The evidence is in: Repetitive transcranial magnetic stimulation is an effective, safe and well-tolerated treatment for patients with major depressive disorder

Abstract

Despite more than 25 years of research establishing the antidepressant efficacy of repetitive transcranial magnetic stimulation, there remains uncertainty about the depth and breadth of this evidence base, resulting in confusion as to where repetitive transcranial magnetic stimulation fits in the therapeutic armamentarium in the management of patients with mood disorders. The purpose of this article is to provide a concise description of the evidence base supporting the use of repetitive transcranial magnetic stimulation in the context of the stages of research that typically accompanies the development of evidence for a new therapy. The antidepressant efficacy for the use of repetitive transcranial magnetic stimulation in the treatment of depression has been established through a relatively traditional pathway beginning with small case series, progressing to single-site clinical trials and then to larger multisite randomised double-blind controlled trials. Antidepressant effects have been confirmed in numerous meta-analyses followed more recently by large network meta-analysis and umbrella reviews, with evidence that repetitive transcranial magnetic stimulation may have greater efficacy than alternatives for patients with treatment-resistant depression. Finally, repetitive transcranial magnetic stimulation has been shown to produce meaningful response and remission rates in real-world samples of greater than 5000 patients. The evidence for the antidepressant efficacy of repetitive transcranial magnetic stimulation therapy is overwhelming, and it should be considered a routine part of clinical care wherever available.

Revisiting the effectiveness of repetitive transcranial magnetic stimulation treatment in depression, again

“…The authors support these claims only by references to the same lead author’s previous publications and with no systematic review of the evidence. As has been presented recently in this journal (Fitzgerald et al, 2021a) and described extensively elsewhere (e.g. Brunoni et al, 2017; Papadimitropoulou et al, 2017; Razza et al, 2020), these statements are inaccurate (see Table 1).…”

“…Brunoni et al, 2017; Papadimitropoulou et al, 2017; Razza et al, 2020), these statements are inaccurate (see Table 1). In fact, there already exists a substantive evidence base supporting the use of rTMS in the treatment of depression that extends from multisite clinical trials to multiple meta-analyses, network meta-analyses, umbrella reviews and large-scale real-world treatment outcome data (Fitzgerald et al, 2021a). Scientific support for the efficacy and cost-effectiveness of rTMS for depression is by no means in ‘ its infancy ’: in fact it is consistent with that required to support the clinical use of a new treatment and is underwritten by a wealth of data exploring its neurobiological mechanisms (Luan et al, 2020) and real-world outcomes (Sackeim et al, 2020).…”

“…In fact, the true ‘ hidden costs ’ derive from denying patients timely access to rTMS, not when rTMS is offered instead of medication. Given that the evidence points to rTMS being more effective than continued pharmacological treatments once patients have failed several antidepressant trials (Fitzgerald et al, 2021a; Papadimitropoulou et al, 2017), then continuing further trials of various medication strategies (which in real-world practice can be protracted over years) instead of offering rTMS therapy constitutes withholding effective treatment and introducing the risk of harms associated with chronic or worsening depression. Repeated unsuccessful trials of medication are much more likely to lead to adverse consequences than a trial of rTMS.…”

Accelerated Repetitive Transcranial Magnetic Stimulation to Treat Major Depression: The Past, Present, and Future

“…[17][18][19][20][21] Multiple randomized, sham-controlled trials and meta-analyses have established rTMS as an evidence-based therapy for TRD. [22][23][24][25] In large, real-world studies, treatment response rates to rTMS of 50-80% have been reported. [26][27][28][29] The physiological and hence therapeutic effects of rTMS are determined by the stimulation protocol, consisting of the stimulation target, frequency/pattern and intensity of the stimulation pulses applied, the number of pulses applied per stimulation session, and the number of sessions applied over a course of treatment.…”

“…rTMS involves the repeated application of electromagnetic pulses delivered by a magnetic coil placed on the scalp to depolarize cortical neurons and modulate neuronal activity 17–21 . Multiple randomized, sham-controlled trials and meta-analyses have established rTMS as an evidence-based therapy for TRD 22–25 . In large, real-world studies, treatment response rates to rTMS of 50–80% have been reported 26–29 .…”