Repetitive Transcranial Magnetic Stimulation for Treatment Resistant Depression: A Systematic Review and Meta Analysis of Randomized Controlled Trials.
BACKGROUND To date, several randomized controlled trials (RCTs) have shown the efficacy of repetitive transcranial magnetic stimulation (rTMS) in the treatment of major depression. OBJECTIVE This analysis examined the antidepressant efficacy of rTMS in patients with treatment resistant unipolar depression. METHODS A literature search was performed for RCTs published from January 1, 1994, to November 20, 2014. The search was updated on March 1, 2015. Two independent reviewers evaluated the abstracts for inclusion, reviewed full texts of eligible studies, and abstracted data. Meta analyses were conducted to obtain summary estimates. The primary outcome was changes in depression scores measured by the Hamilton Rating Scale for Depression (HRSD) and we considered, a priori, the mean difference of 3.5 points to be a clinically important treatment effect. Remission and response to the treatment were secondary outcomes, and we calculated number needed to treat on the basis of these outcomes. We examined the possibility of publication bias by constructing funnel plots and by Begg's and Egger's tests. A meta regression was undertaken to examine the effect of specific rTMS technical parameters on the treatment effects. RESULTS Twenty three RCTs compared rTMS with sham, and six RCTs compared rTMS with electroconvulsive therapy (ECT) Trials of rTMS versus sham showed a statistically significant improvement in depression scores with rTMS (weighted mean difference [WMD] 2.31, 95% CI 1.19 3.43; P .001) This improvement was smaller than the pre specified clinically important treatment effect. There was a 10% absolute difference between rTMS and sham in the rates of remission or response. This translates to a number needed to treat of 10. Risk ratios for remission and response were 2.20 (95% CI 1.44 3.38, P .001 and 1.72 [95% CI] 1.13 2.62, P .01) respectively, favouring rTMS. No publication bias was detected. Trials of rTMS versus ECT showed a statistically and clinically significant difference between rTMS and ECT in favour of ECT (WMD 5.97, 95% CI 0.94 11.0, P .02) Risk ratios for remission and response were 1.44 (95% CI 0.64 3.23, P .38) and 1.72 (95% CI 0.95 3.11, P .07) respectively, favouring ECT. CONCLUSIONS Overall, the body of evidence favoured ECT for treatment of patients who are treatment resistant. Repetitive transcranial magnetic stimulation had a small short term effect for improving depression in comparison with sham, but follow up studies did not show that the small effect will continue for longer periods.
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