rTMS or magnetic Brain stimulation is a new method to treat depression and has shown to be a good alternative to antidepressants. After more then 20 years of research and results from our clinic, this treatment seems very efficacious without adverse side effects. Transcranial Magnetic Stimulation (rTMS) is part of a new development in the treatment of psychiatric disorders, where more often treatments are more focal, localised and personalized. Besides rTMS other treatments such as Deep Brain Stimulation and EEG Biofeedback are also part of this new development; also referred to as Personalized Medicine. The primary goal of Personalized Medicine is to get the right treatment to the right person at the right time, leading to higher efficacies and fewer side effects. For more background information on Personalized Medicine also read our article in the Personalized Medicine section.
In December 2007 the results from a large-scale controlled study were published on the effects of rTMS treatment for depression in 300 patients. These were all treatment-resistive patients who did not respond to antidepressant medication. This study – published in Biological Psychiatry by O’Reardon and colleagues – demonstrated that rTMS is a safe and efficacious treatment for treatment resistive depression. Recently, Dennis Schutter (2008) from the University of Utrecht has published a meta-analysis where he concludes that rTMS in Depression is superior to sham and that the effects size is robust and comparable to at least a subset of commercially available antidepressant drug agents (Schutter, 2008: "These findings show that high-frequency rTMS over the left DLPFC is superior to sham in the treatment of depression. The effect size is robust and comparable to at least a subset of commercially available antidepressant drug agents...").
In the Brainclinics clinics in The Netherlands rTMS is provided in a practical setting and combined with psychotherapy. In this setting any client with depression is treated (so not only treatment resistive patients). The rTMS treatment is personalized for every client using their individual Quantative EEG or QEEG on the basis of which the stimulation site and stimulation frequency is chosen. Furthermore, the EEG is used to rule out contra-indications – such as paroxysmal activity and the presence of focal-beta spindles. Recently, our first clinical results as well as pre- and post-QEEG changes after rTMS treatment have been published in the EEG and Clinical Neuroscience journal (Spronk et al., 2008).
Read here the article: Een jaar rTMS behandeling bij depressie: De stand van zaken with the most recent results (in Dutch, summary in English).
The most recent results based on 108 patients with a primary diagnosis depression or dysthimia demonstrate that the combined rTMS-psychotherapy is efficacious for 77,8% of the patients within on average 20 treatment sessions (Efficacy is defined as >50% decrease in BDI score or full remission).
Furthermore, during these sessions no adverse side effects were reported and patients who did not respond to ECT (electroconvulsive therapy) are more likely to not respond to rTMS as well.
In comparison, Antidepressants such as Citalopram show full remission in maximum 33% of patients (Trivedie et al., 2006; STAR*D trial) and only 30-50% of clients respond well to Antidepressant medication.
From a first cohort of 49 patients the long-term follow-up results have also become available by means of 6 month follow-up. Of these 49 patients 36 were initially classified as a responder. From these, after 6 months 17 could still be classified a responder; 9 were in relapse and 1 still received maintenance sessions. Nine patients did not respond to the follow-up request or did not want to participate in the follow-up.
This results in an optimistic long-term efficacy estimate of 65% and a worst-case estimate of 47% (assuming all clients who did not participate in the follow-up showed a relapse). Also see the graph below with the BDI scores from this sub-group of responders with their follow-up data. After 6 months the group as a whole still demonstrated a 52% decrease of depressive symptoms as compared to intake.
The combination of rTMS and psychotherapy demonstrated for a majority of patients a sustained long-term effect. These results further underscore that the initial results cannot completely be explained by a placebo effect, since placebo efffects usually wear-out within 6 months.
The figure above shows the most recent results of a sub -group of depressive clients (responders) treated with QEEG based rTMS from whom follow-up results were available. The graph shows the Beck's Depression Inventory (BDI) score, which is a very often used questionnaire to assess the severity of depressive symptoms. This questionnaire was assessed every 5th session. The cut-off score is 13, so a score below 13 indicates the client is formally not depressed anymore. The graph below clearly shows that on average clients showed a ‘normal’ BDI score after 15 sessions.
Literature:
Martijn Arns (2008) Personalized Medicine: Nieuwe ontwikkelingen in de diagnostiek en behandeling van Depressie en ADHD. De Psycholoog, september 2008.
Spronk, D. & Arns, M. (2009). Rtms bij depressie. Tijdschrift Voor Neuropsychiatrie & Gedragsneurologie, (Juli-Augustus).
Spronk, D., Arns, M., Bootsma, A., van Ruth, R., & Fitzgerald, P. B. (2008). Long-Term effects of left frontal rtms on EEG and erps in patients with depression. Clinical EEG and Neuroscience : Official Journal of the EEG and Clinical Neuroscience Society (ENCS), 39(3), 118-24.
Schutter (2008) Antidepressant efficacy of high-frequency transcranial magnetic stimulation over the left dorsolateral prefrontal cortex in double-blind sham-controlled designs: a meta-analysis. Psychological Medicine, 1-11.
O'Reardon, J.P., Solvason, H.B., Janicak, P.G., Sampson, S., Isenberg, K.E., Nahas, Z., McDonald, W.M., Avery, D., Fitzgerald, P.B., Loo, C., Demitrack, M.A., George, M.S. & Sackeim (2007) Efficacy and Safety of Transcranial Magnetic Stimulation in the Acute Treatment of Major Depression: A Multisite Randomized Controlled Trial. Biological Psychiatry, 62: 1208-1216.
