A Case Series Study of Weekly or Fortnightly Transcranial Magnetic Stimulation (TMS) in Major Depressive Disorder.

BACKGROUND: Major depressive disorder (MDD) is frequently chronic and relapsing. The use of maintenance or continuation transcranial magnetic stimulation (TMS) has received clinical and some research support. OBJECTIVE: To conduct a case series study to report the outcomes of once-weekly (OW) or once-fortnightly (OF) continuation TMS in a real-life setting. METHODS: We offered OW or OF TMS sessions to patients with MDD in remission or partial remission/relapse. RESULTS: Ten patients received OW TMS and four received OF TMS, for 8 to 46 weeks. No patients in either group who were in remission or partial remission at baseline experienced a relapse. Improvements in HAMD6 and CGI-S scores were statistically significant or of borderline significance for the total sample and the OW group. CONCLUSIONS: This naturalistic, open-label observational study indicates that OW TMS is effective as maintenance therapy in MDD, while also offering some support for OF TMS maintenance in preventing relapse.

Transcranial Magnetic Stimulation (TMS) for Major Depressive Disorder-Modus Operandi!

Background: Transcranial magnetic stimulation (TMS) is effective in the management of treatment resistant major depressive disorder (MDD) and has recently become widely available. Our aim was to explore the literature for evidence of the mechanism of action. Method: We examined our own accumulating TMS library, the reference lists of all available papers and used a search engine to collect information. We collated and examined this information under relevant heading. Results: TMS produces a large number of physiological changes including site of stimulation neurochemical, brain wave and blood flow effects, and distant structure effects including neurotransmitter effects and volume increase. TMS also corrects generalized and local functional connectivity (FC) abnormalities which are a feature of MDD. Conclusion: TMS produces a range of physiological changes. It is unclear which of these underpin its antidepressant. It is likely more than one work synergistically to this end-almost certainly the capacity to correct MDD induced FC abnormalities makes a strong antidepressant contribution.

One Hundred Courses of Cluster Maintenance Transcranial Magnetic Stimulation (CM TMS)-A Clinical Audit Study.

Objective: Major depressive disorder (MDD) which comes to transcranial magnetic stimulation (TMS) is prone to relapse. Cluster maintenance (CM) TMS is courses of 5 treatments delivered over 2.5-5 days, separated by monthly or greater non-treatment periods. Our aim was to characterize the outcomes of 100 courses of CM TMS. Method: This was a Quality Assurance/Clinical Audit study. We studied consecutive CM TMS courses provided to private hospital inpatients. Mood was rated (on admission and discharge) using the six-item Hamilton depression rating (HAMD6) and the Clinical Global Impression - Severity (CGI-S) scales. We also applied recent STAR*D criteria which are designed to measure the 'clinical change' expected to impact patient function [16]. Results: For the total sample, using the HAMD6, 83% of courses featured relapse or partial relapse on admission, and 81% featured remission on discharge. Of 46 courses featuring HAMD6 relapse on admission, 74% featured remission on discharge. For the 100 courses the HAMD6 discharge scores were significantly lower than the admission scores (p = 2.0 × 10-24), as were the CGI-S scores (p = 1.8 × 10-25). Using STAR*D criteria for people in relapse or partial relapse on admission, CM TMS provided least a 'clinically meaningful' outcome in 82% of the cases. Conclusion: For courses featuring relapse or partial relapse on admission, CM TMS converted greater than 70% to remission at discharge. It produced statistically significant reductions in HAMD6 and CGI-S scores, and using STAR*D criteria, at least 'clinically meaningful' change was extensively demonstrated. This evidence indicates CM TMS should be readily available to people living with relapsing MDD.

Transcranial Magnetic Stimulation (TMS) during pregnancy: a fetal risk factor.

OBJECTIVE: To examine reports of Transcranial Magnetic Stimulation (TMS) during pregnancy for evidence of fetal risk. METHOD: PubMed was used to locate relevant literature for the years 1998-2020 and reference lists were examined for materials not located electronically. RESULTS: Ten reports were located dealing with 67 births over 20 years. Stimulation was applied is all trimesters, at low and high frequency, and as intermittent theta-burst stimulation. No mother or baby experienced a serious event. CONCLUSIONS: Certainty awaits large, standardized studies. However, the available reports provide no evidence that TMS to mother during pregnancy has detrimental effects on the fetus.

The impact of 'cluster maintenance TMS' on irritability occurring in major depressive disorder.

OBJECTIVE: To determine the impact of clustered maintenance transcranial magnetic stimulation (TMS) on irritability occurring in treatment-resistant major depressive disorder (MDD). METHOD: A naturalistic study of 106 courses that includes pre- and posttreatment assessments of subjective and objective depression and a subjective measure of irritability developed for this study. RESULTS: Forty-six participants (35 females), mean age 43.2 years (14.3), completed 106 courses. There was a significant reduction in irritability and depression scores (p < .001). The change in irritability scores was significantly correlated with the change in depression scores, r = .40, p < .001. CONCLUSION: TMS has the capacity to reduce the irritability co-occurring with treatment-resistant MDD, known to be responsive to TMS. This increases the possibility of using TMS in the treatment of irritability co-occurring with other disorders or standing alone (should irritability be categorized as a stand-alone disorder).

Daily and spaced treatment with transcranial magnetic stimulation in major depression: a pilot study.

OBJECTIVE: Transcranial magnetic stimulation is an emerging treatment of treatment-resistant depression. Current protocols rely on daily treatments. This study was designed to determine whether the time period over which treatment is delivered is an important factor in efficacy. METHOD: Sixteen adult patients with treatment-resistant major depression were randomly assigned to one of the two treatment groups, both of which received 2 weeks of treatment. One group received daily treatment (10 treatments, on business days). The other group received three treatments in week one, and two treatments in week two (five treatments, on spaced business days). Mood was rated using the Hamilton Depression Rating Scale (HDRS) and a self-rated visual analogue scale. Response was defined as a 50% reduction in HDRS rating, and remission was defined as achieving an HDRS score of 8 or less. The groups were compared throughout the 2-week study period. RESULTS: At entry, there were no demographic differences between the groups. Multivariate tests showed a significant main effect for time (Pillai trace=0.76, F(4,56)=8.56, p<0.001, power=0.99) reflecting the improvement in both measures of depression during treatment. There was no significant difference between the groups overall (Pillai trace=0.25, F(2,13)=2.12, p=0.16, power=0.36). Additionally, there was no significant interaction between time and treatment group (Pillai trace=0.18, F(4,56)=1.35, p=0.26, power=0.39) indicating that the significant improvement in depression over time was similar for both treatment groups. There were no significant differences in response and remission rates between the groups. CONCLUSION: The time period of treatment appeared to be an important outcome factor. This suggests that less than daily transcranial magnetic stimulation treatment may be a useful clinical alternative.

Medication options in the treatment of treatment-resistant depression.

AIM: Less than half of those suffering major depressive episodes achieve remission with the first antidepressant provided and one-third of all patients suffering depression have a chronic condition. Clinical experience indicates that a substantial proportion of patients suffer treatment-resistant depression (TRD). Our aim is to explore the literature reporting the drug treatment of TRD, and to present such information as would be of interest to clinical psychiatrists. METHOD: Literature searches were conducted using PubMed and entering the words antidepressant, augmentation, combined antidepressants, treatment resistant depression and the names of individual antidepressant medications. RESULTS: Most authors recommended that TRD should be first approached by reassessing the diagnosis, adding psychotherapy and attending to psychosocial factors. Details of the following pharmacological options were identified: (i) augmentation of the currently employed antidepressant with a medication which is not an antidepressant; (ii) change of antidepressant; and (iii) addition of a second antidepressant to the current antidepressant, or commencement of a combination of two antidepressants. CONCLUSIONS: When monotherapy provided at the maximum manufacturer-recommended doses for 3-4 weeks has failed to provide remission in depression, the diagnosis should be confirmed, psychotherapy added and psychosocial factors should receive attention. In the sustained absence of remission, a better outcome may be obtained by augmenting the antidepressant, changing from a single-action to a double- or multiple-action drug, or by combining antidepressants.

Cortical excitability of psychiatric disorders: reduced post-exercise facilitation in depression compared to schizophrenia and controls.

OBJECTIVE: In normal subjects, motor evoked potentials (MEPs) produced by transcranial magnetic stimulation (TMS) from the motor cortex are increased after non-fatiguing exercise of hand muscles. This phenomenon is called post-exercise facilitation. This study aims to test the hypothesis that psychiatric syndromes (major depressive episode, schizophrenia) have different levels of post-exercise facilitation compared to controls. METHODS: Patients with DSM-IV major depressive episode (six female, four male), schizophrenia (two female, nine male) and a control group (nine female, four male) participated. MEPs were elicited pre- and post-exercise from the contralateral abductor pollicis brevis by TMS over the primary motor cortex. RESULTS: Post-exercise facilitation expressed as a percentage of baseline was 510% in controls, 110% in depression and 190% in schizophrenia. There were significant differences in patients with depression and schizophrenia compared to controls (p = 0.0001, p = 0.0008). CONCLUSIONS: Post-exercise facilitation was reduced in depression and schizophrenia, suggesting impaired cortical excitability in these disorders. Further studies may discriminate between the two groups.

Comparison of unlimited numbers of rapid transcranial magnetic stimulation (rTMS) and ECT treatment sessions in major depressive episode.

Repetitive transcranial magnetic stimulation (rTMS) is a new technology which holds promise as a treatment of psychiatric disorders. Most work to date has been on depression. Superiority to placebo has been indicated in three small blind studies. We compared the antidepressant effects of rTMS and ECT in 32 patients suffering major depressive episode (MDE) who had failed to respond to at least one course of medication. There was no limit to the number of treatment sessions which could be given and treatment was continued until remission occurred or response plateaued. A significant main effect for treatment type was found [Pillai trace = 0.248, F(3,28) = 3.076, p = 0.044; power = 0.656], reflecting an advantage for ECT patients on measures of depression overall, however, rTMS produced comparable results on a number of measures. Blind raters using the 17-item Hamilton Depression Rating Scale (HDRS) found the rate of remission (HDRS = ? 8) was the same (68.8%), and the percentage improvement over the course of treatment of 55.6% (rTMS) and 66.4% (ECT), while favouring ECT, was not significantly different. Significant differences were shown (p & 0.03) in percentage improvement on Beck Depression Inventory ratings (rTMS, 45.5%; ECT, 69.1%), but not for improvement in Visual Analogue ratings of mood (rTMS 42.3%; ECT, 57%). rTMS has antidepressant effects of useful proportions and further studies are indicated.