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Bilateral repetitive TMS may be most effective for depression

Results from a systematic review and meta-analysis suggested bilateral and priming low-frequency repetitive transcranial magnetic stimulation were most effective for major depressive disorder; however, data were limited.

“In 2010 depressive disorders were the second leading cause of disability among all diseases worldwide. The treatment options available are suboptimal, with most patients being refractory. Therefore, there is an urgent need to develop and optimize novel treatments for depression, such as repetitive transcranial magnetic stimulation,” Andre R. Brunoni, MD, PhD, of University of São Paulo, Brazil, and colleagues wrote.

To determine efficacy and acceptability of different methods of repetitive transcranial magnetic stimulation (TMS) for major depressive disorder (MDD), researchers conducted a systematic review and network meta-analysis of 81 randomized clinical trials including 4,233 patients that compared repetitive TMS with sham or another repetitive TMS intervention.

Priming low-frequency (OR = 4.66; 95% CI, 1.7-12.77), bilateral (OR = 3.96; 95% CI, 2.37-6.6), high-frequency (OR = 3.07; 955 CI, 2.24-4.21), theta burst stimulation (OR = 2.54; 95% CI, 1.07-6.05) and low frequency (OR = 2.37; 95% CI, 1.52-3.68) repetitive TMS were more effective than sham interventions.

Novel TMS interventions, including accelerated, synchronized and deep repetitive TMS, were not more effective than sham interventions.

Researchers found similar associations for remission, excluding theta burst stimulation.

Estimated relative ranking indicated priming low-frequency and bilateral repetitive TMS may be the most effective and acceptable repetitive TMS interventions. However, findings were vague and included limited trials for interventions other than low-frequency, high-frequency and bilateral repetitive TMS.

“Our data suggest that bilateral [repetitive TMS] is probably more effective than [low-frequency repetitive TMS] because their relative [odds ratio] was only marginally not statistically significant and similarly acceptable as both [low-frequency repetitive TMS] and [high-frequency repetitive TMS]; this finding implies that bilateral [repetitive TMS] could be considered also prior to these techniques,” the researchers wrote. “Novel interventions (accelerated, deep, and synchronized [repetitive TMS]) were not found to be more effective than sham. Nonetheless, available evidence on interventions other than bilateral, [low-frequency repetitive TMS] and [high-frequency repetitive TMS] is scarce. Thus, new high-quality [randomized clinical trials] are necessary to establish their efficacy with a higher degree of credibility.” – by Amanda Oldt

Disclosure: Brunoni reports receiving support from the following grants: 2013 NARSAD Young Investigator from the Brain & Behavior Research Foundation (Grant Number 20493), 2013 FAPESP Young Researcher from the São Paulo State Foundation (Grant Number 20911-5), and National Council for Scientific and Technological Development (CNPq, Grant Number 470904) and receiving a research fellowship award from CNPq (303197). Please see the study for a full list of relevant financial disclosures.