Efficacy of repetitive transcranial magnetic stimulation (rTMS) adjunctive therapy for major depressive disorder (MDD) after two antidepressant treatment failures: meta-analysis of randomized sham-controlled trials

Left prefrontal intermittent theta-burst stimulation therapy for major depressive disorder: A real-world, multisite observational study in Japan

BACKGROUND

Although approved for treatment in 2018, the effectiveness of intermittent theta-burst stimulation (iTBS) in a real-world setting remains inadequately studied. This observational study investigated the real-world use of iTBS, a usual medical practice for depression, factors influencing its effectiveness, and differences in effectiveness between 600 and 1200 pulses.

METHODS

Data from patients who received iTBS therapy for depression at four private clinics between January 2021 and April 2024 were extracted. Patients were assessed using the 17-item Hamilton Depression Rating Scale at baseline and after treatment completion. Correlation and multiple regression analyses were performed to investigate clinico-demographic factors and stimulation parameters associated with iTBS effectiveness. Safety was assessed using all relevant data, and effectiveness was evaluated using eligible samples.

RESULTS

Among 538 patients meeting eligibility criteria for effectiveness evaluation (mean age 40.8 ± 13.8 years, 44.1 % women), 63 completed iTBS with 600 pulses, and 475 completed iTBS with 1200 pulses. Overall response and remission rates were 69.1 % and 53.7 %, respectively, with no significant difference in effectiveness between iTBS-600 and iTBS-1200. Multiple regression analysis indicated fewer depressive episodes (β = -0.103, t = -2.080, p = 0.038) and more treatment sessions (β = 0.134, t = 3.155, p = 0.002) may have contributed to the positive effect of iTBS therapy. The most common adverse event was stimulation site pain. No severe adverse events, such as seizure induction or manic switch, were observed.

CONCLUSION

The results suggest the highly favorable effectiveness of iTBS therapy for major depressive disorder in real-world settings.

Impact of repetitive transcranial magnetic stimulation on clinical and cognitive outcomes, and brain-derived neurotrophic factor levels in treatment-resistant depression

Introduction

Treatment-resistant depression (TRD) affects approximately 30% of patients with major depressive disorder (MDD), for whom effective treatment options are limited. Repetitive transcranial magnetic stimulation (rTMS) has shown efficacy in alleviating depressive symptoms in TRD. However, it remains unclear if these improvements are driven or mediated by changes in cognitive function or biological markers, such as brain-derived neurotrophic factor (BDNF).

Methods

This study examines the effects of rTMS on depressive symptoms, cognition, and BDNF levels, as well as the potential moderating role of lifetime suicidal attempts (LSA) on cognition and the predictive value of baseline BDNF for clinical outcomes. Twenty-five TRD patients were included, with 13 in the rTMS treatment group (receiving 20 sessions of rTMS over four weeks) and 12 as control group. Depression severity, cognitive function (Mini-Mental State Examination, Verbal Fluency, Digit Span), and serum BDNF levels were measured pre- and post-treatment. Mixed-effects linear regression models assessed clinical and biological associations.

Results

rTMS significantly reduced HAM-D (p < 0.001) and CGI (p < 0.001) scores compared to controls. Cognitive performance improved significantly in MMSE (p = 0.049) and Digit Span (p = 0.04), with no significant changes in BDNF levels (p = 0.39). LSA did not moderate cognitive outcomes, and baseline BDNF did not predict clinical improvement (p = 0.68).

Discussion

rTMS reduced depressive symptoms in TRD patients, with modest cognitive benefits. Baseline BDNF did not predict outcomes, though the lack of significant change suggests complex neuroplastic responses. Future studies should include larger samples and refined biomarker assessments.

EEG alpha activity as predictor for TBS-rTMS treatment outcome in depression

Repetitive transcranial magnetic stimulation (rTMS) is an established psychiatric procedure for patients suffering from treatment-resistant depression (TRD). Biomarker identification to predict rTMS outcomes may assist the clinician in optimizing treatment selection. In recent years, different electrophysiological markers, in particular electroencephalographic (EEG) markers, were shown to yield discriminative power between responders and non-responders to various TRD treatments. However, so far, predictive markers for the Theta Burst Stimulation (TBS) protocol have remained scarce. The present study, therefore, aimed to identify such markers. Resting state EEGs of 10-15 min were done in a group of 46 TRD patients prior to rTMS TBS treatment (600 stimuli over the left dorsolateral prefrontal cortex). Each patient underwent 19-21 sessions with 4-5 sessions per week. Depression was assessed using the Hamilton Depression Rating Scale and the Beck Depression Inventory II. Our study demonstrated that responders exhibited significantly lower FAA values in a baseline EEG indicating that left frontal alpha dominance was associated with a positive response to TBS-rTMS in TRD patients. FAA was independent of both gender and age. No other biomarker, including alpha peak frequency, or alpha power, showed a significant difference between responders and non-responders. Taken together, FAA observed in EEG readings is emerging as a promising indicator of treatment outcomes in patients with TRD. Given these findings, we suggest considering FAA as a predictive factor when assessing the effectiveness of therapeutic interventions. Further studies replicating these results in larger, diverse populations are needed to confirm FAA as a reliable biomarker of clinical outcome.

Ultrasound Applications in the Treatment of Major Depressive Disorder (MDD): A Systematic Review of Techniques and Efficacy

Objective

Major depressive disorder (MDD) is a debilitating mental health condition characterized by persistent feelings of sadness, loss of interest, and impaired daily functioning. It affects approximately 8% of the U.S. population, posing a significant personal and economic burden. Around 30% of patients with MDD do not respond to conventional antidepressant and psychotherapeutic treatments. Current treatment options for refractory MDD include transcranial magnetic stimulation (TMS) and invasive surgical procedures such as surgical ablation, vagus nerve stimulation, and deep brain stimulation. TMS has modest efficacy, and surgical procedures are associated with surgical risk and low patient acceptance. With the unique advantage of combining non-invasiveness with selective targeting, therapeutic ultrasound emerges as a promising alternative for treating refractory MDD. Over the past 10 years, there has been a growth in focused ultrasound research, leading to an exponential increase in academic and public interest in the technology. To support the continued development of ultrasound for treating MDD, we conducted a systematic review following Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines.

Methods

We included peer-reviewed prospective cohort studies, case-control studies, and randomized control trials that evaluate the efficacy of ultrasonic treatment for depression (PROSPERO registration number: CRD42024626093). We summarized ultrasonic techniques for treating depression and their efficacy. Furthermore, we identified key challenges and future directions for applying ultrasound in treating MDD.

Results

We identified 67 potentially relevant articles, of which 18 studies met all inclusion criteria. The techniques of applying ultrasound to treat depression include magnetic resonance-guided focused ultrasound (MRgFUS) for capsulotomy and low-intensity focused ultrasound (LIFUS) neuromodulation. In human trials, the response rate (⩾50% improvement from baseline on depression score) is 53.85% for MRgFUS and 80.49% for LIFUS neuromodulation. In all preclinical studies using rodent models (8 studies), LIFUS neuromodulation had a medium to large effect (|Cohen's d| > 0.6) on resolving depressive-like behavior in rodents without causing adverse effects such as tissue damage. MRgFUS faces inconsistent lesioning success and a limited response rate, while LIFUS neuromodulation lacks systematic exploration of parameter space and a clear understanding of its mechanistic effects. Future work should refine patient selection for MRgFUS and focus on individualized functional targeting.

Conclusion

LIFUS neuromodulation showed a medium to large effect in reducing depressive behaviors in both rodent models and human trials, representing a promising, noninvasive option for treating refractory MDD.

Effect of DLPFC rTMS on anhedonia and alpha asymmetry in depressed patients

Anhedonia, a core symptom of depression, has been defined as the loss of pleasure or lack of reactivity to pleasurable stimuli. Considering the relevance of alpha asymmetry to MDD and anhedonia, we explored the effect of dorsolateral prefrontal cortex (DLPFC) stimulation on frontal and posterior EEG alpha asymmetry (FAA and PAA, respectively), in this exploratory investigation. 61 participants randomly received sham (n = 11), bilateral (BS; n = 25), or unilateral stimulation (US; n = 25) of the DLPFC. The Snaith-Hamilton Pleasure Scale (SHAPS) was administered. FAA and PAA were calculated by subtracting the natural log-transformed alpha power of the right (F8 or T6) from that of the left (F7 or T5) EEG channel. Furthermore, alpha peak was defined as the frequency where alpha power was at its maximum. BS and US both reduced anhedonia symptoms in the active compared to the sham group. Even non-responders in the BS group showed a decreased anhedonia. Interestingly in the BS group, only the patients who showed a right-lateralized FAA or PAA at baseline showed a reduction in anhedonia. However, in the US group, only patients with left-lateralized FAA or right-lateralized PAA showed a decrease in anhedonia. PAA at baseline predicted symptoms post treatment. Furthermore, a significant positive correlation between baseline alpha peak values and SHAPS scores post treatment were found in the BS group. PAA was a better predictor of anhedonia and reduction of depressive symptoms in both groups. BS may produce larger effects with regard to anhedonia.

Efficacy of repetitive transcranial magnetic stimulation in preventing postoperative delirium in elderly patients undergoing major abdominal surgery: A randomized controlled trial

BACKGROUND

Postoperative delirium (POD) is a serious complication in elderly patients after major surgery, associated with high morbidity and mortality. Treatment and prevention methods are limited. Repetitive transcranial magnetic stimulation (rTMS) shows potential in enhancing cognitive function and improving consciousness.

OBJECTIVE

To evaluate whether early postoperative rTMS has a protective effect against POD and to explore its potential mechanisms.

METHODS

Patients aged 60 years or older, scheduled for major abdominal surgery, were randomly assigned to receive rTMS at 100 % RMT, 10 Hz, with 2000 pulses targeting the DLPFC after extubation in PACU, either as active rTMS(n = 61) or sham rTMS (n = 61). The primary outcome was the incidence of POD during the first 3 postoperative days.

RESULTS

In the modified intention-to-treat analysis of 122 patients (mean [SD] age, 70.2 [4.1] years; 53.3 % women), POD incidence was lower in the rTMS group (11.5 %) compared to the sham rTMS group (29.5 %) (relative risk, .39; 95 % CI, .18 to .86; P = .01). rTMS patients had higher BDNF (8.47 [2.68] vs. 5.76 [1.42] ng/mL; P < .001) and lower NfL (.05 [.04] vs. .06 [.04] ng/mL; P = .02) levels. Mediation analysis suggests that rTMS may reduce POD by increasing brain-derived neurotrophic factor (z = -3.72, P < .001) rather than decreasing neurofilament light (z = 1.92, P = .06).

CONCLUSIONS

Immediate postoperative rTMS can reduce the incidence of POD in elderly patients undergoing major abdominal surgery, probably by upregulating brain-derived neurotrophic factor levels.

Impact of high-frequency rTMS combined with pharmacotherapy on the left dorsolateral prefrontal cortex in treating major depressive disorder: A real-world study

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) combined with pharmacotherapy is a promising treatment method for depression. However, its treatment mechanism needs further research.

METHODS

This study recruited 38 healthy individuals (HC) and 52 patients with severe depression (MDD) and divided patients into two treatment groups: the rTMS combined antidepressant (rTMS+ADP) group and the single antidepressant (ADP) group. We used functional magnetic resonance imaging to calculate the fractional amplitude of low-frequency fluctuations (fALFF) in the left dorsolateral prefrontal cortex (DLPFC) to investigate the functional change after treatment.

RESULT

The fALFF in the left DLPFC was significantly lower in the MDD group than that in the HC group (p < 0.05). In addition, fALFF values of the left DLPFC negatively correlated with HAMD-24 scores (r = -0.294, p = 0.005). After treatment, both MDD groups showed a significant decrease in HAMD-24 scores, with a response rate of 88.89 % and a remission rate of 62.96 % in the rTMS+ADP group, compared to 64 % response and 56 % remission rates in the ADP group. The fALFF values in patients' left DLPFC significantly reduced in the rTMS+ADP group (p < 0.05), but not in the ADP group.

LIMITATIONS

Our study only focused on the treatment effect in the left DLPFC, without exploring the other brain regions or networks.

CONCLUSIONS

This study emphasizes the significance of the left DLPFC in MDD treatment. However, combined left DLPFC rTMS with ADP causes deviation from the normal resting brain function of the left DLPFC, indicating that future research should explore targeted treatment methods to normalize the left DLPFC.

Decoding Motor Excitability in TMS using EEG-Features: An Exploratory Machine Learning Approach

Brain state-dependent transcranial magnetic stimulation (TMS) holds promise for enhancing neuromodulatory effects by synchronizing stimulation with specific features of cortical oscillations derived from real-time electroencephalography (EEG). However, conventional approaches rely on open-loop systems with static stimulation parameters, assuming that pre-determined EEG features universally indicate high or low excitability states. This one-size-fits-all approach overlooks individual neurophysiological differences and the dynamic nature of brain states, potentially compromising therapeutic efficacy. We present a supervised machine learning framework that predicts individual motor excitability states from pre-stimulus EEG features. Our approach combines established biomarkers with a comprehensive set of spectral and connectivity measures, implementing multi-scale feature selection within a nested cross-validation scheme. Validation across multiple classifiers, feature sets, and experimental protocols in 50 healthy participants demonstrated a mean prediction accuracy of 71 ± 7%. Hierarchical clustering of top predictive EEG features revealed two distinct participant subgroups. The first subgroup, comprising approximately 50% of participants, showed predictive features predominantly in alpha and low-beta bands in sensorimotor regions of the stimulated hemisphere, aligning with traditional associations of motor excitability and the sensorimotor μ-rhythm. The second subgroup exhibited predictive features primarily in low and high gamma bands in parietal regions, suggesting that motor excitability is influenced by broader neural dynamics for these individuals. Our data-driven framework effectively identifies personalized motor excitability biomarkers, holding promise to optimize TMS interventions in clinical and research settings. Additionally, our approach provides a versatile platform for biomarker discovery and validation across diverse neuromodulation paradigms and brain signal classification tasks.

Deep transcranial magnetic stimulation for treatment-resistant obsessive-compulsive disorder: A meta-analysis of randomized-controlled trials

BACKGROUND

Deep transcranial magnetic stimulation (dTMS), an advancement of transcranial magnetic stimulation, was created to reach wider and possibly more profound regions of the brain. At present, there is insufficient high-quality evidence to support the effectiveness and safety of dTMS in treating obsessive-compulsive disorder (OCD).

OBJECTIVE

This study used a meta-analysis to evaluate the effectiveness and safety of dTMS for treating OCD.

METHODS

Four randomized controlled trials were found by searching PubMed, Embase, Web of Science, and Cochrane Library up to February 2024. The fixed effects meta-analysis model was used for the purpose of data merging in Stata17. The risk ratio (RR) value was used as the measure of effect size to compare response rates and dropout rates between active and sham dTMS.

RESULTS

The meta-analysis included four randomized-controlled trials involving 252 patients with treatment-resistant OCD. Active dTMS showed a notably greater rate of response on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) in comparison to sham dTMS after treatment (Y-BOCS: RR = 3.71, 95% confidence interval [CI] 2.06 to 6.69) and at the one-month follow-up (Y-BOCS: RR = 2.60, 95% CI 1.59 to 4.26). Subgroup analysis revealed that active dTMS with H-coils was more effective than sham dTMS (RR = 3.57, 95%CI 1.93 to 6.60). No serious adverse events were documented in the studies that were included.

CONCLUSION

The findings suggest that dTMS demonstrates notable efficacy and safety in treating patients with treatment-resistant OCD compared to sham dTMS, with sustained effectiveness noted throughout the one-month post-treatment period.

Early symptom improvement and other clinical predictors of response to repetitive transcranial magnetic stimulation for depression

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is a rapidly emerging treatment for depression, but outcome prediction is still a challenge. This study aimed to identify predictors of response to rTMS among baseline clinical factors and early symptomatic improvements.

METHODS

This cohort study comprised 136 patients with a unipolar or bipolar depressive episode referred for clinical intermittent theta-burst stimulation or right-sided 1 Hz rTMS at the Uppsala Brain Stimulation Unit. The co-primary outcomes used for logistic regression were response, defined as ≥50 % reduction of Montgomery and Åsberg Depression Rating Scale Self-assessment (MADRS-S) total score, and 1-2 points on the Clinical Global Impression Improvement (CGI-I) scale. Early improvement was defined as ≥20 % reduction in the MADRS-S total score, or ≥ 1 point reduction in each MADRS-S item, after two weeks of treatment.

RESULTS

The response rates were 21 % for MADRS-S and 45 % for CGI-I. A depressive episode >24 months had lower odds for MADRS-S response compared to ≤12 months. Early improvement of the MADRS-S total score predicted CGI-I response (95 % CI = 1.35-9.47, p = 0.011), Initiative6 predicted MADRS-S response (95 % CI = 1.08-9.05, p = 0.035), and Emotional involvement7 predicted CGI-I response (95 % CI = 1.03-8.66, p = 0.044).

LIMITATIONS

No adjustment for concurrent medication.

CONCLUSIONS

A depressive episode ≤12 months and early improvement in overall depressive symptoms, as well as the individual items, Initiative6 and Emotional involvement7, predicted subsequent rTMS response in a naturalistic sample of depressed patients. This could facilitate the early identification of patients who will benefit from further rTMS sessions.

Transcranial magnetic stimulation in psychiatry: A Singapore perspective

The use of repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder (MDD) and obsessive-compulsive disorder (OCD) has not been described in Singapore. Reports on the effectiveness of rTMS in populations outside of Western countries are also limited. Thus, Ye et al.’s study on the naturalistic outcomes of rTMS treatment is important in the Asian context.1 The lifetime prevalence of depression in Singapore is 6.3%.2 It has been estimated that 30%–60% of patients with MDD do not respond to a first-line antidepressant, whereas 40% do not respond to a second-line antidepressant. Treatment resistant depression (TRD) is a term often used when a patient has failed to respond to 2 different antidepressants, with adequate adherence for a duration of 4–8 weeks. Further trials of antidepressant medication result in diminishing response rates and prolonging illness duration.3 Options for TRD include continued trials of different medications—utilising switching, augmentation or combination approaches and using psychotherapy and/or non-invasive neurostimulation techniques, such as rTMS and electroconvulsive therapy (ECT). While ECT is recognised as the most effective non-invasive neurostimulation treatment, studies have increasingly demonstrated that rTMS is more cost effective4 and has demonstrated superiority to switching antidepressants.5 In Singapore, the College of Psychiatrists endorsed the use of rTMS for MDD in 2015 and OCD in 2018. The Institute of Mental Health (IMH) has the largest psychiatric rTMS service in Singapore.

Association between rTMS-induced changes in inflammatory markers and improvement in psychiatric diseases: a systematic review

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) has recently gained relevance in treating different psychiatric disorders. Limited evidence suggests that the beneficial effects of rTMS on psychopathology could be at least partly mediated through changes in inflammatory response. This systematic review summarizes the literature on whether rTMS can modulate inflammatory markers and thus positively influence the course of psychiatric illnesses.

MATERIALS AND METHODS

A systematic review of rTMS and inflammatory markers in psychiatric diseases was conducted according to PRISMA guidelines. Information on the association between rTMS treatment response and changes of inflammatory markers was extracted. The quality of the studies was assessed using the National Heart, Lung, and Blood Institute for human studies and the Systematic Review Center for Laboratory Animal Experimentation for animal studies.

RESULTS

This review includes 17 studies (2 animal and 15 human studies) on the relationship between rTMS treatment response and changes of inflammatory markers. Positive changes in microglial activity and anti-inflammatory effects were associated with behavioral improvement in animal models of depression. However, these findings have not been consistently replicated in human studies focusing on treatment-resistant depression. While several studies reported rTMS-induced alterations in peripheral inflammatory markers, only two could demonstrate their association to clinical treatment response. Notably, most studies showed poor or moderate quality in the bias assessment.

CONCLUSIONS

While certain human studies suggest an association between rTMS-induced anti-inflammatory effects and improvement in psychopathology, heterogeneity, and underpowered analyses constrain the generalizability of these results. The discrepancy between animal and human findings highlights the need for larger, standardized human studies.

TRIAL REGISTRATION

(PROSPERO Registration: CRD42023492732).

Management of Depression in Adults: A Review

Importance

Approximately 9% of US adults experience major depression each year, with a lifetime prevalence of approximately 17% for men and 30% for women.

Observations

Major depression is defined by depressed mood, loss of interest in activities, and associated psychological and somatic symptoms lasting at least 2 weeks. Evaluation should include structured assessment of severity as well as risk of self-harm, suspected bipolar disorder, psychotic symptoms, substance use, and co-occurring anxiety disorder. First-line treatments include specific psychotherapies and antidepressant medications. A network meta-analysis of randomized clinical trials reported cognitive therapy, behavioral activation, problem-solving therapy, interpersonal therapy, brief psychodynamic therapy, and mindfulness-based psychotherapy all had at least medium-sized effects in symptom improvement over usual care without psychotherapy (standardized mean difference [SMD] ranging from 0.50 [95% CI, 0.20-0.81] to 0.73 [95% CI, 0.52-0.95]). A network meta-analysis of randomized clinical trials reported 21 antidepressant medications all had small- to medium-sized effects in symptom improvement over placebo (SMD ranging from 0.23 [95% CI, 0.19-0.28] for fluoxetine to 0.48 [95% CI, 0.41-0.55] for amitriptyline). Psychotherapy combined with antidepressant medication may be preferred, especially for more severe or chronic depression. A network meta-analysis of randomized clinical trials reported greater symptom improvement with combined treatment than with psychotherapy alone (SMD, 0.30 [95% CI, 0.14-0.45]) or medication alone (SMD, 0.33 [95% CI, 0.20-0.47]). When initial antidepressant medication is not effective, second-line medication treatment includes changing antidepressant medication, adding a second antidepressant, or augmenting with a nonantidepressant medication, which have approximately equal likelihood of success based on a network meta-analysis. Collaborative care programs, including systematic follow-up and outcome assessment, improve treatment effectiveness, with 1 meta-analysis reporting significantly greater symptom improvement compared with usual care (SMD, 0.42 [95% CI, 0.23-0.61]).

Conclusions and Relevance

Effective first-line depression treatments include specific forms of psychotherapy and more than 20 antidepressant medications. Close monitoring significantly improves the likelihood of treatment success.

A meta-analysis of transcranial magnetic stimulation in Tourette syndrome

There is growing enthusiasm for the treatment of neuropsychiatric disorders using neuromodulation. While some reports claim that transcranial magnetic stimulation (TMS) can be used to treat Tourette Syndrome (TS), little research exists to support this assertion. This meta-analysis examined the efficacy of TMS to reduce tic severity in patients with TS. Additionally, it explored the effect of TMS to reduce premonitory urge severity-the primary mechanism implicated in the frontline evidence-based treatment of TS. Five treatment comparisons were selected using PRISMA guidelines. All studies included were required to be (1) a randomized controlled trial, (2) compare TMS to a sham condition, and (3) have all participants meet diagnostic criteria for a persistent tic disorder and/or TS. A random effects model meta-analysis examined the efficacy of using TMS to reduce tic severity and explored the effect of TMS to reduce premonitory urge severity. TMS did not significantly reduce tic severity (g = 0.44; 95% CI = -0.17, 1.05; z = 1.40; p = 0.16), but a moderate reduction in premonitory urge severity was found (g = 0.63; 95% CI = 0.9, 1.17; z = 2.27; p < 0.02). Trials with larger sample sizes and a preponderance of women were found to have greater therapeutic effects of TMS for tic severity. There is limited support for the use of TMS to reduce tic severity, though reductions in premonitory urge severity were observed. Major limitations of the existing literature are examined, with a call for research investigating newer TMS protocols and their use as a treatment augmentation strategy.

Impact of Repetitive Transcranial Magnetic Stimulation on Cognitive and Psychiatric Dysfunction in Patients with Fibromyalgia: A Double-Blinded, Randomized Clinical Trial

Few randomized controlled trials have reported that repetitive transcranial magnetic stimulation (rTMS) has controversial results for managing multiple domains of fibromyalgia-related symptoms. This work aimed to evaluate the effect of low-frequency rTMS over the right dorsolateral prefrontal area (DLPFC) on the Fibromyalgia Impact Questionnaire (FIQ) concerning psychiatric and cognitive disorders. Forty-two eligible patients with fibromyalgia (FM) were randomized to have 20 sessions of active or sham rTMS (1 Hz, 120% of resting motor threshold with a total of 1200 pules/session) over the right DLPFC. All participants were evaluated at baseline, post sessions, and 3 months after sessions with the FIQ, Hamilton depression, and anxiety rating scales (HDRS and HARS), Montreal Cognitive Assessment (MoCA), Rey Auditory Verbal Learning Test (RAVLT), Tower of London test (TOL), the Trail Making, and Digit Span Tests. Both groups showed improvement in most rating scales at 1 and 3 months follow-up, with greater improvement in the active group, with significant correlation between FIQ cognitive rating scales, including RAVLT and TOL. Twenty sessions of low-frequency rTMS over the right DLPFC can improve FIQ scores regarding the psychiatric and cognitive symptoms of medicated patients with FM to a greater extent than sham. Changes in RAVLT and TOL correlated with changes in FIQ results.

Inappropriate study inclusion in meta-analysis of sham-controlled rTMS for treatment-resistant depression

Dr. Vida and colleagues have published an important meta-analysis on a critical topic in psychiatry: the efficacy of double-blind, sham-controlled rTMS in treatment-resistant depression (TRD) [1]. The primary reported finding was a significant effect of rTMS on remission and response (RR 2.25 and 2.78 respectively) compared to sham rTMS. A close evaluation of the studies included in this meta-analysis raises concerns about the accuracy of these findings.

Comparative Efficacy of Augmenting Escitalopram with Modified Electroconvulsive Therapy or High-Frequency Repetitive Transcranial Magnetic Stimulation on Depressive Symptoms, Quality of Life, and Cognitive Function in Treatment-Resistant Depression

Treatment-resistant depression (TRD) poses significant therapeutic challenges despite available interventions. Escitalopram (ESC) is a highly selective antidepressant. This study aimed to compare ESC alone and ESC combined with modified electroconvulsive therapy (MECT) or high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) in TRD patients. Ninety participants were randomized into ESC alone, ESC + MECT, and ESC + HF-rTMS groups. Notable differences were observed in Hamilton Depression Rating Scale (HDRS-17) scores at 12 weeks among ESC (14.37), ESC + MECT (10.27), and ESC + HF-rTMS (10.77) groups (P = 0.006). In terms of overall quality of life (QoL) evaluated using the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF) at 12 weeks, the ESC, ESC + MECT, and ESC + HF-rTMS groups scored 2, 3, and 3.5, respectively. ESC + MECT/HF-rTMS groups showed reduced depressive symptoms compared to the ESC group, accompanied by higher overall QoL scores and increased satisfaction with health. Patients receiving ESC + MECT demonstrated no significant alterations in short-term memory and orientation, as measured by the Montreal Cognitive Assessment (MoCA), before and after treatment. Moreover, a decline in language was observed compared to baseline (12 weeks: median 2, IQR 2-3; baseline: median 1, IQR 1-3; P = 0.022). The positive impact of ESC with HF-rTMS on cognitive function was evidenced by improvements in all domines MoCA.Combining ESC with MECT or HF-rTMS exhibited enhanced effectiveness in alleviating depressive symptoms and enhancing QoL compared to ESC monotherapy. Specifically, the ESC + HF-rTMS combination displayed potential as a comprehensive treatment strategy for TRD, addressing both emotional and cognitive aspects.

Real-world retrospective study of repetitive transcranial magnetic stimulation (TMS) treatment for bipolar and unipolar depression using TMS registry data in Tokyo

Despite the prevalence of empirical practice, evidence supporting the use of repetitive transcranial magnetic stimulation (rTMS) in treating bipolar depression (BD) is sparse compared to that for unipolar depression. Therefore, this study aimed to conduct a retrospective observational analysis using TMS registry data to compare the efficacy of rTMS treatment for BD and unipolar depression. Data from 20 patients diagnosed with unipolar and BD were retrospectively extracted from the TMS registry to ensure age and sex matching. The primary outcomes of this registry study were measured using the 21-item Hamilton Depression Rating Scale (HAM-D21) and Montgomery-Åsberg Depression Rating Scale (MADRS). Analysis did not reveal significant differences between the two groups in terms of depression severity, motor threshold, or stimulus intensity at baseline. Similarly, no significant differences were observed in absolute or relative changes in the total HAM-D21 and MADRS scores. Furthermore, the response and remission rates following rTMS treatment did not differ significantly between groups. The only adverse event reported in this study was scalp pain at the stimulation site; however, the incidence and severity were not significantly different between the groups. In conclusion, this retrospective study, using real-world TMS registry data, suggests that rTMS treatment for BD could be as effective as that for unipolar depression. These findings underscore the need for further validation in prospective randomized controlled trials with larger sample sizes.

A Retrospective Case-Control Study on the Differences in the Effectiveness of Theta-Burst Stimulation Therapy for Depression with and without Antidepressant Medication

Transcranial magnetic stimulation (TMS) therapy has few side effects and comparable therapeutic effects to antidepressant treatment, but few studies have introduced TMS therapy as an initial treatment for MDD. The objective of this study was to retrospectively compare the clinical outcomes between 50 MDD patients without antidepressants (i.e., TMS monotherapy) and 50 MDD patients with antidepressants plus TMS therapy, matched for age, sex, and depression severity. The presence or absence of antidepressant therapy in first-line treatment was determined via a detailed interview by psychiatrists. The study design was a retrospective observational case-control study using the TMS registry data. The key inclusion criteria were adult patients who met the diagnosis of MDD and received 20-30 sessions of intermittent theta-burst stimulation (iTBS) therapy to the left dorsolateral prefrontal cortex (DLPFC). In this study, the Montgomery-Åsberg Depression Rating Scale (MADRS) was used as the primary outcome measure. No significant group differences existed in the baseline MADRS total score between the unmedicated and medicated patient groups. Following TMS therapy, no significant group differences in response rate, remission rate, or relative total score change in the MADRS were observed. The main limitations were the retrospective design and the use of registry data as a source. Our findings suggest that TMS monotherapy may be as effective as TMS add-on therapy to antidepressants when used as the first-line therapy for MDD, but randomized controlled trials are needed.