Repetitive Transcranial Magnetic Stimulation Combined with Antidepressants for the First Episode of Major Depressive Disorder

Antidepressant class and concurrent rTMS outcomes in major depressive disorder: a systematic review and meta-analysis

Background

Repetitive transcranial magnetic stimulation (rTMS) is frequently used as an adjunctive treatment with antidepressants for depression. We aimed to evaluate the clinical efficacy and safety of antidepressant classes when administered concurrently with rTMS for the management of major depressive disorder (MDD).

Methods

In this systematic review and meta-analysis, MEDLINE, Embase, PsycINFO, and the Cochrane Library were searched from inception to April 12th 2024 for terms relating to medication, depression, and rTMS and appraised by 2 independent screeners. All randomized clinical trials that prospectively evaluated a specific antidepressant adjunctively with sham rTMS as a control in MDD were included. The study was registered with PROSPERO (CRD42023418435). The primary outcome measure assessed symptomatic improvement measured by formal depression scales. We used a random-effects model with pooled Standardized Mean Differences (SMDs) and log odds ratios (OR). All studies were assessed for their methodological quality and bias using the Cochrane Collaboration Risk of Bias tool version 2 (RoB2).

Findings

14 articles from 5376 identified studies were included in the systematic review and meta-analysis. There was only sufficient trial data to evaluate the effects of rTMS and combination therapy with selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs). Across studies, 848 participants (mean [SD] age:41.1 [18.7] years for SSRIs, 51.8 [3.8] years for SNRIs) prospectively examined the efficacy of antidepressant medication with rTMS. Combining rTMS with SSRIs led to significantly lower depression scores, (SMD [CI] of -0.65 [-0.98, -0.31], p = 0.0002, I2 = 66.1%), higher response (OR = 0.97 [0.50, 1.44], p < 0.0001, I2 = 25.33%) and remission rates (OR = 1.04 [0.55, 1.52], p < 0.0001, I2 = 0.00%) than medication with sham rTMS. No additive benefit was found for SNRIs with rTMS (SMD of 0.10 [-0.14, 0.34], p = 0.42, I2 = 0.00%; OR = 0.12 [-0.39, 0.62], p = 0.64, I2 = 0.00%; OR = -0.31 [-0.90, 0.28], p = 0.86, I2 = 39.9%). The overall risk of bias for the included studies ranged from low to high, with 1 study having a high risk of bias.

Interpretation

The combination of rTMS with SSRIs, but not SNRIs, significantly reduced depression severity, increasing response and remission rates. Some analyses demonstrated high heterogeneity, which was influenced by an SSRI trial with a high effect size. Overall, these results suggest that not all antidepressant combination therapies are alike, and SSRIs should be considered when initiating rTMS.

Funding

Donald T. Stuss Young Investigator Research Innovation Award from the Sandra Black Centre for Brain Resilience & Recovery and the Harquail Centre for Neuromodulation through the Sunnybrook Foundation.

Alterations of the amplitude of low-frequency fluctuation induced by repetitive transcranial magnetic stimulation combined with antidepressants treatment for major depressive disorder

We investigated the neuroimaging changes and clinical efficacy of repetitive transcranial magnetic stimulation (rTMS) combined with antidepressants in major depressive disorder (MDD) patients. We scanned 35 patients with MDD and 27 healthy controls (HC) with resting-state functional magnetic resonance imaging (fMRI) before and after treatment. We analyzed amplitude of low-frequency fluctuation (ALFF) and the correlation with clinical variables. The rate of significant efficacy after treatment was higher in the combination treatment group than in the antidepressant group, although not statistically significant. At baseline, ALFF increased in the left middle temporal, brain stem, and left cerebellum and decreased in the right anterior cingulate (ACC), right orbital frontal cortex (OFC), and right caudate. ALFF increased in the left fusiform and decreased in the right lingual gyrus, left middle occipital gyrus, and left superior occipital gyrus after antidepressants. ALFF increased in the right ACC, right OFC, and right rectus after combination treatment. ALFF changes in the right ACC/OFC were negatively correlated with HAMD changes. After treatment, abnormal activity in some brain regions normalized, but these regions differed between the two treatment groups. rTMS combined with antidepressants therapy may improve MDD symptoms by improving neuronal activity levels in the right ACC and right OFC.

Efficacy of non-invasive brain stimulation combined with antidepressant medications for depression: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Antidepressants, noninvasive brain stimulation (NIBS), and their combination are commonly used in routine clinical practice. Nevertheless, there is a continuous dispute regarding whether the effectiveness of NIBS in combination with antidepressants exceeds that of antidepressants alone. This meta-analysis aimed to evaluate the existing evidence and draw a definitive conclusion on this issue.

METHODS

We conducted a comprehensive search of five databases: Embase, PubMed, Web of Science, SinoMed, and the Cochrane Database of Randomized Controlled Trials. The search was conducted until October 6, 2023. The primary outcomes were the pre- and post-intervention depression and anxiety scores. Secondary outcomes included dropout rates, response rates, and certain levels of neurotransmitters [ 5-hydroxytryptamine (5-HT), dopamine (DA), and gamma-aminobutyric acid (GABA)] at the end of the intervention. Subgroup, meta-regression, and sensitivity analyses were performed to explore the sources of heterogeneity. The data were analysed using R 4.2.2.

RESULTS

We included 18 RCTs [1357 participants; 11 studies used repetitive transcranial magnetic stimulation (rTMS) and 7 studies used transcranial direct current stimulation (tDCS)]. The follow-up duration varied from two weeks to three months. Overall, whether in combination with rTMS or tDCS, antidepressants proved more effective in alleviating depressive symptoms compared to when used as monotherapy. However, this advantage was not evident during the follow-up period. (p > 0.05). And the combination's efficacy in improving anxiety was found to be lacking. Post-treatment serum levels of 5-HT, DA, and GABA were higher in the rTMS group were higher than antidepressant medication group (p < 0.05). Furthermore, subgroup analysis results indicated that only the rTMS + antidepressant medication treatment significantly improved remission and remission rates. The meta-regression results showed that the type of antidepressant and the sex of the participants had a significant association with the depression score.

CONCLUSION

Combination treatment with NIBS was significantly more effective in improving depression symptoms than medication alone. rTMS combined with antidepressants appears to be more effective in improving response and remission rates. However, efficacy may be influenced by the type of medicine used in combination, and long-term efficacy data is lacking.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023388259.

Efficacy and safety of non-invasive brain stimulation in combination with antidepressants in adolescents with depression: a systematic review and meta-analysis

Objective

Non-invasive brain stimulation (NIBS) is beneficial to adult patients with depression, but its safety and efficacy in combination with antidepressants in children and adolescents with depression are not clear. We conducted a preliminary meta-analysis to objectively evaluate its clinical effect and provide information for future research and clinical practice.

Methods

PubMed, Cochrane Library, Embase, and Web of Science were searched systematically to find clinical trials published in English before April 11, 2023. Stata software was used for meta-analysis, and random or fixed effect models were used to combine effect sizes.

Results

Nine studies were eligible and included (n = 393). No articles about children were included in the analysis. The results showed that the remission rate was 40% (95% confidence interval [CI]: 13% to 71%). The scores of Children's Depression Rating Scale (CRDS) and Hamilton's depression scale (HAMD) significantly decreased compared to baseline value (MD = -27.04, 95% CI: -30.95, -23.12 and MD = -12.78, 95% CI: -19.55 to -6.01). In addition, the incidence of all adverse events was 13% (95% CI: 5%, 23%), and all were minor pain-related events.

Conclusion

The combination of NIBS and antidepressants has been shown to notably alleviate depressive symptoms in adolescents, offering a considerable level of safety. This therapeutic synergy is particularly effective in patients with major depressive disorder, where repetitive transcranial magnetic stimulation augmented with antidepressants can enhance the amelioration of depressive symptoms.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023442215, PROSPERO CRD42023442215.

Adjunctive repetitive transcranial magnetic stimulation for adolescents with first-episode major depressive disorder: a meta-analysis

Objective

This meta-analysis of randomized clinical trials (RCTs) was conducted to explore the therapeutic effects, tolerability and safety of repetitive transcranial magnetic stimulation (rTMS) as an adjunct treatment in adolescents with first-episode major depressive disorder (FE-MDD).

Methods

RCTs examining the efficacy, tolerability and safety of adjunctive rTMS for adolescents with FE-MDD were included. Data were extracted by three independent authors and synthesized using RevMan 5.3 software with a random effects model.

Results

A total of six RCTs involving 562 adolescents with FE-MDD were included. Adjunctive rTMS was superior in improving depressive symptoms over the control group [standardized mean difference (SMD) = -1.50, 95% confidence interval (CI): -2.16, -0.84; I2 = 89%, p < 0.00001] in adolescents with FE-MDD. A sensitivity analysis and two subgroup analyses also confirmed the significant findings. Adolescents with FE-MDD treated with rTMS had significantly greater response [risk ratio (RR) = 1.35, 95% CI: 1.04, 1.76; I2 = 56%, p = 0.03] and remission (RR = 1.35, 95% CI: 1.03, 1.77; I2 = 0%, p = 0.03) over the control group. All-cause discontinuations were similar between the two groups (RR = 0.79, 95% CI: 0.32, 1.93; I2 = 0%, p = 0.60). No significant differences were found regarding adverse events, including headache, loss of appetite, dizziness and nausea (p = 0.14-0.82). Four out of six RCTs (66.7%), showed that adjunctive rTMS was more efficacious over the control group in improving neurocognitive function (all p < 0.05).

Conclusion

Adjunctive rTMS appears to be a beneficial strategy in improving depressive symptoms and neurocognitive function in adolescents with FE-MDD. Higher quality RCTs with larger sample sizes and longer follow-up periods are warranted in the future.

Efficacy and safety of repetitive transcranial magnetic stimulation combined with antidepressants in children and adolescents with depression: A systematic review and meta-analysis

BACKGROUND

Repetitive Transcranial magnetic stimulation (rTMS) combined with antidepressants benefited adults with depression while its efficacy and safety in children and adolescents with depression remain controversial.

METHODS

We searched PubMed, Embase, the Cochrane Library, Web of Science, CINAHL, LILACS, PsycINFO, CNKI, Wanfang Data Knowledge Service Platform, a Chinese Biology Medical disc database, and relevant clinical registration databases for randomized controlled trials from their inception to October 18, 2022. The efficacy of the treatment was assessed by changes in depression rating scale scores. Safety was assessed by the incidence of adverse events. Heterogeneity was determined using the Cochrane Q statistics and I² statistics. Publication bias was assessed by Egger's test.

RESULTS

Eighteen studies from 10 datasets (1396 patients, 64.7 % female, age range from 8 to 24 years old). The pooled mean-endpoint scores of the depression scale for rTMS combined with the antidepressant group were significantly lower than those of sham combined with the antidepressant group both in two weeks (MD = -4.68, 95 % CI: [-6.66, -2.69]; I² = 91 %; P < 0.05) and four weeks (MD = -5.53, 95 % CI: [-9.90, -1.16]; I² = 98 %; P < 0.05). There were no differences in safety (OR = 0.64, 95 % CI: [0.20, 2.04]; I² = 64 %; P = 0.45) and acceptability between the two groups (3/70 vs 3/70).

LIMITATION

Heterogeneity was found in this study due to the limited number of original studies included.

CONCLUSION

rTMS combined with antidepressants enhanced the efficacy of the antidepressant medication. The safety and acceptability of the two groups were comparable. These findings may help guide future research and clinical practice.

Increased thalamic gray matter volume induced by repetitive transcranial magnetic stimulation treatment in patients with major depressive disorder

Purpose

Repetitive transcranial magnetic stimulation (rTMS) is an effective therapy in improving depressive symptoms in MDD patients, but the intrinsic mechanism is still unclear. In this study, we investigated the influence of rTMS on brain gray matter volume for alleviating depressive symptoms in MDD patients using structural magnetic resonance imaging (sMRI) data.

Methods

Patients with first episode, unmedicated patients with MDD (n = 26), and healthy controls (n = 31) were selected for this study. Depressive symptoms were assessed before and after treatment by using the HAMD-17 score. High-frequency rTMS treatment was conducted in patients with MDD over 15 days. The rTMS treatment target is located at the F3 point of the left dorsolateral prefrontal cortex. Structural magnetic resonance imaging (sMRI) data were collected before and after treatment to compare the changes in brain gray matter volume.

Results

Before treatment, patients with MDD had significantly reduced gray matter volumes in the right fusiform gyrus, left and right inferior frontal gyrus (triangular part), left inferior frontal gyrus (orbital part), left parahippocampal gyrus, left thalamus, right precuneus, right calcarine fissure, and right median cingulate gyrus compared with healthy controls (P < 0.05). After rTMS treatment, significant growth in gray matter volume of the bilateral thalamus was observed in depressed patients (P < 0.05).

Conclusion

Bilateral thalamic gray matter volumes were enlarged in the thalamus of MDD patients after rTMS treatment and may be the underlying neural mechanism for the treatment of rTMS on depression.

Therapeutic Neuromodulation toward a Critical State May Serve as a General Treatment Strategy

Brain disease has become one of this century’s biggest health challenges, urging the development of novel, more effective treatments. To this end, neuromodulation represents an excellent method to modulate the activity of distinct neuronal regions to alleviate disease. Recently, the medical indications for neuromodulation therapy have expanded through the adoption of the idea that neurological disorders emerge from deficits in systems-level structures, such as brain waves and neural topology. Connections between neuronal regions are thought to fluidly form and dissolve again based on the patterns by which neuronal populations synchronize. Akin to a fire that may spread or die out, the brain’s activity may similarly hyper-synchronize and ignite, such as seizures, or dwindle out and go stale, as in a state of coma. Remarkably, however, the healthy brain remains hedged in between these extremes in a critical state around which neuronal activity maneuvers local and global operational modes. While it has been suggested that perturbations of this criticality could underlie neuropathologies, such as vegetative states, epilepsy, and schizophrenia, a major translational impact is yet to be made. In this hypothesis article, we dissect recent computational findings demonstrating that a neural network’s short- and long-range connections have distinct and tractable roles in sustaining the critical regime. While short-range connections shape the dynamics of neuronal activity, long-range connections determine the scope of the neuronal processes. Thus, to facilitate translational progress, we introduce topological and dynamical system concepts within the framework of criticality and discuss the implications and possibilities for therapeutic neuromodulation guided by topological decompositions.

Evidence and expert consensus based German guidelines for the use of repetitive transcranial magnetic stimulation in depression

INTRODUCTION

Non-invasive brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) offer a promising alternative to psychotherapeutic and pharmacological treatments for depression. This paper aims to present a practical guide for its clinical implementation based on evidence from the literature as well as on the experience of a group of leading German experts in the field.

METHODS

The current evidence base for the use of rTMS in depression was examined via review of the literature. From the evidence and from clinical experience, recommendations for the use of rTMS in clinical practice were derived. All members of the of the German Society for Brain Stimulation in Psychiatry and all members of the sections Clinical Brain Stimulation and Experimental Brain Stimulation of the German Society for Psychiatry, Psychotherapy, Psychosomatics and Mental Health were invited to participate in a poll on whether they consent with the recommendations.

FINDINGS

Among rTMS experts, a high consensus rate could be identified for clinical practice concerning the setting and the technical parameters of rTMS treatment in depression, indications and contra-indications, the relation of rTMS to other antidepressive treatment modalities and the frequency and management of side effects.

Altered Brain Function and Causal Connectivity Induced by Repetitive Transcranial Magnetic Stimulation Treatment for Major Depressive Disorder

Objective

Repetitive transcranial magnetic stimulation (rTMS) can effectively improve depression symptoms in patients with major depressive disorder (MDD); however, its mechanism of action remains obscure. This study explored the neuralimaging mechanisms of rTMS in improving depression symptoms in patients with MDD.

Methods

In this study, MDD patients with first-episode, drug-naive (n = 29) and healthy controls (n = 33) were enrolled. Depression symptoms before and after rTMS treatment were assessed using the Hamilton Depression Rating Scale (HAMD-17). Resting-state functional magnetic resonance imaging (rs-fMRI) data were collected both before and after the treatment. Changes in the brain function after the treatment were compared using the following two indices: the amplitude of the low-frequency fluctuation (ALFF) and regional homogeneity (ReHo), which are sensitive for evaluating spontaneous neuronal activity. The brain region with synchronous changes was selected as the seed point, and the differences in the causal connectivity between the seed point and whole brain before and after rTMS treatment were investigated via Granger causality analysis (GCA).

Results

Before treatment, patients with MDD had significantly lower ALFF in the left superior frontal gyrus (p < 0.01), higher ALFF in the left middle frontal gyrus and left precuneus (p < 0.01), and lower ReHo in the left middle frontal and left middle occipital gyri (p < 0.01) than the values observed in healthy controls. After the rTMS treatment, the ALFF was significantly increased in the left superior frontal gyrus (p < 0.01) and decreased in the left middle frontal gyrus and left precuneus (p < 0.01). Furthermore, ReHo was significantly increased in the left middle frontal and left middle occipital gyri (p < 0.01) in patients with MDD. Before treatment, GCA using the left middle frontal gyrus (the brain region with synchronous changes) as the seed point revealed a weak bidirectional causal connectivity between the middle and superior frontal gyri as well as a weak causal connectivity from the inferior temporal to the middle frontal gyri. After treatment, these causal connectivities were strengthened. Moreover, the causal connectivity from the inferior temporal gyrus to the middle frontal gyri negatively correlated with the total HAMD-17 score (r = −0.443, p = 0.021).

Conclusion

rTMS treatment not only improves the local neural activity in the middle frontal gyrus, superior frontal gyrus, and precuneus but also strengthens the bidirectional causal connectivity between the middle and superior frontal gyri and the causal connectivity from the inferior temporal to the middle frontal gyri. Changes in these neuroimaging indices may represent the neural mechanisms underlying rTMS treatment in MDD.

Clinical Trial Registration

This study was registered in the Chinese Clinical Trial Registry (Registration number: ChiCTR1800019761).

Early Effects of Repetitive Transcranial Magnetic Stimulation Combined With Sertraline in Adolescents With First-Episode Major Depressive Disorder

BACKGROUND

Adolescence is a period of high incidence for depression. However, there is a limited treatment option for the adolescent depression. For treatment-resistant major depressive disorder, HF-rTMS of the left dorsolateral prefrontal cortex (DLPFC) appears therapeutically effective. The aim of the study is to explore the early effects of repetitive transcranial magnetic stimulation in combination with sertraline in adolescents with first-episode major depressive disorder.

METHODS

A total of 100 teenage patients with first-episode depression were randomly divided into the study groups. Both groups were treated with sertraline. In addition, the study group was treated with ten sessions of add-on rTMS. The control group was given sertraline only. The depressive symptom and cognitive function were assessed by the Hamilton depression rating scale 17 version (HAMD-17), Children's Depression Rating Scale-Revised (CDRS-R), Integrated visual and auditory continuous performance test (IVA-CPT), and THINC-it.

RESULTS

The number of early improvers after 2 weeks of treatment in the study group was statistically significant higher compared to the control group (95.83% vs 73.47%, χ² = 9.277, P = 0.002). There was significant difference observed in responder rates (62.50% vs. 28.57%, χ² = 11.262, P = 0.001) or in remission rates (31.25% vs. 6.12%, χ² = 10.130, P = 0.001) between the two groups at 4 weeks. The score of HAMD-17 and CDRS-R in the study group were significantly lower than the control group (F_group = 12.91 vs 10.21, P < 0.05). Attention Quotient (listening, visual and full-scale) attention quotient of IVA-CPT in the study group were higher than those in the control group after treatment, and the differences were statistically significant(P < 0.05). The study group showed higher score in Spotter than the control group after treatment (P < 0.05).

DISCUSSION

This is the most extensive blinded, randomized clinical study to date examining the efficacy of 10-Hz add-on rTMS for first-onset adolescent depression. Our results support that add-on rTMS accelerates the efficacy of the antidepressants, improving the depressive symptoms and cold cognitive function in first-episode adolescent depression.

CLINICAL TRIAL REGISTRATION

[www.ClinicalTrials.gov], identifier [ChiCTR2100048534].

Transcranial Direct Current Stimulation as an Add-on Treatment to Cognitive-Behavior Therapy in First Episode Drug-Naïve Major Depression Patients: The ESAP Study Protocol

Background: Major Depressive Disorder (MDD) affects more than 264 million people worldwide. Current treatments include the use of psychotherapy and/or drugs, however ~30% of patients either do not respond to these treatments, or do not tolerate the side effects associated to the use of pharmacological interventions. Thus, it is important to study non-pharmacological interventions targeting mechanisms not directly involved with the regulation of neurotransmitters. Several studies demonstrated that transcranial Direct Current Stimulation (tDCS) can be effective for symptoms relief in MDD. However, tDCS seems to have a better effect when used as an add-on treatment to other interventions. Methods/Design: This is a study protocol for a parallel, randomized, triple-blind, sham-controlled clinical trial in which a total of 90 drug-naïve, first-episode MDD patients (45 per arm) will be randomized to one of two groups to receive a 6-weeks of CBT combined with either active or sham tDCS to the dorsolateral prefrontal cortex (DLPFC). The primary outcome will depressive symptoms improvement as assessed by the Montgomery-Asberg Depression Rating Scale (MADRS) at 6-weeks. The secondary aim is to test whether CBT combined with tDCS can engage the proposed mechanistic target of restoring the prefrontal imbalance and connectivity through the bilateral modulation of the DLPFC, as assessed by changes over resting-state and emotional task eliciting EEG. Discussion: This study evaluates the synergetic clinical effects of CBT and tDCS in the first episode, drug-naïve, patients with MDD. First episode MDD patients provide an interesting opportunity, as their brains were not changed by the pharmacological treatments, by the time course, or by the recurrence of MDD episodes (and other comorbidities). Trial Registration: This study is registered with the United States National Library of Medicine Clinical Trials Registry (NCT03548545). Registered June 7, 2018, clinicaltrials.gov/ct2/show/NCT03548545. Protocol Version 1.