Should We Expand the Toolbox of Psychiatric Treatment Methods to Include Repetitive Transcranial Magnetic Stimulation (rTMS)?

Abstract

Repetitive transcranial magnetic stimulation appears to be an effective and safe treatment for depression and psychosis. It should be more widely available to patients who do not respond to pharmacotherapy. Background: Repetitive transcranial magnetic stimulation (rTMS) is a stimulation therapy approved by the Food and Drug Administration in 2008 for the treatment of depression. However, its use remains obscure. Objective: To determine whether rTMS should be brought out of obscurity for the treatment of depression, schizophrenia, and obsessive-compulsive disorder (OCD). Design: A meta-analysis of rTMS for the management of mood and anxiety disorders, psychosis, attentiondeficit/hyperactivity disorder (ADHD), Tourette syndrome, bulimia nervosa, and addiction. Participants/Methods: A literature search was conducted to identify parallel, double-blind, randomized, controlled studies investigating rTMS published between 1966 and 2008. Only those psychiatric disorders investigated in at least 3 studies were included in the meta-analysis. Effect sizes were calculated for mean differences in pretreatment versus posttreatment rating scales with rTMS compared to sham treatment. Results: The only psychiatric conditions for which rTMS had been studied sufficiently for meta-analysis were depression, psychosis with auditory verbal hallucinations (AVH), psychosis with negative symptoms, and OCD. Studies investigating rTMS for depression had varied methodologies, and they tested rTMS monotherapy, adjunctive therapy with medication, and cotherapy with medication. rTMS was also compared to electroconvulsive treatment (ECT) in 6 studies of major depression. For depression, rTMS monotherapy performed best (effect size, 0.96) followed by adjunctive treatment (effect size, 0.51) and simultaneous cotherapy with an antidepressant (effect size, 0.37). rTMS for depression was applied over the right or left dorsolateral prefrontal cortex (DLPF), although the location of stimulation did not significantly affect performance of rTMS. rTMS was less effective than ECT for severe major depression, with a weighted effect size of-0.47. In 7 randomized controlled trials, rTMS applied to the left temporoparietal cortex was moderately effective for the treatment of AVH (effect size, 0.54). rTMS was also mildly effective for the treatment of negative symptoms of psychosis in 7 studies (effect size, 0.39). Most of these studies applied rTMS over the left DLPF. In contrast, rTMS was not effective for the treatment of OCD in 3 studies (effect size, 0.15; n=38). Conclusions: Based on these meta-analyses, rTMS should be considered standard treatment for major depression and for both positive and negative symptoms of psychosis that are refractory to pharmacotherapy. rTMS appears to be more effective as monotherapy instead of as adjunctive therapy for major depression. The authors do not recommend the use of rTMS for OCD. Reviewer's Comments: Most participants in these studies were resistant to pharmacotherapy, but it was prudent and cost-effective to try an...

Clinically Meaningful Efficacy and Acceptability of Low-Frequency Repetitive Transcranial Magnetic Stimulation (rTMS) for Treating Primary Major Depression: A Meta-Analysis of Randomized, Double-Blind and Sham-Controlled Trials

“…We identified articles for inclusion in this meta-analysis by ' Screening the bibliography of the previous meta-analyses on rTMS for MD (Allan et al, 2011;Burt et al, 2002;Couturier, 2005;Gross et al, 2007;Herrmann and Ebmeier, 2006;Kozel and George, 2002;Lam et al, 2008;Martin et al, 2002;Martin et al, 2003;McNamara et al, 2001;Schutter, 2009;Slotema et al, 2010), of the only meta-analysis on LF-rTMS for MD published to date (Schutter, 2010) The search procedures (including syntaxes, parameters, and results) are described in detail in the Supplementary Material.…”

“…The first evidence for its antidepressant effects was observed with a high-frequency protocol (20 Hz) applied to the left dorsolateral prefrontal cortex (DLPFC) (George et al, 1995), and to date several meta-analyses have confirmed the overall efficacy and safety of HF-rTMS for treating depressed subjects (Berlim et al, submitted-b;Slotema et al, 2010). As the latter can be uncomfortable at higher intensities (Janicak et al, 2008), and is also associated with an increased risk of adverse effects (Loo et al, 2008), LF-rTMS over the right DLPFC has been more recently proposed as an alternative therapeutic strategy for MD .…”

Neurostimulation as an intervention for treatment resistant depression: From research on mechanisms towards targeted neurocognitive strategies

“…A meta-analysis of 34 studies comparing rTMS to sham treatment showed a moderate effect size of 0.55 on depressive symptoms (Slotema, Blom, Hoek, & Sommer, 2010), whereas another meta-analysis of 30 HF-rTMS studies found an effect size of 0.39 (Schutter, 2009). …”

Deep Brain Stimulation in Schizophrenia

“…However, TMS effects are self limited in terms of duration, and the TMS application is restricted to superficial cortical regions. Meta-analyses revealed at best a moderate effect-size of TMS in the treatment of auditory hallucinations, and in the largest randomized controlled trial no superiority of TMS compared to placebo has been found (Aleman, Sommer & Kahn, 2007;Slotema et al, 2010;Slotema et al, 2011). In conclusion, the expertise in TMS is of limited value regarding the target selection for DBS, especially as the latter is delivered exclusively to subcortical brain regions.…”