Maintenance TMS

A patient with treatment resistant depression and an excellent initial response to TMS asked me about the value of maintenance TMS.

The question is a reasonable one given what we know generally about the treatment of chronic and/or treatment resistant depression.

Almost all of the effective treatments (psychotherapy, medications, ECT, etcetera) have acute and maintenance treatment components. And for all of them, maintenance treatment, often at a lower frequency or intensity, plays a key role in sustained response.

TMS has been shown to have surprising durability compared to most of the other treatments. Still, roughly half of patients with an initial good response to treatment will require re-treatment in the subsequent year, often with a shorter course of therapy than the initial one.

Relatively little has been written about the value of maintenance treatment. Two recent studies are encouraging. The older study, in the Journal of Affective Disorders, followed two groups randomly assigned to no additional TMS or a tapering course of TMS from acute (5 times a week) to a week of 3 times a week treatment, then a week of two times a week, then a week of weekly treatment, then every other week  for a month and finally monthly treatment.

The study was not placebo controlled, but did show that there was significant benefit in monthly maintenance treatment.

More recently, the Benadhira study in Psychiatry Research was a small, rnadomized, placebo controlled study (using sham TMS) that followed 35 patients who either received a taper of TMS from 5 times a week to twice a week for a month, then once a week for two months and then every other week for up to a year.

Due to drop outs, the data could only be analyzed for the first six months of treatment, but the results were generally positive. Active TMS at a frequency of once every two weeks maintained the initial response for at least six months, whereas sham TMS showed a gradual worsening of mood (because of drop outs the data beyond month 5 was increasingly unreliable… the apparent “response” to sham TMS in month 6 probably was random variation).

In summary, the data is limited but suggests that some patients may respond well to maintenance TMS at a frequency of between once a month and twice a month. How long this maintenance TMS should continue is unknown. There are no studies that extend beyond a year.

References

Benadhira R, Thomas F, Bouaziz N, Braha S, Andrianisaina PS, Isaac C, Moulier V, Januel D. A randomized, sham-controlled study of maintenance rTMS for treatment-resistant depression (TRD). Psychiatry Res. 2017 Dec;258:226-233. doi: 10.1016/j.psychres.2017.08.029. Epub 2017 Aug 18. PubMed PMID: 28844559.

Richieri R, Guedj E, Michel P, Loundou A, Auquier P, Lançon C, Boyer L. Maintenance transcranial magnetic stimulation reduces depression relapse: a propensity-adjusted analysis. J Affect Disord. 2013 Oct;151(1):129-35. doi: 10.1016/j.jad.2013.05.062. Epub 2013 Jun 18. PubMed PMID: 23790811.

For More Information

How Long Does It Take to Get Well with TMS

The most common question that people ask when they start TMS is how long it will take to get well with TMS. A recent article published in the American Journal of Psychiatry looked at the results from a six week study designed to compare theta burst and regular TMS in …
Read More

TMS Predictors of Outcome in Bipolar Depression and Unipolar Major Depression

What TMS predictors of outcome in bipolar depression and unipolar major depression can we use to identify those who are likely to respond to treatment? An article in 2017 in the journal Clinical Neurophysiology reports data from a very large series of patients with both types of depression who were …
Read More

Maintenance TMS

A patient with treatment resistant depression and an excellent initial response to TMS asked me about the value of maintenance TMS. The question is a reasonable one given what we know generally about the treatment of chronic and/or treatment resistant depression. Almost all of the effective treatments (psychotherapy, medications, ECT, …
Read More

Default Mode Network and Depression Treatment – Ketamine and TMS

Interaction between the default mode network and parts of the pre-frontal cortex may explain some depression phenomena and also links to why TMS and ketamine work …
Read More

TMS Effectiveness Updated

TMS effectiveness for depression is clear. But now there are more machines for providing TMS and more protocols. Is deep TMS better than regular TMS?  Or is deep TMS just a marketing phrase? A major review article in JAMA Psychiatry updated our understanding of alternatives to the initial protocol for …
Read More

TMS for Anxiety

“How effective is TMS for anxiety?” The young woman with a remarkable history of serious adverse effects from multiple trials of psychiatric medications for anxiety recently asked me this question. This post summarizes the results of a thoughtful literature search using the UCSF medical library, data from the Medical Affairs …
Read More

TMS for Depression – Repeat Treatment

TMS is an expensive, time-consuming, but effective treatment for depression, but how should it be used for treating patients with chronic depression? And for those who have an initial positive response when should we consider another course of TMS (known as reintroduction therapy)? These are all questions which have not been …
Read More

TMS Guidelines

In the April edition of Brain Stimulation, the Clinical TMS Society published expert consensus guidelines on the use of TMS. This definitive review of the literature identifies both what is known as well as significant areas of uncertainty about the use of TMS in the treatment of depression. The process of …
Read More

TMS Stimulates Brain Growth

In a recent poster presented at the 2015 Society of Biological Psychiatry meeting Martin Lan and colleagues presented data from the first study of structural changes in the brain following TMS. In the study, 27 patients in an episode of major depression underwent MRIs before and after receiving TMS treatment. Several …
Read More

TMS Cost Effectiveness

“Is TMS Cost-Effective?” His provocative title of an article just published in psychiatric times which summarizes an Australian pharmaco-economic study. In case you don’t want to read through the rest of this article, here is the summary: “Australian researchers compared the cost-effectiveness of rTMS with pharmacotherapy in treatment-resistant patients with …
Read More