Review articleRepetitive transcranial magnetic stimulation versus electroconvulsive therapy for major depression: A systematic review and meta-analysis
Introduction
Electroconvulsive therapy (ECT), is a well-established and effective option for patients refractory or intolerant to pharmacotherapy (Janicak et al., 2002). It is the most effective short term treatment for severe major depression (MD) (Eranti et al., 2007) and has relatively high response and initial remission rates (Daly et al., 2001, Fink and Taylor, 2007, Husain et al., 2004, Lisanby, 2007, McClintock et al., 2011) especially in the presence of catatonia or psychosis (Bauer et al., 2002). Despite the high antidepressant efficacy of ECT (Eranti et al., 2007, Husain et al., 2004, Janicak et al., 1985, Janicak et al., 1989), a substantial number of depressed patients cannot tolerate ECT (Janicak and Martis, 1999) and the prospect of achieving prolonged remission with ECT is uncertain (McClintock et al., 2011, Sackeim et al., 2001). In some individuals, ECT adversely affects cognitive function, disrupting both new learning and remote memory, limiting its overall acceptability (Eranti et al., 2007). Additionally, the use of ECT is often limited by other issues such as need for anesthesia and seizure induction (Lisanby, 2007, Rose et al., 2003).
In the past decade, rTMS has emerged as an effective, non-invasive physical intervention applied to the left or right dorsolateral prefrontal cortex (DLPFC) for MD (Berlim et al., 2012, Fitzgerald et al., 2003, George et al., 2010, Lingeswaran, 2011, O'Reardon et al., 2007, Pallanti and Bernardi, 2009, Rosa and Lisanby, 2012). rTMS appears to target distributed brain networks that are central to the pathophysiology of depression (George and Post, 2011, Schutter, 2009) and is not followed by epileptic seizure activity. Low frequency rTMS (stimulation frequency usually equal to or less than 1 Hz) is thought to inhibit the targeted brain region, while high-frequency rTMS (usually 5–20 Hz) is considered to increase excitability (Pal et al., 2005, Rodriguez-Martin José et al., 2009, Rossi et al., 2009). Depending on the parameters employed, cortical inhibition or excitation resulting from rTMS can last for up to several hours after stimulation (Di Lazzaro et al., 2005, Pal et al., 2005). Compared to ECT, rTMS does not require general anesthesia, and does not give rise to memorizing difficulties or other serious side effects.
To date, several RCTs have compared the antidepressant efficacy and safety of rTMS and ECT (Eranti et al., 2007, Grunhaus et al., 2000, Grunhaus et al., 2003, Hansen et al., 2011, Janicak et al., 2002, Keshtkar et al., 2011, Pridmore et al., 2000, Rosa et al., 2006, Wang et al., 2004). While the antidepressant effects of rTMS are well established, its advantage over ECT continues to be controversial. Secondly, while it is generally accepted that rTMS protocols used for depression do not produce enduring cognitive disruption, it is unclear if this is a specific advantage when compared to ECT in severe depression. Further, sustaining short-term efficacy to achieve long-term remission is a crucial therapeutic goal in MD that is closely linked to social, occupational and economic outcomes (Kelsey, 2004). Given the enduring nature and severity of depression in patients who are referred to receive somatic interventions such as rTMS and ECT, comparing the utility of these interventions with regard to long-term clinical efficacy will potentially aid in complex treatment decisions. To this end we undertook a systematic review and meta-analysis of RCTs that compare rTMS and ECT for depression, with or without psychotic symptoms. We specifically focused on clinically meaningful outcomes namely response, remission and acceptability. We also investigated the differences in self-rated mood improvement, general mental state, cognitive function and adverse effects between the two interventions.
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Search strategy
Relevant randomized controlled trials of rTMS and ECT in patients with depression that were published or made available electronically before November 26, 2013, were identified via Pubmed, Embase, Ovid (all database including Medline, the Cochrane library, PsycInfo and so on) EBSCO host, and major Chinese databases — Chongqing VIP Database (VIP), Wan Fang Database and Chinese National Knowledge Infrastructure (CNKI). The search strategies combined free-text searching with key words probing. Our
Results of literature search and characteristics of included studies
Of 658 articles obtained from the search, 10 articles (Dannon et al., 2002, Eranti et al., 2007, Grunhaus et al., 2000, Grunhaus et al., 2003, Hansen et al., 2011, Janicak et al., 2002, Keshtkar et al., 2011, Pridmore et al., 2000, Rosa et al., 2006, Wang et al., 2004) met the selection criteria and were thus included in further analysis. The study selection process is shown in Fig. 1. Two of the included articles (Dannon et al., 2002, Grunhaus et al., 2000) reported on the short-term and
Cognitive function
Five studies (Eranti et al., 2007, Grunhaus et al., 2000, Grunhaus et al., 2003, Hansen et al., 2011, Rosa et al., 2006) reported on cognitive performance. Of these, three (Eranti et al., 2007, Grunhaus et al., 2000, Grunhaus et al., 2003) reported on global cognitive performance as measured by Mini-Mental State Examination (MMSE). Pooled estimate from these studies revealed no difference in MMSE between rTMS and ECT (MD = 0.65; 95% CI = − 0.51–1.82; p = 0.27, Supplementary Fig. 5). The heterogeneity
Side effects
Most of the studies reported the side effect profile of rTMS and ECT except Dannon et al. (2002) and Rosa et al. (2006). There were no significant adverse events (e.g., seizures) and generally only mild side effects were reported in the rTMS group. Four studies reported the numerical data about adverse events (Grunhaus et al., 2000, Grunhaus et al., 2003, Hansen et al., 2011, Janicak et al., 2002) of rTMS. Altogether, in rTMS froup, 17.0% (9/53, data from Grunhaus et al., 2000, Grunhaus et al.,
Psychotic symptoms
We also examined whether the RR for response and remission differed in trials that included patients with psychotic depression (Supplementary Figs. 6 and 7). Of the ten studies included in this meta-analysis, six included mixed samples of subjects with psychotic depression (Dannon et al., 2002, Eranti et al., 2007, Grunhaus et al., 2000, Hansen et al., 2011, Janicak et al., 2002, Pridmore et al., 2000), and two with only non-psychotic depression (Grunhaus et al., 2003, Rosa et al., 2006). Two
Discussion
In this systematic review and meta-analysis, 10 reports of 9 trials involving 425 participants were pooled. Our quantitative analysis found that ECT was more effective than rTMS for major depression, especially in short-term, particularly for patients with psychotic depression. There was less randomized evidence that the benefits are maintained in the long term. Furthermore, we found no significant between-group difference in all-cause discontinuation rates between the two treatments,
Acknowledgments
We would like to thank Stephanie Sampson for her helpful comments on a previous version of the manuscript.
This research was supported partly by grants from Research Leadership Development Plan of the City of Shanghai (XBR2011005) and Shanghai Key Laboratory of Psychotic Disorders (13dz2260500) for Chunbo Li, Wellcome Research Fellowship (WT096002/11/Z) for Lena Palaniyappan and Shanghai Health Bureau Youth Project (20124Y053, 2013SY003) for Juanjuan Ren and Jijun Wang.
References (50)
- et al.
Three and six-month outcome following courses of either ECT or rTMS in a population of severely depressed individuals — preliminary report
Biol Psychiatry
(2002) - et al.
Efficacy of transcranial magnetic stimulation targets for depression is related to intrinsic functional connectivity with the subgenual cingulate
Biol Psychiatry
(2012) - et al.
Repetitive transcranial magnetic stimulation is as effective as electroconvulsive therapy in the treatment of nondelusional major depressive disorder: an open study
Biol Psychiatry
(2000) - et al.
A randomized controlled comparison of electroconvulsive therapy and repetitive transcranial magnetic stimulation in severe and resistant nonpsychotic major depression
Biol Psychiatry
(2003) - et al.
Strategies for treatment-resistant depression
Clin Cornerstone
(1999) - et al.
Repetitive transcranial magnetic stimulation versus electroconvulsive therapy for major depression: preliminary results of a randomized trial
Biol Psychiatry
(2002) - et al.
Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial
Biol Psychiatry
(2007) - et al.
Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research
Clin Neurophysiol
(2009) - et al.
Objective cognitive performance associated with electroconvulsive therapy for depression: a systematic review and meta-analysis
Biol Psychiatry
(2010) - et al.
World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: acute and continuation treatment of major depressive disorder
World J Biol Psychiatry
(2002)
A systematic review and meta-analysis on the efficacy and acceptability of bilateral repetitive transcranial magnetic stimulation (rTMS) for treating major depression
Psychol Med
Efficacy and acceptability of high frequency repetitive transcranial magnetic stimulation (rTMS) versus electroconvulsive therapy (ECT) for major depression: a systematic review and meta-analysis of randomized trials
Depress Anxiety
Neuropsychiatric applications of transcranial magnetic stimulation: a meta analysis
Int J Neuropsychopharmacol
ECT in bipolar and unipolar depression: differences in speed of response
Bipolar Disord
Theta-burst repetitive transcranial magnetic stimulation suppresses specific excitatory circuits in the human motor cortex
J Physiol
Systematic review and meta-analysis of bifrontal electroconvulsive therapy versus bilateral and unilateral electroconvulsive therapy in depression
World J Biol Psychiatry
Low- vs high-frequency repetitive transcranial magnetic stimulation as an add-on treatment for refractory depression
Front Psychiatry
A randomized, controlled trial with 6-month follow-up of repetitive transcranial magnetic stimulation and electroconvulsive therapy for severe depression
Am J Psychiatry
Electroconvulsive therapy: evidence and challenges
JAMA
Transcranial magnetic stimulation in the treatment of depression: a double-blind, placebo-controlled trial
Arch Gen Psychiatry
A randomized trial of rTMS targeted with MRI based neuro-navigation in treatment-resistant depression
Neuropsychopharmacology
Daily left prefrontal repetitive transcranial magnetic stimulation for acute treatment of medication-resistant depression
Am J Psychiatry
Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial
Arch Gen Psychiatry
Low-frequency repetitive transcranial magnetic stimulation inferior to electroconvulsive therapy in treating depression
J ECT
Factors modifying the efficacy of transcranial magnetic stimulation in the treatment of depression: a review
J Clin Psychiatry
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2022, Neuroscience and Biobehavioral ReviewsCitation Excerpt :Acceptability was significantly higher for ECT compared to AD (OR=2.94, 95 %CI=1.12–16.39), and for B-DLPFC rTMS compared to LF R-DLPFC rTMS (OR=2.43, 95 %CI=1.11–5.30) (Brunoni, Chaimani et al., 2017; UK ECT Review Group, 2003). No other difference in acceptability was found comparing ECT with rTMS (Chen et al., 2017; Ren et al., 2014), among different protocols of ECT (Mutz et al., 2019), and of rTMS (Brunoni, Chaimani et al., 2017; Chen et al., 2014; Mutz et al., 2019). In bipolar depressive episode, compared with inactive interventions, on primary outcome, the largest effect emerged for LT (SMD=0.43, 95%CI=0.04–0.82/GRADE=low) (Lam et al., 2020), followed by rTMS (SMD=0.30, 95 %CI=0.06–0.55/GRADE=low) (Tee and Au, 2020).
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