Prefrontal transcranial magnetic stimulation for depression in US military veterans – A naturalistic cohort study in the veterans health administration

Madore, Michelle; Kozel, F. Andrew; Williams, Leanne M.; Green, L. Chauncey; George, Mark S.; Holtzheimer, Paul E.; Yesavage, Jerome A.; Philip, Noah S.

doi:10.1016/j.jad.2021.10.025

Cited by 27 publications

(22 citation statements)

References 37 publications

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“…al., 2018), though extend this finding to a Veteran population, and to PTSD symptoms as well as depression symptoms. Our findings are also generally consistent with other recent studies from the VA showing that rTMS can improve symptoms of PTSD, though prior reports focused mostly on standard 10Hz stimulation protocols (Madore et al, 2022;Wilkes et al, 2020). Our findings, that rTMS can improve PTSD symptoms in Veterans are also consistent with those from an RCT determining the efficacy of active iTBS targeted to right-DLPFC on PTSD symptoms, as the authors found significant improvement in both PTSD and depression from the active arm of the trial at one month follow up (Philip et al, 2019).…”

Section: Discussionsupporting

confidence: 92%

“…The most recent meta-analysis of rTMS in patients with PTSD (Harris & Reece, 2021) demonstrated large improvements in PTSD symptoms (19 studies, 376 subjects, d=1.17, 95% CI 0.89-1.45, p<0.001). A recent retrospective analysis of treatment outcomes in Veterans treated at multiple VA facilities across the country revealed that 70% of the Veterans in this analysis had comorbid PTSD, with the vast majority being treated with 10 Hz rTMS applied to the left DLPFC (Madore et al, 2022). They found significant improvement in depression and PTSD symptoms as measured by the PHQ-9 and PCL-5, respectively.…”

Section: Introductionmentioning

confidence: 96%

“…They found significant improvement in depression and PTSD symptoms as measured by the PHQ-9 and PCL-5, respectively. Strikingly, among Veterans with comorbid PTSD, 65.3% experienced clinically meaningful reduction and 46.1% no longer met PTSD criteria (Madore et al, 2022). This cohort study serves as proof of concept for the efficacy of left DLPFC-targeted rTMS in veterans with depression and PTSD.…”

Section: Introductionmentioning

confidence: 99%

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Theta burst stimulation is not inferior to high frequency repetitive transcranial magnetic stimulation in reducing symptoms of post-traumatic stress disorder in Veterans with depression: a retrospective case series

Shenasa

Ellerman

Canet

et al. 2022

Preprint

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Background: Two commonly used forms of repetitive transcranial magnetic stimulation (rTMS) were recently shown to be equivalent for the treatment of treatment-resistant depression (TRD): high-frequency stimulation (10 Hz), a protocol that lasts between 19-38 minutes, and intermittent Theta-Burst Stimulation (iTBS), a protocol that can be delivered in just 3 minutes. Intermittent TBS offers significant advantages to patients and clinics and has thus become a default treatment in many clinics. However, it is unclear whether iTBS treatment offers the same benefits as standard 10 Hz rTMS for comorbid symptoms, such as post-traumatic-stress-disorder (PTSD). Methods: In this retrospective case series, we analyzed treatment outcomes in Veterans from the VA San Diego Healthcare system (VASDHS) who received 10 Hz (n = 47) or iTBS (n = 51) rTMS treatments for TRD between the dates of Jan 2017 to June 2022. We compared outcomes between these two stimulation protocols used between these dates on symptoms of depression (using changes in the patient health questionnaire-9, or PHQ-9) and PTSD (using changes in the PTSD Checklist for DSM-5, or PCL-5). We hypothesized that there would be no differences in treatment outcomes between 10 Hz and iTBS protocols for either depression (confirming prior RCT) or PTSD. Results: We found that both types of stimulation showed a clinically meaningful reduction in symptoms with no difference in outcomes based on the type of stimulation. The mean reduction on the PHQ-9 scale was 5.8 +/- 0.93 (p <0.001, n = 47) in Veterans receiving 10 Hz stimulation and 6.6 +/- 0.71 (p < 0.001, n = 51) in the Veterans receiving iTBS. There were no difference between stimulation protocols (p = 0.5). The mean reduction on the PCL-5 symptom scale was 8.1 +/- 2.1 in Veterans receiving 10 Hz stimulation (p <0.001, n =47) and -13.2 +/- 2.4 the Veterans receiving iTBS (p <0.001, n = 51). This difference was not significant (p=0.11) and had a small effect size (eta^2 = 0.026). Follow-up analyses restricting the sample in various ways did not meaningfully change these results. Conclusions: While limited by small sample size, non-blinded and pseudo-randomized assignment, our data suggests that iTBS can be expected to have similar if not slightly greater reductions in PTSD symptoms compared with 10 Hz stimulation. Our findings pave the way for further research trials to validate and optimize iTBS for PTSD symptoms.

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Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 96%

Section: Introductionmentioning

confidence: 99%

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Theta burst stimulation is not inferior to high frequency repetitive transcranial magnetic stimulation in reducing symptoms of post-traumatic stress disorder in Veterans with depression: a retrospective case series

Shenasa

Ellerman

Canet

et al. 2022

Preprint

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“…This study was performed in accordance with the Declaration of Helsinki. The procedures for gathering and analyzing de-identi ed clinical data were approved as quality improvement by the VA Palo Alto/Stanford Institutional Review Board [31]. Additional group-level analyses were based on publicly available data from previously published studies [7,9,10,26,27].…”

Section: Ethics Declarationmentioning

confidence: 99%

Modeling the Antidepressant Treatment Response to Transcranial Magnetic Stimulation using an Exponential Decay Function

Berlow

Zandvakili

Brennan

et al. 2022

Preprint

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Recovery from depression often demonstrates a nonlinear pattern of treatment response, where the largest reduction in symptoms is observed early followed by smaller improvements. This study investigated whether this exponential pattern could model the antidepressant response to repetitive transcranial magnetic stimulation (TMS). Symptom ratings from 97 patients treated with TMS for depression were collected at baseline and after every five sessions. A nonlinear mixed-effects model was constructed using an exponential decay function. This model was also applied to group-level data from several published clinical trials of TMS for treatment-resistant depression. These nonlinear models were compared to corresponding linear models. In our clinical sample, response to TMS was well modeled with the exponential decay function, yielding significant estimates for all parameters and demonstrating superior fit compared to a linear model. Similarly, when applied to multiple studies comparing TMS modalities as well as to previously identified treatment response trajectories, the exponential decay models yielded consistently better fits compared to linear models. These results demonstrate that the antidepressant response to TMS follows a nonlinear pattern of improvement that is well modeled with an exponential decay function. This modeling offers a simple and useful framework to inform clinical decisions and future studies.

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“…The most widely used non-invasive brain stimulation modalities are transcranial magnetic simulation (TMS) and transcranial electrical stimulation. Transcranial magnetic simulation has garnered considerable attention following its success in treating pharmacoresistant depression (1,2) and obsessive compulsive disorder (3), and evidence in treating other psychiatric illnesses (4)(5)(6)(7). Transcranial magnetic simulation uses alternating magnetic fields to induce electrical current in the brain.…”

Section: Introductionmentioning

confidence: 99%

Low Intensity Focused Ultrasound for Non-invasive and Reversible Deep Brain Neuromodulation—A Paradigm Shift in Psychiatric Research

et al. 2022

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This article describes an emerging non-invasive neuromodulatory technology, called low intensity focused ultrasound (LIFU). This technology is potentially paradigm shifting as it can deliver non-invasive and reversible deep brain neuromodulation through acoustic sonication, at millimeter precision. Low intensity focused ultrasound's spatial precision, yet non-invasive nature sets it apart from current technologies, such as transcranial magnetic or electrical stimulation and deep brain stimulation. Additionally, its reversible effects allow for the causal study of deep brain regions implicated in psychiatric illness. Studies to date have demonstrated that LIFU can safely modulate human brain activity at cortical and subcortical levels. Due to its novelty, most researchers and clinicians are not aware of the potential applications and promise of this technique, underscoring the need for foundational papers to introduce the community to LIFU. This mini-review and synthesis of recent advances examines several key papers on LIFU administered to humans, describes the population under study, parameters used, and relevant findings that may guide future research. We conclude with a concise overview of some of the more pressing questions to date, considerations when interpreting new data from an emerging field, and highlight the opportunities and challenges in this exciting new area of study.

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Prefrontal transcranial magnetic stimulation for depression in US military veterans – A naturalistic cohort study in the veterans health administration

Cited by 27 publications

References 37 publications

Theta burst stimulation is not inferior to high frequency repetitive transcranial magnetic stimulation in reducing symptoms of post-traumatic stress disorder in Veterans with depression: a retrospective case series

Theta burst stimulation is not inferior to high frequency repetitive transcranial magnetic stimulation in reducing symptoms of post-traumatic stress disorder in Veterans with depression: a retrospective case series

Modeling the Antidepressant Treatment Response to Transcranial Magnetic Stimulation using an Exponential Decay Function

Low Intensity Focused Ultrasound for Non-invasive and Reversible Deep Brain Neuromodulation—A Paradigm Shift in Psychiatric Research

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