Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression: A Systematic Review and Meta-Analysis
To evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with major depressive disorder (MDD) and 2 or more prior antidepressant treatment failures (often referred to as treatment-resistant depression [TRD]). These patients are less likely to recover with medications alone and often consider nonpharmacologic treatments such as rTMS.
Available from: Noah Philip
- "Transcranial magnetic stimulation (TMS) is a safe and efficacious, noninvasive brain stimulation treatment for medication-resistant MDD. To date, the acute efficacy of TMS is supported by multiple double blind, randomized controlled trials    and a recent meta-analysis . The ideal method for maintaining benefit for a patient who had an adequate response to an acute course of TMS has not been determined. "
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Repetitive transcranial magnetic stimulation (TMS) is efficacious for acute treatment of resistant major depressive disorder (MDD), but there is little information on maintenance TMS after acute response.
This pilot feasibility study investigated 12-month outcomes comparing two maintenance TMS approaches - a scheduled, single TMS session delivered monthly (SCH) vs. observation only (OBS).
Antidepressant-free patients with unipolar, non-psychotic, treatment-resistant MDD participated in a randomized, open-label, multisite trial. Patients meeting protocol-defined criteria for improvement after six weeks of acute TMS were randomized to SCH or OBS regimens. TMS reintroduction was available for symptomatic worsening; all patients remained antidepressant-free during the trial.
Sixty-seven patients enrolled in the acute phase, and 49 (73%) met randomization criteria. Groups were matched, although more patients in the SCH group had failed ≥2 antidepressants (p = .035). There were no significant group differences on any outcome measure. SCH patients had nonsignificantly longer time to first TMS reintroduction, 91 ± 66 days, vs. OBS, 77 ± 52 days; OBS patients were nonsignificantly more likely to need reintroduction (odds ratio = 1.21, 95% CI .38-3.89). Reintroduction lasted 14.3 ± 17.8 days (SCH) and 16.9 ± 18.9 days (OBS); 14/18 (78%) SCH and 17/27 (63%) OBS responded to reintroduction. Sixteen patients (32.7%) completed all 53 weeks of the study.
Maintaining treatment-resistant depressed patients off medications with periodic TMS appears feasible in some cases. There was no statistical advantage of SCH vs. OBS, although SCH was associated with a nonsignificantly longer time to relapse. Those who initially respond to TMS have a strong chance of re-responding if relapse occurs.
Available from: Jessica McClelland
- "More generally, the dorsolateral prefrontal cortex (DLPFC) is involved in decision-making and emotion regulation (Ochsner & Gross, 2007) and has become a common target for neuromodulation-based interventions in psychiatric disorders . Repetitive transcranial magnetic stimulation (rTMS) to the left DLPFC (l-DLPFC) is reported to have clinical efficacy in the treatment of depression (Gaynes et al., 2014) and reduces craving in addictive disorders (Jansen et al., 2013). Given such findings, its effects on food cravings and in ED have also been investigated. "
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This case series examined the therapeutic potential of repetitive transcranial magnetic stimulation in five women with enduring anorexia nervosa.
Participants received ~20 sessions of neuronavigated high-frequency repetitive transcranial magnetic stimulation to the left dorsolateral prefrontal cortex. Body mass index, eating disorder (ED) symptoms and mood were assessed pre-treatment and post-treatment, at 6-month and 12-month follow-up (FU). Qualitative feedback regarding the intervention was obtained from participants and carers.
From pre-treatment to post-treatment, ED and affective symptoms improved significantly, and body mass index remained stable. Further improvements in ED symptoms/mood were seen at 6-month FU with 3/5 and 2/5 participants deemed 'recovered' on the Eating Disorders Examination Questionnaire and Depression, Anxiety and Stress Scale, respectively. However, most participants had lost some weight, and therapeutic effects on psychopathology had waned by 12-month FU. Qualitative feedback regarding the intervention was encouraging.
Repetitive transcranial magnetic stimulation was well tolerated, and preliminary evidence is provided for its therapeutic potential in anorexia nervosa. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.
Available from: Xavier Moisset
- "In addition to its uses in cognitive neuroscience, the clinical applications of repetitive transcranial magnetic stimulation (rTMS) have rapidly expanded over the last few years. This non invasive technique was initially proposed and has been most thoroughly studied for the treatment of depression (Gaynes et al., 2014; George et al., 1995; Lefaucheur et al., 2014). However, rTMS may also be useful for the treatment of other psychiatric and neurological conditions, including negative symptoms of schizophrenia, chronic motor stroke, tinnitus and auditory hallucinations (Lefaucheur et al., 2014). "
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Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive technique that allows cortical stimulation. Recent studies have shown that rTMS of the primary motor cortex or dorsolateral prefrontal cortex decreases pain in various pain conditions. The aim of this review was to summarize the main characteristics of rTMS-induced analgesic effects and to analyse the current data on its mechanisms of action.
Medline, PubMed and Web of Science were searched for studies on the analgesic effects and mechanisms of rTMS-induced analgesic effects. Studies on epidural motor cortex stimulation (EMCS) were also included when required, as several mechanisms of action are probably shared between both techniques.
Stimulation site and stimulation parameters have a major impact on rTMS-related analgesic effects. Local cortical stimulation is able to elicit changes in the functioning of distant brain areas. These modifications outlast the duration of the rTMS session and probably involve LTP-like mechanisms via its influence on glutamatergic networks. Analgesic effects seem to be correlated to restoration of normal cortical excitability in chronic pain patients and depend on pain modulatory systems, in particular endogenous opioids. Dopamine, serotonin, norepinephrine and GABAergic circuitry may also be involved in its effects, as well as rostrocaudal projections.
rTMS activates brain areas distant from the stimulation site. LTP-like mechanisms, dependence on endogenous opioids and increase in concentration of neurotransmitters (monoamines, GABA) have all been implicated in its analgesic effects, although more studies are needed to fill in the still existing gaps in the understanding of its mechanisms of action.
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