Low-Frequency Right Repetitive Transcranial Magnetic Stimulation for the Treatment of Depression After Traumatic Brain Injury: A Randomized Sham-Controlled Pilot Study

Abstract

Objective: Major depression is the most common psychiatric sequela of traumatic brain injury (TBI), but effective treatment continues to be a challenge, with few studies providing guidance.Methods: In a pilot study, the authors evaluated the effect size of low-frequency right-sided (LFR) repetitive transcranial magnetic stimulation (rTMS), compared with sham treatment, over the right dorsolateral prefrontal cortex (DLPFC) in patients (N=30) with TBI depression and co-occurring neuropsychiatric symptoms, including suicidal thoughts, anxiety, posttraumatic stress disorder, sleep disturbance, behavioral problems, and cognitive dysfunction. Exploratory analyses of diffusion tensor imaging pre-and postintervention were performed to determine the effect size of LFR rTMS on white matter integrity.Results: Small (Hedge's g=0.19) and highly variable effects of LRF rTMS over right DLPFC in TBI depression were observed. Similarly, the effect of LFR rTMS for treatment of comorbid neuropsychiatric symptoms varied from small to moderate.Conclusions: These findings suggest that the observed effects of LFR rTMS over the right DLPFC in TBI depression and co-occurring neuropsychiatric symptoms are small, at best, and, preliminarily, that low-frequency right DLPFC stimulation has limited potential in this patient population. However, studies employing different rTMS parameters (e.g., type, location, frequency, duration) or other participant characteristics (e.g., TBI severity, chronicity, comorbidity, concurrent treatment) may potentially yield different responses

Effect of Repetitive Transcranial Magnetic Stimulation on Depression and Cognition in Individuals With Traumatic Brain Injury: A Meta-Analysis

“…Three studies recruited patients with PCS evaluated by using the self-reported Rivermead Post-Concussion Symptom Questionnaire (RPQ-3 and RPQ-13) 23,26,28 .…”

“…Because depression improvement could confound the measurement of somatic symptoms (i.e., PCS), such deviations may have increased bias risk in outcome assessment in two studies 23,28 . Four articles had risk of bias due to high drop-out or loss-to-follow-up rates (>5%) 16,23,24,26 . The study by Lee et al had a high risk of bias of outcome measurement owing to unblinded assessors 25…”

“…In a random-effects model immediately after rTMS intervention, rTMS had a high mean effect size of 1.03 (95% confidence interval [CI] = 0.20-1.86) without heterogeneity (I 2 = 0%; Figure 2a). However, 1 month after rTMS treatment, the effect size of rTMS became smaller and statistically nonsignificant (effect size = 0.39; 95% CI = −1.15 to 1.93; I 2 = 0%), although only three studies were included in the analysis 23,26,28 (Figure 2b).…”

“…Four studies reported depression severity according to the MADRS 16,[23][24][25] , and two articles used the HAMD to assess depression 26,27 . Another study by Stilling et al measured the degree of depression by using the Patient Health Questionnaire 9 (PHQ-9) 28 .…”

“…. Trials that were not analyzed according to prespecified protocols in four studies (Rao et al, Siddiqi et al, Lee et al, and Leung et al) led us to identify a potential risk of reporting bias16,[25][26][27] (Figure 1b).…”