Jonathan C Lee1, Andrew C Wilson2, Juliana Corlier2, Reza Tadayonnejad3, Katharine G Marder2, Christopher M Pleman2, David E Krantz2, Scott A Wilke2, Jennifer G Levitt2, Nathaniel D Ginder4, Andrew F Leuchter2. 1. TMS Clinical and Research Service, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior, and the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, 760 Westwood Plaza, Los Angeles, CA 90024, United States.. Electronic address: JonathanCLee@mednet.ucla.edu. 2. TMS Clinical and Research Service, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior, and the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, 760 Westwood Plaza, Los Angeles, CA 90024, United States. 3. TMS Clinical and Research Service, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior, and the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, 760 Westwood Plaza, Los Angeles, CA 90024, United States.; California Institute of Technology, Division of the Humanities and Social Sciences, 1200 E California Blvd, Pasadena, CA, 91125, United States. 4. TMS Clinical and Research Service, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior, and the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, 760 Westwood Plaza, Los Angeles, CA 90024, United States.; VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA 90073, United States.
Abstract
BACKGROUND: Repetitive Transcranial Magnetic Stimulation (rTMS) is an effective intervention for treatment-resistant Major Depressive Disorder (MDD). Early improvement during high-frequency left-sided (HFL) stimulation of the dorsolateral prefrontal cortex (DLPFC) is an important predictor of longer-term outcome, but most patients benefit later in their treatment course. We examined patients without early improvement with HFL to determine whether augmentation with additional stimulation approaches improved treatment outcome. METHODS: 139 participants received HFL in a measurement-based care paradigm. Participants who achieved < 20% improvement by treatment 10 could continue with HFL (N = 17) or receive one of two augmentation strategies: bilateral stimulation (BL; HFL followed by low-frequency stimulation of right DLPFC) (N = 69) or intermittent theta-burst priming of left DLPFC (iTBS-P) (N = 17) for their remaining treatment sessions. The primary outcome was the percent reduction in depressive symptoms at treatment 30. RESULTS: Participants who achieved < 20% improvement by treatment 10 and continued with HFL showed limited benefit. iTBS-P participants had significantly greater improvement, while those receiving BL trended toward improved outcomes. Ten sessions of either augmentation strategy appeared necessary to determine the likelihood of benefit. CONCLUSIONS: Augmentation of early non-response to HFL appears to improve rTMS outcomes, with a novel iTBS-P strategy surpassing both continued HFL or BL treatment in participants with < 20% improvement after 10 treatments. These findings suggest that measurement-based care with addition of augmented stimulation for those not showing early improvement may yield superior rTMS treatment outcomes. Published by Elsevier B.V.
BACKGROUND: Repetitive Transcranial Magnetic Stimulation (rTMS) is an effective intervention for treatment-resistant Major Depressive Disorder (MDD). Early improvement during high-frequency left-sided (HFL) stimulation of the dorsolateral prefrontal cortex (DLPFC) is an important predictor of longer-term outcome, but most patients benefit later in their treatment course. We examined patients without early improvement with HFL to determine whether augmentation with additional stimulation approaches improved treatment outcome. METHODS: 139 participants received HFL in a measurement-based care paradigm. Participants who achieved < 20% improvement by treatment 10 could continue with HFL (N = 17) or receive one of two augmentation strategies: bilateral stimulation (BL; HFL followed by low-frequency stimulation of right DLPFC) (N = 69) or intermittent theta-burst priming of left DLPFC (iTBS-P) (N = 17) for their remaining treatment sessions. The primary outcome was the percent reduction in depressive symptoms at treatment 30. RESULTS:Participants who achieved < 20% improvement by treatment 10 and continued with HFL showed limited benefit. iTBS-Pparticipants had significantly greater improvement, while those receiving BL trended toward improved outcomes. Ten sessions of either augmentation strategy appeared necessary to determine the likelihood of benefit. CONCLUSIONS: Augmentation of early non-response to HFL appears to improve rTMS outcomes, with a novel iTBS-P strategy surpassing both continued HFL or BL treatment in participants with < 20% improvement after 10 treatments. These findings suggest that measurement-based care with addition of augmented stimulation for those not showing early improvement may yield superior rTMS treatment outcomes. Published by Elsevier B.V.
Entities:
Keywords:
Bilateral rTMS; Major depressive disorder (MDD); Repetitive transcranial magnetic stimulation (rTMS); Theta burst stimulation; Treatment augmentation; Treatment outcome