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TMS Should Be Considered as First-Line Treatment for Moderate to Severe Major Depressive Disorder

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After incorporating transcranial magnetic stimulation (TMS) into my practice back in 2009, I anxiously awaited the release of APA’s Practice Guideline for the Treatment of Patients With Major Depressive Disorder, which was published in 2010. I was concerned that the guideline would not mention TMS. The work group reviewed more than 13,000 articles published between 1999 (when the search from the previous edition ended) and 2006. The pivotal trial that led to the initial FDA clearance for TMS in October 2008 was published in the December 1, 2007, issue of Biological Psychiatry.

To my surprise, not only was TMS mentioned but a number of key guideline changes included recommendations for the following:

  • Psychiatrists should present patients with information concerning the evidence for a broad range of treatment options, including somatic therapies and psychosocial interventions.

  • Psychiatrists should use a clinician- and/or patient-administered rating scale for psychiatric symptoms to help with treatment strategies.

  • ECT is indicated for treatment-resistant depression, but monoamine oxidase inhibitors, TMS, and vagus nerve stimulation are other potential options.

  • Maintenance treatment should be considered after the continuation phase, especially for patients at risk for recurrence.

  • There is currently insufficient evidence to support the use of TMS in the initial treatment of major depressive disorder.

As I read the guidelines recently and considered the number of new outcome studies conducted with TMS, I believe TMS should be considered in addition to pharmacotherapy and psychotherapy as a first-line treatment for patients with moderate to severe major depressive disorder.

Table: TMS Outcomes as First-Line Treatment for Nonpsychotic Major Depression

There are a few key publications that highlight the growth in TMS over the last 10 years (see table). A relatively new systematic qualitative analysis published January 8, 2019, in BMJ Psychiatry indicates the sooner treatment-naïve patients start TMS in the current depressive episode, the better the outcome. Ten articles were included in the analysis (six high grade and four lower grade) that demonstrated a 95% response rate and 63% remission rate in subjects who received TMS as a first-line treatment in the current episode. Furthermore, discontinuation rates are lower with TMS compared with pharmacotherapy, and TMS has no systemic side effects such as weight gain, premature diabetes, and sexual side effects. TMS is cost-effective and leads to higher adjusted quality-adjusted life years.

Given the evidence, it may be considered unethical to not discuss TMS as a treatment option for patients who are treatment naïve or who have failed one antidepressant in the current episode. As ambassadors for recovery, psychiatrists should present patients with information concerning the evidence for a broad range of treatment options, including somatic therapies and psychosocial interventions. ■



John A. Rush et al. “Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report

David L. Dunner et al. “A Multisite, Naturalistic, Observational Study Of Transcranial Magnetic Stimulation for Patients With Pharmacoresistant Major Depressive Disorder: Durability of Benefit Over a 1-Year Follow-up Period

Jeffrey Voigt et al. “A Systematic Literature Review of the Clinical Efficacy of Repetitive Transcranial Magnetic Stimulation (rTMS) in Non-Treatment Resistant Patients With Major Depressive Disorder

1200 630 Taylor Carter