OJD  Vol.8 No.1 , February 2019
Repetitive Transcranial Magnetic Stimulation (rTMS) in Treatment Resistant Depression: Retrospective Data Analysis from Clinical Practice
Abstract: Objective: The aim of this paper is to present the service data results from a clinical repetitive Transcranial Magnetic Stimulation (rTMS) service treating treatment resistant depression (TRD). Methods: The study was a retrospective investigation of routinely collected data on patients receiving rTMS between 2015 and 2018. Measures used were the clinician-rated Clinical Global Impression (CGI) and Hamilton Depression Rating Scale (HAM-D), and patient rated Physical Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder 7 (GAD-7). The outcome data of 144 patients with TRD was analysed. The sample included patients with co-morbid psychiatric diagnosis. Results: Response and remission rates respectively were 34.6% and 20.6% for the HAM-D; 10% and 28.6% for the PHQ-9; 31% and 31.8% for the CGI; and 24.6% and 28.8% for GAD-7. Effect sizes were mostly medium (0.48, 0.27, 0.51, 0.43 respectively). GAD-7 reliable change improvement was 56.1% and PHQ-9 reliable change improvement was 40%. There was a medium positive correlation between anxiety (GAD-7) and depression recovery (HAM-D), r = 0.31, n = 46, p = 0.039, with lower pre-treatment anxiety associated with lower post-treatment HAM-D scores. Conclusions: TRD patients with low pre-treatment anxiety levels respond to treatment better than those with high pre-treatment anxiety. The results show that a clinical rTMS service can have a significant impact on symptoms of depression and anxiety in TRD. The findings support wider availability of rTMS as a treatment option for people with TRD.
Cite this paper: Griffiths, C. , da Silva, K. , De Vai, R. and O’Neill-Kerr, A. (2019) Repetitive Transcranial Magnetic Stimulation (rTMS) in Treatment Resistant Depression: Retrospective Data Analysis from Clinical Practice. Open Journal of Depression, 8, 16-28. doi: 10.4236/ojd.2019.81003.

[1]   Allan, C. L., Herrmann, L. L., & Ebmeier, K. P. (2011). Transcranial Magnetic Stimulation in the Management of Mood Disorders. Neuropsychobiology, 64, 163-169.

[2]   Bagby, R. M., Ryder, A. G., Schuller, D. R., & Marshall, M. B. (2004). The Hamilton Depression Rating Scale: Has the Gold Standard Become a Lead Weight? American Journal of Psychiatry, 161, 2163-2177.

[3]   Berlim, M. T., & Turecki, G. (2007). What Is the Meaning of Treatment Resistant/Refractory Major Depression (TRD)? A Systematic Review of Current Randomized Trials. European Neuropsychopharmacology, 17, 696-707.

[4]   Berlim, M. T., Van den Eynde, F., Tovar-Perdomo, S., & Daskalakis, Z. J. (2014). Response, Remission and Drop-Out Rates Following High-Frequency Repetitive Transcranial Magnetic Stimulation (rTMS) for Treating Major Depression: A Systematic Review and Meta-Analysis of Randomized, Double-Blind and Sham-Controlled Trials. Psychological Medicine, 44, 225-239.

[5]   Carpenter, L. L., Janicak, P. G., Aaronson, S. T., Boyadjis, T., Brock, D. G., Cook, I. A., Demitrack, M. A. et al. (2012). Transcranial Magnetic Stimulation (TMS) for Major Depression: A Multisite, Naturalistic, Observational Study of Acute Treatment Outcomes in Clinical Practice. Depression and Anxiety, 29, 587-596.

[6]   Ciobanu, C., Girard, M., Marin, B., Labrunie, A., & Malauzat, D. (2013). rTMS for Pharmacoresistant Major Depression in the Clinical Setting of a Psychiatric Hospital: Effectiveness and Effects of Age. Journal of Affective Disorders, 150, 677-681.

[7]   Conca, A., Swoboda, E., König, P., Koppi, S., Beraus, W., Künz, A., Weiß, P. et al. (2000). Clinical Impacts of Single Transcranial Magnetic Stimulations (sTMS) as an Add-on Therapy in Severely Depressed Patients under SSRI Treatment. Human Psychopharmacology: Clinical and Experimental, 15, 429-438.<429::AID-HUP227>3.0.CO;2-3

[8]   Connolly, K. R., Helmer, A., Cristancho, M. A., Cristancho, P., & O’Reardon, J. P. (2012). Effectiveness of Transcranial Magnetic Stimulation in Clinical Practice Post-FDA Approval in the United States: Results Observed with the First 100 Consecutive Cases of Depression at an Academic Medical Center. The Journal of Clinical Psychiatry, 73, e567-e573.

[9]   Dilkov, D., Hawken, E. R., Kaludiev, E., & Milev, R. (2017). Repetitive Transcranial Magnetic Stimulation of the Right Dorsal Lateral Prefrontal Cortex in the Treatment of Generalized Anxiety Disorder: A Randomized, Double-Blind Sham Controlled Clinical Trial. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 78, 61-65.

[10]   Flint, A. J., & Rifat, S. L. (1997). Anxious Depression in Elderly Patients: Response to Antidepressant Treatment. American Journal of Geriatric Psychiatry, 5, 107-115.

[11]   Food and Drug Administration (2011). Class II Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems—Guidance for Industry and FDA Staff. U.S. Department of Health and Human Service.

[12]   Forkmann, T., Scherer, A., Boecker, M., Pawelzik, M., Jostes, R., & Gauggel, S. (2011). The Clinical Global Impression Scale and the Influence of Patient or Staff Perspective on Outcome. BMC Psychiatry, 11, 83.

[13]   Galletly, C. A., Clarke, P., Carnell, B. L., & Gill, S. (2015). A Clinical Repetitive Transcranial Magnetic Stimulation Service in Australia: 6 Years on. Australian & New Zealand Journal of Psychiatry, 49, 1040-1047.

[14]   Greenberg, P. E., Fournier, A. A., Sisitsky, T., Pike, C. T., & Kessler, R. C. (2015). The Economic Burden of Adults with Major Depressive Disorder in the United States (2005 and 2010). The Journal of Clinical Psychiatry, 76, 155-162.

[15]   Griffiths, C. A., & Griffiths, L. J. (2015). Recovery and Reliable Change Rates for Patients Scoring Severe on Depression, Anxiety or Impaired Functioning in a Psychological Therapies Service: IAPT. Mental Health Review Journal, 20, 28-35.

[16]   Gross, M., Nakamura, L., Pascual-Leone, A., & Fregni, F. (2007). Has Repetitive Transcranial Magnetic Stimulation (rTMS) Treatment for Depression Improved? A Systematic Review and Meta-Analysis Comparing the Recent vs. the Earlier rTMS Studies. Acta Psychiatrica Scandinavica, 116, 165-173.

[17]   Guy, W. (1976). ECDEU Assessment Manual for Psychopharmacology (pp. 534-537). US Department of Health, and Welfare.

[18]   Gyani, A., Shafran, R., Layard, R., & Clark, D. M. (2013). Enhancing Recovery Rates: Lessons from Year One of IAPT. Behaviour Research and Therapy, 51, 597-606.

[19]   Hadley, D., Anderson, B. S., Borckardt, J. J., Arana, A., Li, X., Nahas, Z., & George, M. S. (2011). Safety, Tolerability, and Effectiveness of High Doses of Adjunctive Daily Left Prefrontal Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression in a Clinical Setting. The Journal of ECT, 27, 18-25.

[20]   Hamilton, M. (1960). A Rating Scale for Depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 56.

[21]   Hardy, S., Bastick, L., O’Neill-Kerr, A., Sabesan, P., Lankappa, S., & Palaniyappan, L. (2016). Transcranial Magnetic Stimulation in Clinical Practice. BJPsych Advances, 22, 373-379.

[22]   Health Quality Ontario (2016). Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Ontario Health Technology Assessment Series, 16, 1.

[23]   Herrmann, L. L., & Ebmeier, K. P. (2006). Factors Modifying the Efficacy of Transcranial Magnetic Stimulation in the Treatment of Depression: A Review. The Journal of Clinical Psychiatry, 67, 1870-1876.

[24]   Huynh, N. N., & McIntyre, R. S. (2008). What Are the Implications of the STAR* D Trial for Primary Care? A Review and Synthesis. Primary Care Companion to the Journal of clinical Psychiatry, 10, 91-96.

[25]   Jackson-Koku, G. (2016). Beck Depression Inventory. Occupational Medicine, 66, 174-175.

[26]   Jacobson, N. S., & Truax, P. (1991). Clinical Significance: A Statistical Approach to Defining Meaningful Change in Psychotherapy Research. Journal of Consulting and Clinical Psychology, 59, 12-19.

[27]   Janicak, P. G., & Dokucu, M. E. (2015). Transcranial Magnetic Stimulation for the Treatment of Major Depression. Neuropsychiatric Disease and Treatment, 11, 1549-1560.

[28]   Kaufman, J., & Charney, D. (2000). Comorbidity of Mood and Anxiety Disorders. Depression and Anxiety, 12, 69-76.<69::AID-DA9>3.0.CO;2-K

[29]   Kito, S., Fujita, K., & Koga, Y. (2008). Regional Cerebral Blood Flow Changes after Low-Frequency Transcranial Magnetic Stimulation of the Right Dorsolateral Prefrontal Cortex in Treatment-Resistant Depression. Neuropsychobiology, 58, 29-36.

[30]   Kozel, F. A., & George, M. S. (2002). Meta-Analysis of Left Prefrontal Repetitive Transcranial Magnetic Stimulation (rTMS) to Treat Depression. Journal of Psychiatric Practice, 8, 270-275.

[31]   Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a Brief Depression Severity Measure. Journal of General Internal Medicine, 16, 606-613.

[32]   Kroenke, K., Spitzer, R. L., Williams, J. B., Monahan, P. O., & Löwe, B. (2007). Anxiety Disorders in Primary Care: Prevalence, Impairment, Comorbidity, and Detection. Annals of Internal Medicine, 146, 317-325.

[33]   Lam, R. W., Chan, P., Wilkins-Ho, M., & Yatham, L. N. (2008). Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression: A Systematic Review and Meta-Analysis. The Canadian Journal of Psychiatry, 53, 621-631.

[34]   Möller, H. J. (2000). Rating Depressed Patients: Observer vs. Self-Assessment. European Psychiatry: The Journal of the Association of European Psychiatrists, 15, 160-172.

[35]   NICE (2015). Repetitive Transcranial Magnetic Stimulation for Depression. IPG542.

[36]   Pallanti, S., Cantisani, A., Grassi, G., Antonini, S., Cecchelli, C., Burian, J., Querciolo, L. et al. (2012). rTMS Age-Dependent Response in Treatment-Resistant Depressed Subjects: A Mini-Review. CNS Spectrum, 17, 24-30.

[37]   Razza, L. B., Moffa, A. H., Moreno, M. L., Carvalho, A. F., Padberg, F., Fregni, F., & Brunoni, A. R. (2018). A Systematic Review and Meta-Analysis on Placebo Response to Repetitive Transcranial Magnetic Stimulation for Depression Trials. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 81, 105-113.

[38]   Richards, D. A., & Borglin, G. (2011). Implementation of Psychological Therapies for Anxiety and Depression in Routine Practice: Two Year Prospective Cohort Study. Journal of Affective Disorders, 133, 51-60.

[39]   Rosenich, E., Gill, S., Clarke, P., Paterson, T., Hahn, L., & Galletly, C. (2018). Does rTMS Reduce Depressive Symptoms in Young People Who Have Not Responded to Antidepressants? Early Intervention in Psychiatry.

[40]   Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Nierenberg, A. A., Stewart, J. W., Warden, D., McGrath, P. J. et al. (2006). Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR* D Report. American Journal of Psychiatry, 163, 1905-1917.

[41]   Schutter, D. J. L. G. (2010). Quantitative Review of the Efficacy of Slow-Frequency Magnetic Brain Stimulation in Major Depressive Disorder. Psychological Medicine, 40, 1789-1795.

[42]   Slotema, C. W., Dirk Blom, J., Hoek, H. W., & Sommer, I. E. (2010). Should We Expand the Toolbox of Psychiatric Treatment Methods to Include Repetitive Transcranial Magnetic Stimulation (rTMS)? A Meta-Analysis of the Efficacy of rTMS in Psychiatric Disorders. Journal of Clinical Psychiatry, 71, 873.

[43]   Souery, D., Oswald, P., Massat, I., Bailer, U., Bollen, J., Demyttenaere, K., Zohar, J. et al. (2007). Clinical Factors Associated with Treatment Resistance in Major Depressive Disorder: Results from a European Multicenter Study. Journal of Clinical Psychiatry, 68, 1062-1070.

[44]   Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7. Archives of Internal Medicine, 166, 1092-1097.

[45]   Taylor, S. F., Bhati, M. T., Dubin, M. J., Hawkins, J. M., Lisanby, S. H., Morales, O., Watcharotone, K. et al. (2017). A Naturalistic, Multi-Site Study of Repetitive Transcranial Magnetic Stimulation Therapy for Depression. Journal of Affective Disorders, 208, 284-290.

[46]   Tsuzuki, D., Watanabe, H., Dan, I., & Taga, G. (2016). MinR 10/20 System: Quantitative and Reproducible Cranial Landmark Setting Method for MRI Based on Minimum Initial Reference Points. Journal of Neuroscience Methods, 264, 86-93.

[47]   Uher, R., Perlis, R. H., Placentino, A., Dernovsek, M. Z., Henigsberg, N., Mors, O., Farmer, A. et al. (2012). Self-Report and Clinician-Rated Measures of Depression Severity: Can One Replace the Other? Depression and Anxiety, 29, 1043-1049.

[48]   WHO (2017). Depression Fact Sheet.

[49]   Xie, J., Chen, J., & Wei, Q. (2013). Repetitive Transcranial Magnetic Stimulation versus Electroconvulsive Therapy for Major Depression: A Meta-Analysis of Stimulus Parameter Effects. Neurological Research, 35, 1084-1091.