By Will Boggs MD
NEW YORK—Several nonsurgical brain-stimulation techniques are effective for treating major depressive episodes in adults, according to a systematic review and network meta-analysis.
"The finding that several of these treatments are highly effective in treating depressive symptoms is remarkable, considering that most patients receiving these treatments had not responded to multiple drug treatments," Julian Mutz from King's College London told Reuters Health by email.
Various nonsurgical brain-stimulation techniques have been used as tertiary treatments for major depressive episodes, including electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS) and magnetic seizure therapy. Little is known about their comparative efficacy and safety.
Mutz and colleagues used data from 113 randomized controlled trials (6,750 total participants) to estimate the efficacy and acceptability of nonsurgical brain stimulation for acute treatment of major depressive episodes.
Bitemporal ECT, high-frequency left rTMS, low-frequency right rTMS, tDCS and deep transcranial magnetic stimulation were all more efficacious than sham therapy across all outcomes, the team reports in The BMJ, online March 27.
The network meta-analysis confirmed the superiority of these approaches over sham therapy, along with high-dose right unilateral ECT, priming transcranial magnetic stimulation, magnetic seizure therapy, bilateral rTMS, bilateral theta-burst stimulation and intermittent theta-burst stimulation.
In the combined analysis of all approaches, the treatment protocols with the highest probabilities of being the most efficacious in terms of response were bitemporal ECT (37%) and priming transcranial magnetic stimulation (19%), and those with the highest probabilities of being the least efficacious were low-frequency left rTMS and continuous theta-burst stimulation (30% each).
In terms of patient acceptance, priming transcranial magnetic stimulation and bilateral theta-burst stimulation ranked highest, whereas low-frequency left rTMS and high-frequency right rTMS ranked lowest.
"We do not currently recommend these treatments as first choice for 'typical' patients with acute major depressive episodes," Mutz said. "Drug treatments, psychotherapy, or their combination should be tried first."
Once the decision has been made to try nonsurgical brain stimulation, he said, "for patients with severe depression who have not responded to drug treatments, bitemporal ECT, high-dose right unilateral ECT, and high-frequency left rTMS should be considered first."
"Treatment protocols with a more robust evidence base should be prioritized over novel protocols for which there is limited evidence," Mutz said. "In this study we did not examine specific undesired side effects. More systematic studies are needed. A project in which we systematically evaluate the cognitive effects of a broad range of nonsurgical brain stimulation techniques is currently ongoing."
Dr. Noah S. Philip from Alpert Medical School of Brown University and Providence VA Medical Center, in Rhode Island, who studies brain stimulation in the treatment of depression, told Reuters Health by email, "This meta-analysis provides continued support that non-invasive brain stimulation is efficacious for patients suffering from depression. It is a good reminder of the broader picture, where ECT remains the most effective option, although for patients who do not wish to pursue ECT, transcranial magnetic stimulation provides an efficacious option with a very good risk/benefit profile."
"Non-invasive brain stimulation works for depression; aside from ECT, all interventions provide decent efficacy with very few side effects," said Dr. Philip, who was not involved in the new work. "For those who pursue 'do no harm' these options provide a very attractive option compared to many existing pharmacological options."
Dr. Philip added, "Access to care and ease of implementation remain a major barrier to psychiatric care - even more so when considering non-invasive brain stimulation - and so our field needs to rise to the challenge of delivering novel interventions that can reliably target brain regions involved in depression and are also easy to deploy to the vast numbers of people suffering from depression."
Dr. Daniel Blumberger of the University of Toronto and Temerty Centre for Therapeutic Brain Intervention, in Canada, who has also investigated the use of several of these techniques for treating major depression, told Reuters Health by email, "All of the established treatments are effective to varying degrees. However, a meta-analysis like this does not take into consideration accessibility to procedures like ECT and the cognitive adverse effects which limit its use on a broader scale."
"Issues around risks and benefits to patients and cost-effectiveness from a healthcare system need to be considered," said Dr. Blumberger, who also did not participate in the study.
"Non-invasive brain stimulation treatment should be considered as integral parts of the treatment options for patients with depression," he concluded.
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