rTMS Targeted with MRI Based Neuro-Navigation in Treatment-Resistant Depression

Dr Shock
January 28, 2009

rTMS

Efficacy of rTMS for treatment resistant depression isn’t impressive to say the least. The results of studies show little clinical relevance of the efficacy compared to sham rTMS, many studies have reported limited effect sizes or response rates.

A recent study tried to address one of the main concerns that could be responsible for the lack of efficacy namely the way in which the rTMS treatment
is targeted over the Dorsolateral Prefrontal Cortex (DLPFC). The localization is done with “the 5 cm measure”, this involves the localization of the motor cortical site for optimal stimulation of a hand muscle, usually the abductor pollicis brevis, and then measurement 5 cm anteriorly along the scalp surface. This traditional method for targeting the DLPFC with rTMS may be suboptimal, potentially explaining the modest therapeutic effects of rTMS.

In this study the neuro-navigational method was used. This method generally involves localization of the scalp position that corresponds to a brain site identified on an MRI scan from an individual subject.

How was this study done?

we conducted a randomized double blind trial comparing left prefrontal rTMS localized either using the 5 cm method or a navigational technique. We hypothesized that the targeted rTMS would result in a greater therapeutic efficacy in major depressive disorder (MDD) compared with the ‘5 cm’ method. We utilized an ‘offline’ navigational technique to localize the site of DLPFC in the experimental group and compared this with the 5 cm localization method.

Fifty-one patients with treatment-resistant depression were randomized to receive a 3-week course (with a potential 1-week extension) of high-frequency (10 Hz) left-sided rTMS. Thirty trains (5 s duration) were applied daily 5 days per week at 100% of the resting motor threshold. Treatment was targeted with either the standard 5 cm technique (n=27) or using a neuro-navigational approach (n=24). This involved localizing the scalp location that corresponds to a specific site at the junction of Brodmann areas 46 and 9 in the DLPFC based on each individual subject’s MRI scan

The efficacy of rTMS with a structural MRI-based neuro-navigational procedure can have the capacity to improve response to the rTMS treatment in TRD. Other such as altering stimulation frequency
increasing dose, and the use of a neuro-navigationally guided rTMS based on pretreatment positron emission tomography (PET) scans did not improve efficacy.

At least a MRI is needed for this neuro-navigational method and:

The miniBIRD is quite inexpensive and the MRIreg and MRIcro software available as freeware. These are also relatively easy to use with training.

From this research it is hard to tell whether rTMS is efficacious for TRD since the results may have been confounded by non-specific effects given that we have not included a sham control group.
I hope this method might improve efficacy, what do you think?

ResearchBlogging.org
Paul B Fitzgerald, Kate Hoy, Susan McQueen, Jerome J Maller, Sally Herring, Rebecca Segrave, Michael Bailey, Greg Been, Jayashri Kulkarni, Zafiris J Daskalakis (2009). A Randomized Trial of rTMS Targeted with MRI Based Neuro-Navigation in Treatment-Resistant Depression Neuropsychopharmacology DOI: 10.1038/npp.2008.233

 

7 Responses to “rTMS Targeted with MRI Based Neuro-Navigation in Treatment-Resistant Depression”

  1. Navigated stimulation should be a must for both clinical and research uses of TMS. this study shows the difference in efficacy of TMS with different targeting methods.

  2. DrBadger on January 29th, 2009 at 6:46 am
  3. I had rTMS with no success in May/June 2008. The MRI involvement, from a layman’s perspective, would seem to be an improvement over the current procedure. After spending several thousand dollars for the procedure, I was disappointed that this did not prove effective.

    With treatment resistent depression (and always looking for a solution), I will be interested if this approach is being carried out anywhere in the country and what the cost may be. I realize rTMS is now FDA approved (mine was prior to approval), but understand insurance companies have still not come aboard.

    Thanks!

  4. Bill Stevens on February 20th, 2009 at 5:46 pm
  5. I am based in The Netherlands, wouldn’t know who is performing rTMS in your country, sorry. Kind regards Dr Shock

  6. Dr Shock on February 21st, 2009 at 11:34 am
  7. Clearly you don’t know what you are talking about – your reference “studies” regarding the efficacy of rTMS for drug resistant depression are extremely limited, and more importantly, outdated. I have recently undergone rTMS for my incapacitating drug-resistant depression, and have had amazing results. Now I actually “feel” hopeful, more motivated, and have energy – MDD destroyed the last 5 years of my life – I either felt very depressed (and/or angry) OR (with some meds) I felt nothing at all, completely empty and numb – with no energy or interests, everything was overwhelming – that wasn’t living, it was barely existing. I have now re-connected with friends, exercise, appreciate simple things like a sunny day, and actually enjoy activities, music, and love playing outside with my dog. Five years of psychiatrists, psychologists, and countless meds with all of the terrible side-effects, I sincerely didn’t think anything could help me – I was planning to schedule ECTs when I learned of rTMS – so far it has worked very well, and if I eventually end up needing follow-up maintanence treatments – so be it!

  8. Kelly on March 5th, 2009 at 5:53 am
  9. Hi Kelly, I just started TMS on Friday and am really hoping it works for my MDD. I would love to talk to you on the phone about it. I don’t know anyone who has undergone it. could you please post a way I could reach you????

  10. Rachel on March 29th, 2009 at 5:41 am
  11. I have been performing rTMS on treatment refractory patients in New York for the past 5 months and have been extremely impressed by the results. Most of the current data supports what I’ve been seeing clinically. This is a promisung therapeutic modality

  12. Michael V. Genovese, M.D. on November 22nd, 2009 at 4:46 am
  13. [...] one antidepressant trial and minimal effective for those patients who failed 2-4 trials. Moreover, the efficacy of rTMS with a structural MRI-based neuro-avigational procedure can have the capacity t…. Other such as altering stimulation frequency increasing dose, and the use of a [...]

  14. TMS for medication resistant depression | Dr Shock MD PhD on May 4th, 2010 at 8:29 am
  1. Navigated stimulation should be a must for both clinical and research uses of TMS. this study shows the difference in efficacy of TMS with different targeting methods.

  2. DrBadger on January 29th, 2009 at 6:46 am
  3. I had rTMS with no success in May/June 2008. The MRI involvement, from a layman’s perspective, would seem to be an improvement over the current procedure. After spending several thousand dollars for the procedure, I was disappointed that this did not prove effective.

    With treatment resistent depression (and always looking for a solution), I will be interested if this approach is being carried out anywhere in the country and what the cost may be. I realize rTMS is now FDA approved (mine was prior to approval), but understand insurance companies have still not come aboard.

    Thanks!

  4. Bill Stevens on February 20th, 2009 at 5:46 pm
  5. I am based in The Netherlands, wouldn’t know who is performing rTMS in your country, sorry. Kind regards Dr Shock

  6. Dr Shock on February 21st, 2009 at 11:34 am
  7. Clearly you don’t know what you are talking about – your reference “studies” regarding the efficacy of rTMS for drug resistant depression are extremely limited, and more importantly, outdated. I have recently undergone rTMS for my incapacitating drug-resistant depression, and have had amazing results. Now I actually “feel” hopeful, more motivated, and have energy – MDD destroyed the last 5 years of my life – I either felt very depressed (and/or angry) OR (with some meds) I felt nothing at all, completely empty and numb – with no energy or interests, everything was overwhelming – that wasn’t living, it was barely existing. I have now re-connected with friends, exercise, appreciate simple things like a sunny day, and actually enjoy activities, music, and love playing outside with my dog. Five years of psychiatrists, psychologists, and countless meds with all of the terrible side-effects, I sincerely didn’t think anything could help me – I was planning to schedule ECTs when I learned of rTMS – so far it has worked very well, and if I eventually end up needing follow-up maintanence treatments – so be it!

  8. Kelly on March 5th, 2009 at 5:53 am
  9. Hi Kelly, I just started TMS on Friday and am really hoping it works for my MDD. I would love to talk to you on the phone about it. I don’t know anyone who has undergone it. could you please post a way I could reach you????

  10. Rachel on March 29th, 2009 at 5:41 am
  11. I have been performing rTMS on treatment refractory patients in New York for the past 5 months and have been extremely impressed by the results. Most of the current data supports what I’ve been seeing clinically. This is a promisung therapeutic modality

  12. Michael V. Genovese, M.D. on November 22nd, 2009 at 4:46 am
  13. [...] one antidepressant trial and minimal effective for those patients who failed 2-4 trials. Moreover, the efficacy of rTMS with a structural MRI-based neuro-avigational procedure can have the capacity t…. Other such as altering stimulation frequency increasing dose, and the use of a [...]

  14. TMS for medication resistant depression | Dr Shock MD PhD on May 4th, 2010 at 8:29 am
  1. Navigated stimulation should be a must for both clinical and research uses of TMS. this study shows the difference in efficacy of TMS with different targeting methods.

  2. DrBadger on January 29th, 2009 at 6:46 am
  3. I had rTMS with no success in May/June 2008. The MRI involvement, from a layman’s perspective, would seem to be an improvement over the current procedure. After spending several thousand dollars for the procedure, I was disappointed that this did not prove effective.

    With treatment resistent depression (and always looking for a solution), I will be interested if this approach is being carried out anywhere in the country and what the cost may be. I realize rTMS is now FDA approved (mine was prior to approval), but understand insurance companies have still not come aboard.

    Thanks!

  4. Bill Stevens on February 20th, 2009 at 5:46 pm
  5. I am based in The Netherlands, wouldn’t know who is performing rTMS in your country, sorry. Kind regards Dr Shock

  6. Dr Shock on February 21st, 2009 at 11:34 am
  7. Clearly you don’t know what you are talking about – your reference “studies” regarding the efficacy of rTMS for drug resistant depression are extremely limited, and more importantly, outdated. I have recently undergone rTMS for my incapacitating drug-resistant depression, and have had amazing results. Now I actually “feel” hopeful, more motivated, and have energy – MDD destroyed the last 5 years of my life – I either felt very depressed (and/or angry) OR (with some meds) I felt nothing at all, completely empty and numb – with no energy or interests, everything was overwhelming – that wasn’t living, it was barely existing. I have now re-connected with friends, exercise, appreciate simple things like a sunny day, and actually enjoy activities, music, and love playing outside with my dog. Five years of psychiatrists, psychologists, and countless meds with all of the terrible side-effects, I sincerely didn’t think anything could help me – I was planning to schedule ECTs when I learned of rTMS – so far it has worked very well, and if I eventually end up needing follow-up maintanence treatments – so be it!

  8. Kelly on March 5th, 2009 at 5:53 am
  9. Hi Kelly, I just started TMS on Friday and am really hoping it works for my MDD. I would love to talk to you on the phone about it. I don’t know anyone who has undergone it. could you please post a way I could reach you????

  10. Rachel on March 29th, 2009 at 5:41 am
  11. I have been performing rTMS on treatment refractory patients in New York for the past 5 months and have been extremely impressed by the results. Most of the current data supports what I’ve been seeing clinically. This is a promisung therapeutic modality

  12. Michael V. Genovese, M.D. on November 22nd, 2009 at 4:46 am
  13. [...] one antidepressant trial and minimal effective for those patients who failed 2-4 trials. Moreover, the efficacy of rTMS with a structural MRI-based neuro-avigational procedure can have the capacity t…. Other such as altering stimulation frequency increasing dose, and the use of a [...]

  14. TMS for medication resistant depression | Dr Shock MD PhD on May 4th, 2010 at 8:29 am
  1. Navigated stimulation should be a must for both clinical and research uses of TMS. this study shows the difference in efficacy of TMS with different targeting methods.

  2. DrBadger on January 29th, 2009 at 6:46 am
  3. I had rTMS with no success in May/June 2008. The MRI involvement, from a layman’s perspective, would seem to be an improvement over the current procedure. After spending several thousand dollars for the procedure, I was disappointed that this did not prove effective.

    With treatment resistent depression (and always looking for a solution), I will be interested if this approach is being carried out anywhere in the country and what the cost may be. I realize rTMS is now FDA approved (mine was prior to approval), but understand insurance companies have still not come aboard.

    Thanks!

  4. Bill Stevens on February 20th, 2009 at 5:46 pm
  5. I am based in The Netherlands, wouldn’t know who is performing rTMS in your country, sorry. Kind regards Dr Shock

  6. Dr Shock on February 21st, 2009 at 11:34 am
  7. Clearly you don’t know what you are talking about – your reference “studies” regarding the efficacy of rTMS for drug resistant depression are extremely limited, and more importantly, outdated. I have recently undergone rTMS for my incapacitating drug-resistant depression, and have had amazing results. Now I actually “feel” hopeful, more motivated, and have energy – MDD destroyed the last 5 years of my life – I either felt very depressed (and/or angry) OR (with some meds) I felt nothing at all, completely empty and numb – with no energy or interests, everything was overwhelming – that wasn’t living, it was barely existing. I have now re-connected with friends, exercise, appreciate simple things like a sunny day, and actually enjoy activities, music, and love playing outside with my dog. Five years of psychiatrists, psychologists, and countless meds with all of the terrible side-effects, I sincerely didn’t think anything could help me – I was planning to schedule ECTs when I learned of rTMS – so far it has worked very well, and if I eventually end up needing follow-up maintanence treatments – so be it!

  8. Kelly on March 5th, 2009 at 5:53 am
  9. Hi Kelly, I just started TMS on Friday and am really hoping it works for my MDD. I would love to talk to you on the phone about it. I don’t know anyone who has undergone it. could you please post a way I could reach you????

  10. Rachel on March 29th, 2009 at 5:41 am
  11. I have been performing rTMS on treatment refractory patients in New York for the past 5 months and have been extremely impressed by the results. Most of the current data supports what I’ve been seeing clinically. This is a promisung therapeutic modality

  12. Michael V. Genovese, M.D. on November 22nd, 2009 at 4:46 am
  13. [...] one antidepressant trial and minimal effective for those patients who failed 2-4 trials. Moreover, the efficacy of rTMS with a structural MRI-based neuro-avigational procedure can have the capacity t…. Other such as altering stimulation frequency increasing dose, and the use of a [...]

  14. TMS for medication resistant depression | Dr Shock MD PhD on May 4th, 2010 at 8:29 am
  1. Navigated stimulation should be a must for both clinical and research uses of TMS. this study shows the difference in efficacy of TMS with different targeting methods.

  2. DrBadger on January 29th, 2009 at 6:46 am
  3. I had rTMS with no success in May/June 2008. The MRI involvement, from a layman’s perspective, would seem to be an improvement over the current procedure. After spending several thousand dollars for the procedure, I was disappointed that this did not prove effective.

    With treatment resistent depression (and always looking for a solution), I will be interested if this approach is being carried out anywhere in the country and what the cost may be. I realize rTMS is now FDA approved (mine was prior to approval), but understand insurance companies have still not come aboard.

    Thanks!

  4. Bill Stevens on February 20th, 2009 at 5:46 pm
  5. I am based in The Netherlands, wouldn’t know who is performing rTMS in your country, sorry. Kind regards Dr Shock

  6. Dr Shock on February 21st, 2009 at 11:34 am
  7. Clearly you don’t know what you are talking about – your reference “studies” regarding the efficacy of rTMS for drug resistant depression are extremely limited, and more importantly, outdated. I have recently undergone rTMS for my incapacitating drug-resistant depression, and have had amazing results. Now I actually “feel” hopeful, more motivated, and have energy – MDD destroyed the last 5 years of my life – I either felt very depressed (and/or angry) OR (with some meds) I felt nothing at all, completely empty and numb – with no energy or interests, everything was overwhelming – that wasn’t living, it was barely existing. I have now re-connected with friends, exercise, appreciate simple things like a sunny day, and actually enjoy activities, music, and love playing outside with my dog. Five years of psychiatrists, psychologists, and countless meds with all of the terrible side-effects, I sincerely didn’t think anything could help me – I was planning to schedule ECTs when I learned of rTMS – so far it has worked very well, and if I eventually end up needing follow-up maintanence treatments – so be it!

  8. Kelly on March 5th, 2009 at 5:53 am
  9. Hi Kelly, I just started TMS on Friday and am really hoping it works for my MDD. I would love to talk to you on the phone about it. I don’t know anyone who has undergone it. could you please post a way I could reach you????

  10. Rachel on March 29th, 2009 at 5:41 am
  11. I have been performing rTMS on treatment refractory patients in New York for the past 5 months and have been extremely impressed by the results. Most of the current data supports what I’ve been seeing clinically. This is a promisung therapeutic modality

  12. Michael V. Genovese, M.D. on November 22nd, 2009 at 4:46 am
  13. [...] one antidepressant trial and minimal effective for those patients who failed 2-4 trials. Moreover, the efficacy of rTMS with a structural MRI-based neuro-avigational procedure can have the capacity t…. Other such as altering stimulation frequency increasing dose, and the use of a [...]

  14. TMS for medication resistant depression | Dr Shock MD PhD on May 4th, 2010 at 8:29 am
  1. Navigated stimulation should be a must for both clinical and research uses of TMS. this study shows the difference in efficacy of TMS with different targeting methods.

  2. DrBadger on January 29th, 2009 at 6:46 am
  3. I had rTMS with no success in May/June 2008. The MRI involvement, from a layman’s perspective, would seem to be an improvement over the current procedure. After spending several thousand dollars for the procedure, I was disappointed that this did not prove effective.

    With treatment resistent depression (and always looking for a solution), I will be interested if this approach is being carried out anywhere in the country and what the cost may be. I realize rTMS is now FDA approved (mine was prior to approval), but understand insurance companies have still not come aboard.

    Thanks!

  4. Bill Stevens on February 20th, 2009 at 5:46 pm
  5. I am based in The Netherlands, wouldn’t know who is performing rTMS in your country, sorry. Kind regards Dr Shock

  6. Dr Shock on February 21st, 2009 at 11:34 am
  7. Clearly you don’t know what you are talking about – your reference “studies” regarding the efficacy of rTMS for drug resistant depression are extremely limited, and more importantly, outdated. I have recently undergone rTMS for my incapacitating drug-resistant depression, and have had amazing results. Now I actually “feel” hopeful, more motivated, and have energy – MDD destroyed the last 5 years of my life – I either felt very depressed (and/or angry) OR (with some meds) I felt nothing at all, completely empty and numb – with no energy or interests, everything was overwhelming – that wasn’t living, it was barely existing. I have now re-connected with friends, exercise, appreciate simple things like a sunny day, and actually enjoy activities, music, and love playing outside with my dog. Five years of psychiatrists, psychologists, and countless meds with all of the terrible side-effects, I sincerely didn’t think anything could help me – I was planning to schedule ECTs when I learned of rTMS – so far it has worked very well, and if I eventually end up needing follow-up maintanence treatments – so be it!

  8. Kelly on March 5th, 2009 at 5:53 am
  9. Hi Kelly, I just started TMS on Friday and am really hoping it works for my MDD. I would love to talk to you on the phone about it. I don’t know anyone who has undergone it. could you please post a way I could reach you????

  10. Rachel on March 29th, 2009 at 5:41 am
  11. I have been performing rTMS on treatment refractory patients in New York for the past 5 months and have been extremely impressed by the results. Most of the current data supports what I’ve been seeing clinically. This is a promisung therapeutic modality

  12. Michael V. Genovese, M.D. on November 22nd, 2009 at 4:46 am
  13. [...] one antidepressant trial and minimal effective for those patients who failed 2-4 trials. Moreover, the efficacy of rTMS with a structural MRI-based neuro-avigational procedure can have the capacity t…. Other such as altering stimulation frequency increasing dose, and the use of a [...]

  14. TMS for medication resistant depression | Dr Shock MD PhD on May 4th, 2010 at 8:29 am
  1. Navigated stimulation should be a must for both clinical and research uses of TMS. this study shows the difference in efficacy of TMS with different targeting methods.

  2. DrBadger on January 29th, 2009 at 6:46 am
  3. I had rTMS with no success in May/June 2008. The MRI involvement, from a layman’s perspective, would seem to be an improvement over the current procedure. After spending several thousand dollars for the procedure, I was disappointed that this did not prove effective.

    With treatment resistent depression (and always looking for a solution), I will be interested if this approach is being carried out anywhere in the country and what the cost may be. I realize rTMS is now FDA approved (mine was prior to approval), but understand insurance companies have still not come aboard.

    Thanks!

  4. Bill Stevens on February 20th, 2009 at 5:46 pm
  5. I am based in The Netherlands, wouldn’t know who is performing rTMS in your country, sorry. Kind regards Dr Shock

  6. Dr Shock on February 21st, 2009 at 11:34 am
  7. Clearly you don’t know what you are talking about – your reference “studies” regarding the efficacy of rTMS for drug resistant depression are extremely limited, and more importantly, outdated. I have recently undergone rTMS for my incapacitating drug-resistant depression, and have had amazing results. Now I actually “feel” hopeful, more motivated, and have energy – MDD destroyed the last 5 years of my life – I either felt very depressed (and/or angry) OR (with some meds) I felt nothing at all, completely empty and numb – with no energy or interests, everything was overwhelming – that wasn’t living, it was barely existing. I have now re-connected with friends, exercise, appreciate simple things like a sunny day, and actually enjoy activities, music, and love playing outside with my dog. Five years of psychiatrists, psychologists, and countless meds with all of the terrible side-effects, I sincerely didn’t think anything could help me – I was planning to schedule ECTs when I learned of rTMS – so far it has worked very well, and if I eventually end up needing follow-up maintanence treatments – so be it!

  8. Kelly on March 5th, 2009 at 5:53 am
  9. Hi Kelly, I just started TMS on Friday and am really hoping it works for my MDD. I would love to talk to you on the phone about it. I don’t know anyone who has undergone it. could you please post a way I could reach you????

  10. Rachel on March 29th, 2009 at 5:41 am
  11. I have been performing rTMS on treatment refractory patients in New York for the past 5 months and have been extremely impressed by the results. Most of the current data supports what I’ve been seeing clinically. This is a promisung therapeutic modality

  12. Michael V. Genovese, M.D. on November 22nd, 2009 at 4:46 am
  13. [...] one antidepressant trial and minimal effective for those patients who failed 2-4 trials. Moreover, the efficacy of rTMS with a structural MRI-based neuro-avigational procedure can have the capacity t…. Other such as altering stimulation frequency increasing dose, and the use of a [...]

  14. TMS for medication resistant depression | Dr Shock MD PhD on May 4th, 2010 at 8:29 am

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