Repetitive Transcranial Magnetic Stimulation in Psychiatry Practice

SOURCE: Psychiatry and Clinical Psychopharmacology. Conference: 11th International Congress on Psychopharmacology and 7th International Symposium on Child and Adolescent Psychopharmacology. Antalya Turkey. 29(Supplement 1) (pp 318-319), 2019



ABSTRACT: Repetitive transcranial magnetic stimulation (rTMS) is used in treatment of major depressive disorder and a series of neuropsychiatric diseases as per approved by FDA. rTMS is used in clinical pictures such as obsessive-compulsive disorder, auditory hallucinations of schizophrenia, posttraumatic stress disorder, panic disorder, tinnitus, dystonia, stroke, and migraine. However, it is most commonly accepted to be used in depression and obsessive-compulsive disorder. The treatment is recommended to be used in depression and obsessive-compulsive disorder for which no benefit has been obtained from a series of treatment modalities as advised by both FDA and companies which sale the device. Since the treatment has been accepted as an affective and reliable modality by FDA and NICE, its capability of being offered as a primary care has also been brought into question. Although rTMS is a modality preferred in cases which are resistant to pharmacologic treatment, evaluation of response to rTMS in those patients is considered biased by some researchers. Response to treatment is 95% in patients with untreated first attack depression, while 63% is in remission [Citation1]. Only 20 to 40 % of the patients with depression who receive proper pharmacotherapy and psychotherapy are reported to be in complete remission [Citation2,Citation3]. This ratio is found to be 28 to 33% in STAR*D study [Citation4]. When response to treatment is evaluated from this perspective, rTMS seems not to be less effective than other pharmacologic agents. In STAR*D study, the remission ratios reached after drug changes and empowerment strategies in the tertiary care, are reported to be 13 to 14% [Citation5]. Regarding response to treatment in rTMS 36.6% remission after one to two failed medication therapies and; 28.9% remission after 3-4 failed medication therapies are reported [Citation6]. All these facts encourage researchers that this treatment should be considered one of the primary care. The term “treatment resistant depression” is used in a certain way for rTMS
treatment by some researchers. Its efficiency is tried to be revealed through clinical studies which failed in 1 to 4 pharmacologic treatments. This idea suggests that rTMS should not be one of the primary care options unless a medical requisite is in place such as pregnancy or breastfeeding. General opinion is psychiatry practice is observed to be in this direction. Age is the prominent factor in the predictors of response to rTMS treatment. The reason for this can be cerebral plasticity and excitability of the cerebral tissue which change with the age. Particularly BDNF studies are supportive of this hypothesis. According to some researchers, cognitive-affective symptoms in patients with depression demonstrate a better recovery than somatic symptoms. However, it seems
contradictory to those findings that somatic symptoms in some patients with some diseases other than depression, such as panic disorder, psychotic disorder and bipolar disorder, shows recovery with rTMS. Depressive mood, guilt, sleep disorders and less severe depression are assessed to be important response predictors [Citation7,Citation8]. When both, debates on treatment priority of rTMS and debates on predictors of response to treatment, are considered as a whole, two results can be concluded on the priority of rTMS in psychiatric diseases; one is the patients who cannot receive pharmacologic treatment, and the other one is the patients’ treatment resistant symptoms, such as somatic symptoms.