Daily Left Prefrontal Repetitive Transcranial Magnetic Stimulation in the Acute Treatment of Major Depression: Clinical Predictors of Outcome in a Multisite, Randomized Controlled Clinical Trial

Abstract

Randomized controlled trials support the antidepressant efficacy of transcranial magnetic stimulation (TMS); however, there is individual variability in the magnitude of response. Examination of response predictors has been hampered by methodological limitations such as small sample sizes and single-site study designs. Data from a multisite sham-controlled trial of the antidepressant efficacy of TMS provided an opportunity to examine predictors of acute outcome. An open-label extension for patients who failed to improve provided the opportunity for confirmatory analysis. Treatment was administered to the left dorsolateral prefrontal cortex at 10 pulses per second, 120% of motor threshold, for a total of 3000 pulses per day. Change on the Montgomery-Asberg Depression Rating Scale after 4 weeks was the primary efficacy outcome. A total of 301 patients with nonpsychotic unipolar major depression at 23 centers were randomized to active or sham TMS. Univariate predictor analyses showed that the degree of prior treatment resistance in the current episode was a predictor of positive treatment outcome in both the controlled study and the open-label extension trial. In the randomized trial, shorter duration of current episode was also associated with a better outcome. In the open-label extension study, absence of anxiety disorder comorbidity was associated with an improved outcome, but duration of current episode was not. The number of prior treatment failures was the strongest predictor for positive response to acute treatment with TMS. Shorter duration of current illness and lack of anxiety comorbidity may also confer an increased likelihood of good antidepressant response to TMS.

Transcranial magnetic stimulation for treatment of major depression during pregnancy: a review

“…Studies in pregnant women with depression reported using 10-25 Hz in the left DLPFC and 1 Hz in the right DLPFC, which are very similar to the frequencies used in depression protocols in non-pregnant adults. [40][41][42][43][44] The number of sessions ranged from one session every undergone TMS during pregnancy, which reported preliminary results of no statistically significant difference in neurodevelopmental parameters when compared to a control group. 26 In that study, Eryilmaz et al confirmed that rTMS exposure during pregnancy was not associated with poorer cognitive or motor development outcomes in children aged 18-62 months.…”

Neuromodulation approaches for the treatment of major depression: challenges and recommendations from a working group meeting

“…Currently, rTMS has been approved for use in Brazil, Canada, Israel, and some European countries and also in the US. Here it should be underscored that rTMS was only approved in the US to treat patients who failed to respond to at least one antidepressant trial as a pivotal rTMS study performed in 2007 with 301 patients with various degrees of refractoriness showed positive results only after a posthoc analysis 61 ; however, a subsequent analysis of patients failing to at least one adequate trial found a robust positive result, with an effect size of 0.83 and a drug-placebo difference of 5 points 62 . To date, most rTMS trials tested its use as a combination therapy, i.e., the combination of rTMS with a pharmacological treatment -usually an antidepressant that has failed however not tapered off 63 .…”

“…5 sessions per week) although other studies used different protocols such as three times a week or two times per day 83 . Finally, several studies have shown that a larger number of sessions is associated with a better response 59,62 as well as a larger time period to relapse 71 . Nevertheless, this number can range from 10 to 30 sessions (i.e.…”

Rapid Relief of Treatment Resistant Depression by Facilitated Ketamine Infusion: A Preliminary Report

“…The same application of rTMS was reportedly somewhat less effective in treating severe depression (Cusin & Dougherty, 2012). Treatment resistance is an important factor in predicting the likelihood of response to rTMSʊthe more resistant a patients' illness has been to well applied medication protocols, the less likely that rTMS will be helpful (Lisanby et al, 2008). Because of this finding, conventional rTMS has been positioned as a treatment for people who have not responded to one adequate trial of medication.…”