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					TITLE: Transcranial Magnetic Stimulation Therapy for Patients with Refractory
       Depression: Clinical-Effectiveness and Guidelines

DATE:       14 April 2009

RESEARCH QUESTIONS:

1.        What is the clinical-effectiveness of transcranial magnetic stimulation therapy for patients
          with refractory depression?

2.        What are the guidelines for using transcranial magnetic stimulation therapy for patients
          with refractory depression?

METHODS:

A limited literature search was conducted on key health technology assessment resources,
including PubMed, the Cochrane Library (Issue 1, 2009), University of York Centre for Reviews
and Dissemination (CRD) databases, ECRI, EuroScan, international HTA agencies, and a
focused Internet search. Results include articles published between 2004 and April 2009, and
are limited to English language publications only. No filters were applied to limit the retrieval by
study type. Internet links are provided, where available.

RESULTS:

HTIS reports are organized so that the higher quality evidence is presented first. Therefore,
health technology assessment reports, systematic reviews, and meta-analyses are presented
first. These are followed by randomized controlled trials (RCTs), controlled clinical trials,
observational studies, and evidence-based guidelines.

One health technology assessment, three systematic reviews, 13 RCTs, three controlled clinical
trials, eight observational studies, and two evidence-based guidelines were identified pertaining
to the use of transcranial magnetic stimulation therapy for patients with refractory depression.
Additional information that may be of interest has been included in the appendix.


Disclaimer: The Health Technology Inquiry Service (HTIS) is an information service for those involved in planning and providing
health care in Canada. HTIS responses are based on a limited literature search and are not comprehensive, systematic reviews.
The intent is to provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts
within the time allowed. HTIS responses should be considered along with other types of information and health care considerations.
The information included in this response is not intended to replace professional medical advice, nor should it be construed as a
recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality
evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for
which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation
of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect.
CADTH is not liable for any loss or damages resulting from use of the information in the report.

Copyright: This report contains CADTH copyright material and may contain material in which a third party owns copyright. This
report may be used for the purposes of research or private study only. It may not be copied, posted on a web site,
redistributed by email or stored on an electronic system without the prior written permission of CADTH or applicable copyright
owner.

Links: This report may contain links to other information available on the websites of third parties on the Internet. CADTH does not
have control over the content of such sites. Use of third party sites is governed by the owners’ own terms and conditions.
Health technology assessments

1.     Repetitive transcranial magnetic stimulation as a treatment for major depression
       [technology assessment report]. Canberra, Australia: Medical Services Advisory
       Committee (MSAC); 2007.
       Summary available:
       http://www.msac.gov.au/internet/msac/publishing.nsf/Content/2E0BACBB8704139ACA25
       745E001C2F21/$File/1101%20-
       %20Repetitive%20transcranial%20magnetic%20stimulation%20Summary.pdf (accessed
       09 Apr 2009)
       Full-text available:
       http://www.msac.gov.au/internet/msac/publishing.nsf/Content/2E0BACBB8704139ACA25
       745E001C2F21/$File/1101%20-
       %20Repetitive%20transcranial%20magnetic%20stimulation%20Report.pdf (accessed
       09 Apr 2009)

Systematic reviews and meta-analyses

2.     Schutter DJ. Antidepressant efficacy of high-frequency transcranial magnetic stimulation
       over the left dorsolateral prefrontal cortex in double-blind sham-controlled designs: a
       meta-analysis. Psychol Med 2009;39(1):65-75. PubMed: PM18447962

3.     Lam RW, Chan P, Wilkins-Ho M, Yatham LN. Repetitive transcranial magnetic stimulation
       for treatment-resistant depression: a systematic review and metaanalysis. Can J
       Psychiatry 2008;53(9):621-31. PubMed: PM18801225

4.     Couturier JL. Efficacy of rapid-rate repetitive transcranial magnetic stimulation in the
       treatment of depression: a systematic review and meta-analysis. Journal of Psychiatry and
       Neuroscience 2005; 30(2): 83-90; 2009.
       Full-text available:
       http://www.cma.ca/multimedia/staticContent/HTML/N0/l2/jpn/vol-30/issue-2/pdf/pg83.pdf
       (accessed 09 Apr 2009)
       Structured abstract available with subscription at: http://www.cochrane.org

Randomized controlled trials

5.     Bares M, Kopecek M, Novak T, Stopkova P, Sos P, Kozeny J, et al. Low frequency (1-Hz),
       right prefrontal repetitive transcranial magnetic stimulation (rTMS) compared with
       venlafaxine ER in the treatment of resistant depression: A double-blind, single-centre,
       randomized study. J Affect Disord 2009. PubMed: PM19249105

6.     Bretlau LG, Lunde M, Lindberg L, Unden M, Dissing S, Bech P. Repetitive transcranial
       magnetic stimulation (rTMS) in combination with escitalopram in patients with treatment-
       resistant major depression: a double-blind, randomised, sham-controlled trial.
       Pharmacopsychiatry 2008;41(2):41-7. PubMed: PM18311683

7.     McLoughlin DM, Mogg A, Eranti S, Pluck G, Purvis R, Edwards D, et al. The Clinical
       effectiveness and cost of repetitive transcranial magnetic stimulation versus
       electroconvulsive therapy in severe depression: a multicentre pragmatic randomised
       controlled trial and economic analysis. Health Technology Assessment 2007;11(24).
       Summary and full-text available:
       http://www.ncchta.org/execsumm/summ1124.shtml (accessed 14 Apr 2009)

     Transcranial Magnetic Stimulation Therapy for Patients with Refractory Depression      2
8.      O'Reardon JP, Solvason HB, Janicak PG, Sampson S, Isenberg KE, Nahas Z, et al.
        Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major
        depression: a multisite randomized controlled trial. Biol Psychiatry 2007;62(11):1208-16.
        PubMed: PM17573044

9.      Avery DH, Holtzheimer PE, III, Fawaz W, Russo J, Neumaier J, Dunner DL, et al. A
        controlled study of repetitive transcranial magnetic stimulation in medication-resistant
        major depression. Biol Psychiatry 2006;59(2):187-94. PubMed: PM16139808

10.     Fitzgerald PB, Huntsman S, Gunewardene R, Kulkarni J, Daskalakis ZJ. A randomized
        trial of low-frequency right-prefrontal-cortex transcranial magnetic stimulation as
        augmentation in treatment-resistant major depression. Int J Neuropsychopharmacol
        2006;9(6):655-66. PubMed: PM16959055

11.     Fitzgerald PB, Benitez J, de Castella A, Daskalakis ZJ, Brown TL, Kulkarni J.
        A randomized, controlled trial of sequential bilateral repetitive transcranial magnetic
        stimulation for treatment-resistant depression. Am J Psychiatry 2006;163(1):88-94.
        PubMed: PM16390894

12.     McDonald WM, Easley K, Byrd EH, Holtzheimer P, Tuohy S, Woodard JL, et al.
        Combination rapid transcranial magnetic stimulation in treatment refractory depression.
        Neuropsychiatr Dis Treat 2006;2(1):85-94.

13.     Rosa MA, Gattaz WF, Pascual-Leone A, Fregni F, Rosa MO, Rumi DO, et al. Comparison
        of repetitive transcranial magnetic stimulation and electroconvulsive therapy in unipolar
        non-psychotic refractory depression: a randomized, single-blind study.
        Int J Neuropsychopharmacol 2006;9(6):667-76. PubMed: PM16923322

14.     Rossini D, Lucca A, Zanardi R, Magri L, Smeraldi E. Transcranial magnetic stimulation in
        treatment-resistant depressed patients: a double-blind, placebo-controlled trial. Psychiatry
        Res 2005;137(1-2):1-10. PubMed: PM16225930

15.     Su TP, Huang CC, Wei IH. Add-on rTMS for medication-resistant depression: a
        randomized, double-blind, sham-controlled trial in Chinese patients. J Clin Psychiatry
        2005;66(7):930-7. PubMed: PM16013911

16.     Mosimann UP, Schmitt W, Greenberg BD, Kosel M, Muri RM, Berkhoff M, et al. Repetitive
        transcranial magnetic stimulation: a putative add-on treatment for major depression in
        elderly patients. Psychiatry Res 2004;126(2):123-33. PubMed: PM15123391

17.     Poulet E, Brunelin J, Boeuve C, Lerond J, D'Amato T, Dalery J, et al. Repetitive
        transcranial magnetic stimulation does not potentiate antidepressant treatment.
        Eur Psychiatry 2004;19(6):382-3. PubMed: PM15363481

Controlled clinical trials

18.     Vanderhasselt MA, De RR, Leyman L, Baeken C. Acute effects of repetitive transcranial
        magnetic stimulation on attentional control are related to antidepressant outcomes.
        J Psychiatry Neurosci 2009;34(2):119-26. PubMed: PM19270762




      Transcranial Magnetic Stimulation Therapy for Patients with Refractory Depression            3
19.     Loo CK, Mitchell PB, McFarquhar TF, Malhi GS, Sachdev PS. A sham-controlled trial of
        the efficacy and safety of twice-daily rTMS in major depression. Psychol Med
        2007;37(3):341-9. PubMed: PM17176505

20.     Kauffmann CD, Cheema MA, Miller BE. Slow right prefrontal transcranial magnetic
        stimulation as a treatment for medication-resistant depression: a double-blind, placebo-
        controlled study. Depress Anxiety 2004;19(1):59-62. PubMed: PM14978787

Observational studies

21.     Cohen RB, Boggio PS, Fregni F. Risk factors for relapse after remission with repetitive
        transcranial magnetic stimulation for the treatment of depression. Depress Anxiety 2009.
        PubMed: PM19170101

22.     Avery DH, Isenberg KE, Sampson SM, Janicak PG, Lisanby SH, Maixner DF, et al.
        Transcranial magnetic stimulation in the acute treatment of major depressive disorder:
        clinical response in an open-label extension trial. J Clin Psychiatry 2008;69(3):441-51.
        PubMed: PM18294022

23.     Bloch Y, Grisaru N, Harel EV, Beitler G, Faivel N, Ratzoni G, et al. Repetitive transcranial
        magnetic stimulation in the treatment of depression in adolescents: an open-label study.
        J ECT 2008;24(2):156-9. PubMed: PM18580562

24.     Demirtas-Tatlidede A, Mechanic-Hamilton D, Press DZ, Pearlman C, Stern WM, Thall M,
        et al. An open-label, prospective study of repetitive transcranial magnetic stimulation
        (rTMS) in the long-term treatment of refractory depression: reproducibility and duration of
        the antidepressant effect in medication-free patients. J Clin Psychiatry 2008;69(6):930-4.
        PubMed: PM18505308

25.     Abraham G, Milev R, Lazowski L, Jokic R, du TR, Lowe A. Repetitive transcranial
        magnetic stimulation for treatment of elderly patients with depression - an open label trial.
        Neuropsychiatr Dis Treat 2007;3(6):919-24. PubMed: PM19300628

26.     Huang CC, Su TP, Wei IH. Repetitive transcranial magnetic stimulation for treating
        medication-resistant depression in Taiwan: a preliminary study. J Chin Med Assoc
        2005;68(5):210-5. PubMed: PM15909725

27.     Schulze-Rauschenbach SC, Harms U, Schlaepfer TE, Maier W, Falkai P, Wagner M.
        Distinctive neurocognitive effects of repetitive transcranial magnetic stimulation and
        electroconvulsive therapy in major depression. Br J Psychiatry 2005;186:410-6. PubMed:
        PM15863746

28.     Nahas Z, Li X, Kozel FA, Mirzki D, Memon M, Miller K, et al. Safety and benefits of
        distance-adjusted prefrontal transcranial magnetic stimulation in depressed patients 55-75
        years of age: a pilot study. Depress Anxiety 2004;19(4):249-56. PubMed: PM15274174

Guidelines and recommendations

29.     Transcranial magnetic stimulation for severe depression [interventional procedure
        guidance 242]. London: National Institute for Health and Clinical Excellence (NICE); 2007.
        Available:
        http://www.nice.org.uk/nicemedia/pdf/IPG242GUIDANCE.pdf (accessed 09 Apr 2009)

      Transcranial Magnetic Stimulation Therapy for Patients with Refractory Depression            4
30.     Major depression in adults in primary care. Bloomington (MN): Institute for Clinical
        Systems Improvement (ICSI); 2008.
        NGC summary available:
        http://www.guideline.gov/summary/pdf.aspx?doc_id=12617&stat=1&string=%22transcrani
        al+magnetic+stimulation%22 (accessed 09 Apr 2009)
        See page 44
        Full guideline available:
        http://www.icsi.org/depression_5/depression__major__in_adults_in_primary_care_3.html
        (accessed 09 Apr 2009)


PREPARED BY:
Kristen Moulton, BA, Research Assistant
Charlene Argáez, MLIS, Information Specialist
Health Technology Inquiry Service
Email: htis@cadth.ca
Tel: 1-866-898-8439




      Transcranial Magnetic Stimulation Therapy for Patients with Refractory Depression   5
APPENDIX – FURTHER INFORMATION:

Randomized controlled trials

31.     Turnier-Shea Y, Bruno R, Pridmore S. Daily and spaced treatment with transcranial
        magnetic stimulation in major depression: a pilot study. Aust N Z J Psychiatry
        2006;40(9):759-63. PubMed: PM16911750


Consensus statements and clinical Policy

32.     Transcranial magnetic stimulation and cranial electric stimulation [clinical policy bulletin no.
        0469]. In: AETNA [website]. Hartford (CT): AETNA; 2008.
        Available:
        http://www.aetna.com/cpb/medical/data/400_499/0469.html (accessed 09 Apr 2009)

33.     Consensus statement on depression in adults: how to improve prevention, diagnosis and
        treatment. Edmonton (AB): Institute of Health Economics; 2008.
        Available:
        http://www.ihe.ca/documents/Depression_Statement.pdf (accessed 09 Apr 2009)




      Transcranial Magnetic Stimulation Therapy for Patients with Refractory Depression            6

				
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