Transcranial Magnetic Stimulator–TMS is Effective to Treat Major Depression

TMS is the very impressive cutting-edge in treating Recurrent Major Depression in adults.

Currently we have one Outpatient depression treatment modality. It is primarily treating Major Depression Disorder with different classes of antidepressants. Recently Abilify and SeroquelXR, which are antipsychotics, have flooded the market as an add on for treating Refractory (Hard to Treat) Major Depresssion. I found out that most consumers of depression meds, especially Abilify and SeroquelXR, do not really understand or realize the scope, tolerability and the long term side effects of meds in general and being given “Antipsychotics in Particular.”

We as practitioners need to be pragmatic with medications’ side effects same as we request that our patients learn and understand their meds’ short and long term side effects.

There was recently an article outlined on Wall-Street that antidepressants do NOT achieve complete or even remission in markedly depressed patients. Most of the studies that carried favorable results, were not carried longer than 6months.

It is well known practice that the most effective management for marked or severe depresssion is ECT. ECT has about 90% success rate and has been very helpful, turning in most cases, the severe depression clinical presentation upside down, upon completion of such ECT treatment. ECT has its own package of potential side effects and limitations, such as no-driving, complete supervision following treatment, Memory loss, Relative contraindications etc. That is besides anethesia potential limitations along with ECT lacking its own long term lasting effect, which is already reported in many cases.

So do we go here? Where does TMS fit here?

I have been reading about this TMS, quite a bit. The brains that looked into this invention are simply, very bright and thoughful Clinicians. It is my personal opinion that TMS is the upcoming treatment, slowly replacing ECT in the next few years. Patients, who can afford its high cost of treatment are speaking positively of the treatment modality, already.

TMS Pending Research Areas are the follwoing:
1- Depression in Bipolar Affective Disorder (is currently studied).
2- Post Traumatic Stress Disorder.
3- Negative Symptom Schizophrenia.
4- Attention Deficit Disorder.
5- Low Frequency Right Prefrontal to Alleviate Acute Mania.

6- Already proven effective in Post Stroke Aphasia Patients.
7- Improving language function (word finding) in Dementia Patients
(limited to only
6 weeks study).
8- Parkinson’s Depression and Parkinsonain’s movement (Proven already).
9- Migraine Headache.
10- Chronic Pain Syndrome through Cortical Stimulation.

I will list the updates on this TMS material as soon as I get them.
Good Luck..

May 3, 2010 — Daily monotherapy with left prefrontal repetitive transcranial magnetic stimulation (rTMS) appears to be effective and well tolerated in patients with antidepressant-resistant major depression, a new phase 1 study suggests.

In what is reportedly the first industry-independent, multicenter, randomized, tightly controlled trial of rTMS, investigators at the Medical University of South Carolina in Charleston found a 14.1% remission rate in patients with major depression vs 5.1% in patients receiving active sham treatment.

“One of the most important aspects of the study was ensuring that no one who knew the randomization status of the patient ever came in contact with the patient or interacted with the data,” the researchers, led by Mark S. George, MD, write.

“We developed a new, active sham transcranial magnetic stimulation system that stimulated the repetitive transcranial magnetic stimulation somatosensory experience and effectively masked the patients, the raters, and, to a large extent, the treaters,” the investigators add.

The National Institutes of Health–funded study is published in the May issue of Archives of General Psychiatry.

Thomas R. Insel, MD, director of the National Institute of Mental Health, said in a statement that although rTMS treatment has not lived up to early hopes that it might replace more invasive therapies, such as electroconvulsive therapy, these findings suggest “that the treatment may be effective in at least some treatment-resistant patients.”

rTMS aims to “jump-start” underactive mood-regulating circuitry by targeting the top left front part of the brain with an electromagnetic coil that emits 3000 pulses during a 37-minute session. It can be safely administered in a physician’s office with few adverse effects.

Although most meta-analyses indicate the treatment has a large effect size for change in depressive symptoms compared with sham-control interventions, the investigators note there has been controversy about the quality of the research — including questions about the validity of the sham-control interventions and inadequate dosing.

“Many of the early TMS trials used small doses (number of stimuli per day) and administered treatment for only 2 weeks,” the study authors write.

To address these and other methodological concerns, the investigators recruited a sample of 190 subjects who had previously not responded to treatment with antidepressant medications.

Participants were randomized to receive 3 weeks of daily weekday treatment or sham treatment followed by continued masked treatment for up to another 3 weeks in improvers.

The study’s primary outcome measure was comparison of remission rates in the 2 treatment arms after controlling for site, treatment resistance, age, and duration of the current depressive episode.

A total of 92 subjects were randomized to the active treatment group, which involved stimulation of the left prefrontal cortex with an electromagnetic coil for 37.5 minutes daily for 3 weeks. The remaining 98 subjects received a sham treatment that mimicked the sensory experience of stimulation using a similar coil and scalp electrodes but with the magnetic field blocked.

Study completion rates were 90% for the sham group and 86% for the active treatment group. Among these, depression remitted in 14.1% of subjects who received rTMS and 5.1% in those who received sham treatment.

“The odds of attaining remission were 4.2 times greater with active rTMS than with sham (95% CI [confidence interval], 1.32 – 13.24),” the investigators report.

Those who showed improvement received up to an additional 3 weeks of masked treatment.

Patients who received active rTMS were more likely to reach remission, particularly if they had been moderately, rather than severely, treatment resistant.

The researchers found no significant difference in adverse events by treatment arm. Adverse effects in both groups included headache, site discomfort, and facial twitching. No seizures or suicides occurred. The number needed to treat was 12.

In a 3-week, open-label, follow-up phase of the study in which all patients received active therapy but remained masked to their original treatment arm, remission rates climbed to almost 30% — 30.2% in the originally active group and 29.6% in the original sham group.

“The results of this study suggest that prefrontal rTMS is a monotherapy with few adverse effects and significant antidepressant effects for unipolar depressed patients who do not respond to medications or who cannot tolerate them,” the investigators conclude.

Dr. George reports receiving research grants in the past 5 years from Brainsway, Cephos, Force Protection, GlaxoSmithKline, and Jazz Pharmaceuticals. He has been an unpaid adviser to Brainsonix, Neostim, Neosync, and Neuronetics Inc (because they make products related to TMS) and a paid adviser to Cyberonics, Jazz, Neuropace, and Puretech ventures. The full amount of his advisory income has never been more than 10% of his university salary. The Medical University of South Carolina has 2 patent applications in Dr George’s name on combining TMS with magnetic resonance imaging. The disclosures of the other investigators can be found in the original paper.

Arch Gen Psychiatry. 2010;67:507-516.

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