In the Journals

Brain stimulation therapy effective in veterans with major depression

Almost 40% of veterans with major depressive disorder who were previously treatment-resistant achieved symptom remission with repetitive transcranial magnetic stimulation, data published in JAMA Psychiatry showed.

“New [treatment-resistant MDD] treatments are needed, preferably without major safety concerns or adverse effects as seen with aggressive polypharmacy or [electroconvulsive therapy],” Jerome A. Yesavage, MD, of the department of psychiatry and behavioral sciences, Stanford University School of Medicine, and colleagues wrote. "There is the potential for a significant advance in Veterans Affairs mental health care, with associated cost savings, if [repetitive transcranial magnetic stimulation] were to be shown as effective in the treatment of [treatment-resistant MDD] in VA patients.”

At nine VA medical centers, researchers conducted a double-blind, sham-controlled randomized clinical trial to examine the efficacy of repetitive transcranial magnetic stimulation (rTMS) in treating 164 veterans with treatment-resistant major depression.

Patients were randomly allocated to receive left prefrontal rTMS treatment (10 Hz, 120% motor threshold, 4,000 pulses/session) or sham (control) rTMS treatment for up to 30 sessions. After treatment, the investigators measured the remission rate using the Hamilton Rating Scale for Depression. They also conducted secondary analyses on other indicators of PTSD, depression, hopelessness, suicidality and quality of life.

The results showed that rTMS was safe, effective and well-tolerated in veterans with treatment-resistant MDD. Of 164 participants, 81 received active rTMS and 83 received sham treatment.

Analysis revealed no significant differences in depressive symptom remission rates between the two treatments (OR = 1.16; 95% CI, 0.59-2.26), with 40.7% of veterans in the active treatment group achieving depressive symptom remission, compared with 37.4% of those in the sham treatment group at the end of treatment. Overall, 64 of 164 (39%) participants achieved remission by the end of acute treatment. Almost 50% (16 of 33) of active rTMS participants with acute remission remained in remission 24 weeks later, as did about 42% (13 of 31) of those in the sham group.

“Achieving remission rates of 40% and over in treatment-resistant veterans is a clinically meaningful result warranting evaluation of such comprehensive approaches to treatment of patients with difficult-to-treat MDD within the VA,” the authors wrote. “Future work with rTMS may show an enhanced effect when newer coil models, better stimulus targeting, biological markers of response, higher frequency rates of stimulation, and longer duration of treatment are implemented.”

Though this study offers important information, it does not completely determine the best role for rTMS for veterans with treatment-resistant major depression, Charles B. Nemeroff, MD, PhD, department of psychiatry and behavioral sciences, Miller School of Medicine, University of Miami, wrote in a related comment.

“As personalized medicine in psychiatry progresses, we will likely someday soon be able to accurately identify the best treatment for individual patients,” Nemeroff wrote. “This will likely involve both genomic markers as well as functional brain imaging predictors of response.” – by Savannah Demko

Disclosures: Yesavage reports no relevant financial disclosures. Please see the study for other authors’ relevant financial disclosures. Nemeroff reports various ties with and support from pharmaceutical companies. Please see the full editorial for all relevant financial disclosures.

Almost 40% of veterans with major depressive disorder who were previously treatment-resistant achieved symptom remission with repetitive transcranial magnetic stimulation, data published in JAMA Psychiatry showed.

“New [treatment-resistant MDD] treatments are needed, preferably without major safety concerns or adverse effects as seen with aggressive polypharmacy or [electroconvulsive therapy],” Jerome A. Yesavage, MD, of the department of psychiatry and behavioral sciences, Stanford University School of Medicine, and colleagues wrote. "There is the potential for a significant advance in Veterans Affairs mental health care, with associated cost savings, if [repetitive transcranial magnetic stimulation] were to be shown as effective in the treatment of [treatment-resistant MDD] in VA patients.”

At nine VA medical centers, researchers conducted a double-blind, sham-controlled randomized clinical trial to examine the efficacy of repetitive transcranial magnetic stimulation (rTMS) in treating 164 veterans with treatment-resistant major depression.

Patients were randomly allocated to receive left prefrontal rTMS treatment (10 Hz, 120% motor threshold, 4,000 pulses/session) or sham (control) rTMS treatment for up to 30 sessions. After treatment, the investigators measured the remission rate using the Hamilton Rating Scale for Depression. They also conducted secondary analyses on other indicators of PTSD, depression, hopelessness, suicidality and quality of life.

The results showed that rTMS was safe, effective and well-tolerated in veterans with treatment-resistant MDD. Of 164 participants, 81 received active rTMS and 83 received sham treatment.

Analysis revealed no significant differences in depressive symptom remission rates between the two treatments (OR = 1.16; 95% CI, 0.59-2.26), with 40.7% of veterans in the active treatment group achieving depressive symptom remission, compared with 37.4% of those in the sham treatment group at the end of treatment. Overall, 64 of 164 (39%) participants achieved remission by the end of acute treatment. Almost 50% (16 of 33) of active rTMS participants with acute remission remained in remission 24 weeks later, as did about 42% (13 of 31) of those in the sham group.

“Achieving remission rates of 40% and over in treatment-resistant veterans is a clinically meaningful result warranting evaluation of such comprehensive approaches to treatment of patients with difficult-to-treat MDD within the VA,” the authors wrote. “Future work with rTMS may show an enhanced effect when newer coil models, better stimulus targeting, biological markers of response, higher frequency rates of stimulation, and longer duration of treatment are implemented.”

Though this study offers important information, it does not completely determine the best role for rTMS for veterans with treatment-resistant major depression, Charles B. Nemeroff, MD, PhD, department of psychiatry and behavioral sciences, Miller School of Medicine, University of Miami, wrote in a related comment.

“As personalized medicine in psychiatry progresses, we will likely someday soon be able to accurately identify the best treatment for individual patients,” Nemeroff wrote. “This will likely involve both genomic markers as well as functional brain imaging predictors of response.” – by Savannah Demko

Disclosures: Yesavage reports no relevant financial disclosures. Please see the study for other authors’ relevant financial disclosures. Nemeroff reports various ties with and support from pharmaceutical companies. Please see the full editorial for all relevant financial disclosures.