Abstract
BackgroundTreatment 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 QuestionDoes 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? MethodWe 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. ResultsAn 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.
Highlights
Major depressive disorder (MDD) is a prevalent psychiatric disorder with a significant impact on quality of life
It remains unclear whether repetitive transcranial magnetic stimulation (rTMS) is a viable treatment option for patients with chronic, treatment resistant depression that lasts longer than two years and who do not respond to both antidepressant and psychological forms of treatment
Major depressive disorder was diagnosed by the Structured Clinical Interview for DSM-IV (SCID) (First et al, 1996) by trained psychiatrists (PvE, IT)
Summary
Major depressive disorder (MDD) is a prevalent psychiatric disorder with a significant impact on quality of life. RTMS has been shown to be reasonably effective for patients resistant to two prior antidepressant treatments (Gaynes et al, 2014) It remains unclear whether rTMS is a viable treatment option for patients with chronic, treatment resistant depression that lasts longer than two years and who do not respond to both antidepressant and psychological forms of treatment. It is still an open question whether rTMS could be an alternative for patients who reject, are contraindicated or failed to respond to ECT. 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
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