rTMS in Severe, Treatment Resistant Depression-A Negative Trial
Out on PubMed from researchers in the Netherlands is this study:
A randomized controlled trial of a standard 4-week protocol of repetitive transcranial magnetic stimulation in severe treatment resistant depression
Background: Treatment options for major depressive disorder (MDD) in individuals who are depressed for at least 2 years and failed two or more different types of therapeutic intervention, remain scarce. Being less invasive than electroconvulsive therapy, repetitive transcranial magnetic stimulation (rTMS) might be an alternative treatment option.
Research question: Does high frequency rTMS applied over the left prefrontal cortex ameliorate depressive symptoms in patients with treatment resistant major depressive disorder and is the efficacy dependent on treatment resistance?
Method: We performed a randomized controlled trial investigating the effect of twenty sessions of real or sham-rTMS, during 4 consecutive weeks. Efficacy was blindly rated with the Hamilton depression rating scale (HDRS-17) at baseline and 1 week after end of treatment, and the Dutch method for quantification of treatment resistance in Depression (DM-TRD) was assessed at baseline.
Results: An interim analysis showed no differences in antidepressant response between real and sham rTMS and we therefore discontinued the RCT after 31 patients. The mean difference of the HDRS score between baseline and post-treatment was 3.7 (± 4.0; change 16%), indicating a small but significant improvement across time (F(1,30)=25.4;p < 0.01). There were no differences however between the treatment arms (F(1.30) = 1.5;p = 0.23). We did find a negative correlation between the change in HDRS score and DM-TRD in the active rTMS group, but this correlation was not significantly different from the sham group.
Conclusion: "Standard" 4-week rTMS treatment is not effective in chronic, severe treatment-resistant depressed patients. While a replication of our data in this patient group may be ethically difficult, further research with less treatment resistant patients might help in positioning rTMS within the current stepped care approach to depression.
Keywords: Chronic depression; Repetitive transcranial magnetic stimulation; Treatment resistant depression.
I chose to blog about this study as it is an uncommonly realistic assessment of rTMS. The efficacy of rTMS was initially over-promised. Indeed, many assumed it would be powerful enough to replace ECT. rTMS has caught on because it safe, attractive and, frankly, lucrative; it appears to have modest-moderate antidepressant qualities and may be able to be optimized to become more powerful in the future. But to conflate it with ECT, accidentally or purposefully, is misleading. There is a time and a place for every treatment in Psychiatry.
The concept of "treatment resistance" is a fraught one (please see: 'Treatment resistance' in electroconvulsive therapy (ECT) patients: time to move on C H Kellner 1 2, A Nordenskjöld 3 Acta Psychiatr Scand. 2019 Nov;140(5):490-491) and it is unclear to what extent the patients in this study resemble typical ECT populations (psychotic patients were excluded).
Our responsibility as ECT practitioners is to insure that ECT is appropriately prescribed and available to the seriously ill patients who need it. Another perspective from which to view ourselves as ECT practitioners, is that we are specialists in taking care of the very seriously ill.
Comments
Post a Comment