Transcranial Magnetic Stimulation

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March 2017. The growing availability of repetitive transcranial magnetic stimulation (rTMS) in clinical practice has generated widespread interest in its use. Approved by the Food and Drug Administration in 2008 for patients with major depression who have not responded to at least 1 adequate trial of antidepressant medication, rTMS is being sought by patients and families as a noninvasive treatment option with a reasonable safety profile. Insurance coverage for this treatment remains uneven, however, and the usual treatment course requires daily sessions for multiple weeks and may not be conveniently geographically accessible for many.
A quick survey of recent publications regarding rTMS reveals that its potential benefit as a treatment for many other conditions is being intensively studied. Conditions for which rTMS is being explored include attention-deficit/hyperactivity disorder, amyotrophic lateral sclerosis, anorexia nervosa, fibromyalgia, multiple sclerosis, neuropathic pain, obsessive-compulsive disorder, Parkinson disease, schizophrenia (auditory hallucinations, cognitive functioning, negative symptoms), spinal cord injury, stroke (post-stroke motor recovery), and others. Given this broad scope of interest, it is not surprising that some critics view rTMS as the latest “magical elixir, good for all ailments.” It is extremely important, therefore, to stay focused on the evidence and on careful, thoughtful clinical observations on its use, while recognizing that, as a little-understood nonspecific brain intervention, rTMS could well be beneficial for a number of brain disorders.
In this issue of the Journal, Rachid and colleagues report on the use of rTMS for patients with unipolar or bipolar depression in a private practice setting. One goal of this study was to examine the effectiveness of rTMS for patients with treatment-resistant depression in a “real world” clinical setting where stringent exclusion criteria, necessary in randomized controlled efficacy trials, do not apply. The authors found that, although the study involved a relatively small sample, 50% of the participants showed favorable response to the treatment, and 41% of the participants achieved remission.
Among the infrequent adverse effects that can develop in the course of depression treatment is the potential induction of manic or hypomanic episodes, described in patients receiving antidepressant medications. Also in this issue of the Journal, Rachid reports the results of a Medline search focused on treatment-emergent mania or hypomania during the course of rTMS. Although it is unclear how often, if at all, this development is caused by rTMS, 15 studies were identified reporting patients who developed manic or hypomanic symptoms in the course of rTMS treatment. The author advises clinicians to be on the alert for this complication—one that is infrequent but that can be minimized if identified rapidly.
Finally, 2 case presentations in this issue’s “Clinical Case Discussion” section focus on another potential use of rTMS, to treat patients with depersonalization disorder. Karris and colleagues present a case of a patient with major depressive disorder and depersonalization disorder who had not responded well to standard antidepressant treatment, who showed improvement after a course of rTMS. A second case is presented by Rachid, of a patient who, similarly, had developed both depressive and depersonalization symptoms who responded to treatment with rTMS. In both cases, improvement occurred in both the depressive and the depersonalization symptoms. As pointed out in the Commentary by guest discussant Joshua Berman, we may be grappling with various patterns of “neural circuit dysfunction,” which some patients with different clinical syndromes may have in common.
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