Rapid Symptom Improvement in Major Depressive Disorder Using Accelerated Repetitive Transcranial Magnetic Stimulation

Comparison between accelerated and standard or sham rTMS in the treatment of depression: A systematic review

Major depressive disorder (MDD) represents a major global health challenge, with a significant proportion of patients being resistant to drug treatment (TRD). Repetitive transcranial magnetic stimulation (rTMS) has shown promise in the treatment of MDD/TRD, with a single stimulation session per day for five days per week over several weeks (the "standard" protocol). The two main paradigms used are high-frequency rTMS and intermittent theta burst stimulation (iTBS) delivered to the left dorsolateral prefrontal cortex (DLPFC). Accelerated TMS (aTMS) protocols aim to make the treatment more effective, or at least more rapidly effective, by delivering more stimulations in a shorter time, which could also facilitate the implementation of the protocols for a larger number of patients. In this systematic literature review, articles comparing in the same study an aTMS protocol to a standard or sham rTMS protocol were retained for analysis. Thus, 23 articles were retained and the analysis focused on the efficacy of aTMS protocols used for the treatment of depression (MDD/TRD) as well as on the impact of various stimulation parameters, such as stimulation pattern, intersession interval, dosage, and methods of cortical targeting. Although some studies did not report significant differences between aTMS and standard or sham protocols, others suggested potential advantages of aTMS, such as twice-daily HF-rTMS of the left DLPFC or more intensive iTBS protocols with a long interval between two sessions and personalized cortical targeting. Our results highlight the influence of the number of sessions or pulses per session (dosage), the duration of the interval between sessions, and the precision of target localization (using image-guided neuronavigation) on therapeutic efficacy. However, limitations in sample size, few independent studies replicating the same methodology, and variability in the clinical profile of treated patients, given different definitions of treatment resistance or the presence of comorbidities, hamper definitive conclusions.

Short-term and long-term efficacy of accelerated transcranial magnetic stimulation for depression: a systematic review and meta-analysis

BACKGROUND

In recent years, accelerated transcranial magnetic stimulation (aTMS) has been developed, which has a shortened treatment period. The aim of this study was to evaluate the efficacy and long-term maintenance effects of aTMS in patients with major depressive disorder (MDD).

METHODS

We systematically searched online databases for aTMS studies in patients with MDD published before February 2023 and performed a meta-analysis on the extracted data.

RESULTS

Four randomized controlled trials (RCTs) and 10 before-and-after controlled studies were included. The findings showed that depression scores significantly decreased following the intervention (SMD = 1.80, 95% CI (1.31, 2.30), p < 0.00001). There was no significant difference in antidepressant effectiveness between aTMS and standard TMS (SMD = -0.67, 95% CI (-1.62, 0.27), p = 0.16). Depression scores at follow-up were lower than those directly after the intervention based on the depression rating scale (SMD = 0.22, 95% CI (0.06, 0.37), p = 0.006), suggesting a potential long-term maintenance effect of aTMS. Subgroup meta-analysis results indicated that different modes of aTMS may have diverse long-term effects. At the end of treatment with the accelerated repetitive transcranial magnetic stimulation (arTMS) mode, depressive symptoms may continue to improve (SMD = 0.29, 95% CI (0.10, 0.49), I2 = 22%, p = 0.003), while the accelerated intermittent theta burst stimulation (aiTBS) mode only maintains posttreatment effects (SMD = 0.01, 95% CI (-0.45, 0.47), I2 = 66%, p = 0.98).

CONCLUSIONS

Compared with standard TMS, aTMS can rapidly improve depressive symptoms, but there is no significant difference in efficacy. aTMS may also have long-term maintenance effects, but longer follow-up periods are needed to assess this possibility.

TRIAL REGISTRATION

This article is original and not under simultaneous consideration for publication. The study was registered on PROSPERO ( https://www.crd.york.ac.uk/prospero/ ) (number: CRD42023406590).

Association between daily dose and efficacy of rTMS over the left dorsolateral prefrontal cortex in depression: A meta-analysis

Repetitive transcranial magnetic stimulation (rTMS) is a well-established, safe, and effective brain stimulation technique for depression; however, uniform parameters have not been used in clinical practice. The aim of this study was to identify the parameters that affect rTMS effectiveness and ascertain the range in which that parameter has optimal efficacy. A meta-analysis of sham-controlled trials using rTMS delivered over the left dorsolateral prefrontal cortex (DLPFC) in depression was conducted. In the meta-regression and subgroup analyses, all rTMS stimulation parameters were extracted and their association with efficacy was investigated. Of the 17,800 references, 52 sham-controlled trials were included. Compared to sham controls, our results demonstrated a significant improvement in depressive symptoms at the end of treatment. According to the results of meta-regression, the number of pulses and sessions per day correlated with rTMS efficacy; however, the positioning method, stimulation intensity, frequency, number of treatment days, and total pulses did not. Furthermore, subgroup analysis revealed that the efficacy was correspondingly better in the group with higher daily pulses. In clinical practice, increasing the number of daily pulses and sessions may improve the effectiveness of rTMS.

The Association Between Sample and Treatment Characteristics and the Efficacy of Repetitive Transcranial Magnetic Stimulation in Depression: A Meta-analysis and Meta-regression of Sham-controlled Trials

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is a form of non-invasive neuromodulation that is increasingly used to treat major depressive disorder (MDD). However, treatment with rTMS could be optimized by identifying optimal treatment parameters or characteristics of patients that are most likely to benefit. This meta-analysis and meta-regression aims to identify sample and treatment characteristics that are associated with change in depressive symptom level, treatment response and remission.

METHODS

The databases PubMed, Embase, Web of Science and Cochrane library were searched for randomized controlled trials (RCTs) reporting on the therapeutic efficacy of high-frequent, low-frequent, or bilateral rTMS for MDD compared to sham. Study and sample characteristics as well as rTMS parameters and outcome variables were extracted. Effect sizes were calculated for change in depression score and risk ratios for response and remission.

RESULTS

Sixty-five RCTs with a total of 2982 subjects were included in this meta-analysis. Active rTMS resulted in a larger depressive symptom reduction than sham protocol (Hedges' g = -0.791 95% CI -0.977; -0.605). Risk ratios for response and remission were 2.378 (95% CI 1.882; 3.005) and 2.450 (95% CI 1.779; 3.375), respectively. We found no significant association between sample and treatment parameters and rTMS efficacy.

CONCLUSIONS

rTMS is an efficacious treatment for MDD. No associations between sample or treatment characteristics and efficacy were found, for which we caution that publication bias, heterogeneity and lack of consistency in the definition of remission might bias these latter null findings. Our results are clinically relevant and support the use of rTMS as a non-invasive and effective treatment option for depression.

Intensive rTMS for treatment-resistant depression patients with suicidal ideation: An open-label study

The advantages of intensive repetitive transcranial magnetic stimulation (rTMS) protocol are in the possible acute effect of the stimulation and in the possible reduction in the time required to achieve remission in depression. Here, we investigated the antidepressant effects and antisuicidal effects of a more intensive rTMS protocol for treatment-resistant depression (TRD) patients with suicidal ideation. Thirty-one outpatients were included in this study, including 22 military veterans and 9 non- militaries. The rTMS treatment consisted of 25 sessions, each session lasting 30 min (60 trains of 50 pulsations, 110 % resting motor threshold intensity) for a total of 3000 pulse. The total amount of stimulation (750,000 pulses) applied by our rTMS protocol was equivalent to that of a 5-week standard rTMS protocol. We found a significant effect of time on the 17-item Hamilton Depression Rating Scale (HAMD-17) scores and the Sheehan Disability Scale (SDS) scores. There was no difference in change in the HAMD-17 scores and SDS scores between the military veteran group and the non-military group between baseline and the week 4 assessment time point. The response rate of depression was 64.52 %, and the remission rate of depression was 51.61 % at day 5. 48.39 % and 35.48 % at week 4, respectively. All patients (100 %) met response criteria of suicidal ideation, and the remission rate was 87.09 % at day 5. The response rate was 83.87 % %, and the remission rate was 77.42 % at week 4. The accelerated high-dose rTMS treatment was well tolerated by all patients. Our intensive rTMS protocol is preliminarily safe and feasible. The TRD patients with suicidal ideation could benefit from much shorter exposure to this protocol with more efficacy in comparison with conventional rTMS protocol. In addition, intensive rTMS offers a promising treatment for military veteran populations.

A transdiagnostic review of safety, efficacy, and parameter space in accelerated transcranial magnetic stimulation

BACKGROUND

Accelerated transcranial magnetic stimulation (aTMS) is an emerging delivery schedule of repetitive TMS (rTMS). TMS is "accelerated" by applying two or more stimulation sessions within a day. This three-part review comprehensively reports the safety/tolerability, efficacy, and stimulation parameters affecting response across disorders.

METHODS

We used the PubMed database to identify studies administering aTMS, which we defined as applying at least two rTMS sessions within one day.

RESULTS

Our targeted literature search identified 85 aTMS studies across 18 diagnostic and healthy control groups published from July 2001 to June 2022. Excluding overlapping populations, 63 studies delivered 43,873 aTMS sessions using low frequency, high frequency, and theta burst stimulation in 1543 participants. Regarding safety, aTMS studies had similar seizure and side effect incidence rates to those reported for once daily rTMS. One seizure was reported from aTMS (0.0023% of aTMS sessions, compared with 0.0075% in once daily rTMS). The most common side effects were acute headache (28.4%), fatigue (8.6%), and scalp discomfort (8.3%), with all others under 5%. We evaluated aTMS efficacy in 23 depression studies (the condition with the most studies), finding an average response rate of 42.4% and remission rate of 28.4% (range = 0-90.5% for both). Regarding parameters, aTMS studies ranged from 2 to 10 sessions per day over 2-30 treatment days, 10-640 min between sessions, and a total of 9-104 total accelerated TMS sessions per participant (including tapering sessions). Qualitatively, response rate tends to be higher with an increasing number of sessions per day, total sessions, and total pulses.

DISCUSSION

The literature to date suggests that aTMS is safe and well-tolerated across conditions. Taken together, these early studies suggest potential effectiveness even in highly treatment refractory conditions with the added potential to reduce patient burden while also expediting response time. Future studies are warranted to systematically investigate how key aTMS parameters affect treatment outcome and durability.

Long-term Safety and Efficacy of Esketamine Nasal Spray Plus an Oral Antidepressant in Patients with Treatment-resistant Depression- an Asian Sub-group Analysis from the SUSTAIN-2 Study

Objective

To evaluate the long-term safety and efficacy of intranasal esketamine in patients with treatment-resistant depression from the Asian subgroup of the SUSTAIN-2 study.

Methods

SUSTAIN-2 was a phase 3, open-label, single-arm, multicenter study comprising a 4-week screening, 4-week induction, 48-week optimization/maintenance, and 4-week follow-up (upon esketamine discontinuation) phase. Patients with treatment-resistant depression received esketamine plus an oral antidepressant during the treatment period.

Results

The incidence of ≥ 1 serious treatment-emergent adverse event (TEAE) among the 78 subjects from the Asian subgroup (Taiwan 33, Korea 26, Malaysia 19) was 11.5% (n = 9); with no fatal TEAE. 13 Asian patients (16.7%) discontinued esketamine due to TEAEs. The most common TEAEs were dizziness (37.2%), nausea (29.5%), dissociation (28.2%), and headache (21.8%). Most TEAEs were mild to moderate in severity, transient and resolved on the same day. Upon discontinuation of esketamine, no trend in withdrawal symptoms was observed to associate long-term use of esketamine with withdrawal syndrome. There were no reports of drug seeking, abuse, or overdose. Improvements in symptoms, functioning and quality of life, occurred during in the induction phase and were generally maintained through the optimization/maintenance phases of the study.

Conclusion

The safety and efficacy of esketamine in the Asian subgroup was generally consistent with the total SUSTAIN-2 population. There was no new safety signal and no indication of a high potential for abuse with the long-term (up to one year) use of esketamine in the Asian subgroup. Most of the benefits of esketamine occurred early during the induction phase.