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A systematic review and meta-analysis on the efficacy and acceptability of bilateral repetitive transcranial magnetic stimulation (rTMS) for treating major depression

Published online by Cambridge University Press:  03 December 2012

M. T. Berlim ,
F. Van den Eynde  and
Z. J. Daskalakis
M. T. Berlim*
Affiliation:
Neuromodulation Research Clinic, Douglas Mental Health University Institute and McGill University, Montréal, Québec, Canada Depressive Disorders Program, Douglas Mental Health University Institute and McGill University, Montréal, Québec, Canada
F. Van den Eynde
Affiliation:
Neuromodulation Research Clinic, Douglas Mental Health University Institute and McGill University, Montréal, Québec, Canada
Z. J. Daskalakis
Affiliation:
Depressive Disorders Program, Douglas Mental Health University Institute and McGill University, Montréal, Québec, Canada
*
*Address for correspondence: M. T. Berlim, M.D., Douglas Mental Health University Institute, 6875 LaSalle Blvd, FBC-3 Pavilion, Montréal, Québec, Canada, H4H 1R3. (Email: [email protected])
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Abstract

Background

Bilateral repetitive magnetic stimulation (rTMS) is a promising novel therapeutic intervention for major depression (MD). However, clinical trials to date have reported conflicting evidence concerning its overall efficacy, which might have resulted from low statistical power. Thus, meta-analytical approaches could be useful in examining this issue by allowing the integration of findings from multiple studies and thus producing more accurate estimates of the treatment effect.

Method

We searched the literature for randomized, double-blind and sham-controlled trials (RCTs) on bilateral rTMS for treating MD from 1995 to July 2012 using EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, SCOPUS, and ProQuest Dissertations and Theses, and from October 2008 until May 2012 using Medline. The main outcome measures were response and remission rates. We used a random-effects model, odds ratios (ORs) and the number needed to treat.

Results

Data were obtained from seven RCTs, totaling 279 subjects with MD. After an average of 12.9 (s.d. = 2.7) sessions, 24.7% (40/162) and 6.8% (8/117) of subjects receiving active bilateral rTMS and sham rTMS were classified as responders [OR 4.3, 95% confidence interval (CI) 1.95–9.52, p < 0.0001]. Also, 19% (23/121) and 2.6% (2/77) of subjects were remitters following active bilateral rTMS and sham rTMS, respectively (OR 6.0, 95% CI 1.65–21.8, p = 0.006). No difference between baseline mean depression scores for the bilateral and sham rTMS groups was found, and the former was comparable with the latter in terms of drop-out rates at study end. Furthermore, we did not find significant differences efficacy- and acceptability-wise between active bilateral and unilateral rTMS at study end. Finally, heterogeneity between the included RCTs was not significant, and the risk of publication bias was found to be low.

Conclusions

Bilateral rTMS is a promising treatment for MD as it provides clinically meaningful benefits that are comparable with those of standard antidepressants and unilateral rTMS. Furthermore, bilateral rTMS seems to be an acceptable treatment for depressed subjects.

Keywords

Acceptabilitybilateral rTMSefficacymajor depressionmeta-analysistranscranial magnetic stimulation
Type
Review Article
Information
Psychological Medicine , Volume 43 , Issue 11 , November 2013 , pp. 2245 - 2254
Copyright
Copyright © Cambridge University Press 2012 

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References

Allan, CL, Herrmann, LL, Ebmeier, KP (2011). Transcranial magnetic stimulation in the management of mood disorders. Neuropsychobiology 64, 163–169.CrossRefGoogle ScholarPubMed
Arns, M, Drinkenburg, WH, Fitzgerald, PB, Kenemans, JL (2012). Neurophysiological predictors of non-response to rTMS in depression. Brain Stimulation 5, 569–576.CrossRefGoogle ScholarPubMed
Bajbouj, M, Lisanby, SH, Lang, UE, Danker-Hopfe, H, Heuser, I, Neu, P (2006). Evidence for impaired cortical inhibition in patients with unipolar major depression. Biological Psychiatry 59, 395–400.CrossRefGoogle ScholarPubMed
Berlim, MT, 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.CrossRefGoogle ScholarPubMed
Blumberger, DM, Mulsant, BH, Fitzgerald, PB, Rajji, TK, Ravindran, AV, Young, LT, Levinson, AJ, Daskalakis, ZJ (2012). A randomized double-blind sham-controlled comparison of unilateral and bilateral repetitive transcranial magnetic stimulation for treatment-resistant major depression. World Journal of Biological Psychiatry 13, 423–435.CrossRefGoogle ScholarPubMed
Borenstein, M, Hedges, LV, Higgins, JPT, Rothstein, HR (2009). Introduction to Meta-Analysis. John Wiley and Sons Ltd: Chichester.CrossRefGoogle Scholar
Burt, T, Lisanby, SH, Sackeim, HA (2002). Neuropsychiatric applications of transcranial magnetic stimulation: a meta analysis. International Journal of Neuropsychopharmacology 5, 73–103.CrossRefGoogle ScholarPubMed
Citrome, L (2011). Number needed to treat: what it is and what it isn't, and why every clinician should know how to calculate it. Journal of Clinical Psychiatry 72, 412–413.CrossRefGoogle Scholar
Cooper, H, Hedges, LV, Valentine, JC (2009). The Handbook of Research Synthesis and Meta-Analysis. Russell Sage Foundation Publications: New York.Google Scholar
Couturier, JL (2005). Efficacy of rapid-rate repetitive transcranial magnetic stimulation in the treatment of depression: a systematic review and meta-analysis. Journal of Psychiatry and Neuroscience 30, 83–90.Google ScholarPubMed
Daskalakis, ZJ, Levinson, AJ, Fitzgerald, PB (2008). Repetitive transcranial magnetic stimulation for major depressive disorder: a review [article in French]. Canadian Journal of Psychiatry 53, 555–566.CrossRefGoogle ScholarPubMed
Duval, S, Tweedie, R (2000). Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 56, 455–463.CrossRefGoogle ScholarPubMed
Egger, M, Davey Smith, G, Schneider, M, Minder, C (1997). Bias in meta-analysis detected by a simple, graphical test. British Medical Journal 315, 629–634.CrossRefGoogle ScholarPubMed
Fergusson, D, Aaron, SD, Guyatt, G, Hebert, P (2002). Post-randomisation exclusions: the intention to treat principle and excluding patients from analysis. British Medical Journal 325, 652–654.CrossRefGoogle ScholarPubMed
Fitzgerald, PB, Benitez, J, de Castella, A, Daskalakis, ZJ, Brown, TL, Kulkarni, J (2006 a). A randomized, controlled trial of sequential bilateral repetitive transcranial magnetic stimulation for treatment-resistant depression. American Journal of Psychiatry 163, 88–94.CrossRefGoogle ScholarPubMed
Fitzgerald, PB, Brown, TL, Daskalakis, ZJ (2002). The application of transcranial magnetic stimulation in psychiatry and neurosciences research. Acta Psychiatrica Scandinavica 105, 324–340.CrossRefGoogle ScholarPubMed
Fitzgerald, PB, Brown, TL, Marston, NA, Daskalakis, ZJ, De Castella, A, Kulkarni, J (2003). Transcranial magnetic stimulation in the treatment of depression: a double-blind, placebo-controlled trial. Archives of General Psychiatry 60, 1002–1008.CrossRefGoogle ScholarPubMed
Fitzgerald, PB, Hoy, K, Daskalakis, ZJ, Kulkarni, J (2009). A randomized trial of the anti-depressant effects of low- and high-frequency transcranial magnetic stimulation in treatment-resistant depression. Depression and Anxiety 26, 229–234.CrossRefGoogle ScholarPubMed
Fitzgerald, PB, Hoy, KE, Herring, SE, McQueen, S, Peachey, AV, Segrave, RA, Maller, J, Hall, P, Daskalakis, ZJ (2012). A double blind randomized trial of unilateral left and bilateral prefrontal cortex transcranial magnetic stimulation in treatment resistant major depression. Journal of Affective Disorders 139, 193–198.CrossRefGoogle ScholarPubMed
Fitzgerald, PB, Laird, AR, Maller, J, Daskalakis, ZJ (2008). A meta-analytic study of changes in brain activation in depression. Human Brain Mapping 29, 683–695.CrossRefGoogle ScholarPubMed
Fitzgerald, PB, Oxley, TJ, Laird, AR, Kulkarni, J, Egan, GF, Daskalakis, ZJ (2006 b). An analysis of functional neuroimaging studies of dorsolateral prefrontal cortical activity in depression. Psychiatry Research 148, 33–45.CrossRefGoogle ScholarPubMed
Fregni, F, Pascual-Leone, A (2007). Technology insight: noninvasive brain stimulation in neurology – perspectives on the therapeutic potential of rTMS and tDCS. Nature Clinical Practice. Neurology 3, 383–393.CrossRefGoogle ScholarPubMed
Garcia-Toro, M, Salva, J, Daumal, J, Andres, J, Romera, M, Lafau, O, Echevarria, M, Mestre, M, Bosch, C, Collado, C, Ibarra, O, Aguirre, I (2006). High (20-Hz) and low (1-Hz) frequency transcranial magnetic stimulation as adjuvant treatment in medication-resistant depression. Psychiatry Research 146, 53–57.CrossRefGoogle ScholarPubMed
George, MS, Aston-Jones, G (2010). Noninvasive techniques for probing neurocircuitry and treating illness: vagus nerve stimulation (VNS), transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS). Neuropsychopharmacology 35, 301–316.CrossRefGoogle ScholarPubMed
George, MS, Lisanby, SH, Avery, D, McDonald, WM, Durkalski, V, Pavlicova, M, Anderson, B, Nahas, Z, Bulow, P, Zarkowski, P, Holtzheimer, PE 3rd, Schwartz, T, Sackeim, HA (2010). Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Archives of General Psychiatry 67, 507–516.CrossRefGoogle ScholarPubMed
George, MS, Post, RM (2011). Daily left prefrontal repetitive transcranial magnetic stimulation for acute treatment of medication-resistant depression. American Journal of Psychiatry 168, 356–364.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
Hamilton, M (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry 23, 56–62.CrossRefGoogle ScholarPubMed
Herrmann, LL, Ebmeier, KP (2006). Factors modifying the efficacy of transcranial magnetic stimulation in the treatment of depression: a review. Journal of Clinical Psychiatry 67, 1870–1876.CrossRefGoogle ScholarPubMed
Higgins, JPT, Green, S (2008). Cochrane Handbook for Systematic Reviews of Interventions. John Wiley and Sons Ltd: Chichester.CrossRefGoogle Scholar
Huf, W, Kalcher, K, Pail, G, Friedrich, ME, Filzmoser, P, Kasper, S (2011). Meta-analysis: fact or fiction? How to interpret meta-analyses. World Journal of Biological Psychiatry 12, 188–200.CrossRefGoogle ScholarPubMed
Kimbrell, TA, Little, JT, Dunn, RT, Frye, MA, Greenberg, BD, Wassermann, EM, Repella, JD, Danielson, AL, Willis, MW, Benson, BE, Speer, AM, Osuch, E, George, MS, Post, RM (1999). Frequency dependence of antidepressant response to left prefrontal repetitive transcranial magnetic stimulation (rTMS) as a function of baseline cerebral glucose metabolism. Biological Psychiatry 46, 1603–1613.CrossRefGoogle ScholarPubMed
Kito, S, Hasegawa, T, Koga, Y (2011). Neuroanatomical correlates of therapeutic efficacy of low-frequency right prefrontal transcranial magnetic stimulation in treatment-resistant depression. Psychiatry and Clinical Neurosciences 65, 175–182.CrossRefGoogle ScholarPubMed
Kozel, FA, George, MS (2002). Meta-analysis of left prefrontal repetitive transcranial magnetic stimulation (rTMS) to treat depression. Journal of Psychiatric Practice 8, 270–275.CrossRefGoogle ScholarPubMed
Lam, RW, Chan, P, Wilkins-Ho, M, Yatham, LN (2008). Repetitive transcranial magnetic stimulation for treatment-resistant depression: a systematic review and metaanalysis. Canadian Journal of Psychiatry 53, 621–631.CrossRefGoogle ScholarPubMed
Loo, CK, Mitchell, PB, Croker, VM, Malhi, GS, Wen, W, Gandevia, SC, Sachdev, PS (2003). Double-blind controlled investigation of bilateral prefrontal transcranial magnetic stimulation for the treatment of resistant major depression. Psychological Medicine 33, 33–40.CrossRefGoogle ScholarPubMed
Marangell, LB, Martinez, M, Jurdi, RA, Zboyan, H (2007). Neurostimulation therapies in depression: a review of new modalities. Acta Psychiatrica Scandinavica 116, 174–181.CrossRefGoogle ScholarPubMed
Martin, JL, Barbanoj, MJ, Schlaepfer, TE, Clos, S, Perez, V, Kulisevsky, J, Gironell, A (2002). Transcranial magnetic stimulation for treating depression. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. no.: CD003493. doi:10.1002/14651858.CD003493.CrossRefGoogle Scholar
Martin, JL, Barbanoj, MJ, Schlaepfer, TE, Thompson, E, Perez, V, Kulisevsky, J (2003). Repetitive transcranial magnetic stimulation for the treatment of depression. Systematic review and meta-analysis. British Journal of Psychiatry 182, 480–491.CrossRefGoogle ScholarPubMed
Martinot, ML, Martinot, JL, Ringuenet, D, Galinowski, A, Gallarda, T, Bellivier, F, Lefaucheur, JP, Lemaitre, H, Artiges, E (2011). Baseline brain metabolism in resistant depression and response to transcranial magnetic stimulation. Neuropsychopharmacology 36, 2710–2719.CrossRefGoogle Scholar
Maxwell, SE, Kelley, K, Rausch, JR (2008). Sample size planning for statistical power and accuracy in parameter estimation. Annual Review of Psychology 59, 537–563.CrossRefGoogle ScholarPubMed
McDonald, WM, Easley, K, Byrd, EH, Holtzheimer, P, Tuohy, S, Woodard, JL, Beyer, K, Epstein, CM (2006). Combination rapid transcranial magnetic stimulation in treatment refractory depression. Neuropsychiatric Disease and Treatment 2, 85–94.Google ScholarPubMed
McNamara, B, Ray, JL, Arthurs, OJ, Boniface, S (2001). Transcranial magnetic stimulation for depression and other psychiatric disorders. Psychological Medicine 31, 1141–1146.CrossRefGoogle ScholarPubMed
Montgomery, SA, Asberg, M (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry 134, 382–389.CrossRefGoogle ScholarPubMed
Nierenberg, AA, Fava, M, Trivedi, MH, Wisniewski, SR, Thase, ME, McGrath, PJ, Alpert, JE, Warden, D, Luther, JF, Niederehe, G, Lebowitz, B, Shores-Wilson, K, Rush, AJ (2006). A comparison of lithium and T(3) augmentation following two failed medication treatments for depression: a STAR*D report. American Journal of Psychiatry 163, 1519–1530; quiz 1665.CrossRefGoogle Scholar
O'Reardon, JP, Solvason, HB, Janicak, PG, Sampson, S, Isenberg, KE, Nahas, Z, McDonald, WM, Avery, D, Fitzgerald, PB, Loo, C, Demitrack, MA, George, MS, Sackeim, HA (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.CrossRefGoogle ScholarPubMed
Pallanti, S, Bernardi, S, Di Rollo, A, Antonini, S, Quercioli, L (2010). Unilateral low frequency versus sequential bilateral repetitive transcranial magnetic stimulation: is simpler better for treatment of resistant depression? Neuroscience 167, 323–328.CrossRefGoogle ScholarPubMed
Riley, RD, Higgins, JP, Deeks, JJ (2011). Interpretation of random effects meta-analyses. British Medical Journal 342, d549.CrossRefGoogle ScholarPubMed
Rosa, MA, Lisanby, SH (2012). Somatic treatments for mood disorders. Neuropsychopharmacology 37, 102–116.CrossRefGoogle ScholarPubMed
Rossi, S, Hallett, M, Rossini, PM, Pascual-Leone, A (2009). Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clinical Neurophysiology 120, 2008–2039.CrossRefGoogle ScholarPubMed
Rossini, D, Lucca, A, Magri, L, Malaguti, A, Smeraldi, E, Colombo, C, Zanardi, R (2010). A symptom-specific analysis of the effect of high-frequency left or low-frequency right transcranial magnetic stimulation over the dorsolateral prefrontal cortex in major depression. Neuropsychobiology 62, 91–97.CrossRefGoogle ScholarPubMed
Rotenberg, VS (2008). Functional brain asymmetry as a determinative factor in the treatment of depression: theoretical implications. Progress in Neuro-Psychopharmacology and Biological Psychiatry 32, 1772–1777.CrossRefGoogle ScholarPubMed
Rothstein, HR, Sutton, AJ, Borenstein, M (2005). Publication Bias in Meta-Analysis: Prevention, Assessment and Adjustments. John Wiley and Sons Ltd: Chichester.CrossRefGoogle Scholar
Rush, AJ, Trivedi, MH, Wisniewski, SR, Nierenberg, AA, Stewart, JW, Warden, D, Niederehe, G, Thase, ME, Lavori, PW, Lebowitz, BD, McGrath, PJ, Rosenbaum, JF, Sackeim, HA, Kupfer, DJ, Luther, J, Fava, M (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.CrossRefGoogle ScholarPubMed
Salustri, C, Tecchio, F, Zappasodi, F, Bevacqua, G, Fontana, M, Ercolani, M, Milazzo, D, Squitti, R, Rossini, PM (2007). Cortical excitability and rest activity properties in patients with depression. Journal of Psychiatry and Neuroscience 32, 259–266.Google ScholarPubMed
Schonfeldt-Lecuona, C, Lefaucheur, JP, Cardenas-Morales, L, Wolf, RC, Kammer, T, Herwig, U (2010). The value of neuronavigated rTMS for the treatment of depression. Neurophysiologie Clinique 40, 37–43.CrossRefGoogle ScholarPubMed
Schutter, DJ (2009). 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 39, 65–75.CrossRefGoogle ScholarPubMed
Schutter, DJ (2010). Quantitative review of the efficacy of slow-frequency magnetic brain stimulation in major depressive disorder. Psychological Medicine 40, 1789–1795.CrossRefGoogle ScholarPubMed
Slotema, CW, Blom, JD, Hoek, HW, Sommer, IE (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, 873–884.CrossRefGoogle ScholarPubMed
Speer, AM, Benson, BE, Kimbrell, TK, Wassermann, EM, Willis, MW, Herscovitch, P, Post, RM (2009). Opposite effects of high and low frequency rTMS on mood in depressed patients: relationship to baseline cerebral activity on PET. Journal of Affective Disorders 115, 386–394.CrossRefGoogle ScholarPubMed
Undurraga, J, Baldessarini, RJ (2012). Randomized, placebo-controlled trials of antidepressants for acute major depression: thirty-year meta-analytic review. Neuropsychopharmacology 37, 851–864.CrossRefGoogle ScholarPubMed
Wassermann, EM, Zimmermann, T (2012). Transcranial magnetic brain stimulation: therapeutic promises and scientific gaps. Pharmacology and Therapeutics 133, 98–107.CrossRefGoogle ScholarPubMed
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