Repetitive transcranial magnetic stimulation for major depression: A naturalistic observational study in an Australian private hospital

Association between Stimulation-Site Pain and Clinical Improvement during Repetitive Transcranial Magnetic Stimulation for Patients with Major Depressive Disorders: A Prospective Observational Study at Two Sites

INTRODUCTION

The clinical efficacy of repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant depression (TRD) in Japan has not been adequately investigated. Furthermore, the relationship between stimulation-site pain and the antidepressant effects of rTMS has not been thoroughly examined. Therefore, this study aimed to clarify (1) the real-world efficacy and safety of rTMS for TRD in Japan and (2) the relationship between stimulation-site pain and clinical improvement of depressive symptoms.

METHODS

We conducted a retrospective observational study involving 50 right-handed patients with TRD. All patients received high-frequency rTMS for up to 6 weeks. Depressive symptoms were assessed using the Montgomery-Åsberg depression rating scale (MADRS). Pain at the stimulation site was reported by the patients using a visual analog scale (VAS) after each session. Remission and response rates at 3 and 6 weeks were calculated based on the MADRS scores. The correlation between changes in the MADRS and VAS scores was examined.

RESULTS

Remission and response rates were 36% and 46%, respectively, at the end of 3 weeks, and 60% and 70%, respectively, at 6 weeks. At the end of the treatment, there was significant correlation between the reduction of MADRS and VAS scores (r = 0.42, p = 0.003).

CONCLUSION

This study demonstrates the clinical efficacy of rTMS in Japan and the correlation between its antidepressant effects and stimulation-site pain.

Equal remission rates and reduced length of hospital stay with twice-daily repetitive transcranial magnetic stimulation (rTMS) for major depression - A large naturalistic retrospective cohort association study

OBJECTIVES

Repetitive transcranial magnetic stimulation (rTMS) is a level 1a evidence-based treatment for major depression, but high cost of care and limited effectiveness in naturalistic cohorts have been lingering criticisms. This naturalistic, retrospective cohort analysis compares the effect of once and twice daily treatment protocols of rTMS using quality assurance data collected at an Australian private psychiatric hospital.

METHODS

A total of 210 inpatients self-selected into two groups receiving up to 30 sessions of either daily (n = 101) or twice daily (n = 109) 10 Hz rTMS to the left dorsolateral prefrontal cortex (DLPFC). The a priori primary outcome measure was remission rate as measured by pre and post treatment HAMD-17 scores. Length of hospital stay was a secondary post hoc outcome adopted due to the importance to cost of acute psychiatric care.

RESULTS

Remission rates were similar across groups, with 44.9% and 45.4% for twice daily and daily rTMS groups respectively, although these may be confounded by patient expectations, other treatments and medication changes given the naturalistic setting. The length of hospital stay was 10.11 days and 18.44 days for twice daily and daily rTMS respectively - the twice daily rTMS length of hospital stay was 45.1% shorter 95% CI [38.7% - 51.56%]. Dropout rates were high; Twenty-seven (24.77%) twice daily participants dropped out before 20 sessions were completed, and 35 (34.65%) of daily participants.

CONCLUSIONS

Twice daily 10 Hz left sided rTMS remission outcomes were similar to traditional once daily rTMS but required a shorter length of hospital stay. This finding has substantial cost of care implications. If these findings are independently replicated, twice daily rTMS may become the standard of care for inpatient rTMS.

Efficacy and safety of transcranial magnetic stimulation for treating major depressive disorder: An umbrella review and re-analysis of published meta-analyses of randomised controlled trials

OBJECTIVES

We re-analysed data from published meta-analyses testing the effects of Transcranial Magnetic Stimulation (TMS) on Major Depressive Disorder (MDD) in adults. We applied up-to-date meta-analytic techniques for handling heterogeneity including the random-effects Hartung-Knapp-Sidik-Jonkman method and estimated 95% prediction intervals. Heterogeneity practices in published meta-analyses were assessed as a secondary aim.

STUDY DESIGN AND SETTING

We performed systematic searches of systematic reviews with meta-analyses that included randomised controlled trials assessing the efficacy, tolerability, and side effects of TMS on MDD. We performed risk of bias assessment using A MeaSurement Tool to Assess Reviews (AMSTAR) 2 and re-analysed meta-analyses involving 10 or more primary studies.

RESULTS

We included 29 systematic reviews and re-analysed 15 meta-analyses. Authors of all meta-analyses interpreted findings to suggest TMS is safe and effective for MDD. Our re-analysis showed that in 14 out of 15 meta-analyses, the 95% prediction intervals included the null and captured values in the opposite effect direction. We also detected presence of small-study effects in some meta-analyses and 24 out of 25 systematic reviews received an AMSTAR 2 rating classed as critically low.

CONCLUSION

Authors of all included meta-analyses interpreted findings to suggest TMS is safe and effective for MDD despite lack of comprehensive investigation of heterogeneity. Our re-analysis revealed the direction and magnitude of treatment effects vary widely across different settings. We also found high risk of bias in the majority of included systematic reviews and presence of small-study effects in some meta-analyses. Because of these reasons, we argue TMS for MDD may not be as effective and potentially less tolerated in some populations than current evidence suggests.

Add-On Intermittent Theta Burst Stimulation Improves the Efficacy of First-Episode and Recurrent Major Depressive Disorder: Real-World Clinical Practice

OBJECTIVE

Repetitive transcranial magnetic stimulation (rTMS) is an effective and evidence-based treatment for major depressive disorder (MDD). This retrospective study aimed to explore the efficacy of add-on iTBS treatment in MDD in real-world clinical practice.

METHODS

One hundred and fifty-nine inpatients with MDD in a general hospital were included in this study. These patients were treated with at least 8 sessions of iTBS, in addition to antidepressants and supportive psychotherapy. Symptoms of depression and anxiety were assessed with the Hamilton Depression Rating Scale (HDRS) and the Hamilton Rating Scale for Anxiety (HAMA) at baseline and after 2-4 weeks of treatment. The improvement degree of depressive and anxious symptoms was compared between the first-episode MDD (n=107) and recurrent MDD (n=52) groups.

RESULTS

Depressive and anxious symptoms were reduced significantly after the add-on iTBS treatment; the response and remission rates in the first-episode MDD group were 55.14% and 28.97%, which were 63.46% and 28.85% for the recurrent MDD group, respectively (P>0.05). The response rate and remission rate of anxiety in the first-episode MDD group was 64.13% and 57.45% for HAMA, and 66.67% and 62.50% for the recurrent MDD group (P>0.05).

CONCLUSION

Our findings indicated that antidepressant and anti-anxiety efficacy of add-on iTBS treatment remains equivocal in real-world clinical practice, regardless of a first-episode depression diagnosis or recurrent depression.

Long-Term Management of Generalised Anxiety Disorder with Low-Dose Continuous Infusions of Flumazenil: A Case Series

Background: Generalised anxiety disorder (GAD) is a common anxiety disorder associated with social and occupational impairment. Recently, a theory was postulated that dysfunctional gamma aminobutyric acid type A receptors (GABAA) are implicated in anxiety symptomology, which could be corrected by flumazenil, an antagonist at the benzodiazepine binding site on the GABAA receptor. Method: Participants had a primary diagnosis of GAD and were treated initially with an eight-day continuous low-dose flumazenil infusion (total 32 mg at a rate of 4 mg/24 h). Some participants were re-treated with a further four- or eight-day infusion. Treatment response was measured as a 50% reduction in anxiety or stress scores on the Depression Anxiety Stress Scale—21 (DASS-21). Remission was measured as scores ≤3 or ≤7 on the anxiety and stress subscales of the DASS-21, respectively. Results: Eight cases are reported. All cases met the criteria for treatment response on the anxiety and stress subscale of the DASS-21. Remission was achieved in seven participants on the anxiety subscale and in five on the stress subscale. No changes in hepatic, renal, or haematological function were likely attributed to flumazenil. Conclusion: Data suggest that low-dose continuous flumazenil infusion manages GAD symptoms and is safe. Although these results are promising, future randomised control trials are required to confirm these results.

Could bipolar depressed patients respond better to rTMS than unipolar depressed patients? A naturalistic, observational study

Previous studies of rTMS for bipolar depressed (BD) patients have yielded mixed results. In this retrospective, naturalistic, observational study, we reviewed charts of 317 patients undergoing rTMS treatment between 1/2015-2/2018, yielding 283 unipolar depressed (UD) and 34 BD patients. All were treated with a figure-of-8 coil, with either high-frequency (HF) left-sided, sequential bilateral (HF left-sided and low-frequency right-sided), or mixed protocols (switched from unilateral to bilateral mid-course).  Outcomes were the Generalized Anxiety Disorder scale (GAD-7) and Patient Health Questionnaire (PHQ-9). Total number of treatments and initial PHQ-9 scores did not differ between groups. BD patients had greater PHQ-9 change by treatment conclusion than UD patients. GAD-7 changes showed no between-group differences overall. PHQ-9 changes differences between groups were only seen with unilateral treatment, not with bilateral or mixed protocols. Unilateral treatment resulted in 45% remission (9/20) for BD patients vs. 15% (24/160) for UD patients by treatment end. Response was seen in 80% (16/20) of the unilaterally-treated BD patients vs. 39% (62/160) in UD patients. Regression analyses within BD patients found that unilateral treatment, use of non-lithium mood stabilizers, male sex, and number of treatments predicted PHQ-9 improvement.

Assessment of multiple salivary biomarkers during repetitive transcranial magnetic stimulation (rTMS) treatment for major depression

Steroid hormones may serve as potential biomarkers of treatment response for major depressive disorder (MDD). Here, we assessed salivary levels of cortisol, dehydroepiandrosterone (DHEA), and DHEA sulfate (DHEA-S), as well as α-amylase activity, across 30 sessions of bilateral repetitive transcranial magnetic stimulation (rTMS) of the dorsolateral prefrontal cortex in MDD patients. While rTMS significantly improved symptoms as measured by three different symptom scales, salivary biomarker levels and their ratios showed no significant changes across sessions. These results do not support the routine clinical use of these biomarkers as reliable indicators of treatment outcome during rTMS administration for MDD.