The Frontier Psychiatrists is a daily health-themed newsletter. Today, I have good news…for me. Ok, it’s also good news for patients with depression. For me, it’s good news because I get to experience the most delicious pleasure of the know-it-all…I get to be Right about something I have been saying this…whole…time. Insufferable, I know.
Today, I bring news about my favorite intervention, transcranial magnetic stimulation, abbreviated TMS. I regularly write about TMS in this fine newsletter, for example here, also here, as well as review its use in OCD here, make snarky comments about here, review my coauthored data on its use in an accelerated manner here, and also explain the science here, I podcast here, make the case that remission with TMS is the best acceptable outcome here, podcast again about here, I discuss the treatment modality with
here, describe the Soft White Underbelly here, discuss issues in TMS clinical trial design here, was in a band in college called The Magnets, comment on the insurance coverage policies around TMS here, have a cute video about here, do a somewhat clever financial takedown of one of the industry players here, advise on office furniture for TMS here, comment on the somewhat creepy use case of modifying hypnotizability here, excitedly announce new FDA clearances here, write essays on the use of the word “cure” concerning TMS here, comment on its use in inpatient psychiatry here. Let’s just say I write about TMS a lot—I even have a non-trivial academic track record.Today, we address a new paper in Molecular Psychiatry, with the snappy abbreviation: “Ascertain-TRD”
And for non-scientists—YES, we absolutely come up with acronyms first and make the trial names fit them. This is a fabulous chatGPT use case, by the way, back-solving to acronym for science writers!
The study had the following inclusion criteria:
A subject was considered to be eligible for inclusion only if all inclusion criteria were met. Subjects were
a) women and men ages 18–80,
b) with MDD, of at least 12 weeks duration,
c) who had a Montgomery-Asberg Depression Rating Scale (MADRS [17]) score of at least 20 at screening and baseline [OM: this is moderate depression]
d) who met criteria for TRD during the current major depressive episode, documented in the MGH Antidepressant Treatment History Questionnaire (ATRQ) [18].
TRD was defined as being non-responders during the current episode (less than 50% of symptom improvement) to two or more depression treatment trials of adequate dose and duration, as defined by the MGH ATRQ. In addition, included subjects had documented non-response to their current antidepressant.
These are people with significant depression symptoms who haven't gotten better with their current treatment, or their previous treatments. These people are really suffering, and really haven't been helped yet. It is completely appropriate to want to know what to do next. Previously, the STAR*D paper took patients who started with depression, and followed them through the course of their depression treatment—it didn't select treatment refractory individuals at baseline. This study is selecting for individuals for whom placebo response is unlikely to be a contributor, and thus compared active treatments.
First: Table 1!
Oh, right, commentary!
I’m not gonna let you down, dear readers! This study compares three different options for augmentation of antidepressant treatment:
Adding aripiprazole
Switching to venlafaxine or duloxetine
Adding rTMS
For a total of 8 weeks. The results are striking:
And…in these hard to treat cases, at 8 weeks later:
Recall, this is once daily rTMS, not using either neuronavigation or an H-coil system.
After 2 drugs, it is time for rTMS. Maybe we can demand prior authorization for bad ideas like aripiprazole augmentation before an adequate TMS trial?
(This is the opposite of the current state of affairs, for those who do not spend all day thinking about coverage criteria).
Depression can be over. It doesn’t need to include a long terms risk of tardive dyskinesia and obesity.
“After 2 drugs, it is time for rTMS. Maybe we can demand prior authorization for bad ideas like aripiprazole augmentation before an adequate TMS trial?”
Cannot agree more vigorously. I will be poking my chain of command (fortuitously, these days, the chief of “mental health” at my VA is himself a neuromodulation person) with these results in the ongoing quest for Moar Staffing/Resources because the demand for our services from veterans themselves is off the charts.
Yes, you ARE insufferable. But, in the best possible way. To paraphrase, your purpose is to explain the ways of medicine to man. You do a great job at that. I am a fan of the process you espouse and want this made available to veterans. www.VeteranMissionPossible.com