Tue, 02/28/2023 - 13:42
Submitted by Timothy Buckley on Wed, 10/13/2021 - 09:09
Repetitive Transcranial Magnetic Stimulation for Depression: Managing Poor or Late Response
Timothy Buckley a,c, Kevin Reeves a,b,
aClinical TMS Society, Clinical Standards Committee, Fresno, California
bOhio State University, Wexner Medical Center, Department of Psychiatry, Columbus, Ohio
cHines Veterans Affairs Medical Center, Mental Health Service Line, Hines, Illinois
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Abstract:
Repetitive Transcranial Magnetic Stimulation (rTMS) is now widely used for depression, with several devices FDA approved for this indication. While the field is evolving rapidly, the question of what to do with patients who have little or no response early in treatment (e.g., 10-15 treatments) to the standard protocol remains a difficult one. A similar dilemma can occur at the end of a series when a patient has had only a partial response. There is intriguing work being done on new protocols and augmentation strategies but at this time there is still insufficient randomized controlled (RCT) data to definitively guide management in these non-responders. There is, however, a body of open label continuation studies regarding extended courses of treatment. There are also a few retrospective studies examining the trajectories of response over a treatment course. While RCTs are the gold standard for clinical data, it is worth noting that it may be unlikely that any new RCT’s extending the current FDA protocol for depression emerge, given that the field is now focusing its resources more on newer protocols and various indications. As such, the clinician seeking guidance on this question may need to rely more on the above mentioned open-label studies in conjunction with many individual patient factors. Clinicians may be able to make decisions to abort a course of treatment when significant benefit seems unlikely, thereby sparing the patient the burden of several weeks of futile effort. An alternative argument will be made that completing a course of treatment despite minimal response at least provides a baseline for future reference. A minimal response under current protocols may be improved upon as the field evolves. Furthermore, many clinicians are already using alternative protocols to augment or switch treatments when the risk/benefit ratio seems favorable.
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Background
The standard protocol for rTMS is 30 treatments over the course of 6 weeks. This remains a significant commitment and burden for most patients. While metanalyses show encouraging response rates, the majority of study subjects still fall in the non-response or partial-response categories16, It is common for patients to show little or no improvement at the 2- or 3-week assessment points11. The dilemma for clinicians is whether to recommend continuing treatment for another 3 to 4 weeks when there are minimal gains. Just as with medication trials, and along the lines of sound clinical methodology, clinicians generally want to be sure a treatment is given adequate time to take effect so that they can proceed with the next treatment option with confidence that they have ruled out the current option. Neither physicians nor their patients want to give up hope prematurely. When both parties support continuing treatment, the dilemma may not be as acute. However, when patients make large sacrifices to undergo the treatment and seek guidance from the physician, or when other factors such as insurance reimbursement, or limited clinical resources are play, the question of whether to continue or not becomes more pressing. Complicating this question is the fact that rTMS is evolving rapidly and it can be reasonably hoped that it will become more effective in the future. Moreover, as we learn more about the mechanism of action, we may find that there are benefits that are only seen when augmentation with other treatments are paired with rTMS. For example, are there delayed or occult benefits such as priming the patient for psychotherapy even when rTMS all by itself has no apparent benefit7? In short there is no easy answer to this dilemma, and it will inevitably be a decision made on an individual basis depending on numerous variables. Below we will try to summarize and rank10 some of the research evidence that may assist clinicians in making these difficult treatment decisions. Other standard practices in rTMS such as redoing the motor threshold, double checking the location of the treatment target, revisiting the initial evaluation and diagnosis, reviewing medications, psychosocial factors at play. etc. will not be addressed in this paper as they should already be part of a sound rTMS practice and are addressed in other guidelines.
Defining “non-response” in the clinic
Before looking at the evidence it may be useful to examine the definition of non-response and its relevance to clinical care. Translating the research literature into real-world patient care can be tricky. Non-response has a precise meaning in clinical trials. It is determined by numerical cut-offs of measures. The measures themselves are chosen with many considerations for research, including the logistics of administration, the unique population being studied, or the need to compare outcomes to other studies within the field. Tools such as the HAM-D are a standard by which studies can compare themselves 26. The downside is that standards tend to change slowly. Therefore, a measure that suits a research study may not be ideally suited to a particular clinic patient or may provide only a limited data source. As Nierenberg26 points out, the research categories of remission, response and non-response can be misleading when applied to clinical care. Clinicians can consider several different metrics for depression and may be surprised at the variability in results. What’s more, subjective reports by patients can conflict with their own metric results. Their reports can also be rich in nuance that’s not captured by the metrics being used. At Baseline, a broader array of metrics may help identify what the key markers of improvement are likely to be for a given patient22. We must remind ourselves that for treatment resistant (TRD) patients, even a small improvement can represent a glimmer of hope after years of disappointment.
Trajectories of response and prediction
Trajectories of response or dose-response patterns can be helpful in guiding clinical care. Most experienced psychiatrists have spent countless hours advising their patients that it may take 4 to 6 weeks to see a response with SSRI’s. rTMS providers may find themselves wondering if a patient’s flat or sluggish response at 2 weeks might suddenly “kick-in” (be non-linear) at week 3 or beyond. Conversely, they may wonder if most of the benefit is had in the early stages of treatment. What does the data say about trajectories? There are a couple of secondary analysis of level I evidence trials that have examined trajectories specifically, along with one retrospective case series of 101 patients. The findings are mixed: Kaster et al20., conducted a secondary analysis of the Three-D study (N-388) which was the non-inferiority study comparing the standard 10hz protocol to intermittent thetaburst (iTBS). By using a different type of modelling than the original study (group-based vs. linear mixed) they identified four distinct trajectories of response, two of which were roughly linear, and one, a fast-responding group, with was non-linear. The fourth was a non-responding group. Furthermore, their modelling found that these distinct trajectories or subgroups of patients were associated with certain clinical characteristics. For example, higher severity being a negative predicter, and older age a positive predicter. Notably, the linear response groups did not reach plateau at 6 weeks which is also a feature of early large rTMS trials. The relevance of this to extended treatment will be discussed below. Another secondary analysis by Kaster et al19., examined data from two trials (N=189) which compared accelerated treatment to standard (one using accelerated iTBS and the other accelerated standard 10hz) (. Group-based modeling of MADRAS scores again found four distinct trajectories, although in a different pattern. However, in this study all trajectories were roughly linear. These sorts of findings could prove useful as it gives us a way to predict the likelihood, and roughly the amount, of response that will be achieved at the end of a course of treatment based on a patient’s early response, say at 10 treatments. There is also some interesting, and perhaps more generalizable, level IV evidence: Following an approach used with both ECT and pharmacotherapy, Feffer et al11., in a retrospective case series of 101 patients receiving bilateral dorsomedial prefrontal cortex stimulation with either 10hz or iTBS, analyzed the results to determine the negative predictive value (NPV) of responses at the end of 2 weeks (total treatment being 4 weeks). Using a cut-off of <20% improvement they achieved a NPV of 88.2% using conventional non-response criteria and 80.4% using more stringent criteria (<35% vs. <50% response). Interestingly, in examining the distribution of outcomes they identify 3 distinct (trimodal distribution) groups, echoing the trajectories analysis above. Finally, they created from their data a tool (look-up table) for predicting outcome based on a patient’s early response, broken down to every % point from 0-50% and providing NPV for both conventional and strict non-response criteria. A later study31, replicating the methods of Feffer et al., but using standard 10hz to LDLPC extended to 6 weeks and emphasis on different metrics (IDS-SR and PHQ9 vs. BDI-II in the earlier study), found that the NPV for similar cut-offs fell to 72% when attempting to predict out to 6 weeks. There 4-week outcomes yielded an NPV of 93%. In their conclusions they supported further validation of such an approach but cautioned about missing late responders. If validated by future studies and perhaps even refined by adding in subgroups of clinical characteristics, tools like this could be extremely useful for clinicians, saving individual patients time and effort when non-response is highly likely. It would also help with resource utilization. Last but certainly not least there is important level II evidence supporting the findings above regarding subgroups or patterns of response in the form of a pooled analysis (N= 1,132) of 11 trials (several, but not all, of which were sham-controlled) by Fitzgerald et al14. In their 2016 analysis they identified a bimodal distribution of outcomes with 46% responding and 32 % not responding. The 32% of non-responders were defined as 0-25% reduction in symptoms. Another 20.5% were partial responders (25-50%). The separating out of partial responders is significant here as this group fell roughly at the nadir between the other groups. While the pattern is not identical to those described in the secondary analyses above, it does seem to support the finding that there may indeed be distinct subgroups of patients. They also found associated clinical characteristics such as older age and recurrent episodes (positive predictors of response) and treatment resistance (negative predictor of response) which partly confirm findings in the above-mentioned studies. This would seem to lend weight to the idea of using NPV tools for making decisions about aborting treatment. They did also caution, however, that the signals of associated clinical characteristics were not strong enough to warrant use in patient selection for treatment.
Extended treatment
Closely related to the question of trajectories is that of extending treatments. As has been noted by Fitzgerald in his recent update12, most of the major clinical trials did not identify a plateau of response at the end of the studies (ranging from 3 to 6 weeks). There is, therefore, a possibility that maximal response, or a plateau, occurs on average somewhere beyond 6 weeks of the standard FDA approved protocol. There is still no level I evidence for additional benefit beyond 6 weeks and there is only one study to date that would meet Level II evidence criteria on this question for the standard protocol for the left dorsolateral prefrontal cortex33. This is the only clinical trial for this protocol to date that has extended randomization beyond 6 weeks and notably it did find a plateauing of response at 5 weeks. Another extended trial which was randomized into an extended phase was the Brainsway deep TMS pivotal trial32. However, this was a post-hoc analysis, blinded but active only (no comparator group) extension and therefore still falls within level II evidence (see below). The former study by Zhang et al33. was a large, randomized study with an N of 221 extended randomization to an optional 12 weeks but has a couple of important limitations. It compared four arms examining 5hz and 10 hz, and both left and bilateral treatment. However, the number of pulses per session was lower (1,200) than most other major trials. Secondly, it did not include a placebo arm so while patients were blinded to the specific parameters of treatment, they were essentially analogous to open label subjects. This would simultaneously seem to cast doubt on the effect size (larger than average for randomized trials) but also strengthen the finding of a plateau at 5 weeks in contrast to the aforementioned open label extension trials which would be presumed to be skewed by a placebo effect. In short, more randomized controlled trials beyond 6 weeks are needed. Regarding level III evidence, there have been some open-label (OL) extensions of major clinical trials that have shown additional responses beyond 6 weeks ranging roughly between 20 and 60%. In 2007 O’Reardon et al34. published the findings of one of the early large multicenter RCT’s for the safety and efficacy of TMS for depression. As an add on study to this, Janicak et al17. conducted a durability follow up study, part of which included a 6-week OL extension for non-responders (0-25% response). While a group of non-responders did achieve partial response in the OL phase, the study focused more on the question of relapse occurrence across various levels of response. McDonald et al24. in 2011 conducted an OL extension of the OPT-TMS RCT which addresses the question of optimizing the number of treatments more directly. Phase I was the randomized, 3–6-week study which started with an N of 190 and utilized standard 10hz at 120% motor threshold over the dorsolateral prefrontal cortex (DLPFC), 3,000 pulses per session. These subjects had between 3-6 weeks of treatment and up to 90,000 pulses. Remission in this study was defined as a HAM-D score of <3 or two consecutive weeks under 10. Subjects who failed to achieve remission in phase I had the option to join this OL extension study (phases 2 and 3). Phase 2a was an additional 3-6 weeks of fast left treatment. Those that failed to remit is 2a could opt to enter phase 2b which was up to 4 weeks of slow right DLPFC (1hz for 30 min, 120% motor threshold). 16% (22/141) of subjects in the OL fast left (phase 2a) remitted. 26% (21/81) of the subjects in the OL slow right (phase 2b) remitted for a grand total of 30.5% (43/141) of patients remitting who initially joined the OL phases. The two main drawbacks of the study are that one, it was open lab, and two, subjects were receiving treatment for as many as 16 weeks which begins to include a significant temporal confound ie. some of these subjects may have remitted in this time frame even without treatment. However, since this was a treatment resistant group from the beginning, this is likely not as great a factor. Interestingly, as the authors note, the 2b group (slow right) did not show a relative correlation with medication resistance as the 2a group had, which may suggest that 1hz to the RDLPFC may represent a distinct subgroup and, as such, support switching protocols for non-remitters. In regard to deep TMS, the Brainsway study33 mentioned above extended their 4-week double-blinded initial phase with up to another 12 weeks of twice-weekly double-blinded but all active continuation treatment. For this continuation study only subjects with active treatment in the acute and continuation phases were studied. 61% (20/33) of non-responders to the acute phase (<50% reduction in HDRS-21 score) went on the achieve responder status in the continuation phase within 4 weeks of twice-weekly treatments. Lastly, but importantly, one large registry trial (N=307)6 showed a subset of patients (22%) attained response (<3 on the CGI-S) beyond 6 weeks, echoing the results on the above open-label studies in real world settings.
Conclusion
Choosing an endpoint for treatment in patients who respond minimally or late in a course of rTMS for now is a difficult dilemma and one that may not receive much more guidance from randomized controlled trials with regard to the current FDA-approved protocol. The good news is that the field is evolving rapidly. New data on biomarkers and predictors of response may eventually help us with decisions about patient selection. New protocols may offer options for switching from the standard protocol when it is ineffective. Accelerated protocols now being studied may relieve the burden of time for patients, making decisions about extending treatment less troublesome. Perhaps more importantly, the field of psychiatry is seeing a burgeoning of new treatments including novel neuromodulation and pharmacological treatments and new paradigms of treatment such as psychedelic-assisted psychotherapy. As the toolbox grows our algorithms for selecting treatments and combining treatments (in series or in parallel) becomes exponentially more complex. This is great news for the field at large but a daunting task for the busy clinician who will find it increasingly taxing to stay abreast of the developments in all of these areas. It is our hope that the summary of the literature provided above may provide some grounding to the very difficult clinical decision at hand. While falling well short of being a set of guidelines, it is hopefully a context and reference point to assist with these decisions.
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