Repetitive Transcranial Magnetic Stimulation For Depressive Disorders By Paul B. Fitzgerald and Z. Jeff Daskalakis -Springer 2013 (ISBN-13: 978-3642364662)

​Repetitive transcranial magnetic stimulation (rTMS) treatment is increasingly being used in the management of patients with depression. Nevertheless, considerable ignorance still exists about the treatment in general psychiatric practice. This concise clinical guide will serve as a reference and practical tool for clinicians working with or learning about this treatment technique. The opening chapters provide basic information on the history and development of rTMS treatment and its mechanism of action. Use of the treatment in depression is then addressed in detail, with explanation of the evidence base and discussion of a variety of clinical issues. Side-effects of treatment are explored, and careful consideration is given to the establishment of rTMS treatment programs and the training of clinicians. The final chapters will provide a brief overview of potential rTMS applications in other psychiatric conditions and some background on related treatments.

The relationship between brain oscillatory activity and therapeutic effectiveness of transcranial magnetic stimulation in the treatment of major depressive disorder. Frontiers in Human Neuroscience. February 2013 Volume 7 Article 37

Major depressive disorder (MDD) is marked by disturbances in brain functional connectivity. This connectivity is modulated by rhythmic oscillations of brain electrical activity, which enable coordinated functions across brain regions. Oscillatory activity plays a central role in regulating thinking and memory, mood, cerebral blood flow, and neurotransmitter levels, and restoration of normal oscillatory patterns is associated with effective treatment of MDD. Repetitive transcranial magnetic stimulation (rTMS) is a robust treatment for MDD, but the mechanism of action (MOA) of its benefits for mood disorders remains incompletely understood. Benefits of rTMS have been tied to enhanced neuroplasticity in specific brain pathways. We summarize here the evidence that rTMS entrains and resets thalamocortical oscillators, normalizes regulation and facilitates reemergence of intrinsic cerebral rhythms, and through this mechanism restores normal brain function. This entrainment and resetting may be a critical step in engendering neuroplastic changes and the antidepressant effects of rTMS. It may be possible to modify the method of rTMS administration to enhance this MOA and achieve better antidepressant effectiveness. We propose that rTMS can be administered: (1) synchronized to a patient’s individual alpha frequency (IAF), or synchronized rTMS (sTMS); (2) as a low magnetic field strength sinusoidal waveform; and, (3) broadly to multiple brain areas simultaneously. We present here the theory and evidence indicating that these modifications could enhance the therapeutic effectiveness of rTMS for the treatment of MDD.

Transcranial Magnetic Stimulation (TMS) for Major Depression: A Multisite, Naturalistic, Observational Study of Acute Treatment Outcomes in Clinical Practice

Few studies have examined the effectiveness of transcranial magnetic stimulation (TMS) in real-world clinical practice settings. Forty-two US-based clinical TMS practice sites treated 307 outpatients with Major Depressive Disorder (MDD), and persistent symptoms despite antidepressant pharmacotherapy. Treatment was based on the labeled procedures of the approved TMS device. Assessments were performed at baseline, week 2, at the point of maximal acute benefit, and at week 6 when the acute course extended beyond 6 weeks. The primary outcome was change in the Clinician Global Impressions-Severity of Illness from baseline to end of acute phase. Secondary outcomes were change in continuous and categorical outcomes on self-report depression scales (9-Item Patient Health Questionnaire [PHQ-9], and Inventory of Depressive Symptoms-Self Report [IDS-SR]). Patients had a mean ± SD age of 48.6 ± 14.2 years and 66.8% were female. Patients received an average of 2.5 (± 2.4) antidepressant treatments of adequate dose and duration without satisfactory improvement in this episode. There was a significant change in CGI-S from baseline to end of treatment (-1.9 ± 1.4, P < .0001). Clinician-assessed response rate (CGI-S) was 58.0% and remission rate was 37.1%. Patient-reported response rate ranged from 56.4 to 41.5% and remission rate ranged from 28.7 to 26.5%, (PHQ-9 and IDS-SR, respectively). Outcomes demonstrated response and adherence rates similar to research populations. These data indicate that TMS is an effective treatment for those unable to benefit from initial antidepressant medication.

Long-Term Efficacy of Repeated Daily Prefrontal Transcranial Magnetic Stimulation (TMS) in Treatment-Resistant Depression. Depress Anxiety. 2012 October ; 29(10): 883–890

A few studies have examined the durability of transcranial magnetic stimulation (TMS) antidepressant benefit once patients remitted. This study examined the long-term durability of clinical benefit from TMS using a protocol-specified TMS taper and either continuation pharmacotherapy or naturalistic follow-up.

Effectiveness of transcranial magnetic stimulation in clinical practice post-FDA approval in the United States: results observed with the first 100 consecutive cases of depression at an academic medical center. J Clin Psychiatry. 2012; 73: e567–73

Transcranial magnetic stimulation (TMS) is a US Food and Drug Administration–approved treatment for major depressive disorder (MDD) in patients who have not responded to 1 adequate antidepressant trial in the current episode. In a retrospective cohort study, we examined the effectiveness and safety of TMS in the first 100 consecutive patients treated for depression (full DSM-IV criteria for major depressive episode in either major depressive disorder or bipolar disorder) at an academic medical center between July 21, 2008, and March 25, 2011.

H-Coil Repetitive Transcranial Magnetic Stimulation for Treatment Resistant Major Depressive Disorder

Evidence has shown that repetitive transcranial magnetic stimulation (rTMS) can be effective as an acute treatment for major depressive disorder (MDD). However, few studies have examined the safety and feasibility of rTMS as a long-term\continuation treatment. Deep-TMS is a novel tool enabling deeper stimulation than standard coils. The current study examined the safety and feasibility of repetitive deep-TMS continuation treatment for MDD over the course of 18 weeks, following 4 weeks of acute treatment. A total of 29 MDD patients were enrolled in the study. rTMS sessions (20 Hz) were given for a total of 22 weeks, divided into: 4 weeks of acute daily treatments, followed by 18 weeks of continuation treatments. Clinical evaluations were performed weekly throughout the study. A significant decrease from baseline in Hamilton Depression Rating Scale (HDRS) score was found at the end of the acute phase, and maintained throughout the study ( P < 0.0001). The Kaplan – Meier estimated probability of response was 46.15% (SE = 9.78%) at the end of the acute phase, and 81.12% (SE = 9.32%) at the end of the study (22 weeks). Probability of remission at the end of the acute phase was 26.92% (SE = 8.70%) and 71.45% (SE = 10.99%) at the end of the study. Response in the acute phase was indicative of response in the continuation phases. The procedure was generally well tolerated and no adverse events were reported. The results suggest that H-coil deep-TMS administered continuation treatment can help maintain an antidepressant effect for 18 weeks, following 4 weeks of acute treatment.

Transcranial Magnetic Stimulation for Major Depressive Disorder: A Pragmatic Approach to Implementing TMS in a Clinical Practice. Ann Clin Psychiatry. 2010 Nov;22(4 Suppl):S4-11.

Another option for managing major depressive disorder (MDD) became available in October 2008 with the Food and Drug Administration’s (FDA) market clearance of NeuroStar TMS (transcranial magnetic stimulation) Therapy System. A panel of psychiatrists who have been treating patients with NeuroStar TMS Therapy in their clinics assembled for a virtual roundtable discussion regarding their experiences. In this supplement, the panel addresses the following issues: the FDA-cleared indication for use of NeuroStar TMS Therapy; logistic and staffing considerations in the outpatient setting; selecting the right patient for TMS Therapy; talking with patients and family about TMS Therapy. To give the overview a meaningful context, each panelist shares a personal account of a patient case, describing the treatment course and outcomes achieved with TMS Therapy.

Accelerated Repetitive Transcranial Magnetic Stimulation for Treatment Resistant Depression. Depression and Anxiety 27:960-963

Repetitive transcranial magnetic stimulation (rTMS) has shown safety and efficacy for treatment-resistant depression, but requires daily treatment for 4-6 weeks. Accelerated TMS, with all treatments delivered over a few days, would have significant advantages in terms of access and patient acceptance.

Demitrack, M.A. (2010) Transcranial Magnetic Stimulation for the Treatment of Major Depression clinical. Economic, and Practical Issues: Part II Psychopharm Review, Vol. 45, No. 8 August 2010

Part I of this two-part series (vol. 45, no. 4) discussed the clinical and economic burder of major depression; the compounding issue of treatment resistance; and cost analyses comparing transcranial magnetic stimulation (TMS) with standard clinical care (e.g., complex pharmacotherapy, electrconvulsive therapy [ECT]) for treatment resistance depression (TRD). Part II reviews practical issues in the clinical use of TMS, which have merged since its approval by the FDA for this indication.