Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Neuronavigation-guided rTMS may be effective for suicidal ideation in MDD

Key clinical point: Neuronavigation-guided high-dose repetitive transcranial magnetic stimulation (rTMS) may be a novel method to rapidly reduce suicidal ideation in patients with major depressive disorder (MDD).

Major finding: The rTMS vs. sham group demonstrated a significantly greater reduction in the Beck Scale for Suicide Ideation (−14.76 vs. −4.71), 24-item Hamilton Depression rating scale (−19.19 vs. −4.48), and Montgomery-Asberg Depression Rating Scale scores (−19.67 vs. −4.33) on day 7 (P less than .001 for all).

Study details: A total of 42 treatment-naïve patients with MDD with suicidal ideation were randomly assigned to receive escitalopram oxalate in combination with rTMS via either active (n = 21) or sham coil (n = 21) for 1 week.

Disclosures: This study was supported by the National Natural Science Foundation of China. The authors declared no conflict of interest.

Commentary

“This paper by Pan et al. uses TMS for the treatment of suicidal ideation associated with major depressive disorder (MDD). TMS is approved for MDD treatment and often takes a few weeks to become generally effective. In order to speed up response specifically to abort suicidal thinking, these researchers used MRI assisted navigation to better ensure that the TMS magnetic coil be accurately placed to better guarantee an effective treatment dosing strategy. Usual TMS mapping can have an error rate of 2cm geographically and generally cannot guarantee an ultimately accurate target for subsequent dosing. Use of MRI allowed for accurate placement of the treatment coil over a specified neurologic landmark (BA46) using three dimensional imaging software.

In this manner, TMS could be delivered much more specifically to an individual patient’s exact brain structure instead of extrapolating to the usual homunculus motor threshold mapping approach and its error rate. It seems the more focused MRI mapping method allowed for faster antidepressant effects including a lowering of suicidality by day 3. Ideally this study can be replicated on a larger scale as we continue to look into approaches to lower suicidality (acutely and chronically) in addition to the use of ECT, clozapine, lithium and esketamine.”

Thomas L. Schwartz, MD

Senior Associate Dean of Education, Interim Chair/Professor of Psychiatry

SUNY Upstate Medical University

Citation:

Pan F et al. Clin Pharmacol Ther. 2020 Apr 22. doi: 10.1002/cpt.1858.