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Comments and Controversies

TMS for depression

Vol. 11, No. 09 / September 2012

I want to correct an error in a recent letter regarding the use of transcranial magnetic stimulation (TMS) in treatment-resistant depression (TRD) (Comments & Controversies, Current Psychiatry, June 2012, p. 19; The letter writers assert that a March 2012 article in Current Psychiatry should have included TMS as a treatment for TRD because it is “FDA-approved for TRD.” TMS is FDA-approved for the treatment of unipolar depression in patients who failed to respond to a single antidepressant trial. There are various definitions of TRD, but failing to respond to 1 antidepressant trial would not satisfy criteria for any such definition. A pivotal study of TMS, upon which the FDA approval was based, found that patients who had failed to respond to a single antidepressant were significantly more likely to respond to TMS than those who failed 2 to 4 antidepressant trials (P = .021).1 Therefore, TMS is of questionable utility in treating TRD.

Brian Feldman, MD
Boca Raton Psychiatric Group
Boca Raton, FL

The authors respond

We appreciate Dr. Feldman noting our technical error. He is correct that TMS is FDA-approved for treating unipolar depression in individuals who had failed 1 adequate antidepressant trial during their current episode. However, Dr. Feldman is not correct that by no definition would this constitute TRD. For example, Fava1 stated TRD “typically refers to inadequate response to at least one antidepressant trial of adequate doses and duration.”

Based on the research literature, we also disagree with Dr. Feldman’s assertion of “questionable utility” of TMS in TRD. As part of research presented to the FDA, O’Reardon et al2 characterized the study sample as having failed an average of 1.6 adequate antidepressant treatment trial, with approximately one-half having failed ≥2 treatments in their current episode. Connolly et al3 described results in treating 100 consecutive depressed patients with TMS as equivalent to research findings. Most patients had >1 failed adequate antidepressant trial in their current episode. The Agency for Healthcare Research and Quality concluded that evidence supported use of TMS.4 Overall, the panel concluded that there is a substantial and well-replicated body of evidence that TMS is beneficial compared with controls in severity of symptoms, response rate, and remission rate. In a head-to-head comparison with electroconvulsive therapy, TMS was equally effective. TMS is a valuable addition to the therapeutic armamentarium that can help patients early in an illness not fall into a treatment-resistant state, and can offer another chance for those who have.

Gordon Baumbacher MD
Caroline Mulder, MD

Private Practice
Corte Madera, CA

Richard Bermudes, MD
Private Practice
Sacramento, CA

Jennifer Beck, MD
Private Practice
Santa Rosa, CA

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