioning, and quality of life.
Collapse
Affiliation(s)
- Gabor I Keitner
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02912, USA.
| | | |
Collapse
|
18
|
Eche J, Mondino M, Haesebaert F, Saoud M, Poulet E, Brunelin J. Low- vs High-Frequency Repetitive Transcranial Magnetic Stimulation as an Add-On Treatment for Refractory Depression. Front Psychiatry 2012; 3:13. [PMID: 22408627 PMCID: PMC3296064 DOI: 10.3389/fpsyt.2012.00013] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 02/12/2012] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Repetitive transcranial magnetic stimulation (rTMS) seems to be effective as an antidepressant, however, some confusion remains about the best parameters to apply and the efficacy of its association with pharmacological antidepressant treatments. METHOD In a single blind randomized study 14 patients with unipolar resistant depression to one antidepressant treatment were enrolled to receive, in combination with venlafaxine (150 mg), either 20 sessions of 10 Hz rTMS (2000 pulses per session) applied over the left dorsolateral prefrontal cortex (DLPFC) or 20 sessions of 1 Hz rTMS (120 stimulations per sessions) applied over the right DLPFC. RESULTS A similar antidepressant effect was observed in both groups with a comparable antidepressant delay of action (2 weeks) and a comparable number of responders (MADRS < 15) after 4 weeks of daily rTMS sessions (66 vs 50%). CONCLUSION Low- and high- frequency rTMS seems to be effective as an add-on treatment to venlafaxine as monotherapy in pharmacological refractory major depression (stage 1). Due to its short duration (one session of 1 Hz rTMS lasts 4 min vs 16 for 10 Hz rTMS) and its safety, low frequency rTMS may be a useful alternative treatment for patients with refractory depression.
Collapse
|
19
|
Abstract
Major depressive disorder (MDD) trials - investigating either non-pharmacological or pharmacological interventions - have shown mixed results. Many reasons explain this heterogeneity, but one that stands out is the trial design due to specific challenges in the field. We aimed therefore to review the methodology of non-invasive brain stimulation (NIBS) trials and provide a framework to improve clinical trial design. We performed a systematic review for randomized, controlled MDD trials whose intervention was transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) in MEDLINE and other databases from April 2002 to April 2008. We created an unstructured checklist based on CONSORT guidelines to extract items such as power analysis, sham method, blinding assessment, allocation concealment, operational criteria used for MDD, definition of refractory depression and primary study hypotheses. Thirty-one studies were included. We found that the main methodological issues can be divided in to three groups: (1) issues related to phase II/small trials, (2) issues related to MDD trials and, (3) specific issues of NIBS studies. Taken together, they can threaten study validity and lead to inconclusive results. Feasible solutions include: estimating the sample size a priori; measuring the degree of refractoriness of the subjects; specifying the primary hypothesis and statistical tests; controlling predictor variables through stratification randomization methods or using strict eligibility criteria; adjusting the study design to the target population; using adaptive designs and exploring NIBS efficacy employing biological markers. In conclusion, our study summarizes the main methodological issues of NIBS trials and proposes a number of alternatives to manage them.
Collapse
|
20
|
Triggs WJ, Ricciuti N, Ward HE, Cheng J, Bowers D, Goodman WK, Kluger BM, Nadeau SE. Right and left dorsolateral pre-frontal rTMS treatment of refractory depression: a randomized, sham-controlled trial. Psychiatry Res 2010; 178:467-74. [PMID: 20643486 DOI: 10.1016/j.psychres.2010.05.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 04/20/2010] [Accepted: 05/07/2010] [Indexed: 11/22/2022]
Abstract
We conducted a prospective, randomized, sham-controlled, double blind, parallel group study of right or left pre-frontal rTMS in 48 subjects with medication-resistant depression. Two thousand (50x8-s trains of 5Hz) stimuli at MEP threshold were delivered each weekday for 2weeks. We employed a sham coil and simultaneous electrical stimulation of the scalp to simulate rTMS. Mean (+/-S.D.) reductions in the HAMD-24 from baseline to 3-months were not significantly different between rTMS and sham treatment groups. However, right cranial stimulation (sham or rTMS) was significantly more effective than left cranial stimulation (sham or rTMS) (P=0.012). Mean (+/-S.D.) reductions in the HAMD from baseline to 3 months were: left: 28.1 (+/-5.36) to 19.2 (+/-11.2); and right 27.2 (+/-4.2) to 11.5 (+/-9.4). Left rTMS achieved a reduction in HAMD 9.5 points greater than that achieved by left sham, a benefit greater than that reported in a recent multi-center Phase III trial of rTMS (O'Reardon et al., 2007), albeit not statistically significant. These results suggest that somatosensory stimuli that repeatedly engage the left hemisphere may be important to the achievement of therapeutic effect.
Collapse
|
21
|
Szekely D, Polosan M, Grimaldi I, Buis C, Lhommée E, Bougerol T. Applications thérapeutiques actuelles de la stimulation magnétique transcrânienne répétée en psychiatrie. Rev Med Interne 2010; 31:508-14. [DOI: 10.1016/j.revmed.2009.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Revised: 07/15/2009] [Accepted: 08/17/2009] [Indexed: 01/18/2023]
|
22
|
Edelmuth RCL, Nitsche MA, Battistella L, Fregni F. Why do some promising brain-stimulation devices fail the next steps of clinical development? Expert Rev Med Devices 2010; 7:67-97. [PMID: 20021241 DOI: 10.1586/erd.09.64] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Interest in techniques of noninvasive brain stimulation (NIBS) has been growing exponentially in the last decade. Recent studies have shown that some of these techniques induce significant neurophysiological and clinical effects. Although recent results are promising, there are several techniques that have been abandoned despite positive initial results. In this study, we performed a systematic review to identify NIBS methods with promising preliminary clinical results that were not fully developed and adopted into clinical practice, and discuss its clinical, research and device characteristics. We identified five devices (transmeatal cochlear laser stimulation, transcranial micropolarization, transcranial electrostimulation, cranial electric stimulation and stimulation with weak electromagnetic fields) and compared them with two established NIBS devices (transcranial magnetic stimulation and transcranial direct current stimulation) and with well-known drugs used in neuropsychiatry (pramipexole and escitalopram) in order to understand the reasons why they failed to reach clinical practice and further steps of research development. Finally, we also discuss novel NIBS devices that have recently showed promising results: brain ultrasound and transcranial high-frequency random noise stimulation. Our results show that some of the reasons for the failure of NIBS devices with promising clinical findings are the difficulty to disseminate results, lack of controlled studies, duration of research development, mixed results and lack of standardization.
Collapse
Affiliation(s)
- Rodrigo C L Edelmuth
- Laboratory of Neuromodulation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | |
Collapse
|
23
|
Abstract
Treatment-resistant depression (TRD) presents major challenges for both patients and clinicians. There is no universally accepted definition of TRD, but results from the US National Institute of Mental Health's (NIMH) STAR*D (Sequenced Treatment Alternatives to Relieve Depression) programme indicate that after the failure of two treatment trials, the chances of remission decrease significantly. Several pharmacological and nonpharmacological treatments for TRD may be considered when optimized (adequate dose and duration) therapy has not produced a successful outcome and a patient is classified as resistant to treatment. Nonpharmacological strategies include psychotherapy (often in conjunction with pharmacotherapy), electroconvulsive therapy and vagus nerve stimulation. The US FDA recently approved vagus nerve stimulation as adjunctive therapy (after four prior treatment failures); however, its benefits are seen only after prolonged (up to 1 year) use. Other nonpharmacological options, such as repetitive transcranial stimulation, deep brain stimulation or psychosurgery, remain experimental and are not widely available. Pharmacological treatments of TRD can be grouped in two main categories: 'switching' or 'combining'. In the first, treatment is switched within and between classes of compounds. The benefits of switching include avoidance of polypharmacy, a narrower range of treatment-emergent adverse events and lower costs. An inherent disadvantage of any switching strategy is that partial treatment responses resulting from the initial treatment might be lost by its discontinuation in favour of another medication trial. Monotherapy switches have also been shown to have limited effectiveness in achieving remission. The advantage of combination strategies is the potential to build upon achieved improvements; they are generally recommended if partial response was achieved with the current treatment trial. Various non-antidepressant augmenting agents, such as lithium and thyroid hormones, are well studied, although not commonly used. There is also evidence of efficacy and increasing use of atypical antipsychotics in combination with antidepressants, for example, olanzapine in combination with fluoxetine (OFC) or augmentation with aripiprazole. The disadvantages of a combination strategy include multiple medications, a broader range of treatment-emergent adverse events and higher costs. Several experimental pharmaceutical treatment alternatives for TRD are also being explored in combination with antidepressants or as monotherapy. These less studied alternative compounds include pindolol, inositol, CNS stimulants, hormones, herbal supplements, omega-3 fatty acids, S-adenosyl-L-methionine, folic acid, lamotrigine, modafinil, riluzole and topiramate. In summary, despite an increasing variety of choices for the treatment of TRD, this condition remains universally undefined and represents an area of unmet medical need. There are few known approved pharmacological agents for TRD (aripiprazole and OFC) and overall outcomes remain poor. This might be an indication that depression itself is a heterogeneous condition with a great diversity of pathologies, highlighting the need for careful evaluation of individuals with depressive symptoms who are unresponsive to treatment. Clearly, more research is needed to provide clinicians with better guidance in making those treatment decisions--especially in light of accumulating evidence that the longer patients are unsuccessfully treated, the worse their long-term prognosis tends to be.
Collapse
Affiliation(s)
- Richard C Shelton
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | | | | |
Collapse
|
24
|
Kennedy SH, Milev R, Giacobbe P, Ramasubbu R, Lam RW, Parikh SV, Patten SB, Ravindran AV. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. IV. Neurostimulation therapies. J Affect Disord 2009; 117 Suppl 1:S44-53. [PMID: 19656575 DOI: 10.1016/j.jad.2009.06.039] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Accepted: 06/23/2009] [Indexed: 01/28/2023]
Abstract
BACKGROUND In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. There is renewed interest in refined approaches to brain stimulation, particularly for treatment resistant major depressive disorder (MDD). METHODS The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included evidence and expert clinical support. This section on "Neurostimulation Therapies" is one of 5 guidelines articles. RESULTS Among the four forms of neurostimulation reviewed in this section, electroconvulsive therapy (ECT) has the most extensive evidence, spanning seven decades. Repetitive transcranial magnetic (rTMS) and vagus nerve stimulation (VNS) have been approved to treat depressed adults in both Canada and the United States with a much smaller evidence base. There is also emerging evidence that deep brain stimulation (DBS) is effective for otherwise treatment resistant depression, but this is an investigational approach in 2009. LIMITATIONS Compared to other modalities for the treatment of MDD, the data based is limited by the relatively small numbers of randomized controlled trials (RCTs) and small sample sizes. CONCLUSIONS There is most evidence to support ECT as a first-line treatment under specific circumstances and rTMS as a second-line treatment. Evidence to support VNS is less robust and DBS remains an investigational treatment.
Collapse
|
25
|
Speer A, Benson B, Kimbrell T, Wassermann E, Willis M, Herscovitch P, Post R. Opposite effects of high and low frequency rTMS on mood in depressed patients: relationship to baseline cerebral activity on PET. J Affect Disord 2009; 115:386-94. [PMID: 19027962 PMCID: PMC2779113 DOI: 10.1016/j.jad.2008.10.006] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2006] [Revised: 09/08/2008] [Accepted: 10/03/2008] [Indexed: 11/16/2022]
Abstract
BACKGROUND Optimal parameters of rTMS for antidepressant efficacy in general, or within patients, have not been adequately delineated. METHODS Using a double-blind, sham-controlled, cross-over design, 22 adult patients with treatment refractory major depression (n=9; bipolar disorder, depressed phase) were randomized to active rTMS (20-Hz or 1-Hz) or sham rTMS conditions and given 5 rTMS treatments per week for two weeks. Repetitive TMS was administered at 100% of motor threshold for 1600 pulses over the left prefrontal cortex using a figure-eight coil. Patients initially randomized to sham rTMS were then exposed to two weeks of active rTMS with each frequency under blinded conditions. Those who received active 20-Hz and 1-Hz rTMS were crossed over to the opposite frequency for two weeks. Improvement in Hamilton Depression ratings were assessed after each two-week treatment phase. PET imaging was used to evaluate the patient's baseline absolute regional cerebral activity (blood flow and metabolism) as potential predictor of clinical response. RESULTS Changes in depression severity on 1-Hz and 20-Hz rTMS were inversely correlated. PET scans with baseline hypoperfusion (but not hypometabolism) were associated with better improvement on 20-Hz rTMS as predicted. LIMITATIONS The magnitude of the clinical change with either frequency at 100% motor threshold was not robust, and larger studies with higher intensities of rTMS for longer durations of time should be explored. CONCLUSIONS High and low frequency rTMS exerts differential effects on depressed mood within individual subjects. The brain activity predictors and correlates of an optimal antidepressant response to rTMS remain to be better defined.
Collapse
Affiliation(s)
- A.M. Speer
- Biological Psychiatry Branch, NIMH, NIH, Bethesda, Maryland
| | - B.E. Benson
- Biological Psychiatry Branch, NIMH, NIH, Bethesda, Maryland
| | | | | | - M.W. Willis
- Dept of Psychiatry, USUHS, Bethesda, Maryland
| | | | - R.M. Post
- Biological Psychiatry Branch, NIMH, NIH, Bethesda, Maryland
| |
Collapse
|
26
|
Brunoni AR, Lopes M, Kaptchuk TJ, Fregni F. Placebo response of non-pharmacological and pharmacological trials in major depression: a systematic review and meta-analysis. PLoS One 2009; 4:e4824. [PMID: 19293925 PMCID: PMC2653635 DOI: 10.1371/journal.pone.0004824] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 02/03/2009] [Indexed: 01/18/2023] Open
Abstract
Background Although meta-analyses have shown that placebo responses are large in Major Depressive Disorder (MDD) trials; the placebo response of devices such as repetitive transcranial magnetic stimulation (rTMS) has not been systematically assessed. We proposed to assess placebo responses in two categories of MDD trials: pharmacological (antidepressant drugs) and non-pharmacological (device- rTMS) trials. Methodology/Principal Findings We performed a systematic review and meta-analysis of the literature from April 2002 to April 2008, searching MEDLINE, Cochrane, Scielo and CRISP electronic databases and reference lists from retrieved studies and conference abstracts. We used the keywords placebo and depression and escitalopram for pharmacological studies; and transcranial magnetic stimulation and depression and sham for non-pharmacological studies. All randomized, double-blinded, placebo-controlled, parallel articles on major depressive disorder were included. Forty-one studies met our inclusion criteria - 29 in the rTMS arm and 12 in the escitalopram arm. We extracted the mean and standard values of depression scores in the placebo group of each study. Then, we calculated the pooled effect size for escitalopram and rTMS arm separately, using Cohen's d as the measure of effect size. We found that placebo response are large for both escitalopram (Cohen's d - random-effects model - 1.48; 95%C.I. 1.26 to 1.6) and rTMS studies (0.82; 95%C.I. 0.63 to 1). Exploratory analyses show that sham response is associated with refractoriness and with the use of rTMS as an add-on therapy, but not with age, gender and sham method utilized. Conclusions/Significance We confirmed that placebo response in MDD is large regardless of the intervention and is associated with depression refractoriness and treatment combination (add-on rTMS studies). The magnitude of the placebo response seems to be related with study population and study design rather than the intervention itself.
Collapse
Affiliation(s)
- André Russowsky Brunoni
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- Department and Institute of Psychiatry, University of Sao Paulo, Sao Paulo, Brazil
| | - Mariana Lopes
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ted J. Kaptchuk
- Osher Research Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Felipe Fregni
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| |
Collapse
|
27
|
Schutter DJLG. Antidepressant efficacy of high-frequency transcranial magnetic stimulation over the left dorsolateral prefrontal cortex in double-blind sham-controlled designs: a meta-analysis. Psychol Med 2009; 39:65-75. [PMID: 18447962 DOI: 10.1017/s0033291708003462] [Citation(s) in RCA: 245] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND For more than a decade high-frequency repetitive transcranial magnetic stimulation (rTMS) has been applied to the left dorsolateral prefrontal cortex (DLPFC) in search of an alternative treatment for depression. The aim of this study was to provide an update on its clinical efficacy by performing a meta-analysis involving double-blind sham-controlled studies. METHOD A literature search was conducted in the databases PubMed and Web of Science in the period between January 1980 and November 2007 with the search terms 'depression' and 'transcranial magnetic stimulation'. Thirty double-blind sham-controlled parallel studies with 1164 patients comparing the percentage change in depression scores from baseline to endpoint of active versus sham treatment were included. A random effects meta-analysis was performed to investigate the clinical efficacy of fast-frequency rTMS over the left DLPFC in depression. RESULTS The test for heterogeneity was not significant (QT=30.46, p=0.39). A significant overall weighted mean effect size, d=0.39 [95% confidence interval (CI) 0.25-0.54], for active treatment was observed (z=6.52, p<0.0001). Medication resistance and intensity of rTMS did not play a role in the effect size. CONCLUSIONS These findings show that high-frequency rTMS over the left DLPFC is superior to sham in the treatment of depression. The effect size is robust and comparable to at least a subset of commercially available antidepressant drug agents. Current limitations and future prospects are discussed.
Collapse
Affiliation(s)
- D J L G Schutter
- Experimental Psychology, Utrecht University, Utrecht, The Netherlands.
| |
Collapse
|
28
|
Foucher J, Luck D, Chassagnon S, Offerlin-meyer I, Pham B. Que manque-t-il à la rTMS pour devenir une thérapie ? Encephale 2007; 33:982-9. [DOI: 10.1016/j.encep.2007.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Accepted: 06/15/2007] [Indexed: 11/23/2022]
|
29
|
Herwig U, Fallgatter AJ, Höppner J, Eschweiler GW, Kron M, Hajak G, Padberg F, Naderi-Heiden A, Abler B, Eichhammer P, Grossheinrich N, Hay B, Kammer T, Langguth B, Laske C, Plewnia C, Richter MM, Schulz M, Unterecker S, Zinke A, Spitzer M, Schönfeldt-Lecuona C. Antidepressant effects of augmentative transcranial magnetic stimulation: randomised multicentre trial. Br J Psychiatry 2007; 191:441-8. [PMID: 17978325 DOI: 10.1192/bjp.bp.106.034371] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) has been proposed as a new treatment option for depression. Previous studies were performed with low sample sizes in single centres and reported heterogeneous results. AIMS To investigate the efficacy of rTMS as augmentative treatment in depression. METHOD In a randomised, double-blind, sham-controlled multicentre trial 127 patients with moderate to severe depressive episodes were randomly assigned to real or sham stimulation for 3 weeks in addition to simultaneously initiated antidepressant medication. RESULTS We found no difference in the responder rates of the real and the sham treatment groups (31% in each) or in the decrease of the scores on the depression rating scales. CONCLUSIONS The data do not support previous reports from smaller samples indicating an augmenting or accelerating antidepressant effect of rTMS. Further exploration of the possible efficacy of other stimulation protocols or within selected sub-populations of patients is necessary.
Collapse
Affiliation(s)
- U Herwig
- Psychiatric University Hospital, University of Zürich, Lenggstrasse 31, Zürich, Switzerland.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
|
31
|
Brunelin J, Poulet E, Boeuve C, Zeroug-vial H, d'Amato T, Saoud M. Efficacité de la stimulation magnétique transcrânienne (rTMS) dans le traitement de la dépression : revue de la littérature. Encephale 2007; 33:126-34. [PMID: 17675907 DOI: 10.1016/s0013-7006(07)91542-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION In 1985, Barker et al. showed that it was possible to stimulate both nerves and brain using external magnetic stimulation without significant pain. During the past 10 years, therapeutic effects of repeated Transcranial Magnetic Stimulation (rTMS) have been widely studied in psychiatry and its efficacy has been demonstrated in the treatment of major depressive disorders, particularly as an alternative to electroconvulsivotherapy (ECT). Facing the large range of studies, we found necessary to propose an up-to-date review in French of the methodological and therapeutic variations among them. METHOD Based on an exhaustive consultation of Medline data and the Avery-George-Holtzheimer Database of rTMS Depression-Studies, supplemented by a manual research, only works evaluating the therapeutic efficacy of rTMS on depressive symptoms were retained, excluding all studies exclusively investigating the stimulation parameters or the tolerance as well as case reports. RESULTS Out the 66 available reports we retained 30 studies. After a description of the main results of these 30 studies, several elements of the 66 will be discussed. Open studies demonstrated that short courses rTMS (5 to 10 sessions) produced a decrease in the mean Hamilton Depression Ratting Scale (HDRS) scores, although significant remission of depression in individuals was rare. Most authors had used high frequency rTMS applied to the left Dorso Lateral Prefrontal Cortex (left DLPFC). However, low frequency rTMS applied to the right DLPFC was also followed by significant reduction of HDRS scores. Parallel arm, double blind versus placebo studies are designed to clarify the therapeutic efficacy of rTMS therapy but conclude in contradicting results. Literature data globally confirms a greater efficacy of rTMS compared to placebo (37% responders in the active group vs 20% in the sham). This efficacy could in fact be even greater because the sham procedure is disputable in most studies. Indeed, positioning rTMS coil at 45 or 90 from the scalp may not represent an accurate sham procedure and the use of real sham coil is to be recommended. Only one study has suggested that associating rTMS and ECT could decrease the number of general anesthesia required. Therapeutic efficacy has been shown by either inhibiting the right DLPFC or by stimulating the left DLPFC, although some patients exhibit paradoxical responses. High frequency rTMS (>5 Hz) increases cortical excitability and metabolism, while low-frequency rTMS stimulation ( 1 Hz) has the opposite effect. Other parameters are: relevant: intensity (from 80 to 110% of motor threshold), total number of stimulations (from 120 to 2 000) and total number of rTMS sessions (from 5 to 20). As suggested in most recent studies, higher-intensity pulses, higher number of stimulation or longer treatment courses may be more effective. Greater responsiveness to rTMS may be predicted by several patients' factors, including the absence of psychosis, younger age and previous response to rTMS therapy. DISCUSSION Conclusions on these factors and others, such as the importance of anatomically accurate coil placement and the distance from the coil to the brain, await further investigation. Despite heterogeneity of these reports according to methodology and treatment parameters, the antidepressive properties of rTMS now appear obvious, opening interesting prospects, in particular in the treatment of pharmacoresistant major depressive patients and, we hope, administered as adjuvant therapy in non-resistant depression. CONCLUSION Thus, many questions remain unanswered concerning the optimal stimulation parameters, privileged indications and maintenance sessions. This justifies the development of structured evaluation trials on larger samples.
Collapse
Affiliation(s)
- J Brunelin
- EA 3092, UCBL, Professeur J. Daléry, CH Le Vinatier, 95 boulevard Pinel, 69677 Bron cedex
| | | | | | | | | | | |
Collapse
|
32
|
Rachid F, Bertschy G. Safety and efficacy of repetitive transcranial magnetic stimulation in the treatment of depression: a critical appraisal of the last 10 years. Neurophysiol Clin 2006; 36:157-83. [PMID: 17046610 DOI: 10.1016/j.neucli.2006.08.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2006] [Indexed: 01/18/2023] Open
Abstract
Depression is a common and debilitating illness, for which alternative treatments are urgently needed. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive and relatively painless experimental technique of altering brain physiology. The authors critically review the evidence for the efficacy, safety and tolerability of rTMS in the treatment of depression based on published data over the last decade. They also discuss studies which have examined relevant clinical, demographic, methodological, and technical parameters that might be implicated in optimizing the antidepressant efficacy of this technique. rTMS depression trials conducted through early 2006 are included in this review, which focuses mainly on the results of published sham-controlled studies, literature reviews and meta-analyses. Trials published so far have been characterized by the use of a great variety of stimulation parameters, study designs, questionable sham controls, small sample sizes and heterogeneously depressed populations, all of which have made comparisons between studies difficult. Meta-analyses of 2-week rTMS sham-controlled studies support, for the most part, the antidepressant effects of rTMS which are statistically superior to sham. However, the degree of clinical improvement remains small, although greater efficacy has been shown with longer treatment courses and predictors of response to rTMS are progressively being identified. rTMS is a promising antidepressant treatment with overall minor adverse effects. Because the clinical efficacy of rTMS as an antidepressant remains questionable, further systematic, large-scale multicenter studies comparing rTMS to a sham and/or to an antidepressant medication along with more stringent stimulation parameters are warranted in order to identify patient populations most likely to benefit and treatment parameters most likely to optimize its antidepressant efficacy.
Collapse
Affiliation(s)
- F Rachid
- Département de psychiatrie, service de psychiatrie adulte, hôpitaux universitaires de Genève, consultation de la jonction, 16-18, boulevard Saint-Georges, 1205 Genève, Switzerland.
| | | |
Collapse
|
33
|
Abstract
In this review of the last 5 years' developments in research into depression we focus on recent advances and current controversies. We cover epidemiology and basic science as well as the treatment of depression in adults in all its forms. Depression in , as well as in has been covered in recent Seminars in The Lancet. Depression in adulthood remains a very common and under-treated condition, resulting in a high degree of disability. Increasingly detailed knowledge about impairment of information processing in depression is being supplemented by quantitative studies of the brain processes underlying these impairments. Most patients improve with present treatments. The mechanisms of action of antidepressants are not fully understood; the hypothesis that reversing hippocampal cell loss in depression may be their active principle is a fascinating new development. Moral panic about the claim that antidepressant serotonin reuptake inhibitors cause patients to commit suicide and become addicted to their medication may have disconcerted the public and members of the medical profession. We will try to describe the considerable effort that has gone into collecting evidence to enlighten this debate.
Collapse
Affiliation(s)
- Klaus P Ebmeier
- Division of Psychiatry, University of Edinburgh, Kennedy Tower, Morningside Park, Edinburgh, UK.
| | | | | |
Collapse
|