|
 
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| BRIEF REPORT |
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| Year : 2017 | Volume
: 4
| Issue : 2 | Page : 140-142 |
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The experience with repetitive transcranial magnetic stimulation as add-on treatment in the elderly with depression: A preliminary report
Shubh Mohan Singh, Anish Shouan, N Dalton, Akhilesh Sharma
Department of Psychiatry, PGIMER, Chandigarh, India
| Date of Web Publication | 29-Dec-2017 |
Correspondence Address:
Shubh Mohan Singh
Department of Psychiatry, PGIMER, Chandigarh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jgmh.jgmh_4_17
Background: Elderly depression is a fairly common and often difficult to treat condition. Elderly patients also often have comorbid medical conditions that preclude the use of other somatic treatment modalities. Repetitive transcranial magnetic stimulation (rTMS) is a treatment methodology that is approved to be used in depression and is supposed to have fewer side-effects. This paper describes the experience of a recently started rTMS service in a tertiary hospital in North India with referred elderly patients suffering from depression. Methods: Results of rTMS therapy administered to 7 elderly patients who were referred during this period are described. Results: Only one patient with bipolar depression perceived significant benefit from rTMS. Three patients complained of mild and transient side-effects, and one patient discontinued treatment due to his medical condition (unrelated to rTMS). Conclusions: rTMS seems to be safe and well-tolerated in this population. However, further experience is needed before commenting definitely on effectiveness of this treatment modality.
Keywords: Depression, geriatric, repetitive transcranial magnetic stimulation
How to cite this article:
Singh SM, Shouan A, Dalton N, Sharma A. The experience with repetitive transcranial magnetic stimulation as add-on treatment in the elderly with depression: A preliminary report. J Geriatr Ment Health 2017;4:140-2 |
How to cite this URL:
Singh SM, Shouan A, Dalton N, Sharma A. The experience with repetitive transcranial magnetic stimulation as add-on treatment in the elderly with depression: A preliminary report. J Geriatr Ment Health [serial online] 2017 [cited 2023 Mar 21];4:140-2. Available from: https://www.jgmh.org/text.asp?2017/4/2/140/221904 |
| Introduction | |  |
Depression is a fairly common psychiatric disorder in the elderly and India is no exception.[1] Depression in the elderly may differ from that seen in other age groups in phenomenology and in treatment options and response to treatment.[2],[3] The possible reasons could be physiological such as changes in brain structure, cognitive decline, other comorbid conditions and disability from these, and psychosocial stressors among other reasons.[4] As a result, sometimes the elderly may not respond to conventional treatment protocols for depression as readily as the younger patients.[5]
Neuromodulatory techniques in the treatment of geriatric depression such as electroconvulsive therapy (ECT) and lately repetitive transcranial magnetic stimulation (rTMS) have attracted a lot of attention worldwide.[6] Many patients refuse ECT due to the need of general anesthesia, cognitive side effects, and stigma attached to it. However, rTMS is not known to have any of these disadvantages.[7] In brief, rTMS is based on the premise that repeated application of a magnetic field over the scalp can induce the underlying neurons to fire and eventually lead to plastic changes that can be harnessed therapeutically.[8] rTMS has been used for depression since the 1990s and has been approved by the US Food and Drug Administration since 2008.[9] The evidence base for rTMS in geriatric depression is limited.[10]
The Department of Psychiatry of a tertiary hospital in North India started an rTMS service in the latter half of 2016. At this point, the rTMS service is free. We present the initial experience with geriatric patients undergoing treatment with rTMS at this service.
| Methods | | |
Subjects and methodology
The rTMS service in the department follows a referral model in which patients that are considered appropriate for this treatment are offered the same by their treating psychiatrist and after a written informed consent are taken up for treatment. We defined geriatric as being >55 years of age at the time of rTMS treatment. Seven right-handed patients fitted these criteria among those who were referred to the rTMS service. A total of 31 patients had been referred for rTMS during this period. [Table 1] presents the details of the patients.
All patients were on multiple psychotropics at the time of rTMS, had chronic course of illness (mean duration ~20 years) and were referred for rTMS due to refractory nature of depressive symptoms. Medications were continued as per the discretion of the treating psychiatrist throughout the course of rTMS sessions. Two patients (1 and 2) had comorbid medical illness in the form of Hypertension and one patient [3] had been advised ECT that was discontinued after he developed asystole post-ECT. All patients were treated with rTMS as per a commonly used protocol.[11] As per this protocol, F3 location of the scalp was determined as per the 10–20 system. This location generally corresponds to the left dorsolateral prefrontal cortex (DLPFC) which is the target of rTMS stimulation in this protocol. Motor threshold was detected using the visual method as per the intensity required to evoke contraction of the Abductor pollicis brevis muscle of the right hand at least 50% of the times the stimulus was delivered.[12] The pulses were delivered at 100% of the motor threshold. The rTMS was delivered in the form of pulses delivered at a frequency of 10 Hz for 4 s followed by a wait period of 26 s (high frequency). We delivered 1200 pulses/session (30 trains/session). One session/day was delivered each working day (Monday–Saturday). We aimed at delivering at least 15 sessions/patient. As is obvious from [Table 1], most patients exceeded this. rTMS was delivered using a figure-of-8 coil on the Magstim Rapid2 machine.[13] Assessments were carried out by a qualified psychiatrist. As a matter of routine, all patients were assessed on the Hamilton depression rating scale (HDRS) once a week, percentage change was calculated using the baseline HDRS compared to the score derived at the end of the sessions.[14] HDRS is routinely used for patient assessment and as a widely accepted measure of treatment effectiveness. We did not specifically check for cognitive dysfunction either at baseline or during the treatment.
| Discussion | | |
Patient profile
All the referred patients had chronic illnesses with chronic symptoms that were poorly responsive to long-term conventional treatments. In fact, most were on multiple psychotropics. In addition, two patients had a comorbid medical condition and one patient had a serious adverse event during ECT which necessitated its discontinuation. At the outset, the patients fulfilled the criteria for poor prognosis.[15]
Effectiveness
rTMS is considered to be useful in the treatment of resistant depression.[16] rTMS has also been used as add-on treatment in resistant depression.[17] The use of rTMS in geriatric depression has also been considered to be promising.[10] However, the evidence is mixed. For instance, one study using stimulation with a different protocol than ours found it to be beneficial.[18] Another study with a sample size of twenty patients also found it beneficial.[19] However, other studies using slightly different protocols in term of frequency and number of pulses did not find rTMS to be beneficial in elderly patients with depression.[20],[21] In addition, both of these studies were controlled and hence methodologically more robust. There are very scarce data regarding rTMS in recurrent depressive disorder (F33) which made up the majority of patients in our series.[22] Similarly, the evidence base for the use of rTMS in comorbid depression and psychotic disorder is also scarce. Low-frequency rTMS has been found to be useful in bipolar depression.[23] Another study found it to be safe but ineffective in bipolar depression.[24]
Our experience in the light of literature review suggests the following. First, most studies have used varying treatment protocols on varying combinations of pharmacotherapy and comparisons are difficult to make. However, it seems that elderly depressed patients seem to constitute a distinct group where various factors dictate the poor response to rTMS. Most of our patients did not benefit from rTMS at the current protocol. One patient [4] perceived worsening in symptoms. A patient with bipolar depression, however, perceived a significant benefit. This indicates that elderly patients with geriatric depression may require different treatment protocols, with frontal cortical atrophy and vascular changes necessitating a greater number of pulses delivered at higher frequencies.[21],[25] It may be worthwhile to conduct initial assessments regarding brain architecture and use the information to devise better treatment protocols. Furthermore, the localization of the DLPFC in our service is blind; it is possible that better results may be had with more sophisticated neuronavigational tools that would enhance the accuracy of the rTMS stimulation. This is particularly important as the spatial penetrance of the rTMS is only about 2–3 cm.[26]
Safety and tolerability
In line with other studies, rTMS was found to be safe and effective in elderly depressed patients.[27] No major adverse events were noted. Only one patient discontinued treatment and that too due to unrelated medical conditions. The side-effects noted were headache, stiffness in neck and tinnitus in three patients and these were mild and transient. We did not specifically explore the possibility of cognitive side-effects. However, no patient complained about the same.
| Conclusions | | |
rTMS appears to be a safe and well-tolerated treatment modality in elderly patients with depression. However, considering the patient profile and poor prognostic factors, more robust treatment protocols and technological aids need to be tried out for the possibility of better effectiveness.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1]
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