Maintenance repetitive transcranial magnetic stimulation (rTMS) for relapse prevention in with depression: A review

Optimally combining transcranial magnetic stimulation with antidepressants in major depressive disorder: A systematic review and Meta-analysis

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.

A randomised controlled feasibility trial of intermittent theta burst stimulation with an open longer-term follow-up for young people with persistent anorexia nervosa (RaISE): Study protocol

OBJECTIVE

We present the protocol of a feasibility randomised controlled trial (RCT) of intermittent theta burst stimulation (iTBS) for young people with anorexia nervosa (AN). Effective first-line psychological therapies exist for young people with AN, but little is known about how to treat those who do not respond. Non-invasive neuromodulation, such as iTBS, could address unmet treatment needs by targeting neurocircuitry associated with the development and/or maintenance of AN.

DESIGN

Sixty-six young people (aged 13-30 years) with persistent AN will be randomly allocated to receive 20 sessions of real or sham iTBS over the left dorsolateral prefrontal cortex in addition to their usual treatment. Outcomes will be measured at baseline, post-treatment (1-month post-randomisation) and 4-months post-randomisation (when unblinding will occur). Additional open follow-ups will be conducted at 12- and 24-months post-randomisation. The primary feasibility outcome is the proportion of participants retained in the study at 4-months. Secondary outcomes include AN symptomatology, other psychopathology, quality of life, service utilisation, neurocognitive processes, and neuroimaging measures.

DISCUSSION

Findings will inform the development of a future large-scale RCT. They will also provide exploratory data on treatment efficacy, and neural and neurocognitive predictors and correlates of treatment response to iTBS in AN.

A systematic review and meta-analysis of neuromodulation therapies for substance use disorders

While pharmacological, behavioral and psychosocial treatments are available for substance use disorders (SUDs), they are not always effective or well-tolerated. Neuromodulation (NM) methods, including repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS) and deep brain stimulation (DBS) may address SUDs by targeting addiction neurocircuitry. We evaluated the efficacy of NM to improve behavioral outcomes in SUDs. A systematic literature search was performed on MEDLINE, PsychINFO, and PubMed databases and a list of search terms for four key concepts (SUD, rTMS, tDCS, DBS) was applied. Ninety-four studies were identified that examined the effects of rTMS, tDCS, and DBS on substance use outcomes (e.g., craving, consumption, and relapse) amongst individuals with SUDs including alcohol, tobacco, cannabis, stimulants, and opioids. Meta-analyses were performed for alcohol and tobacco studies using rTMS and tDCS. We found that rTMS reduced substance use and craving, as indicated by medium to large effect sizes (Hedge's g > 0.5). Results were most encouraging when multiple stimulation sessions were applied, and the left dorsolateral prefrontal cortex (DLPFC) was targeted. tDCS also produced medium effect sizes for drug use and craving, though they were highly variable and less robust than rTMS; right anodal DLPFC stimulation appeared to be most efficacious. DBS studies were typically small, uncontrolled studies, but showed promise in reducing misuse of multiple substances. NM may be promising for the treatment of SUDs. Future studies should determine underlying neural mechanisms of NM, and further evaluate extended treatment durations, accelerated administration protocols and long-term outcomes with biochemical verification of substance use.

Effects of repetitive transcranial magnetic stimulation combined with cognitive training on cognitive function in patients with Alzheimer's disease: a systematic review and meta-analysis

Purpose

To evaluate the effect of repetitive transcranial magnetic stimulation (rTMS) paired with cognitive training on cognitive function in Alzheimer's Disease (AD) patients.

Methods

PubMed, The Cochrane Library, Embase, CINAHL Complete (EBSCO), China National Knowledge Infrastructure (CNKI) and WanFang Database were searched. The risk of bias was appraised through the Cochrane collaboration tool. A meta-analysis was conducted, including an assessment of heterogeneity.

Results

Ten studies comprising 408 participants were included. The addition of rTMS significantly improved overall cognition in patients compared with cognitive intervention alone (p < 0.05 for all tests). The treatment also had some continuity, with significant improvements in cognitive function within weeks after the treatment ended (p < 0.05 for all tests).

Conclusion

Repetitive transcranial magnetic stimulation combined with cognitive training (rTMS-CT) is a valuable technique for the cognitive rehabilitation of AD patients. It is beneficial to improve the cognitive ability of patients and restore their overall functional state. The results of the study may provide a basis for clinical providers to implement interventions that facilitate the design of more rigorous and high-quality interventions.

Limitations

The number of studies and sample size in our study were small. We did not explore possible interactions between rTMS and medications and mood improvement after rTMS due to inadequate data.

Systematic review registration

This study was registered on PROSPERO with registration number CRD42023405615.

Can Medication be a Factor that Can Negatively Affect the Effect of Transcranial Magnetic Stimulation in Depression?

BACKGROUND

This study aims to evaluate the efficacy of transcranial magnetic stimulation (TMS) in patients with depression and whether concurrent psychotropic medication use negatively affects the treatment outcome of TMS. Patients' characteristics, predictors of treatment response, the relationship between demographics, and the selection of TMS as a treatment modality were also analyzed.

STUDY QUESTION

Can psychotropic medication be a factor that can negatively affect the efficacy of TMS in patients with depression?

STUDY DESIGN

This pilot-controlled study included 40 subjects from Romanian clinical practice who were treated with pharmacological treatment and TMS for major depressive disorder. The severity of depression and anxiety symptoms was measured using validated scales at baseline (day 1) and follow-up (day 30).

DATA SOURCES

All patients' characteristics and information were collected manually from the clinic's medical records, deidentified, and then introduced into an electronic database for analysis.

LIMITATIONS

Conducting the study in a clinical routine practice, it was not possible to include an active and/or sham control group. In addition, because TMS is not used as a monotherapy in this type of practice, we could not evaluate its safety and efficacy without concomitant pharmacological treatment. The study sample is small; therefore, the results cannot be generalized.

RESULTS

Sixty percentage of patients (n = 24) included in this study obtained a clinical response, and 30% of patients (n = 12) obtained remission of depression. The group with pharmacological treatment obtained clinical responses in 80% of patients (n = 16) and remission of depression in 45% of patients (n = 9). The group with pharmacological treatment and TMS obtained clinical responses in 40% of patients (n = 8) and remission of depression in 15% (n = 3) of cases.

CONCLUSIONS

The study results show a lack of efficacy for TMS as an adjunctive therapy to pharmacological treatment for patients with depression. In addition, a negative impact of psychotropic medication on TMS efficacy is observed in our study sample.

A naturalistic study comparing the efficacy of unilateral and bilateral sequential theta burst stimulation in treating major depression - the U-B-D study protocol

BACKGROUND

Major depressive disorder (MDD) is a prevalent mental health condition affecting millions worldwide, leading to disability and reduced quality of life. MDD poses a global health priority due to its early onset and association with other disabling conditions. Available treatments for MDD exhibit varying effectiveness, and a substantial portion of individuals remain resistant to treatment. Repetitive transcranial magnetic stimulation (rTMS), applied to the left and/or right dorsolateral prefrontal cortex (DLPFC), is an alternative treatment strategy for those experiencing treatment-resistant MDD. The objective of this study is to investigate whether this newer form of rTMS, namely theta burst stimulation (TBS), when performed unilaterally or bilaterally, is efficacious in treatment-resistant MDD.

METHODS

In this naturalistic, randomized double-blinded non-inferiority trial, participants with a major depressive episode will be randomized to receive either unilateral (i.e., continuous TBS [cTBS] to the right and sham TBS to the left DLPFC) or bilateral sequential TBS (i.e., cTBS to the right and intermittent TBS [iTBS] to the left DLPFC) delivered 5 days a week for 4-6 weeks. Responders will move onto a 6-month flexible maintenance phase where TBS treatment will be delivered at a decreasing frequency depending on degree of symptom mitigation. Several clinical assessments and neuroimaging and neurophysiological biomarkers will be collected to investigate treatment response and potential associated biomarkers. A non-inferiority analysis will investigate whether bilateral sequential TBS is non-inferior to unilateral TBS and regression analyses will investigate biomarkers of treatment response. We expect to recruit a maximal of 256 participants. This trial is approved by the Research Ethics Board of The Royal's Institute of Mental Health Research (REB# 2,019,071) and will follow the Declaration of Helsinki. Findings will be published in peer-reviewed journals.

DISCUSSION

Comprehensive assessment of symptoms and neurophysiological biomarkers will contribute to understanding the differential efficacy of the tested treatment protocols, identifying biomarkers for treatment response, and shedding light into underlying mechanisms of TBS. Our findings will inform future clinical trials and aid in personalizing treatment selection and scheduling for individuals with MDD.

TRIAL REGISTRATION

The trial is registered on https://clinicaltrials.gov/ct2/home (#NCT04142996).

Trajectory of changes in depressive symptoms after acute repetitive transcranial magnetic stimulation: A meta-analysis of follow-up effects

BACKGROUND

The follow-up effect after acute repetitive transcranial magnetic stimulation (rTMS) for major depressive episodes remains unclear. Furthermore, the benefits of maintenance rTMS are poorly understood.

AIM

To investigate the trajectory of changes in depressive symptoms after acute rTMS and effects of maintenance rTMS during this period.

METHOD

This meta-analysis (PROSPERO: CRD42022374077) searched major databases up to October 1, 2022. Treatment outcome was depressive scores collected at least 3 months after the end of an acute rTMS course for depression. We extracted data at different time points after acute rTMS and categorized by whether maintenance rTMS was performed. A single-stage random-effects dose-response meta-analysis was undertaken to model the nonlinear relationships. Effect sizes were calculated as standardized mean differences (SMDs) with 95% confidence intervals (CIs).

RESULTS

24 eligible studies comprising 911 total patients-225 of whom received maintenance rTMS-were included. Maintenance rTMS contributed to relative stability in patients' mood symptoms during the first 5 months (SMD [95% CI]: 3rd month, -0.10 [-0.30 to 0.10]; 5th month, 0.00 [-0.55 to 0.55]), with heterogeneity characterized as low to moderate. Further analysis revealed that maintenance rTMS performed monthly or more frequently provided sustained benefits for up to 6-12 months. Conversely, patients without maintenance rTMS had moderate to high heterogeneity, although the change in mean mood symptom scores during the 12-month follow-up was also minor (6th month, 0.03 [-0.51 to 0.56]; 12th month, 0.10 [-0.59 to 0.79]).

CONCLUSION

Maintenance rTMS might keep patients' mood relatively stable for up to 5 months after acute rTMS. Monthly or more frequent maintenance rTMS offers greater benefits.

Accelerated intermittent theta burst stimulation in smoking cessation: No differences between active and placebo stimulation when using advanced placebo coil technology. A double-blind follow-up study

Objective

This study aims to investigate the longer-term effects of accelerated intermittent theta burst stimulation (aiTBS) in smoking cessation and to examine whether there is a difference in outcome between active and placebo stimulation. The present study constitutes an ancillary study from a main Randomized Controlled Trial (RCT) evaluating the acute effects of aiTBS in smoking reduction.

Method

A double-blind randomized control trial was conducted where 89 participants were randomly allocated to three groups (transcranial magnetic stimulation (TMS)&N group: active aiTBS stimulation combined with neutral videos; TMS&S group: active aiTBS stimulation combined with smoking-related videos; Placebo group: placebo stimulation combined with smoking-related videos). Nicotine dependence, tobacco craving, perceived stress and motivation to quit smoking were measured after completion of 20 aiTBS sessions and during various follow ups (post one week, post one month and post six months).

Results

Our results show that the positive effect on nicotine dependence and tobacco craving that occurred at the end of treatment lasts at least one month post treatment. This effect seems to dissipate six months post treatment. No significant differences were found between the three groups.

Conclusion

Both active and placebo stimulation were equally effective in reducing nicotine dependence and tobacco craving up to one month after the end of treatment.

Extended Repetitive Transcranial Magnetic Stimulation Therapy for Post-stroke Depression in a Patient With a Pre-frontal Cortical Lesion: A Case Study

Approximately one-third of stroke survivors experience post-stroke depression. Repetitive transcranial magnetic stimulation (rTMS) of the prefrontal cortex has shown promise as a treatment for depression with few side effects and high tolerability. However, previous post-stroke depression trials have not considered the effect of lesion location, the persistence of clinical improvements, nor the value of ongoing maintenance treatments. These questions are important to determine the therapeutic value of rTMS as a treatment for post-stroke depression. We report a unique case study of a 71-year-old male who had experienced a left hemispheric ischemic stroke 4 years prior. The patient was screened with the Beck Depression Inventory and Patient Health Questionnaire and found to be experiencing moderate levels of depression. Ten daily sessions of left dorsolateral pre-frontal cortex rTMS were applied over a two-week period. A clinically meaningful reduction in depression was achieved. Approximately 10 weeks following rTMS treatment, improvements in depression were attenuating. Weekly maintenance rTMS was delivered to the left dorsolateral pre-frontal cortex for 10 sessions. At the conclusion of maintenance rTMS, clinical assessments indicated depressive symptoms had reduced to a minimal to nil level. Clinically meaningful improvements in depression were maintained at 3 months after rTMS treatment had ceased. These findings provide novel insight to suggest rTMS may reduce depressive symptoms in stroke survivors with a lesion at the site of stimulation. Ongoing maintenance treatments might prove beneficial to enhance persistence of clinical improvements.

Evidence and expert consensus based German guidelines for the use of repetitive transcranial magnetic stimulation in depression

INTRODUCTION

Non-invasive brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) offer a promising alternative to psychotherapeutic and pharmacological treatments for depression. This paper aims to present a practical guide for its clinical implementation based on evidence from the literature as well as on the experience of a group of leading German experts in the field.

METHODS

The current evidence base for the use of rTMS in depression was examined via review of the literature. From the evidence and from clinical experience, recommendations for the use of rTMS in clinical practice were derived. All members of the of the German Society for Brain Stimulation in Psychiatry and all members of the sections Clinical Brain Stimulation and Experimental Brain Stimulation of the German Society for Psychiatry, Psychotherapy, Psychosomatics and Mental Health were invited to participate in a poll on whether they consent with the recommendations.

FINDINGS

Among rTMS experts, a high consensus rate could be identified for clinical practice concerning the setting and the technical parameters of rTMS treatment in depression, indications and contra-indications, the relation of rTMS to other antidepressive treatment modalities and the frequency and management of side effects.

Depression in Sub-Saharan Africa

Mood disorders can be considered among the most common and debilitating mental disorders. Major depression, as an example of mood disorders, is known to severely reduce the quality of life as well as psychosocial functioning of those affected. Its impact on the burden of disease worldwide has been enormous, with the World Health Organisation projecting depression to be the leading cause of mental illness by 2030. Despite several studies on the subject, little has been done to contextualise the condition in Africa, coupled with the fact that there is still much to be understood on the subject. This review attempts to shed more light on the prevalence of depression in Sub-Saharan Africa (SSA), its pathophysiology, risk factors, diagnosis and the experimental models available to study depression within the sub-region. It also evaluates the contribution of the sub-region to the global research output of depression as well as bottlenecks associated with full exploitation of the sub region's resources to manage the disorder.

Repetitive Transcranial Magnetic Stimulation (rTMS) as a Promising Treatment for Craving in Stimulant Drugs and Behavioral Addiction: A Meta-Analysis

Addiction is a mental disorder with limited available treatment options. The therapeutic potential of repetitive transcranial magnetic stimulation (rTMS) on it, by targeting craving in particular, has been explored with heterogenous results. This meta-analysis uses updated evidence to assess overall rTMS efficacy on craving, differential effects between addiction types clustered into three groups (depressant (alcohol, cannabis, opiate), stimulant (nicotine, cocaine, methamphetamine), and behavioral addiction (gambling, eating disorder)), and stimulation settings. Studies on substance use, gambling, and eating disorders are included, with unrestricted stimulation settings, by searching the PubMed, Embase, PsycINFO, and Cochrane databases up to 30 April 2020. A total of 34 eligible studies (42 units of analysis) were identified. Because of highly significant heterogeneity in primary results, a sensitivity analysis was performed on a remaining sample of 26 studies (30 units of analysis). Analyses performed using random effects model revealed a small effect size favoring active rTMS over shamTMS stimulation in the reduction in craving. We found a significant difference between addiction types, with a persistent small effect only for stimulant and behavioral groups. In these groups we found no difference between the different combinations of target and frequency of stimulation, but a significant correlation between number of sessions and craving reduction. In conclusion, efficacy of rTMS on craving in stimulant and behavioral addiction was highlighted, but recommendations on optimal stimulation settings and its clinical application await further research.

The Development of GABAergic Network in Depression in Recent 17 Years: A Visual Analysis Based on CiteSpace and VOSviewer

In this study, we analyzed the status and research trends of the GABAergic system in depression from 2004 to 2020 to provide a reference for further research. The Web of Science database was used as the data source and 1,658 publishments were included. Using two visualization analysis software, CiteSpace and VOSviewer, we analyzed the publishing years, countries, institutions, authors, journals, categories, keywords, and research frontiers in depression. The publishments revealed an upward trend from 2004 to 2020; the most prolific country and institutions were the United States and INSERM, respectively. The journal of Neuroscience was the most published and cited journal. The most relevant category was neurosciences. The hot topics in this field were GABAergic research in Gaba(a) receptor; the research frontier was depressive model. These analysis results provide a new perspective for researchers to conduct studies on related topics in the future and guidance for scientists to identify potential collaborators and research cooperation institutions.

Heading for Personalized rTMS in Tinnitus: Reliability of Individualized Stimulation Protocols in Behavioral and Electrophysiological Responses

Background: Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation tool potentially modulating pathological brain activity. Its clinical effectiveness is hampered by varying results and characterized by inter-individual variability in treatment responses. RTMS individualization might constitute a useful strategy to overcome this variability. A precondition for this approach would be that repeatedly applied protocols result in reliable effects. The condition tinnitus provides the advantage of immediate behavioral consequences (tinnitus loudness changes) after interventions and thus offers an excellent model to exemplify TMS personalization. Objective: The aim was to investigate the test–retest reliability of short rTMS stimulations in modifying tinnitus loudness and oscillatory brain activity as well as to examine the feasibility of rTMS individualization in tinnitus. Methods: Three short verum (1, 10, 20 Hz; 200 pulses) and one sham (0.1 Hz; 20 pulses) rTMS protocol were administered on two different days in 22 tinnitus patients. Before and after each protocol, oscillatory brain activity was recorded with electroencephalography (EEG), together with behavioral tinnitus loudness ratings. RTMS individualization was executed on the basis of behavioral and electrophysiological responses. Stimulation responders were identified via consistent sham-superior increases in tinnitus loudness (behavioral responders) and alpha power increases or gamma power decreases (alpha responders/gamma responders) in accordance with the prevalent neurophysiological models for tinnitus. Results: It was feasible to identify individualized rTMS protocols featuring reliable tinnitus loudness changes (55% behavioral responder), alpha increases (91% alpha responder) and gamma decreases (100% gamma responder), respectively. Alpha responses primary occurred over parieto-occipital areas, whereas gamma responses mainly appeared over frontal regions. On the contrary, test–retest correlation analyses per protocol at a group level were not significant neither for behavioral nor for electrophysiological effects. No associations between behavioral and EEG responses were found. Conclusion: RTMS individualization via behavioral and electrophysiological data in tinnitus can be considered as a feasible approach to overcome low reliability at the group level. The present results open the discussion favoring personalization utilizing neurophysiological markers rather than behavioral responses. These insights are not only useful for the rTMS treatment of tinnitus but also for neuromodulation interventions in other pathologies, as our results suggest that the individualization of stimulation protocols is feasible despite absent group-level reliability.

Repetitive Transcranial Magnetic Stimulation for Adolescent Major Depressive Disorder: A Focus on Neurodevelopment

Adolescent depression is a potentially lethal condition and a leading cause of disability for this age group. There is an urgent need for novel efficacious treatments since half of adolescents with depression fail to respond to current therapies and up to 70% of those who respond will relapse within 5 years. Repetitive transcranial magnetic stimulation (rTMS) has emerged as a promising treatment for major depressive disorder (MDD) in adults who do not respond to pharmacological or behavioral interventions. In contrast, rTMS has not demonstrated the same degree of efficacy in adolescent MDD. We argue that this is due, in part, to conceptual and methodological shortcomings in the existing literature. In our review, we first provide a neurodevelopmentally focused overview of adolescent depression. We then summarize the rTMS literature in adult and adolescent MDD focusing on both the putative mechanisms of action and neurodevelopmental factors that may influence efficacy in adolescents. We then identify limitations in the existing adolescent MDD rTMS literature and propose specific parameters and approaches that may be used to optimize efficacy in this uniquely vulnerable age group. Specifically, we suggest ways in which future studies reduce clinical and neural heterogeneity, optimize neuronavigation by drawing from functional brain imaging, apply current knowledge of rTMS parameters and neurodevelopment, and employ an experimental therapeutics platform to identify neural targets and biomarkers for response. We conclude that rTMS is worthy of further investigation. Furthermore, we suggest that following these recommendations in future studies will offer a more rigorous test of rTMS as an effective treatment for adolescent depression.

A bibliometric analysis of top 50-most cited articles on repetitive trans-cranial magnetic stimulation (rTMS) for treatment of depression

Background

Citation count can be used as a key tool to assess the quality of the published literature and because of its immense advantages it is now widely used in ranking the articles on specific topics.

Objective/hypothesis

To extract and assess the top cited work on repetitive transcranial magnetic stimulation (rTMS) for depression treatment.

Methods

Scopus Library Database was searched and two independent authors produced a list of 50 most cited articles on repetitive transcranial magnetic stimulation (rTMS) for treatment of depression. All the relevant articles having key-terms within their titles, abstract and keywords were included in our search. Our list was categorized into two categories, “mixed” and “focused”.

Results

The articles in the produced list of top 50 most cited articles on rTMS for treatment of depression belong to the time period 1993–2012 with total citation count 12078. George MS was prominent in the list. ‘Biological Psychiatry’ published most number of articles (n = 13) among the list. Articles were categorized on the basis of primary population and intervention into ‘Focused’ and ‘Mixed’ categories.

Limitations

Articles that were published before 1993 and after 2012 on rTMS for depression couldn't made it to the final list of top-50 most cited article.

Conclusion

We attempted to conduct a topic-specific citation analysis considering the paucity of specified bibliometrics in medical literature. Our research provides an insight on emerging trends in rTMS for depression and highlights the characteristics, quality and dynamics of frequently cited articles in the field.

Repetitive transcranial magnetic stimulation for major depressive disorder: basic principles and future directions

Repetitive transcranial magnetic stimulation (rTMS) is a safe and well-tolerated intervention for major depressive disorder (MDD). Over 150 randomized controlled trials (RCTs) have been carried out, and its efficacy has been confirmed in dozens of meta-analyses. Real world data has also confirmed the effectiveness of rTMS for MDD in clinical practice, with the most recent literature indicating response rates of 40-50% and remission rates of 25-30%. In this review, we first offer an historical perspective, followed by a review of basic principles, such as putative mechanisms, procedures and protocols, stimulation targets, efficacy and durability of response, side effects, and the placebo controversy. In the second part of this review, we first discuss solutions to increase accessibility to rTMS, such as modifications to treatment equipment, protocols and setting. We continue with possible means to further increase effectiveness, such as treatment personalization and extension. We conclude by addressing the scheduling issue, with accelerated rTMS (arTMS) as a possible solution.

An update on the clinical use of repetitive transcranial magnetic stimulation in the treatment of depression

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is an increasingly used treatment for patients with depression. The use of rTMS in depression is supported by over 20 years of clinical trials. There has been a significant increase in knowledge around the use of rTMS in recent years.

OBJECTIVE

The aim of this paper was to review the use of rTMS in depression to provide an update for rTMS practitioners and clinicians interested in the clinical use of this treatment.

METHODS

A targeted review of the literature around the use of rTMS treatment of depression with a specific focus on studies published in the last 3 years.

RESULTS

High-frequency rTMS applied to the left dorsolateral prefrontal cortex is an effective treatment for acute episodes of major depressive disorder. There are several additional methods of rTMS delivery that are supported by clinical trials and meta-analyses but no substantive evidence that any one approach is any more effective than any other. rTMS is effective in unipolar depression and most likely bipolar depression. rTMS courses may be repeated in the management of depressive relapse but there is less evidence for the use of rTMS in the maintenance phase.

CONCLUSIONS

The science around the use of rTMS is rapidly evolving and there is a considerable need for practitioners to remain abreast of the current state of this literature and its implications for clinical practice. rTMS is an effective antidepressant treatment but its optimal use should be continually informed by knowledge of the state of the art.

Equipment for Repetitive Transcranial Magnetic Stimulation

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation technique used for the treatment of a great variety of neurological disorders. The technique involves applying a magnetic field in certain areas of the cerebral cortex in order to modify neuronal excitability outside the skull. However, the exact brain mechanisms underlying rTMS effects are not completely elucidated. For that purpose, and in order to generate a pulsed magnetic field, a half-bridge converter controlled by a microcontroller has been designed to apply rTMS in small animals. Moreover, the small size of the rodent head makes it necessary to design a magnetic transducer, with the aim of focusing the magnetic field on selected brain areas using a specific and a small magnetic head. Using such devices, our purpose was to compare the effects of five different rTMS dosages on rat brain metabolic activity. The experimental results showed that one day of stimulation leads to an enhancement of brain metabolic activity in cortical areas, meanwhile with three days of stimulation it is possible to also modify subcortical zones, results that were not found when extending the number of rTMS applications up to seven days. In consequence, the number of pulses delivered might be an important parameter in rTMS protocols, highlighting its importance in rTMS impact.

Temporal sequences of brain activity at rest are constrained by white matter structure and modulated by cognitive demands

A diverse set of white matter connections supports seamless transitions between cognitive states. However, it remains unclear how these connections guide the temporal progression of large-scale brain activity patterns in different cognitive states. Here, we analyze the brain's trajectories across a set of single time point activity patterns from functional magnetic resonance imaging data acquired during the resting state and an n-back working memory task. We find that specific temporal sequences of brain activity are modulated by cognitive load, associated with age, and related to task performance. Using diffusion-weighted imaging acquired from the same subjects, we apply tools from network control theory to show that linear spread of activity along white matter connections constrains the probabilities of these sequences at rest, while stimulus-driven visual inputs explain the sequences observed during the n-back task. Overall, these results elucidate the structural underpinnings of cognitively and developmentally relevant spatiotemporal brain dynamics.

Pharmacological, psychological and non-invasive brain stimulation interventions for preventing depression after stroke

BACKGROUND

Depression is an important consequence of stroke that influences recovery yet often is not detected, or is inadequately treated. This is an update and expansion of a Cochrane Review first published in 2004 and previously updated in 2008.

OBJECTIVES

The primary objective is to test the hypothesis that pharmacological, psychological therapy, non-invasive brain stimulation, or combinations of these interventions reduce the incidence of diagnosable depression after stroke. Secondary objectives are to test the hypothesis that pharmacological, psychological therapy, non-invasive brain stimulation or combinations of these interventions reduce levels of depressive symptoms and dependency, and improve physical functioning after stroke. We also aim to determine the safety of, and adherence to, the interventions.

SEARCH METHODS

We searched the Specialised Register of Cochrane Stroke and the Cochrane Depression Anxiety and Neurosis (last searched August 2018). In addition, we searched the following databases; Cochrane Central Register of Controlled Trials, CENTRAL (the Cochrane Library, 2018, Issue 8), MEDLINE (1966 to August 2018), Embase (1980 to August 2018), PsycINFO (1967 to August 2018), CINAHL (1982 to August 2018) and three Web of Science indexes (2002 to August 2018). We also searched reference lists, clinical trial registers (World Health Organization International Clinical Trials Registry Platform (WHO ICTRP); to August 2018 and ClinicalTrials.gov; to August 2018), conference proceedings; we also contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing: 1) pharmacological interventions with placebo; 2) one of various forms of psychological therapy with usual care and/or attention control; 3) one of various forms of non-invasive brain stimulation with sham stimulation or usual care; 4) a pharmacological intervention and one of various forms of psychological therapy with a pharmacological intervention and usual care and/or attention control; 5) non-invasive brain stimulation and pharmacological intervention with a pharmacological intervention and sham stimulation or usual care; 6) pharmacological intervention and one of various forms of psychological therapy with placebo and psychological therapy; 7) pharmacological intervention and non-invasive brain stimulation with placebo plus non-invasive brain stimulation; 8) non-invasive brain stimulation and one of various forms of psychological therapy versus non-invasive brain stimulation plus usual care and/or attention control; and 9) non-invasive brain stimulation and one of various forms of psychological therapy versus sham brain stimulation or usual care plus psychological therapy, with the intention of preventing depression after stroke.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed risk of bias, and extracted data from all included studies. We calculated mean difference (MD) or standardised mean difference (SMD) for continuous data and risk ratio (RR) for dichotomous data with 95% confidence intervals (CIs). We assessed heterogeneity using the I² statistic and assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 19 RCTs (21 interventions), with 1771 participants in the review. Data were available for 12 pharmacological trials (14 interventions) and seven psychological trials. There were no trials of non-invasive brain stimulation compared with sham stimulation or usual care, a combination of pharmacological intervention and one of various forms of psychological therapy with placebo and psychological therapy, or a combination of non-invasive brain stimulation and a pharmacological intervention with a pharmacological intervention and sham stimulation or usual care to prevent depression after stroke. Treatment effects were observed on the primary outcome of meeting the study criteria for depression at the end of treatment: there is very low-certainty evidence from eight trials (nine interventions) that pharmacological interventions decrease the number of people meeting the study criteria for depression (RR 0.50, 95% CI 0.37 to 0.68; 734 participants) compared to placebo. There is very low-certainty evidence from two trials that psychological interventions reduce the proportion of people meeting the study criteria for depression (RR 0.68, 95% CI 0.49 to 0.94, 607 participants) compared to usual care and/or attention control. Eight trials (nine interventions) found no difference in death and other adverse events between pharmacological intervention and placebo groups (RR 1.25, 95% CI 0.32 to 4.91; 496 participants) based on very low-certainty evidence. Five trials found no difference in psychological intervention and usual care and/or attention control groups for death and other adverse events (RR 1.18, 95% CI 0.73 to 1.91; 975 participants) based on very low-certainty evidence.

AUTHORS' CONCLUSIONS

The available evidence suggests that pharmacological interventions and psychological therapy may prevent depression and improve mood after stroke. However, there is very low certainty in these conclusions because of the very low-certainty evidence. More trials are required before reliable recommendations can be made about the routine use of such treatments after stroke.

Repetitive Transcranial Magnetic Stimulation in the Treatment of Skin Picking Disorder: An Exploratory Trial

OBJECTIVES

Skin picking disorder (SPD) falls into the category of "obsessive-compulsive disorder and related disorders" in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Repetitive transcranial magnetic stimulation (rTMS) treatment has been reported to be a promising therapy in obsessive-compulsive disorder-related disorders. The purpose of this study was to demonstrate the efficacy of rTMS treatment in patients with SPD.

METHODS

Fifteen patients with SPD were assigned to receive 3 weeks' treatment with either active (n = 8) or sham rTMS targeting the pre-supplementary motor area. Patients were evaluated using the Beck Depression Inventory, Beck Anxiety Inventory, Skin Picking Impact Scale, and the Yale-Brown Obsessive Compulsive Scale Modified for Neurotic Excoriation. Response to treatment was defined as a ≥35% decrease on Yale-Brown Obsessive Compulsive Scale modified for Neurotic Excoriation.

RESULTS

Treatment response was achieved in 62.5% of patients (5/8) in the active group and 33.3% of patients (2/6) in the sham group. However, there were no significant differences between the groups in terms of primary and secondary outcomes.

CONCLUSIONS

In this exploratory study, active rTMS could not be demonstrated to be superior over sham in treatment of SPD. The results of this study indicate the need for further rTMS studies to be conducted with larger sample sizes and subtypes of SPD.

Cost-Utility Analysis of Electroconvulsive Therapy and Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression in Ontario

OBJECTIVES

To evaluate the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT), and combining both treatments in a stepped care pathway for patients with treatment-resistant depression (TRD) in Ontario.

METHODS

A cost-utility analysis evaluated the lifetime costs and benefits to society of rTMS and ECT as first-line treatments for TRD using a Markov model, which simulates the costs and health benefits of patients over their lifetime. Health states included acute treatment, maintenance treatment, remission, and severe depression. Treatment efficacy and health utility data were extracted and synthesized from randomized controlled trials and meta-analyses evaluating these techniques. Direct costing data were obtained from national and provincial costing databases. Indirect costs were derived from government records. Scenario, threshold, and probabilistic sensitivity analyses were performed to test robustness of the results.

RESULTS

rTMS dominated ECT, as it was less costly and produced better health outcomes, measured in quality-adjusted life years (QALYs), in the base case scenario. rTMS patients gained an average of 0.96 additional QALYs (equivalent to approximately 1 year in perfect health) over their lifetime with costs that were $46,094 less than ECT. rTMS remained dominant in the majority of scenario and threshold analyses. However, results from scenarios in which the model's maximum lifetime allowance of rTMS treatment courses was substantially limited, the dominance of rTMS over ECT was attenuated. The scenario that showed the highest QALY gain (1.19) and the greatest cost-savings ($46,614) was when rTMS nonresponders switched to ECT.

CONCLUSION

From a societal perspective utilizing a lifetime horizon, rTMS is a cost-effective first-line treatment option for TRD relative to ECT, as it is less expensive and produces better health outcomes. The reduced side effect profile and greater patient acceptability of rTMS that allow it to be administered more times than ECT in a patient's lifetime may contribute to its cost-effectiveness.

What is good mental health? A scoping review

Promotion of good mental health in young people with and without mental disorders has received little empirical research attention and interventions for improving mental health in young people are not well established. This situation could be explained among other reasons due to the difficulties to define and operationalise what good mental health is. The current manuscript, produced by the European College of Neuropsychopharmacology Thematic Working Group on the Prevention of Mental Disorders and Mental Health Promotion (ECNP TWG PMD-MHP), presents a critical review of the available operationalizations for good mental health. A pragmatic conceptual operationalisation of good mental health is a much-needed step towards more standardised research in this field. Good mental health can be defined as a state of well-being that allows individuals to cope with the normal stresses of life and function productively. Universal and selective interventions are suitable to promote mental health. Core domains that define good mental health encompass: (i) mental health literacy, (ii) attitude towards mental disorders, (iii) self-perceptions and values, (iv) cognitive skills, (v) academic/ occupational performance, (vi) emotions, (vii) behaviours, (viii) self-management strategies, (ix) social skills, (x) family and significant relationships (xi) physical health, (xii) sexual health, (xiii) meaning of life, (xiv) and quality of life. These domains should be widely traceable in the literature and can be used to conduct further empirical research in the field of good mental health. Such data can lead to more robust evidence to identify and establish the pathways to follow in order to improve mental health.

Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): An update (2014-2018)

A group of European experts reappraised the guidelines on the therapeutic efficacy of repetitive transcranial magnetic stimulation (rTMS) previously published in 2014 [Lefaucheur et al., Clin Neurophysiol 2014;125:2150-206]. These updated recommendations take into account all rTMS publications, including data prior to 2014, as well as currently reviewed literature until the end of 2018. Level A evidence (definite efficacy) was reached for: high-frequency (HF) rTMS of the primary motor cortex (M1) contralateral to the painful side for neuropathic pain; HF-rTMS of the left dorsolateral prefrontal cortex (DLPFC) using a figure-of-8 or a H1-coil for depression; low-frequency (LF) rTMS of contralesional M1 for hand motor recovery in the post-acute stage of stroke. Level B evidence (probable efficacy) was reached for: HF-rTMS of the left M1 or DLPFC for improving quality of life or pain, respectively, in fibromyalgia; HF-rTMS of bilateral M1 regions or the left DLPFC for improving motor impairment or depression, respectively, in Parkinson's disease; HF-rTMS of ipsilesional M1 for promoting motor recovery at the post-acute stage of stroke; intermittent theta burst stimulation targeted to the leg motor cortex for lower limb spasticity in multiple sclerosis; HF-rTMS of the right DLPFC in posttraumatic stress disorder; LF-rTMS of the right inferior frontal gyrus in chronic post-stroke non-fluent aphasia; LF-rTMS of the right DLPFC in depression; and bihemispheric stimulation of the DLPFC combining right-sided LF-rTMS (or continuous theta burst stimulation) and left-sided HF-rTMS (or intermittent theta burst stimulation) in depression. Level A/B evidence is not reached concerning efficacy of rTMS in any other condition. The current recommendations are based on the differences reached in therapeutic efficacy of real vs. sham rTMS protocols, replicated in a sufficient number of independent studies. This does not mean that the benefit produced by rTMS inevitably reaches a level of clinical relevance.

European college of neuropsychopharmacology network on the prevention of mental disorders and mental health promotion (ECNP PMD-MHP)

Prevention is the most promising way to reduce the high personal, familial, societal, clinical and economic costs of mental disorders in Europe and worldwide. A complementary approach is to go beyond the prevention of mental ill health, to promote good mental health. This manuscript highlights the first European consortium fostering cutting-edge multidisciplinary research in these two areas. The ECNP-funded Network on the Prevention of Mental Disorders and Mental Health Promotion (ECNP PMD-MHP) brings together European sites of excellence with different expertise for translational research collaboration, including partnerships with the industry. The ECNP PMD-MHP Network adopts a transdiagnostic, lifespan, clinical staging model which cuts across different mental disorders and different methodologies. The main aims of the ECNP PMD-MHP Network are to facilitate multidisciplinary collaboration, enhance knowledge and data sharing, standardise core assessment and outcome measures, promote clinical research, apply for grant funding, and generate research reports. By supporting collaborative research, the ECNP PMD-MHP Network will be vital for fostering European psychiatry in the field of prevention of mental disorders and promotion of good mental health.

An Update on Repetitive Transcranial Magnetic Stimulation for the Treatment of Major Depressive Disorder

Repetitive transcranial magnetic stimulation (rTMS) has emerged as an evidenced-based treatment for major depression that does not respond to standard first-line therapies. The majority of data support the use of high-frequency (10 Hz) treatment delivered to the left dorsolateral prefrontal cortex. Intermittent theta burst stimulation is a new emerging treatment that reduces the time required to deliver treatment and can increase capacity and access to this treatment. This review will comprehensively cover recent advancements in the field of rTMS for depression, including stimulation parameters and targets aimed at enhancing outcomes. In addition, efforts to use modern neuroscience tools to personalize this treatment and optimize outcomes will be reviewed.

High frequency repetitive transcranial magnetic stimulation improves neuronal activity without affecting astrocytes and microglia density

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation technique capable of producing changes in the electrical potential of neurons. Currently, the application of rTMS in clinical practice and as a neurophysiological tool is increasing. However, the exact cellular mechanisms underlying rTMS-based therapies are not completely clear. Additionally, glial cells have been studied less. Our aim was to investigate the effect of three days of high-frequency rTMS on neuronal metabolism and neuronal activation, in addition to its effect on glial cells. For this purpose, we performed histochemistry and immunohistochemistry procedures: the histochemistry of cytochrome oxidase (COx) to assess neuronal metabolic activity, and the immunohistochemistry of c-Fos (marker of neuronal activity), GFAP (marker of astrocytic reactivity), and Iba1 (selective marker of reactive microglia). Our results showed enhanced metabolic activity after rTMS in the retrosplenial and parietal cortex and CA1 and CA3 subfields of the hippocampus. Moreover, higher c-Fos activity was found in the agranular retrosplenial cortex. Finally, we did not find changes between groups in the induction of astrocyte and microglia reactivity in any of the immunostained regions. In conclusion, we can assume that three days of high-frequency rTMS applied in healthy rats does not alter astroglia reactivity or inflammatory responses, such as microglia proliferation. Because we have shown an upregulation of neuronal metabolic activity in many limbic brain structures, in addition to higher c-Fos levels in the nearest cortical area to the rTMS, our work provides novel insight into the effectiveness and safety of rTMS as a brain modulation therapy.

Harnessing networks and machine learning in neuropsychiatric care

The development of next-generation therapies for neuropsychiatric illness will likely rely on a precise and accurate understanding of human brain dynamics. Toward this end, researchers have focused on collecting large quantities of neuroimaging data. For simplicity, we will refer to large cross-sectional neuroimaging studies as broad studies and to intensive longitudinal studies as deep studies. Recent progress in identifying illness subtypes and predicting treatment response in neuropsychiatry has been supported by these study designs, along with methods bridging machine learning and network science. Such methods combine analytic power, interpretability, and direct connection to underlying theory in cognitive neuroscience. Ultimately, we propose a general framework for the treatment of neuropsychiatric illness relying on the findings from broad and deep studies combined with basic cognitive and physiologic measurements.

Tachyphylaxis in major depressive disorder: A review of the current state of research

BACKGROUND

Patients with major depressive disorder (MDD) often experience a re-emergence or worsening of symptoms despite ongoing treatment with previously effective antidepressant pharmacotherapy. This lost or reduced antidepressant response during maintenance, referred to as tachyphylaxis, negatively impacts treatment outcomes and quality of life for patients with MDD. This review assesses the prevalence of antidepressant tachyphylaxis as well as the evidence for interventions to manage it.

METHODS

We searched PubMed/Medline for the relevant clinical trials and meta-analyses on antidepressant tachyphylaxis up to January 2017. Search terms included "depression" paired with "treatment" (n = 186,674), "tachyphylaxis" paired with "depression" (n = 112), "tachyphylaxis" paired with "major depressive disorder" (n = 21), and "antidepressant" paired with "tachyphylaxis" (n = 68). Studies were included if they reported on a clinical trial or meta-analysis exploring tachyphylaxis in MDD and were excluded if the sample population did not have a primary DSM diagnosis of MDD.

RESULTS

Rates of tachyphylaxis varied from 9% to 57% depending on the patient population and duration of follow-up. Limited evidence suggests potentially beneficial strategies for managing tachyphylaxis, including change in antidepressant dosing, switch of class of antidepressant medication, augmentation or combination pharmacotherapy, and psychotherapy.

LIMITATIONS

Studies of antidepressant tachyphylaxis are largely heterogeneous in nature and employ strict inclusion/exclusion criteria; thus, these findings may not be generalizable to all depressed populations.

CONCLUSION

Few established treatment strategies exist to manage antidepressant tachyphylaxis. Further interventional research is needed to provide symptomatic relief for patients with tachyphylaxis in MDD.

Changes in Global and Nodal Networks in Patients With Unipolar Depression After 3-Week Repeated Transcranial Magnetic Stimulation Treatment

Objectives: Repeated transcranial magnetic stimulation (rTMS) therapy has been applied in depressive disorders, but its neurobiological effect has not been well understood. Changes in cortical source network after treatment need to be confirmed. The present study investigated the effect of 3-week rTMS therapy on the symptom severity and cortical source network in patients with unipolar depression. Methods: Thirty-five patients with unipolar major depressive disorder participated in the study. High-frequency (10 Hz) rTMS was applied at the left dorsolateral prefrontal cortex during 3 weeks (five consecutive weekdays every week). Clinical symptoms were examined using the Hamilton Rating Scale for Depression and Anxiety. The resting state electroencephalography was recorded with 62 scalp channels before and after rTMS treatment. Results: Clinical symptoms significantly improved after rTMS treatment in both the active (p = 0.001) and sham groups (p = 0.002). However, an increased cortical source network in global and nodal levels was observed only in the active group after a 3-week treatment. Conclusions: The present study indicates that rTMS treatment leads to improved symptoms in patients with unipolar depression. Furthermore, treatment outcome of real effect was assured in changes of cortical source network.

Clinical Usefulness of Therapeutic Neuromodulation for Major Depression: A Systematic Meta-Review of Recent Meta-Analyses

The authors conducted a meta-review of meta-analyses published in the past decade on therapeutic neuromodulation (ie, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, vagus nerve stimulation and deep brain stimulation) for major depression. Active repetitive transcranial magnetic stimulation and transcranial direct current stimulation have been generally associated with small to moderate effect sizes vis-à-vis their efficacy and with similar acceptability compared with sham. Vagus nerve stimulation and deep brain stimulation (although more challenging to investigate) have demonstrated preliminary effectiveness, particularly during longer-term follow-up.

Treatment resistant schizophrenia: Clinical, biological, and therapeutic perspectives

Treatment resistant schizophrenia (TRS) refers to the significant proportion of schizophrenia patients who continue to have symptoms and poor outcomes despite treatment. While many definitions of TRS include failure of two different antipsychotics as a minimum criterion, the wide variability in inclusion criteria has challenged the consistency and reproducibility of results from studies of TRS. We begin by reviewing the clinical, neuroimaging, and neurobiological characteristics of TRS. We further review the current treatment strategies available, addressing clozapine, the first-line pharmacological agent for TRS, as well as pharmacological and non-pharmacological augmentation of clozapine including medication combinations, electroconvulsive therapy, repetitive transcranial magnetic stimulation, deep brain stimulation, and psychotherapies. We conclude by highlighting the most recent consensus for defining TRS proposed by the Treatment Response and Resistance in Psychosis Working Group, and provide our overview of future perspectives and directions that could help advance the field of TRS research, including the concept of TRS as a potential subtype of schizophrenia.

Relapse prevention (RP) TMS

BACKGROUND

TMS is safe and effective in the treatment of MDD, but as with other treatments, relapse may occur on cessation of treatment.

OBJECTIVE

To prevent relapse in MDD, following successful acute TMS treatment.

METHOD

5 TMS treatments over 3 days, repeated at about monthly intervals.

RESULTS

14 patients received this care for more than 12 months. At the commencement of each series the mood scores were close to relapse, but at completion they were in the remitted range.

CONCLUSION

Such treatment is useful. It is better conceptualized as relapse prevention rather than remittance maintenance.

Vagus Nerve Stimulation (VNS) and Other Augmentation Strategies for Therapy-Resistant Depression (TRD): Review of the Evidence and Clinical Advice for Use

In addition to electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS) is one of the approved neurostimulation tools for treatment of major depression. VNS is particularly used in therapy-resistant depression (TRD) and exhibits antidepressive and augmentative effects. In long-term treatment, up to two-thirds of patients respond. This mini-review provides a comprehensive overview of augmentation pharmacotherapy and neurostimulation-based treatment strategies, with a special focus on VNS in TRD, and provides practical clinical advice for how to select TRD patients for add-on neurostimulation treatment strategies.

Effects of 20 Hz Repetitive Transcranial Magnetic Stimulation on Disorders of Consciousness: A Resting-State Electroencephalography Study

Repetitive transcranial magnetic stimulation (rTMS) has been proposed as an experimental approach for the treatment of disorders of consciousness (DOC). To date, there has been little research into the use of rTMS in DOC and the therapeutic effects have been variously documented. This study aimed to examine the effects of 20 Hz rTMS on the electroencephalography (EEG) reactivity and clinical response in patients with DOC and to explore the neuromodulatory effects of high-frequency rTMS. In this randomized, sham-controlled, crossover study, real or sham 20 Hz rTMS was applied to the left primary motor cortex (M1) of patients with DOC for 5 consecutive days. Evaluations were blindly performed at the baseline (T0), immediately after the end of the 5 days of treatment (T1) and 1 week after the treatment (T2) using the JFK coma recovery scale-revised (CRS-R) and resting-state EEG. Only one patient, with a history of 2 months of traumatic brain injury, showed long-lasting (T1, T2) behavioral and neurophysiological modifications after the real rTMS stimulation. The 5 remaining patients presented brain reactivity localized at several electrodes, and the EEG modification was not significant. rTMS stimulation may improve awareness and arousal of DOC. Additionally, EEG represents a potential biomarker for the therapeutic efficacy of rTMS. This trial is registered with (NCT03385278).