Theta burst stimulation noninferior to TMS in reducing depression symptoms

In older adults with treatment-resistant depression, bilateral theta burst stimulation was noninferior to standard bilateral repetitive transcranial magnetic stimulation in reducing symptoms, per a recently published study.

“Nonresponse to first-line antidepressant treatment in older adult patients contributes to diminished quality of life,” Daniel M. Blumberger, MD, of the Temerty Centre for Therapeutic Brain Intervention at the Centre for Addiction and Mental Health in Toronto, and colleagues wrote in JAMA Psychiatry. “As a result, treatment-resistant depression (TRD) in older adults has been identified as a priority area for research.”

Blumberger and fellow researchers sought to establish the effectiveness and tolerability of theta burst stimulation (TBS) compared with standard repetitive transcranial magnetic stimulation (rTMS) in older adults with TRD.

They initiated a randomized noninferiority trial with open treatment and blinded assessors, conducted at the Centre for Addiction and Mental Health in Toronto. The study included 172 outpatients aged 60 years and older with a diagnosis of depression, moderate severity, and nonresponse to one or more antidepressant trial of adequate dosage and duration or intolerance of two or more trials. Participants were randomized on a 1:1 basis to receive a 4-6-week course of either bilateral standard rTMS (n= 87) or TBS (n=85).

The primary outcome was change in Montgomery-Åsberg Depression Rating Scale. Secondary outcome measures including the 17-item Hamilton Rating Scale for Depression, the 16-item, self-reported Quick Inventory of Depressive Symptomatology, and dropout rates. A noninferiority margin of 2.75 points was used for the primary outcome. All participants who attained the primary completion point of 4 weeks were analyzed. 

Results showed that 85 (98%) participants in the rTMS group and 79 (93%) from the TBS group were assessed for the primary outcome, while tolerability was assessed in all participants. Mean Montgomery-Åsberg Depression Rating Scale total scores improved from 25.6(4.0) to 17.3(8.9) for rTMS and 25.7(4.7) to 15.8(9.1) for TBS (adjusted difference, 1.55; lower 95% CI, 0.67), establishing noninferiority for TBS. The all-cause dropout rates were relatively similar between groups (rTMS: two of 87 [2.3%]; TBS: six of 85 [7.1%]).

“Given both its effectiveness and excellent tolerability, bilateral rTMS or TBS could be considered at an earlier stage in the treatment algorithm for older adults with TRD,” Blumberger and colleagues wrote.