Repetitive Transcranial Magnetic Stimulation with and without Internet-delivered Cognitive Behaviour Therapy for the Treatment of Resistant Depression: Patient-centred Randomized Controlled Pilot Trial
Creators: Adu, Medard Kofi
Publisher: name: University of Alberta Library
Year: 2022

<p>Abstract<br>
Background: Major depression is a severe, disabling, and potentially lethal clinical disorder. Only about half of patients respond to an initial course of antidepressant pharmacotherapy. At least 15% of patients with major depression disorder (MDD) remain refractory to any treatment intervention. Repetitive Transcranial Magnetic Stimulation (rTMS) is considered a treatment option for patients with MDD who are refractory to antidepressant treatment as well as cognitive-behavioural therapy (CBT: an evidence-based, structured, intensive, time-limited, symptom-focused form of psychotherapy recommended for the treatment of MDD). It is not known if the addition of iCBT enhances a patient’s response to rTMS treatments. <br>
Objectives: The aims of this study are to 1) conduct a scoping review of the literature in support of the use of rTMS for the management of the psychiatric disorders (treatment-resistant depression (TRD), PTSD, bipolar disorder, and obsessive-compulsive disorder (OCD)) 2) conduct a general review of the literature in relation to iCBT for the management of TRD. 3) evaluate the initial comparative clinical effectiveness of rTMS with and without iCBT as an innovative patient-centred intervention for the treatment of participants diagnosed with TRD. <br>
Methods: Five databases were searched (MEDLINE, CINAHL, PsychINFO, SCOPUS, and EMBASE) to identify empirical studies and randomized controlled trials (RCTs) aimed at the treatment of TRD, PTSD, bipolar disorder, and OCD with rTMS. Again, a general search was conducted in the afore-mentioned databases to generate a general review of literature on the use of iCBT for the management of TRD. Regarding the prospective RCT, overall, 78 participants diagnosed with TRD were randomized to one of two treatment interventions; rTMS sessions alone and rTMS sessions plus iCBT. Participants in each group completed evaluation measures at baseline and 6 weeks (discharge) from treatment. The primary outcome measure was the mean change in the 17-item Hamilton depression rating scale (HAMD-17) from baseline to six weeks. Secondary outcomes included mean changes from baseline to six weeks in the Columbia suicide severity rating scale (CSSRS), which rates suicidal ideations, Quick inventory of depressive symptomatology-self rated scale (QIDS-SR16) for subjective depression, and the EQ-5D-5L to assess the quality of health in participants. <br>
Results: The major findings from the scoping reviews conducted on the efficacy of rTMS were that rTMS application is efficacious in the management of TRD, PTSD, bipolar disorder, and OCD. From the reviewed papers, iCBT seems an effective and promising internet-based intervention for the management of MDD and TRD, with a greater accessibility for the target population.<br>
Regarding the prospective RCT, the majority of participants were females 50(64.1%), aged ≥40 39(50.0%), and had college/university education 54(73.0%). After adjusting for baseline scores, the study failed to find a significant difference in the changes in mean scores for participants from baseline to six weeks between the two interventions under study on the HAMD-17 scale; F (1, 53) = 0.15,   p = 0.70, partial eta squared = 0.003, CSSRS; F (1, 56) = 0.04   p = 0.85, partial eta squared = .001, QIDS-SR16 scale; F (1, 53) = 0.04   p = 0.61, partial eta squared = 0.005, and EQ-5D-VAS; F (1,51) = 0.46   p = 0.50, partial eta squared = .009. However, it found a significant reduction in means scores at week six compared to baseline scores for the combined study population on the HAMD-17 scale (42%), CSSRS (41%) and QIDS-SR16 scale (35%). Additionally, it noted an improvement of about 62% in the quality of life of all participants, as recorded via the EQ-VAS scale.<br>
Conclusion: The scoping reviews suggest that rTMS is effective for management of TRD, PTSD, bipolar disorder, and OCD. Future narratives on effective implementation strategies of iCBT interventions for the management of TRD should consider issues on specific predictors and impediments of their usage, and address them in future studies and practices.<br>
The RCT failed to demonstrate a significant difference regarding the management of MDD symptoms, subjective MDD, suicidal ideations, and the quality of health between rTMS alone and rTMS plus unguided iCBT on all scales.</p>