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

Abstract

Following on from the publication of the Royal Australian and New Zealand Journal of Psychiatry Mood Disorder Clinical Practice Guidelines (2020) and criticisms of how these aberrantly addressed repetitive transcranial magnetic stimulation treatment of depression, questions have continued to be raised in the journal about this treatment by a small group of authors, whose views we contend do not reflect the broad acceptance of this treatment nationally and internationally. In fact, the evidence supporting the use of repetitive transcranial magnetic stimulation treatment in depression is unambiguous and substantial, consisting of an extensive series of clinical trials supported by multiple meta-analyses, network meta-analysis and umbrella reviews. Importantly, the use of repetitive transcranial magnetic stimulation treatment in depression has also been subject to a series of health economic analyses. These indicate that repetitive transcranial magnetic stimulation is a cost-effective therapy and have been used in some jurisdictions, including Australia, in support of public funding. An argument has been made that offering repetitive transcranial magnetic stimulation treatment may delay potentially effective pharmacotherapy. In fact, there is considerably greater danger of the opposite happening. Repetitive transcranial magnetic stimulation is as, if not more effective, than antidepressant medication after two unsuccessful medication trials and should be a consideration for all patients under these circumstances where available. There is no meaningful ongoing debate about the use of repetitive transcranial magnetic stimulation treatment in depression – it is a safe, effective and cost-effective treatment.

Baseline Clinical and Neuroimaging Biomarkers of Treatment Response to High-Frequency rTMS Over the Left DLPFC for Resistant Depression

“…Regarding associated treatment, there is growing evidence that concomitant use of medication can impair the clinical effectiveness of rTMS, especially for benzodiazepines ( 57 ). However, the impact of concomitant medication on rTMS effectiveness is still debatable ( 58 , 59 ). Finally, we did not find a link between baseline RMT and response.…”

The Effect of Continuous Theta Burst Stimulation over the Right Dorsolateral Prefrontal Cortex on Cognitive Function and Emotional Regulation in Patients with Cerebral Small Vessel Disease

“…Each participant was evaluated by a professionally trained psychiatrist using the Hamilton depression scale (HAMD). The scores were categorized as no depression (0-7), mild depression (8)(9)(10)(11)(12)(13)(14)(15)(16), moderate depression (17)(18)(19)(20)(21)(22)(23), and severe depression (≥24) [25].…”

Letter to the Editor regarding ‘Falling through the cracks in science and clinical service – A call to action for people with OCD’

“…First, the comparative efficacy of rTMS has been documented in a network meta-analysis (notably published by authors from the pharmaceutical industry) which found that rTMS produced either the equal best or clearly best outcomes on response and remission rates after 4 and 6 weeks of treatment compared to all other interventions for treatment-resistant depression (TRD): clear evidence of 'comparative efficacy' (Papadimitropoulou et al, 2017). The overall efficacy of rTMS has been explored although in a more limited set of studies than the vast (over 50) randomised trials (see among other studies, Brunoni et al, 2017;Razza et al, 2020) which have confirmed that it is an effective intervention when compared to sham (Fitzgerald et al, 2021). These sham-controlled studies of rTMS in patients who have failed two or more medications show that active treatment results in superior outcomes to those reported at the equivalent third or fourth levels in the STAR*D trial.…”

“…No attempt has been made to address the considerable body of evidence presented in previous articles addressing these claims (e.g. Fitzgerald et al, 2021) or to provide a balanced or systematic review of the actual evidence. These claims and evidence-based rebuttals are presented in Table 1.…”

“…Third, there is overwhelming evidence of antidepressant effects of rTMS greater than those attributable to placebo: this includes over 50 clinical trials, meta-analyses, systematic reviews, umbrella reviews and real-world studies clearly demonstrating efficacy, superiority to placebo and clinical utility (Fitzgerald et al, 2021).…”