Improving the antidepressant efficacy of transcranial magnetic stimulation: maximizing the number of stimulations and treatment location in treatment-resistant depression


  • The authors disclose the following financial relationships within the past 3 years: Following a competitive bid and request involving all TMS manufacturers at the time of trial initiation, Neuronetics Inc. was selected and loaned the TMS devices, head holders, and coils for the trial and allowed use of the safety Investigational Device Exemption for their device. Neuronetics did not provide any financial support for the study which was funded by the NIMH. Potential conflicts are reported over the past 3 years. Dr. McDonald is presently an unpaid consultant to NeoStim. Dr. Holtzheimer reports consulting fees from St. Jude Medical Neuromodulation, AvaCat Consulting, and Tetragenex, and is an unpaid consultant to NeoStim. Drs. McDonald and Holtzheimer are faculty at Emory University which holds a patent on TMS technology. Neither received royalties or is involved in the development or promotion of this patent. Dr. Lisanby reports research grants, speaking fees, or advisory board work with Neuronetics, Advanced Neuromodulatory Systems, Brainsway, and Cyberonics. Dr. Lisanby has a patent application with Columbia University on neuromodulation technology for which she receives no royalties or compensation. Dr. Avery has received research support from Neuronetics and Takeda, has been a consultant for Neuronetics and has been on the speaker's bureau for Eli Lilly, Takeda and Forest Pharmaceuticals. Dr. Nahas reports past and current research grants, speaking fees or consulting work with Cyberonics, Neuronetics, MECTA Corporation, and Medtronic. Dr. Nahas has acted as an unpaid consultant for Neuropace. Dr. Sackeim received consultant fees from MECTA Corporation and Cyberonics. Dr. George received consultant fees from PureTech Ventures and reports research grants, speaking fees, or advisory work with Brainsway, Mecta Corporation, Neuronetics, Cephos, NeoStim and NeoSync, Brainsonix, Cyberonics, and Cephos. Dr. George is faculty at MUSC which has two patent applications in Dr. George's name combining MRI and TMS.


Objective: To assess the efficacy of increasing the number of fast left repetitive transcranial magnetic stimulations (rTMS) (10 Hz @ 120% of motor threshold (MT) over the left dorsolateral prefrontal cortex (DLPFC)) needed to achieve remission in treatment-resistant depression (TRD). And, to determine if patients who do not remit to fast left will remit using slow right rTMS (1 Hz @ 120% MT over the right DLPFC). Method: Patients were part of a multicenter sham-controlled trial investigating the efficacy of fast left rTMS. Patients who failed to meet minimal response criteria in the sham-controlled study could enroll in this open fast left rTMS study for an additional 3–6 weeks. Patients who failed to remit to fast left could switch to slow right rTMS for up to 4 additional weeks. The final outcome measure was remission, defined as a HAM-D score of <3 or 2 consecutive HAM-D scores less than 10. Results: Forty-three of 141 (30.5%) patients who enrolled in the open phase study eventually met criteria for remission. Patients who remitted during fast left treatment received a mean of 26 active treatments (90,000 pulses). Twenty-six percent of patients who failed fast left remitted during slow right treatment. Conclusion: The total number of rTMS stimulations needed to achieve remission in TRD may be higher than is used in most studies. TRD patients who do not respond to fast left rTMS may remit to slow right rTMS or additional rTMS stimulations. Depression and Anxiety, 2011. © 2011 Wiley Periodicals, Inc.