Kfir Feffer1, Hyewon Helen Lee2, Farrokh Mansouri3, Peter Giacobbe4, Fidel Vila-Rodriguez5, Sidney H Kennedy6, Zafiris J Daskalakis7, Daniel M Blumberger7, Jonathan Downar8. 1. MRI-Guided rTMS Clinic, University Health Network, Toronto, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada; Shalvata Mental Health Center, Hod-Hasharon, Israel. 2. Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada. 3. Institute of Biomaterial and Biomedical Engineering, University of Toronto, Toronto, Canada. 4. MRI-Guided rTMS Clinic, University Health Network, Toronto, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada. 5. Non-invasive Neurostimulation Therapies Lab, UBC Hospital, Department of Psychiatry, University of British Columbia, Vancouver, Canada. 6. Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada; Li Ka-Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada. 7. Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada; Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Canada. 8. MRI-Guided rTMS Clinic, University Health Network, Toronto, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada; Krembil Research Institute, University Health Network, Toronto, Canada. Electronic address: jonathan.downar@uhn.ca.
Abstract
BACKGROUND: Predicting rTMS nonresponse could be helpful in sparing patients from futile treatment, and in improving use of limited rTMS resources. While several predictive biomarkers have been proposed, few are accurate for individual-level prediction; none have entered routine use. An alternative approach in pharmacotherapy predicts outcome from early response; patients showing minimal (e.g., ≤20%) improvement at 2 weeks can be predicted as nonresponders with negative predictive values (NPV) > 80-90%. This approach has recently been extended to ECT, but never before to rTMS. OBJECTIVE: To assess the accuracy of 2-week clinical response in predicting rTMS treatment outcome. METHODS: We reviewed clinical symptom scores for 101 patients who underwent 20 sessions of dorsomedial prefrontal rTMS for unipolar major depression in a naturalistic retrospective case series, defining nonresponders both at the conventional <50% improvement criterion and at a more stringent <35% criterion. RESULTS: Patients achieving <20% improvement at session 10 were correctly predicted as nonresponders with NPVs of 88.2% by the conventional and 80.4% by the stringent criterion. Achieving <10% improvement at session 10 predicted nonresponse with NPVs of 89.5% and 86.8% by conventional and stringent criteria, respectively. Using the least-depressed score of either session 5 or 10, <20% improvement predicted nonresponse with NPVs of 91.3% and 82.6%, and <10% improvement predicted nonresponse with NPVs of 93.5% and 93.5%, by conventional and stringent criteria. CONCLUSION: For DMPFC-rTMS, a '<20% improvement at 2 weeks' rule concurred with previous pharmacotherapy and ECT studies on predicting nonresponse, and could prove useful for treatment decision-making in clinical settings.
BACKGROUND: Predicting rTMS nonresponse could be helpful in sparing patients from futile treatment, and in improving use of limited rTMS resources. While several predictive biomarkers have been proposed, few are accurate for individual-level prediction; none have entered routine use. An alternative approach in pharmacotherapy predicts outcome from early response; patients showing minimal (e.g., ≤20%) improvement at 2 weeks can be predicted as nonresponders with negative predictive values (NPV) > 80-90%. This approach has recently been extended to ECT, but never before to rTMS. OBJECTIVE: To assess the accuracy of 2-week clinical response in predicting rTMS treatment outcome. METHODS: We reviewed clinical symptom scores for 101 patients who underwent 20 sessions of dorsomedial prefrontal rTMS for unipolar major depression in a naturalistic retrospective case series, defining nonresponders both at the conventional <50% improvement criterion and at a more stringent <35% criterion. RESULTS:Patients achieving <20% improvement at session 10 were correctly predicted as nonresponders with NPVs of 88.2% by the conventional and 80.4% by the stringent criterion. Achieving <10% improvement at session 10 predicted nonresponse with NPVs of 89.5% and 86.8% by conventional and stringent criteria, respectively. Using the least-depressed score of either session 5 or 10, <20% improvement predicted nonresponse with NPVs of 91.3% and 82.6%, and <10% improvement predicted nonresponse with NPVs of 93.5% and 93.5%, by conventional and stringent criteria. CONCLUSION: For DMPFC-rTMS, a '<20% improvement at 2 weeks' rule concurred with previous pharmacotherapy and ECT studies on predicting nonresponse, and could prove useful for treatment decision-making in clinical settings.
Authors: Lucas Borrione; Helena Bellini; Lais Boralli Razza; Ana G Avila; Chris Baeken; Anna-Katharine Brem; Geraldo Busatto; Andre F Carvalho; Adam Chekroud; Zafiris J Daskalakis; Zhi-De Deng; Jonathan Downar; Wagner Gattaz; Colleen Loo; Paulo A Lotufo; Maria da Graça M Martin; Shawn M McClintock; Jacinta O'Shea; Frank Padberg; Ives C Passos; Giovanni A Salum; Marie-Anne Vanderhasselt; Renerio Fraguas; Isabela Benseñor; Leandro Valiengo; Andre R Brunoni Journal: Braz J Psychiatry Date: 2020-03-16 Impact factor: 2.697