TMS for medication resistant depression
It’s been a while since my last post on this blog about transcranial magnetic stimulation (TMS).
Myself ‘m not impressed by it’s efficacy for treatment resistant depression. Especially in treatment resistant depression, whatever that may be, rTMS is probably best avoided for more evidence based form of treatments with proven efficacy.
The reason for this post about TMS is a recent publication in the Journal of Clinical Psychiatry. FDA approval for rTMS was based on a large, industry-sponsored, multicenter, double-blind, monotherapy study with 325 patients with “moderately treatment resistant depression” also discussed on this blog here. My opinion on this trial was
This is a trial very well done. Due to its design only the scores on time point of week 4 are truly double-blind. They introduced a new method for sham treatment: the sham coil had a embedded magnetic shield. This study also shows that longer treatment with rTMS is well tolerated. The use of pharmacotherapy treatment failure as an inclusion criterion every time amazes Dr Shock. There are far better treatment options e.g. plasma level controlled TCAs, lithium addition and ECT to name a few.
Considering the outcome on the time point at week 4, Dr Shock is not very impressed by the results. For significant difference with the primary outcome 6 patients had to be excluded from the analysis. The mean difference between active and sham on the severity scales is in the range of 2-3 points, significant but hardly clinical relevant. Absolute figures on response and remission at week 4 are not given in this article. Remission rate at 6 weeks on the HAMD-17 was 15.5% increasing to 22.6% at week 9 with open labeled therapy. Not very impressive.
Fortunately in this article the authors also state that rTMS was more effective in those with failure of just 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 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.
The conclusion of this article sums it up nicely:
….questions remain about patient selection, how best to deliver the treatment, and it’s place in the treatment algorithm relative to existing treatments for depression
What is TMS?
rTMS is a non-invasive method to stimulate the brain. Weak electric currents are induced in the cortex of the brain by rapidly changing magnetic fields (electromagnetic induction). This way, brain activity can be triggered with minimal discomfort, no need for anesthesia, and no cognitive side-effects. Side effects of rTMS are: discomfort or pain from the stimulation of the scalp and associated nerves and muscles on the overlying skin and hearing from the loud click made by the TMS pulses. You can see a treatment with TMS in the video above.
Yip AG, & Carpenter LL (2010). Transcranial magnetic stimulation for medication-resistant depression. The Journal of clinical psychiatry, 71 (4), 502-3 PMID: 20409447
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May 12, 2010 @ 5:53 am
Hi Doc,
“Myself ‘m not impressed by it’s efficacy for treatment resistant depression. Especially in treatment resistant depression, whatever that may be, rTMS is probably best avoided for more evidence based form of treatments with proven efficacy.” — Dr. Shock
I’m somewhat surprised or dismayed by what I consider your convoluted statement and/or reasoning. As we discussed some time ago CMS (Centers for Medicare & Medicaid Services) here in the U.S. does not recognize any such terminology as “treatment resistant depression” as this is not a diagnosis contained in the DSM IV whereas recurrent and chronic depression or MDD are and was so stated in their decision to not approve VNS for reimbursement.
Although we both understand the meaning of TRD as customarily used by most professionals and lay people the point is those patients experiencing recurrent and chronic depression or MDD would in most likelihood have tried what you refer to as “more evidence based form of treatments” except for the reality that it is this unique population of patients that have not responded to these so called “evidence based form of treatments” and it is for this very reason this unique patient population is in need of newer approaches toward potential efficacy.
As Joyce’s attending psychiatrist has stated to me and I shall paraphrase, “When these treatments don’t work what other alternatives would you suggest?”
My point being although you may not be impressed with rTMS or any of the newer neuromodulation therapies I think it incumbent upon the attending psychiatrist to be knowledgeable of the therapies and to inform and encourage his/her patient especially when conventional therapies have proven ineffective that there are additional treatment options to be considered. I personally would also take exception to your use of the word “avoided” especially in those patients of which I am familiar who are experiencing unrelenting suicidal ideations.
Sorry, but in this instance I would respectfully have to disagree with your thoughts.
Warmly,
Herb
VNSdepression.com
May 27, 2010 @ 5:11 pm
Hi Doc,
I wanted to take a moment to alert you to the following bulletin I’ve received this morning.
Cyberonics Announces Data from Depression Dosing Study
http://vnsdepression.com/vns/index.php/topic,2.0.html
I just returned home last evening from seeing the grandchildren and haven’t as yet had a chance to find the medical papers for the study but I thought you might find this information of some interest.
Doc, after digesting the medical reports maybe you’d reconsider posting some additional thoughts on the subject.
Warmly,
Herb
VNSdepression.com
June 23, 2010 @ 3:04 am
Alright,
im almost 14 ys. old and i think i might have depression. I used to cut myself for no reason at all and would be to embarresed to tell my parents why. The truth? i never really had a reason. When im alone in my house i cry, dont know why. Im getting tired and atible all the time and lately thats been pissing off my parents. I love gymnastics and lately ive just not been wanting to go. im sore all the time! and belive me i have thought about telling my parets that i think i might have depression, but i know they would probably laugh and say i need to stop trying to act like something is wrong with me. Tell me something, anything, prove it or deny it, i just want to know.
February 23, 2012 @ 1:11 pm
very nice article, I have been trying to look for this. Thanks!
March 1, 2012 @ 7:45 am
I’ve read mostly positive posts about TMS. It’s good to get an alternative view. Aside from treatment of depression, I’ve heard it can also address symptoms such as anxiety, insomnia, and some level of ADD/ADHD with favorable results. Does that sound viable or just marketing from the industry?