Abstract
BackgroundDozens of randomized controlled trials (RCTs) and meta-analyses have demonstrated the efficacy of repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder (MDD) treatment, but there has not been a meta-analysis report which evaluates the efficacy and tolerability of rTMS used as an augmentative strategy for antidepressants in treatment-resistant depression (TRD) treatment. We thus conducted this meta-analysis, aimed at clarifying whether rTMS enhances the efficacy of TRD.MethodsWe searched MEDLINE and Cochrane Central Register of Controlled Trials for RCTs for studying the efficacy of rTMS versus (vs) sham condition when combined with antidepressants in TRD treatment, and screened the references of the previous meta-analysis about the rTMS for MDD treatment. Response rates and NNT were chose as the primary outcomes, and remission rates, change from baseline of HAMD scores, dropouts were used as secondary outcomes. For dichotomous data, an intention-to-treat analysis principle was applied; for continuous data, we calculated the standard mean difference between groups with a random-effect model. Sensitivity analysis was done to explore the source of heterogeneity and the factors which potentially impact the efficacy.ResultsSeven RCTs were finally included in the meta-analysis. The total sample size was 279, with 171 in the rTMS group and 108 in the sham group. The pooled response and remission rate for the rTMS and sham group was 46.6% and 22.1%, respectively; the pooled odds ratio (OR) was 5.12 [95% confidence interval (CI) 2.11-12.45, z = 3.60, p = 0.0003, and the associated number needed to treat (NNT) was 3.4. rTMS group achieved a significant reduction of HAMD score than the sham group, the pooled SMD of change from baseline was 0.86 [95% confidence interval (CI) 0.57-1.15, z = 5.75, p < 0.00001]. Because of the small number of included RCTs, the preplanned sensitivity and subgroup analyses were finally abandoned. The dropouts in both groups were relatively low, indicating the high acceptability of rTMS.ConclusionsFor TRD patients, augmentative rTMS after the failure of medications significantly increases the effect of antidepressants, and rTMS was a safe strategy with relatively low adverse events and low dropout rate, suggesting that augmentative rTMS is an effective intervention for TRD.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-014-0342-4) contains supplementary material, which is available to authorized users.
Highlights
Dozens of randomized controlled trials (RCTs) and meta-analyses have demonstrated the efficacy of repetitive transcranial magnetic stimulation for major depressive disorder (MDD) treatment, but there has not been a meta-analysis report which evaluates the efficacy and tolerability of rTMS used as an augmentative strategy for antidepressants in treatment-resistant depression (TRD) treatment
ECT is the oldest and most effective while often criticized by the adverse effects of seizure induction and cognitive side effects [3,4], and patients who accepted ECT treatment often have to bear the stigma on this therapy [5].the limitations of ECT has resulted great interest in the two newly non-invasive neuromodulation methods: rTMS and tDCS, which are both of relatively low adverse effects and similar magnitude of antidepressant effects compared with antidepressant drugs [6]
Literature search and screening All the 7 RCTs [27,30,35,36,37,38,39] included in this metaanalysis were identified by electronic database searching, and the hand searching of bibliographies of previous meta-analyses did not result in additional studies available for data synthesis; two RCTs [40,41] on rTMS’s augmentative effect for TRD obtained by hand searching
Summary
Dozens of randomized controlled trials (RCTs) and meta-analyses have demonstrated the efficacy of repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder (MDD) treatment, but there has not been a meta-analysis report which evaluates the efficacy and tolerability of rTMS used as an augmentative strategy for antidepressants in treatment-resistant depression (TRD) treatment. We conducted this meta-analysis, aimed at clarifying whether rTMS enhances the efficacy of TRD. ECT is the oldest and most effective while often criticized by the adverse effects of seizure induction and cognitive side effects [3,4], and patients who accepted ECT treatment often have to bear the stigma on this therapy [5].the limitations of ECT has resulted great interest in the two newly non-invasive neuromodulation methods: rTMS and tDCS, which are both of relatively low adverse effects and similar magnitude of antidepressant effects compared with antidepressant drugs [6]
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