Potential Use of TMS for Depression in Special Populations
Transcranial magnetic stimulation (TMS) is increasingly being utilized as a treatment option for depression, and with this comes a need for a conversation about special groups that may need and benefit from this treatment. More than 35 randomized control trials have been published reporting the efficacy of TMS when compared to sham stimulation, most of them in adult samples. There is consistent, high quality (level A) evidence of its efficacy and tolerability as a treatment for depression.
This blog focuses on information and opinion regarding TMS for depression in older patients, adolescents and young people, and for those who are pregnant or living with developmental disorders. These populations require special consideration when prescribing and monitoring treatment courses (not addressed in this blog). The data and controlled trials regarding safety and efficacy in special populations is very limited.
TMS for Geriatric Depression
As the global population gets older, depression in the elderly is emerging as an important health issues. At present it is estimated that 8-16% of the elderly (age>65) living in the community suffer from clinically significant depressive symptoms. Furthermore treatment resistant depression is common with an estimated rate of between 26-41 per 100. There are at least four randomized controlled trials specifically including older people. A consistent observation across all controlled and uncontrolled trials supports (toll over #12) shows a high degree of tolerability and safety among elderly patients. Geriatric depression is accompanied by a greater degree of cognitive impairment. Antidepressant medications and other invasive treatment modalities increase the risk for further cognitive decline in this population already experiencing deficits. Exclusion of this group from a well-tolerated and safe treatment option for depression such as TMS appears to be clearly unsupportable.
TMS for Developmental Disorders
Treatment of depression in the context of developmental disorders (i.e Down’s syndrome, autism spectrum disorder – ASD) is complicated by the fact that those conditions present with either abnormal intellectual ability (Down’s) or different degrees of severity (ASD).Treatments (medications) and other more invasive treatments may induce further decline in cognition or intellectual abilities including education, speech and ability to live independently. Down’s Syndrome is an intellectual disability of genetic origin (1/700 births) and 30% will develop clinically significant depression. ASD affects at least 60 per 10,000 youth, with estimates as high as 120 per 10,000. A study showed that during episodes of psychiatric illness, 87% of the subjects with developmental disorders presented a decreased independence in daily activities, and 33% presented a total loss of independence.
Adolescents and Young Adults
TMS for depression in adolescents and young adults offers special opportunities. Treatment options are often limited, in many cases treatment is suboptimal, and polypharmacy may become a resource with repeated psychiatric admission and adverse developmental consequences. A review of studies utilizing TMS for a broad range of conditions (for those under 18 years of age) shows that rTMS is generally well tolerated, with minor side effects at rates similar to those seen in adult populations.
Pregnancy has a high prevalence of mental disorders, and depression is the most common of these disorders. Conventional treatment options include antidepressant medications, psychotherapies and ECT. The choice of therapy is complicated by potential unwanted effects in the mother and fetus or unborn baby. Any decision making is complex and has to balance potential benefits and risks to both mother and child. There is growing concern of fetal risk during the pregnancy and in the perinatal period with medications and anesthetics. Others potential concerns include effect on fetal development. There are over ten published studies (open, case reports, review). TMS can be considered an effective therapeutic alternative for the treatment of depression in pregnant women. There have been no reports of malformations or other negative fetal outcomes. The evidence is very limited and adequate studies are needed to further understand all aspects of safety.
I believe that every treatment for depression has risks as well as benefits. Research suggests that if you participate in deciding what treatment you have, you are likely to recover more quickly than if you don’t take part in decisions. Before making a decision look into all possible treatment options, make sure you understand the how the risks and benefits will affect you or your loved one, and make sure you have enough information to make a reasoned choice. One of the great advantages of TMS is its low risk profile. This makes a difference for special populations who are at higher risk for potential complications with other more invasive treatments.
How can you make a decision regarding treatments (medications, invasive modalities, TMS, etc..) for depression? When deciding on a treatment here are some questions you might ask yourself:
- What will happen if I do not have the treatment?
- What are my choices for treatment?
- What is the evidence-based (research)?
- What are the risks and benefits of each treatment?
You can talk to your doctor, nurse and therapist, . You may also want to talk with other patients who had similar treatments.
To learn more about our treatment at Achieve please call -800-HOPE-TMS or visit us at www.achievetms.com.