​​​​​​​Magnetic stimulation good alternative in treatment resistant depression Treatment guideline for depression has been updated

If two or more different drugs for depression do not work, treatment with magnetic stimulation gives better results than a new drug switch, according to research published by Radboudumc and partners in the American Journal of Psychiatry.

Worldwide, nearly three hundred million people struggle with major depression. Two thirds of them respond well to treatment with pills and talking (pharmacotherapy and psychotherapy), but a significant part doesn’t improve after one or more antidepressants. Moreover, the chances that a third or fourth drug will work in this group of patients are getting smaller and smaller. Therefore, researcher Iris Dalhuisen and psychiatrists Indira Tendolkar and Philip van Eijndhoven of Radboudumc and Dutch colleagues analyzed whether magnetic brain stimulation (rTMS) could be a good alternative in such cases.

Outpatient treatment

"In about a hundred treatment-resistant patients we compared the effect of yet another antidepressant with the effect of rTMS, in both cases combined with psychotherapy," Dalhuisen says. "With rTMS, the patient receives 8 weeks of outpatient treatment lasting about half an hour. A total of 25 treatments are involved, four times a week in the beginning, twice at the end. With a magnet, we stimulate a specific brain area, involved in emotions and cognitive control that plays a role in depression. People with depression have somewhat abnormal activity there. By stimulating this specific location, we also activate the underlying brain network that’s part of it."

rTMS more effective than medication switch

In the Netherlands, rTMS has been reimbursed for somewhat more severe depression since 2017. However a good comparison with the use of a third or fourth antidepressant had not been carried out before. Dalhuisen: "Whether and when to use rTMS was not clear. Sometimes it is used fairly quickly, but often not at all. If various medications don't work, electroconvulsive therapy, called ECT for short, can eventually be tried. In our research with several institutions, we now show that rTMS in treatment-resistant depression is much more effective than the usual medication switch. Less than 15 percent benefit from a third or fourth medication switch, and in only 5 percent do we see the depression diminish or disappear. When we look at rTMS, we find nearly 40 percent benefit from it and depression diminishes or disappears in over a quarter."

Included in guideline

The results of this study, published in the American Journal of Psychiatry are consistent with the recently updated edition of the Dutch guideline for the treatment of depression, in which rTMS has now officially been given a place. Rightly so, according to Dalhuisen, who also has an eye for possible other factors that may influence the positive results. "Possibly a small part of the positive results can be attributed to the placebo effect, where the extra attention can already improve the condition. And the fact that people have to visit a hospital or mental health institution with some regularity for treatment may as well have a positive, activating effect. But these are small effects and disappear quickly. On the contrary, we see major effects, which also last a long time. That's because rTMS leads to neurological changes, which actually affect depressive symptoms. It doesn't mean the depression is gone and cured for good, but when there is a relapse, we often get positive results with an rTMS boost or maintenance dose."

Toolbox

With rTMS added to the guideline, the toolbox for addressing depression has been filled a little further. Other treatments may eventually follow. For example, several hospitals are currently investigating the use of esketamine as a potential treatment. Dalhuisen: "The department of psychiatry at Radboudumc is one of the institutions researching this. And fairly recently the effects of psilocybin are also being looked at. But because of the positive results from our research, it’s important now to make responsible use of rTMS available to patients through education and information. Something promoted by, among others, the Brain Stimulation Foundation.”
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Paper in American Journal of Psychiatry: rTMS as a next step in antidepressant non-responders: a randomized comparison with current antidepressant treatment approaches - Iris Dalhuisen, Iris van Oostrom, Jan Spijker, Ben Wijnen, Eric van Exel, Hans van Mierlo, Dieuwertje de Waardt, Martijn Arns, Indira Tendolkar & Philip van Eijndhoven

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