Bilateral rTMS Shows No Advantage in Depression nor in Comorbid Depression and Anxiety: A Naturalistic Study.

The objective was to determine if adding low-frequency right-sided rTMS treatment to the standard high-frequency left-sided treatment (LUL), referred to as sequential bilateral treatment (SBT), confers additional benefit for depression or anxiety outcomes. A retrospective chart review from January 2015 through December 2018 yielded 275 patients, all of whom were treated with a figure-8 coil for a major depressive episode. Their protocol was either LUL or SBL. Outcome measures were the Generalized Anxiety Disorder 7-item scale (GAD-7) and the Patient Health Questionnaire (PHQ-9). There was no significant difference in GAD-7 change scores between patients who had LUL or SBL (4.2 vs 4.8). This was also true when the sample was restricted to only patients who started with high GAD-7 scores. There was likewise no significant difference in PHQ-9 change scores between patients who had LUL or SBL (6.8 vs 5.1). Patients switching from LUL to SBL mid-course had poorer overall outcomes as compared to patients who stayed with the same protocol throughout treatment. This large naturalistic study shows no advantage for SBL treatment any group or condition examined. The results of this study have clinical applicability and sound a cautionary note regarding the use of combination rTMS protocols.

Could bipolar depressed patients respond better to rTMS than unipolar depressed patients? A naturalistic, observational study.

Previous studies of rTMS for bipolar depressed (BD) patients have yielded mixed results. In this retrospective, naturalistic, observational study, we reviewed charts of 317 patients undergoing rTMS treatment between 1/2015-2/2018, yielding 283 unipolar depressed (UD) and 34 BD patients. All were treated with a figure-of-8 coil, with either high-frequency (HF) left-sided, sequential bilateral (HF left-sided and low-frequency right-sided), or mixed protocols (switched from unilateral to bilateral mid-course).  Outcomes were the Generalized Anxiety Disorder scale (GAD-7) and Patient Health Questionnaire (PHQ-9). Total number of treatments and initial PHQ-9 scores did not differ between groups. BD patients had greater PHQ-9 change by treatment conclusion than UD patients. GAD-7 changes showed no between-group differences overall. PHQ-9 changes differences between groups were only seen with unilateral treatment, not with bilateral or mixed protocols. Unilateral treatment resulted in 45% remission (9/20) for BD patients vs. 15% (24/160) for UD patients by treatment end. Response was seen in 80% (16/20) of the unilaterally-treated BD patients vs. 39% (62/160) in UD patients. Regression analyses within BD patients found that unilateral treatment, use of non-lithium mood stabilizers, male sex, and number of treatments predicted PHQ-9 improvement.