Treatment of Major Depressive Disorder

MDD, also referred to as clinical depression, is a significant medical condition that can affect many areas of life. MDD is one of the most common mental disorders, 1 out of 6 adults experiences depression. Standard treatment of MDD is medication and psychotherapy. However, about a third of patients with MDD do not respond to pharmacotherapy or psychotherapy. For those  patients with treatment ­resistant depression, non­invasive brain stimulation such as repetitive transcranial magnetic stimulation (rTMS) is an emerging option; it uses powerful, focused magnetic field pulses to induce durable changes in the activity of brain regions that are affected by MDD (Bloomberg, 2018). TMS has hardly any side effects.

The use of rTMS in depression  has been proven effective and safe in clinical trials for over 20 years  (Fitzgerald, 2020); 50% of patients responded significantly to treatment and 15–37% of patients showed a sustaining total absence of depression symptoms.

The standard protocol involves the provision of daily treatment sessions during 37,5 min at with stimulation at a frequency of 10 Hz of the targeted brain  area (usually the dorso-lateral pre-frontal cortex or DLPFC), 5 days per week for a minimum of 4 weeks (Bloomberg, 2018) . Substantially different approaches should be considered experimental. rTMS is effective in the treatment of an index episode of MDD and is highly likely to be effective in treating a subsequent episode of relapse. There is limited evidence to support the maintenance rTMS treatment although these are used widely in clinical practise because of the clinical need.
As provided in the largest multicentre studies, rTMS should be provided at 120% of the resting motor threshold (RMT) or above, and when switching to right DLPFC, low frequency treatment should be considered. Four weeks is a reasonable minimum duration of TMS treatment. Continuation for another 2 weeks might be an option in case of response failure.
MRI guided neuronavigation with a more accurate the localization of DLPFC has the potential to significantly improve clinical outcomes. 

Treatment of Major Depressive Disorder