rTMS deserves a fair chance as a novel treatment for depression

Antidepressant outcomes of high-frequency repetitive transcranial magnetic stimulation (rTMS) with F8-coil and deep transcranial magnetic stimulation (DTMS) with H1-coil in major depression: a systematic review and meta-analysis

BACKGROUND

The current study aims to systematically assess and compare the antidepressant outcomes of repetitive transcranial magnetic stimulation (rTMS) with the figure-of-eight (F8)-coil and deep transcranial magnetic stimulation (DTMS) with the H1-coil in studies matched on stimulation frequency in unipolar major depressive disorder (MDD).

METHODS

Electronic search of Medline and PsycInfo identified 19 studies with stimulation frequency of 18-20 Hz using F8-coil (k = 8 randomised sham-controlled trials, RCTs, k = 3 open-label; n = 168 patients) or H1-coil (k = 1 RCT, k = 7 open-label; n = 200). Depression severity (the primary outcome) and response/remission rates (the secondary outcomes) were assessed at session 10.

RESULTS

Effects pooled with random-effects meta-analysis showed a large reduction in depression severity, 29% response, and 15% remission rates after 10 sessions of active stimulation with either coil relative to baseline. Reduction in depression severity was greater in studies with younger patients using either coil. The comparison between coils showed a larger reduction in depression severity in H1-coil vs. F8-coil studies (independent of the study design or the concurrent pharmacotherapy) and a trend towards higher remission rates in F8-coil vs. H1-coils studies. These effects are based on a low volume of studies, are not controlled for placebo, and may not be clinically-relevant. The stimulation protocols differed systematically because stimulation was more focal but less intense (80-110% of the resting motor threshold, MT) in the F8-coil studies and less focal but more intense (120% MT) in the H1-coil studies. Two seizures occurred in the H1-coil studies relative to none in the F8-coil studies.

CONCLUSION

When matched on frequency, the higher-intensity and less focal stimulation with the H1-coil reduces depression more than the lower-intensity and more focal stimulation with the F8-coil. Head-to-head trials should compare the antidepressant outcomes of F8-coil and H1-coil to identify the most optimal stimulation protocols for acute and longer-lasting efficacy.

Remission rate of transcranial magnetic stimulation compared with electroconvulsive therapy: a case-control study

PURPOSE

To compare the rate of remission, rate of response, change in depressive symptoms, and adverse effects between repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT).

MATERIALS AND METHODS

In this retrospective case-control study, 35 patients treated for depression with rTMS (left dorsolateral prefrontal cortex, 90% observed motor threshold, 10 Hz, 2000 pulses/session, 15 sessions) at Örebro University Hospital, Sweden (cases), were compared with a matched group of 35 patients treated for depression with ECT (controls). Data on controls were obtained from the Swedish National Quality Register for ECT (Q-ECT). Severity of depression was evaluated using the Montgomery-Åsberg Depression rating scale (MADRS).

RESULTS

Remission rate was 26% for cases and 43% for controls (p = .3). Response rate was 40% for cases and 51% for controls (p = .63). The median decrease in MADRS was 11 (IQR 3-19) vs. 17 (IQR 6-27; p = .10) for rTMS and ECT, respectively. There was no statistically significant difference in any measure of treatment effect between rTMS and ECT. More than half of the patients of the rTMS group experienced scalp discomfort and 11% of the ECT group had memory disturbances.

CONCLUSIONS

All measures of therapeutic efficacy were numerically inferior in the rTMS group compared to the ECT group. The differences were not statistically significant, probably because the sample size was small. More studies are required to find the optimal place for rTMS within the Swedish health care system. Such studies could be facilitated by inclusion of rTMS in the Q-ECT.

Defending psychiatry or defending the trivial effects of therapeutic interventions? A citation content analysis of an influential paper

AIMS

Leucht et al. in 2012 described an overview of meta-analyses of the efficacy of medication in psychiatry and general medicine, concluding that psychiatric drugs were not less efficacious than other drugs. Our goal was to explore the dissemination of this highly cited paper, which combined a thought provoking message with a series of caveats.

METHODS

We conducted a prospectively registered citation content analysis. All papers published before June 1st citing the target paper were independently rated by two investigators. The primary outcome coded dichotomously was whether the citation was used to justify a small or modest effect observed for a given treatment. Secondary outcomes regarded mentioning any caveats when citing the target paper, the point the citation was making (treatment effectiveness in psychiatry closely resembles that in general medicine, others), the type of condition (psychiatric, medical or both), specific disease, treatment category and specific type. We also extracted information about the type of citing paper, financial conflict of interest (COI) declared and any industry support. The primary analysis was descriptive by tabulating the extracted variables, with numbers and percentages where appropriate. Co-authorship networks were constructed to identify possible clusters of citing authors. An exploratory univariate logistic regression was used to explore the relationship between each of a subset of pre-specified secondary outcomes and the primary outcome.

RESULTS

We identified 135 records and retrieved and analysed 120. Sixty-three (53%) quoted Leucht et al.'s paper to justify a small or modest effect observed for a given therapy, and 113 (94%) did not mention any caveats. Seventy-two (60%) used the citation to claim that treatment effectiveness in psychiatry closely resembles that in general medicine; 110 (91%) paper were about psychiatric conditions. Forty-one (34%) papers quoted it without pointing towards any specific treatment category, 28 (23%) were about antidepressants, 18 (15%) about antipsychotics. Forty (33%) of the citing papers included data. COIs were reported in 55 papers (46%). Univariate and multivariate regressions showed an association between a quote justifying small or modest effects and the point that treatment effectiveness in psychiatry closely resembles that in general medicine.

CONCLUSIONS

Our evaluation revealed an overwhelmingly uncritical reception and seemed to indicate that beyond defending psychiatry as a discipline, the paper by Leucht et al. served to lend support and credibility to a therapeutic myth: trivial effects of mental health interventions, most often drugs, are to be expected and therefore accepted.Protocol registration: https://osf.io/9dqat/.

Therapeutic Efficacy of Neurostimulation for Depression: Techniques, Current Modalities, and Future Challenges

Depression is the most prevalent debilitating mental illness; it is characterized as a disorder of mood, cognitive function, and neurovegetative function. About one in ten individuals experience depression at some stage of their lives. Antidepressant drugs are used to reduce the symptoms but relapse occurs in ~20% of patients. However, alternate therapies like brain stimulation techniques have shown promising results in this regard. This review covers the brain stimulation techniques electroconvulsive therapy, transcranial direct current stimulation, repetitive transcranial magnetic stimulation, vagus nerve stimulation, and deep brain stimulation, which are used as alternatives to antidepressant drugs, and elucidates their research and clinical outcomes.

Mood disorders in the elderly: prevalence, functional impact, and management challenges

Despite the lower prevalence of severe mood disorders in the elderly as compared to younger adults, late-life depression and bipolar disorder (BD) are more strongly associated with negative outcomes related to the presence of medical comorbidities, cognitive deficits, and increased suicide risk and overall mortality. The mechanisms that contribute to these associations are probably multifactorial, involving pathological factors related directly and indirectly to the disease itself, ranging from biological to psychosocial factors. Most of the accumulated knowledge on the nature of these associations derives from naturalistic and observational studies, and controlled data are still scarce. Nonetheless, there has clearly been a recent growth of the scientific interest on late-life BD and geriatric depression. In the present study, we review the most relevant studies on prevalence, clinical presentation, and cognitive/functional impact of mood disorders in elderly. Several clinical-epidemiological studies were dedicated to the study of the prevalence of mood disorders in old age in distinct settings; however, fewer studies investigated the underlying neurobiological findings and treatment specificities in late-life depression and BD. In the present study, we further discuss the implications of these findings on the management of mood disorders in older adults.

Deep transcranial magnetic stimulation (DTMS) in the treatment of major depression: An exploratory systematic review and meta-analysis

BACKGROUND

Deep transcranial magnetic stimulation (DTMS) is a relatively new, non-invasive method of stimulating larger and, presumably, deeper brain regions. The current study investigated if DTMS delivered with H-coils has acute antidepressant effects in major depression using a systematic literature review and a quantitative meta-analysis.

METHODS

Seventeen studies on 'DTMS or H-coil' and 'depression' were identified on Medline, PsycInfo, and Google Scholar (until November 2014). Data from nine open-label studies were meta-analysed using a random-effects model with inverse-variance weights. The outcome measures were the standardised paired mean difference (Cohen's d) in depression scores on Hamilton Depression Rating Scale (HDRS), response, remission, and dropout rates after acute DTMS treatment compared to baseline.

RESULTS

There was a large antidepressant effect after 20 acute, high-frequency DTMS sessions compared to baseline according to HDRS change scores (overall mean weighted d=2.04, 95% confidence interval: 1.53-2.55; nine studies; 150 patients). Overall weighted response, remission, and dropout rates were 60%, 29%, and 18% respectively. HDRS change scores and response rates tended to be higher in four studies with 68 patients on concurrent antidepressants compared to two studies with 26 patients who received DTMS as a monotherapy.

LIMITATIONS

These results are based on data from a low number of open-label studies.

CONCLUSION

High-frequency DTMS appears to have acute antidepressant effects after 20 sessions in mostly unipolar and treatment-resistant patients. Concurrent treatment with antidepressants might enhance the efficacy of DTMS.

Transcranial magnetic stimulation for geriatric depression: Promises and pitfalls

As the global population gets older, depression in the elderly is emerging as an important health issue. A major challenge in treating geriatric depression is the lack of robust efficacy for many treatments that are of significant benefit to depressed working age adults. Repetitive transcranial magnetic stimulation (rTMS) is a novel physical treatment approach used mostly in working age adults with depression. Many TMS trials and clinics continue to exclude the elderly from treatment citing lack of evidence in this age group. In this review, we appraise the evidence regarding the safety and efficacy of rTMS in the elderly. A consistent observation supporting a high degree of tolerability and safety among the elderly patients emerged across the Randomised Controlled Trials and the uncontrolled trials. Further, there is no reliable evidence negating the utility of rTMS in the elderly with depression. We also identified several factors other than age that moderate the observed variations in the efficacy of rTMS in the elderly. These factors include but not limited to: (1) brain atrophy; (2) intensity and number of pulses (dose-response relationship); and (3) clinical profile of patients. On the basis of the current evidence, the practice of excluding elderly patients from TMS clinics and trials cannot be supported.