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

Evaluating the efficacy of non-invasive brain stimulation techniques in managing pediatric epilepsy

BACKGROUND

Pediatric epilepsy significantly affects cognitive and developmental outcomes, with drug-resistant epilepsy (DRE) posing a major challenge. While pharmacological and surgical interventions remain standard treatments, they often fail in refractory cases. Non-Invasive Brain Stimulation (NIBS), including Transcranial Magnetic Stimulation (TMS) and Transcranial Direct Current Stimulation (tDCS), has emerged as a promising therapeutic alternative.

NEW METHOD

This study systematically reviews and compares the efficacy, safety, and feasibility of TMS and tDCS in pediatric epilepsy. The analysis evaluates seizure reduction, cognitive improvements, and treatment tolerability. A comparative assessment considers mechanisms of action, precision, accessibility, and clinical applications.

RESULTS

TMS and tDCS treatments produce a 30-40 % seizure reduction effect in addition to attaining enhanced attention and memory functions. TMS provides top-level spatial precision but tDCS allows low-cost portable treatment that suits home use. Studies show that patients experience minimal and short-term discomfort on their scalp but only minor headaches as reported side effects.

COMPARISON WITH EXISTING METHODS

Compared to pharmacological treatments, NIBS offers a non-invasive alternative with fewer systemic side effects. Unlike surgery, which requires invasive intervention, NIBS is safe, repeatable, and adaptable. However, cost (TMS), lack of standardization, and patient response variability remain challenges to clinical adoption.

CONCLUSIONS

NIBS is a safe and effective alternative for pediatric epilepsy but requires protocol standardization, accessibility improvements, and long-term efficacy validation. Future research should focus on biomarker-driven personalized treatments, AI-optimized stimulation, and affordable device development for broader clinical applications.

No sex difference in the antidepressive effect of transcranial magnetic stimulation (TMS): results from a retrospective analysis of a large real-world sample

OBJECTIVES

There is only limited knowledge about the impact of sex on the effectiveness of repetitive transcranial magnetic stimulation (rTMS) in depressive disorders. Here, we analysed a large real-world sample of depressive patients with respect to potential sex-specific effects of rTMS treatment.

METHODS

Data of 984 patients (539 females/445 males) were analysed. Patients received various antidepressant TMS protocols, most of them 10Hz, 20 Hz, Theta burst or accelerated protocols over the left dorsolateral prefrontal cortex. Changes in Hamilton Depression Scale (HAMD) and Major Depression Inventory (MDI) scores as well as response and remission rates were compared between female and male patients.

RESULTS

There were no significant differences in any outcome between female and male patients. Response rates according to the HAMD-21 scores were 34.3% for females and 30.1% for males, according to the MDI 33.1% and 33.5% respectively. In an additional explorative analysis there was a tendency towards better outcome for females for the 20 Hz protocol.

CONCLUSIONS

The antidepressive effectiveness of rTMS does not differ between men and women.

Antidepressant efficacy of administering repetitive transcranial magnetic stimulation (rTMS) with psychological and other non-pharmacological methods: a scoping review and meta-analysis

To optimize the antidepressant efficacy of repetitive transcranial magnetic stimulation (rTMS), it is important to examine the impact of brain state during therapeutic rTMS. Evidence suggests that brain state can modulate the brain's response to stimulation, potentially diminishing antidepressant efficacy if left uncontrolled or enhancing it with inexpensive psychological or other non-pharmacological methods. Thus, we conducted a PRISMA-ScR-based scoping review to pool studies administering rTMS with psychological and other non-pharmacological methods. PubMed and Web of Science databases were searched from inception to 10 July 2024. Inclusion criteria: neuropsychiatric patients underwent rTMS; studies assessed depressive symptom severity; non-pharmacological tasks or interventions were administered during rTMS, or did not include a wash-out period. Of 8,442 studies, 20 combined rTMS with aerobic exercise, bright light therapy, cognitive training or reactivation, psychotherapy, sleep deprivation, or a psychophysical task. Meta-analyses using random effects models were conducted based on change scores on standardized scales. The effect size was large and therapeutic for uncontrolled pretest-posttest comparisons (17 studies, Hedges' g = -1.91, (standard error) SE = 0.45, 95% (confidence interval) CI = -2.80 to -1.03, p < 0.01); medium when studies compared active combinations with sham rTMS plus active non-pharmacological methods (8 studies, g = -0.55, SE = 0.14, 95% CI = -0.82 to -0.28, p < 0.01); and non-significant when active combinations were compared with active rTMS plus sham psychological methods (4 studies, p = 0.96). Attempts to administer rTMS with non-pharmacological methods show promise but have not yet outperformed rTMS alone.

Treatment expectations and clinical outcomes following repetitive transcranial magnetic stimulation for treatment-resistant depression

BACKGROUND

Patient expectations, including both positive (placebo) and negative (nocebo) effects, influence treatment outcomes, yet their impact on acute repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant depression (TRD) is unclear.

METHODS

In this single-center retrospective chart review, 208 TRD patients completed the Stanford Expectation of Treatment Scale (SETS) before starting open-label rTMS treatment. Patients were offered two excitatory rTMS protocols (deep TMS or intermittent theta-burst stimulation), which stimulated the left dorsolateral prefrontal cortex. A minimum of 20 once daily treatments were provided, delivered over 4-6 weeks. Primary outcomes were 1) remission, measured by a post-treatment score of <8 on the Hamilton Depression Rating Scale (HAMD-17), and 2) premature discontinuation. The change in HAMD-17 scores over time was used as a secondary outcome. Physicians were blinded to SETS scores. Logistic and linear regression, adjusting for covariates, assessed SETS and HAMD-17 relationships.

RESULTS

Of 208 patients, 177 had baseline and covariate data available. The mean positivity bias score (positive expectancy minus negative expectancy subscale averages) was 0.48 ± 2.21, indicating the cohort was neutral regarding the expectations of their treatment on average. Higher positive expectancy scores were significantly associated with greater odds of remission (OR = 1.90, p = 0.003) and greater reduction in HAMD-17 scores (β = 1.30, p = 0.005) at the end of acute treatment, after adjusting for covariates. Negative expectancy was not associated with decreased odds of remission (p = 0.2) or treatment discontinuation (p = 0.8).

CONCLUSIONS

Higher pre-treatment positive expectations were associated with greater remission rates with open-label rTMS in a naturalistic cohort of patients with TRD.

Effectiveness of Repetitive Transcranial Magnetic Stimulation in the Treatment of Depression in the Elderly: A Retrospective Natural Analysis

INTRODUCTION

Depression in the elderly is an understudied condition. Psychopharmacological and psychotherapeutic approaches suffer from specific difficulties with this patient group. Brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) offer a therapeutic alternative. rTMS remains understudied in this age group when compared with younger patients.

METHODS

A cohort of 505 patients with depression was analyzed in retrospect concerning their response to rTMS treatment. A total of 15.5% were 60 years old or older, defined as the elderly group of depressed patients. The majority of these were treated with high-frequency protocols over the left dorsolateral prefrontal cortex (DLPFC). For group comparisons, we used Student t-tests or chi-square-tests, depending on the scales of measurement. As measures for effect size, we used Cohen's d for the relative and absolute change in the HDRS total score.

RESULTS

Groups did not differ significantly with respect to baseline depression severity or treatment parameters. In the group of elderly patients, a higher number of females were present. Groups did not differ significantly with respect to treatment efficacy, as indicated by the absolute and relative changes in the HDRS-21 sum score. Elderly patients tended to take higher numbers of mood stabilizers. Elderly patients showed a significantly superior reduction for the item "appetite" and a superior reduction tending towards significance for the item "work and interests".

CONCLUSIONS

Antidepressant rTMS treatment showed comparable efficacy for patients above 60 years to that in younger patients. Differences between the age groups concerning amelioration of distinct HDRS single items deserve further investigation.

Effectiveness of Repetitive Transcranial Magnetic Stimulation in the Treatment of Bipolar Disorder in Comparison to the Treatment of Unipolar Depression in a Naturalistic Setting

Repetitive transcranial magnetic stimulation (rTMS) is effective in the treatment of depression. However, for the subset of patients with bipolar disorder, less data is available and overall strength of evidence is weaker than for its use in unipolar depression. A cohort of 505 patients (of which 46 had a diagnosis of bipolar disorder) with depression who were treated with rTMS were analyzed retrospectively with regards to their response to several weeks of treatment. Hamilton Depression Rating Scale (HDRS) was assessed as main outcome. Unipolar and bipolar patients with depression did not differ significantly in baseline demographic variables or severity of depression. Both groups did not differ significantly in their response to treatment as indicated by absolute and relative changes in the HDRS and response and remission rates. On HDRS subitem-analysis, bipolar patients showed superior amelioration of the symptom “paranoid symptoms” in a statistically significant manner. In conclusion, depressed patients with a diagnosis of bipolar disorder benefit from rTMS in a similar fashion as patients with unipolar depression in a naturalistic setting. rTMS might be more effective in reducing paranoia in bipolar than in unipolar patients.