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Repetitive transcranial magnetic stimulation for the treatment of depression: Systematic review and meta-analysis

  • José Luis R. Martin (a1), Manuel J. Barbanoj (a2), Thomas E. Schlaepfer (a3), Elinor Thompson (a4), Víctor Pérez (a5) and Jaime Kulisevsky (a6)...

Abstract

Background

Repetitive transcranial magnetic stimulation (rTMS) may be useful in the treatment of depression but results from trials have been inconclusive to date.

Aims

To assess the efficacy of rTMS in treating depression.

Method

We conducted a systematic review of randomised controlled trials that compared rTMS with sham in patients with depression. We assessed the quality of design of all studies and conducted a metaanalysis of data from trials with similar rTMS delivery.

Results

We included a total of 14 trials. The quality of the included studies was low. Pooled analysis using the Hamilton Rating Scale for Depression showed an effect in favour of rTMS compared with sham after 2 weeks of treatment (standardised mean difference=–0.35; 95% CI –0.66 to –0.04), but this was not significant at the 2-week follow-up (standardised mean difference= — 0.33; 95% CI —0.84 to 0.17).

Conclusions

Current trials are of low quality and provide insufficient evidence to support the use of rTMS in the treatment of depression.

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Copyright

Corresponding author

José Luis Rodríguez Martin, Centro Cochrane Iberoamericano, Servei d'Epidemiologia Clínica i Salut Pública, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona UAB, Casa de Convalesccència, C/171 Sant Antoni Ma Claret, Barcelona 08041, Spain. E-mail: jrodriguezma@hsp.santpau.es

Footnotes

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Declaration of interest

The study was funded by the Ministerio de Sanidad y Consumo, Instituto de Salud Carlos III, Spain (grant no. 00/10099). T. E.S. is involved in one of the studies included in this review and is also Secretary-Treasurer of the International Society for Transcranial Stimulation.

Footnotes

References

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Repetitive transcranial magnetic stimulation for the treatment of depression: Systematic review and meta-analysis

  • José Luis R. Martin (a1), Manuel J. Barbanoj (a2), Thomas E. Schlaepfer (a3), Elinor Thompson (a4), Víctor Pérez (a5) and Jaime Kulisevsky (a6)...

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Repetitive transcranial magnetic stimulation for the treatment of depression: Systematic review and meta-analysis

  • José Luis R. Martin (a1), Manuel J. Barbanoj (a2), Thomas E. Schlaepfer (a3), Elinor Thompson (a4), Víctor Pérez (a5) and Jaime Kulisevsky (a6)...
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eLetters

Is it a 'sham'?

M E Jan Wise, Psychiatrist
12 July 2003

EditorBJP17 Belgrave SquLondon SW1X 8PG

11th June 2003

Dear Editor,

Martin et al reviewed repetitive transcranial magnetic stimulation (rTMS) as a treatment of depression (1). They make many valid points about rTMS, not least of which may be the difficulty of providing sham treatment. Recently manufacturers have included shielding within the fieldprojector allowing for adequate blinding of the patient and assessor. In all other respects the ‘sham’ treatment is identical as the temperature rise in the device as well as the noise generated remain consistent (2).

They have failed to consider in their analysis that for most of the equivocal studies the ‘sham’ treatment involved holding the field generator at a 45-degree angle to the head. Thus not only can the therapist but also the patient tell that treatment is different. Of even greater concern than this difficulty is that a 45-degree angle still projects a magnetic field through the cortex. Shielding the field projector ensures that the sham treatment has no magnetic influence on thecortex.

A point that the authors attempted to explore is the complexity of the treatment. Whilst there are problems with correctly placing the magnetic field over the prefrontal cortex (L Grunhaus, personal communication), there are further issues over the correct intensity, duration, intertrain frequency and frequency of the stimulus. This is analogous to wondering with ECT what dose, how many times per week, at what frequency should the alternating current be, and how many times in each session should the current be applied.

With the increased hostility to ECT(3) it is important that whilst all these questions are investigated, a potential alternative is not prematurely discounted.

Yours sincerely

Dr M E Jan WiseAdult Psychiatry, St Charles HospitalExmoor Str, London W10 6 DZ

1 Marin J.L., Manuel J.B., Schlaepfer T.E et al, Repetitive transcranial stimulation for the treatment of depression. BJP,182,480-491.

2 Magstim Placebo Coil System operating Manual. The Magstim Company Ltd, Wales , UK 1999.

3 White C. New Guidance on ECT looks set to curb its use. BMJ, 326, 1003. 10 May 2003.

Conflict of interest: None
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