Daily Left Prefrontal Repetitive Transcranial Magnetic Stimulation for Acute Treatment of Medication-Resistant Depression

After much controversy over the past 15 years, the data now demonstrate that daily left prefrontal rTMS for at least several weeks treats acute depression in a subset of moderately but not extremely treatment-resistant patients with unipolar illness. The effects are about as large as those of medication in this group, but not as large as ECT. The debate and research thus now shift from determining whether rTMS works in the acute setting to trying to improve the technology and maximizing its clinical effectiveness, utility, and durability. Research is also now focusing on whether rTMS can be used as a maintenance treatment and whether it is effective in depression subgroups, such as adolescents, patients with bipolar depression, and depressed patients with anxiety disorders and other comorbidities. It is not yet clear which subgroups of depressed patients are most likely to benefit from rTMS. The trials to date have largely been performed in mildly to moderately treatment-resistant adult unipolar patients in an acute episode. Thus, for a newly depressed patient, prescribing an antidepressant medication would be more expeditious and less expensive than delivering rTMS as it is currently performed (86-88). The place of rTMS in the treatment algorithm is likely to continue to evolve as new data become available. Currently, one might use rTMS to treat depression in patients who have tried at least one antidepressant medication and did not respond adequately (or were unable to tolerate the treatment) and some form of targeted psychotherapy. In patients who respond to rTMS, one should attempt to maintain the remission with prophylactic oral medications. If the patient relapses or does not tolerate the medication side effects, one can reapply rTMS, as in the patient described in the vignette, and perhaps even attempt maintenance TMS despite the meager supporting evidence.