Should We Expand the Toolbox of Psychiatric Treatment Methods to Include Repetitive Transcranial Magnetic Stimulation (rTMS)? A Meta-Analysis of the Efficacy of rTMS in Psychiatric Disorders

Center for Personality Disorders, Lijnbaan 4, The Hague, the Netherlands.
The Journal of Clinical Psychiatry (Impact Factor: 5.5). 03/2010; 71(7):873-84. DOI: 10.4088/JCP.08m04872gre
Source: PubMed


Repetitive transcranial magnetic stimulation (rTMS) is a safe treatment method with few side effects. However, efficacy for various psychiatric disorders is currently not clear.
A literature search was performed from 1966 through October 2008 using PubMed, Ovid Medline, Embase Psychiatry, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and PsycINFO. The following search terms were used: transcranial magnetic stimulation, TMS, repetitive TMS, psychiatry, mental disorder, psychiatric disorder, anxiety disorder, attention-deficit hyperactivity disorder, bipolar disorder, catatonia, mania, depression, obsessive-compulsive disorder, psychosis, posttraumatic stress disorder, schizophrenia, Tourette's syndrome, bulimia nervosa, and addiction.
Data were obtained from randomized, sham-controlled studies of rTMS treatment for depression (34 studies), auditory verbal hallucinations (AVH, 7 studies), negative symptoms in schizophrenia (7 studies), and obsessive-compulsive disorder (OCD, 3 studies). Studies of rTMS versus electroconvulsive treatment (ECT, 6 studies) for depression were meta-analyzed.
Standardized mean effect sizes of rTMS versus sham were computed based on pretreatment-posttreatment comparisons.
The mean weighted effect size of rTMS versus sham for depression was 0.55 (P < .001). Monotherapy with rTMS was more effective than rTMS as adjunctive to antidepressant medication. ECT was superior to rTMS in the treatment of depression (mean weighted effect size -0.47, P = .004). In the treatment of AVH, rTMS was superior to sham treatment, with a mean weighted effect size of 0.54 (P < .001). The mean weighted effect size for rTMS versus sham in the treatment of negative symptoms in schizophrenia was 0.39 (P = .11) and for OCD, 0.15 (P = .52). Side effects were mild, yet more prevalent with high-frequency rTMS at frontal locations.
It is time to provide rTMS as a clinical treatment method for depression, for auditory verbal hallucinations, and possibly for negative symptoms. We do not recommend rTMS for the treatment of OCD.

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    • "In the last decade , TMS has evolved into a therapeutic modality for several psychiatric and neurological symptoms . In particular , TMS is widely used to treat patients with major depression , obsessive - compulsive disorder ( OCD ) and specific symptoms of schizophrenia ( AVH and negative symptoms ) ( Slotema et al . , 2010 ) . Its application as an adjunctive therapy is currently proposed by European specialists with evidence level C ( Lefaucheur et al . , 2014 ) taking into account that it is generally regarded as safe . We consider the application of TMS for treating individuals presenting with persistent AVH as paradigmatic . The use of TMS impressivel"
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    ABSTRACT: This mini-review focuses on noninvasive brain stimulation techniques as an augmentation method for the treatment of persistent auditory verbal hallucinations (AVH) in patients with schizophrenia. Paradigmatically, we place emphasis on transcranial magnetic stimulation (TMS). We specifically discuss rationales of stimulation and consider methodological questions together with issues of phenotypic diversity in individuals with drug-refractory and persistent AVH. Eventually, we provide a brief outlook for future investigations and treatment directions. Taken together, current evidence suggests TMS as a promising method in the treatment of AVH. Low-frequency stimulation of the superior temporal cortex (STC) may reduce symptom severity and frequency. Yet clinical effects are of relatively short duration and effect sizes appear to decrease over time along with publication of larger trials. Apart from considering other innovative stimulation techniques, such as transcranial Direct Current Stimulation (tDCS), and optimizing stimulation protocols, treatment of AVH using noninvasive brain stimulation will essentially rely on accurate identification of potential responders and non-responders for these treatment modalities. In this regard, future studies will need to consider distinct phenotypic presentations of AVH in patients with schizophrenia, together with the putative functional neurocircuitry underlying these phenotypes.
    Frontiers in Systems Neuroscience 10/2015; 9. DOI:10.3389/fnsys.2015.00131
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    • "Three meta-analyses have been performed on the rTMS treatment of negative symptoms of schizophrenia (Slotema et al., 2010; Dlabac-de Lange et al., 2010; Shi et al., 2013). One included 7 studies and found a trend for improvement of negative symptoms after rTMS (Slotema et al., 2010). The other two included more studies (9 and 13) and both found a statistically significant positive treatment effect (Dlabac-de Lange et al., 2010; Shi et al., 2013). "
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    ABSTRACT: Prefrontal cortical dysfunction is frequently reported in schizophrenia and is thought to underlie negative symptoms of schizophrenia. Repetitive Transcranial Magnetic Stimulation (rTMS) can modulate neuronal activity and has been shown to improve negative symptoms in patients with schizophrenia, but the underlying neural mechanism is unknown. To examine whether 3weeks of 10Hz rTMS treatment of the bilateral dorsolateral prefrontal cortex (DLPFC) would improve frontal brain activation in patients with negative symptoms of schizophrenia, as measured by functional magnetic resonance imaging (fMRI) during the Tower of London (ToL) task. 24 patients with the diagnosis of schizophrenia with moderate to severe negative symptoms (Positive and Negative Syndrome Scale (PANSS) negative subscale≥15) participated. Patients were randomized to a 3-week (15day) course of active or sham rTMS. All patients performed the ToL task during fMRI scanning both pre-treatment and post-treatment. Differences in brain activation between the two groups were compared non-parametrically. After rTMS treatment, brain activity in the active group increased in the right DLPFC and the right medial frontal gyrus as compared to the sham group. In addition, the groups significantly differed with regard to activation change in the left posterior cingulate, with decreased activation in the active and increased activation in the sham group. Treatment with rTMS over the DLPFC may have the potential for increasing task-related activation in frontal areas in patients with schizophrenia. Effects of different rTMS parameters and fMRI tasks targeting relevant brain circuitry deserve further investigation. Nederlands Trial Register, registration number: NTR1261. Copyright © 2015 Elsevier B.V. All rights reserved.
    Schizophrenia Research 07/2015; 168(1). DOI:10.1016/j.schres.2015.06.018 · 3.92 Impact Factor
    • "Repetitive Transcranial Magnetic Stimulation (rTMS) is safe and effective for treatment of Major Depressive Disorder (MDD) in patients who have failed to benefit from antidepressant medication [1e7]. rTMS is administered using a high-field (w1.5 T) electromagnet , with the best established protocols targeting the left dorsolateral prefrontal cortex (DLPFC) at frequencies of 10e20 Hz [2] [4], or the right DLPFC at a frequency of 1 Hz [8] [9]. The optimal intensity, brain area, and frequency of stimulation have not been established through controlled studies [10]. "

    Brain Stimulation 03/2015; 8(2):404. DOI:10.1016/j.brs.2015.01.287 · 4.40 Impact Factor
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