Hard To Treat Depression Patients Recover Completely With Repetitive Transcranial Magnetic Stimulation (rTMS)
Data from the first ‘real-world’ treatment audit presented at The Royal College of Psychiatrists’ International Congress 2013 in Edinburgh show that 60% of patients with treatment-resistant depression achieved complete remission (patients report and show no symptoms) when treated with repetitive Transcranial Magnetic Stimulation (rTMS). These data are in-line with results reported in major treatment centres in the US and Canada.
Results from the ‘real-world’ audit of the first ten UK patients to be treated with rTMS at The London Psychiatry Centre, showed that six of the ten patients assessed achieved no anxiety or depression symptoms at the end of the treatment. Furthermore, one other patient responded to treatment as indicated by a 50% reduction in their depression score. All patients tolerated the treatments well with no significant side effects, with two subjects reporting an occasional mild headache, responding to paracetaomol.
Dr Rafael Euba, Consultant Psychiatrist at the Centre said, “These data reinforce the body of existing worldwide evidence for rTMS and its proven ability to treat depressed patients who have not responded to drug treatment and/or therapy.”
rTMS is a painless and non-invasive method of brain stimulation that relies on electromagnetic induction using an insulated coil placed over the scalp, focused on an area of the brain thought to play a role in mood regulation. Treatment with rTMS is licenced in the UK for adults with depression who have failed to achieve satisfactory improvement from two prior antidepressant medications, at or above the minimal effective dose and duration in the current episode. For these patients, rTMS provides an effective and pain-free alternative to experience relief from depression, without the side-effects that may be associated with more extreme or chemical alternatives.[3,4,5,6,7] Offered widely at high profile hospitals and centres in the US, including John Hopkins and Harvard’s McLean Hospital, The London Psychiatry Centre is the first and only clinic to offer rTMS treatment in the UK.
One of the patients who recently completed the four week treatment said, “The treatment shifted the way I approach problems and almost blocks my negative way of thinking. I feel like the person I used to be 30 years ago! I’ve got my brain back!” After two weeks of treatment, not only had the patient stopped taking her medication completely, she no longer felt the dread she woke up with every day and decided to start doing new things, feeling optimistic about her future.
Around one in ten people in the UK suffer from depression at some point in their lifetime, which is over six million people, a number equivalent to the entire population of Scotland. More frequently prescribed treatments don’t always work or are not suitable, plus their side-effects can cause weight gain, low sex drive and even heart problems. Up to 70% of people with depression will continue to experience symptoms despite taking medication and/or receiving psychotherapy. This is known as treatment-resistant depression, which is very common.
According to larger international clinical studies, one in two patients who were unresponsive to antidepressant medication experience a significant improvement in their depressive symptoms when treated with rTMS, while 1 in 3 experiences recovery. Patients with resistant depression treated with rTMS also benefited from a shorter recovery time of around 4 weeks. This compares to those trying alternative medications that would typically experience improvements in around 6-9 months, if recognised treatment protocols are followed.
A further 13 patients have been treated with rTMS since the audit presented recently, with all of them achieving complete remission within 4 weeks. An audit of all 23 patients treated showed that 78% of the patients treated at The London Psychiatry Centre with rTMS achieved complete remission, a further 9% improved but did not achieve remission and 13% did not improve.
Around one in ten people in the UK suffer needlessly from depression at some point in their lifetime and it is thought that a large number of people are still undiagnosed. The condition can impact every aspect of a person’s life including their ability to work, establish and maintain relationships and their overall quality of life. Depression has also been associated with an increased risk of cardiovascular disease, such as heart attack and stroke.[9,10,11,12]
rTMS is a non-invasive method of brain stimulation that relies on electromagnetic induction using an insulated coil placed over the scalp, focused on an area of the brain thought to play a role in mood regulation. The coil generates brief magnetic pulses, which pass easily and painlessly through the skull and into the brain. The pulses generated are comparable to those generated by magnetic resonance imaging (MRI) machines. When these pulses are administered in rapid succession, it is referred to as “repetitive TMS ” or “rTMS”, which can produce longer lasting changes in brain activity.4 Clinical studies have consistently shown that rTMS is effective in treatment- resistant depression,[6,14,15,16,17,18,19,20]. rTMS has been licensed in the UK to treat patients with depression who have not seen a satisfactory response to 2 antidepressants.
In comparison to more extreme alternatives such as electroconvulsive therapy (ECT), rTMS is considerably less invasive, has minimal side effects, and has proven to offer equivalent health benefits. rTMS is therefore seen as a safe middle step in people who do not respond to antidepressants, before considering ECT. In the US, rTMS is offered as a standard therapy in a number of high profile health clinics including John Hopkins and the Mayo Clinic.
rTMS treatment is well tolerated and non-invasive, requiring only five sessions per week for between two to six weeks, sometimes followed by maintenance or top-up treatment 6 -12 months later.[19,20] Patients also recover faster in around 4 weeks, compared to those who tried different forms of medication, who took between 6-9 months to see significant improvements. Patients don’t need to go to hospital to receive treatment with rTMS; the simple procedure is performed in an outpatient clinic.
1 Euba R, Poster presented at The Royal College of Psychiatrists’ International Congress 2013
2 George M, Taylor J, Baron Short E, The expanding evidence base for rTMS treatment of depression, Current Opinion Psychiatry, 2013,26:13-18
3 O’Reardon JP, Solvason HB, Janicak PG, et al.Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biol Psychiatry 2007; 62:1208–1216.
4 Demitrack MA, Thase ME. Clinical significance of transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistant depression: synthesis of recent data. Psychopharmacol Bull 2009; 42:5–38.
5 George MS, Lisanby SH, Avery D, et al. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Arch Gen Psychiatry 2010; 67:507–516.
6 McDonald WM, Durkalski V, Ball ER, et al.Improving the antidepressant efficacy of transcranial magnetic stimulation: maximizing the number of stimulations and treatment location in treatment-resistant depression. Depress Anxiety 2011; 28:973–980
7 Mantovani A, Pavlicova M, Avery D, et al.Long-term efficacy of repeated daily prefrontal transcranial magnetic stimulation (TMS) in treatment-resistant depression. Depress Anxiety 2012; 29:883–890
8 The London Psychiatry Centre data on file
9 Ludescher B, Machann J, Eschweiler GW, Thamer C, Maenz C, Hipp A, Claussen CD, & Schick F (2011). Active depression is associated with regional adiposity in the upper abdomen and the neck. International journal of psychiatry in medicine, 41 (3), 271-80 PMID: 22073766
10 Rubin RR, Gaussoin SA, Peyrot M, DiLillo V, Miller K, Wadden TA, West DS, Wing RR, Knowler WC, & Look AHEAD Research Group (2010). Cardiovascular disease risk factors, depression symptoms and antidepressant medicine use in the Look AHEAD (Action for Health in Diabetes) clinical trial of weight loss in diabetes. Diabetologia, 53 (8), 1581-9 PMID: 20422396
11 Rutledge T, Linke SE, Krantz DS, Johnson BD, Bittner V, Eastwood JA, Eteiba W, Pepine CJ, Vaccarino V, Francis J, Vido DA, & Merz CN (2009). Comorbid depression and anxiety symptoms as predictors of cardiovascular events: results from the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation (WISE) study. Psychosomatic medicine, 71 (9), 958-64 PMID: 19834049
12 Shah AJ, Veledar E, Hong Y, Bremner JD, & Vaccarino V (2011). Depression and history of attempted suicide as risk factors for heart disease mortality in young individuals. Archives of general psychiatry, 68 (11), 1135-42 PMID: 22065529
13 George M, Taylor J, Baron Short E, The expanding evidence base for rTMS treatment of depression, Current Opinion Psychiatry, 2013,26:13-18
14 Li CT, Wang SJ, Hirvonen J, et al. Antidepressant mechanism of add-on repetitive transcranial magnetic stimulation in medication-resistant depression using cerebral glucose metabolism. J Affect Disord. 2010, 127(1-3):219-29
15 Blumberger DM, Mulsant BH, Fitzgerald PB, et al. A randomized double-blind sham-controlled comparison of unilateral and bilateral repetitive transcranial magnetic stimulation for treatment-resistant major depression. World J Biol Psychiatry. 2012;13(6):423-35
16 Fitzgerald PB, Hoy K, Gunewardene R, et al. A randomized trial of unilateral and bilateral prefrontal cortex transcranial magnetic stimulation in treatment-resistant major depression. Psychol Med. 2010;41:1187-1196
17 Galletly C, Gill S, Clarke P, Burton C, Fitzgerald PB. A randomized trial comparing repetitive transcranial magnetic stimulation given 3 days/week and 5 days/week for the treatment of major depression: is efficacy related to the duration of treatment or the number of treatments? Psychol Med. Sep 13 2011:1-8.
18 Holtzheimer PE, 3rd, McDonald WM, Mufti M, et al. Accelerated repetitive transcranial magnetic stimulation for treatment-resistant depression. Depress Anxiety. Oct 2010;27(10):960-963.
19 Carpenter LL, Janicak PG, Aaronson ST, Boyadjis T, Brock DG, Cook IA, Dunner DL, Lanocha K, Solvason HB, Demitrack MA. Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depress Anxiety. 2012;29(7):587-96.
20 Connolly KR, Helmer A, Cristancho MA, Cristancho P, O’Reardon JP. 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. J Clin Psychiatry. 2012;73(4):e567-73.
21 Eranti S, Mogg, et al. A Randomized, Controlled Trial with 6-Month Follow-Up of Repetitive Transcranial Magnetic Stimulation and Electroconvulsive Therapy for Severe Depression”. American Journal of Psychiatry, 2007164 (1): 73–81
22 Coverage Policy Analysis: Repetitive Transcranial Magnetic Stimulation (rTMS), The New England Comparative Effectiveness Public Advisory Council, completed by: The Institute for Clinical and Economic Review. June 2012