A systematic review of the clinical relevance of repetitive transcranial magnetic stimulation

Abstract

Whilst rTMS appears to be efficacious for both non-refractory and treatment-resistant depression, the clinical relevance of its efficacy is doubtful.

Theta-Burst Stimulation: A New Form of TMS Treatment for Depression?

“…A recent meta‐analysis on the clinical relevance of rTMS concluded unfavorably toward its antidepressant effect, but it did not examine the treatment duration and cumulative dose as factors affecting the outcome. It is critical to note that fairly clear dose–response relationship has emerged in depression treatment with rTMS in the recent years, and rTMS clinical trial reports reveal reasonably consistent efficacy signals …”

“…[50,51] The largest multisite randomized controlled trial (301 medication-free patients) to date showed significant antidepressant results compared to sham using 10 Hz, [52] followed by a more recent shamcontrolled randomized trial involving 190 intention-totreat patients that reported clinically meaningful antidepressant effects compared to sham with 10 Hz rTMS. [33] A recent meta-analysis on the clinical relevance of rTMS concluded unfavorably toward its antidepressant effect, [53] but it did not examine the treatment duration and cumulative dose as factors affecting the outcome. It is critical to note that fairly clear dose-response relationship has emerged in depression treatment with rTMS in the recent years, [54,55] and rTMS clinical trial reports reveal reasonably consistent efficacy signals.…”

How can we make the results of trials and their meta‐analyses using continuous outcomes clinically interpretable?

“…However, the clinical relevance of this statistical superiority remains unclear, and Lepping and colleagues in this issue of Acta Psychiatrica Scandinavica addressed this problem with a novel and clinically intuitive approach (1).…”

rTMS deserves a fair chance as a novel treatment for depression

“…Lepping et al (1) report a meta-analysis of treatment effects of rTMS on depression in which they converted improvement on the Hamilton depression rating scale (HAMD) into nominal Clinical Global Impression-Improvement (CGI-I) scores. The results showed a small difference in favor of rTMS, which the authors consider to be clinically irrelevant.…”

“…They therefore conclude that rTMS cannot be recommended as a first line treatment for depression. We commend the systematic integration of published evidence as conducted by Lepping et al (1) and applaud their efforts to investigate clinical relevance. However, their strong conclusion may be unwarranted at this point, given several critical remarks that can be made regarding their approach, and given the fact that much remains unclear when it comes to the clinical efficacy of rTMS and for that matter, of any other therapy for depression, be it antidepressant medication or psychotherapy.…”