Antidepressant class and concurrent rTMS outcomes in major depressive disorder: a systematic review and meta-analysis

Alina Zaidi; Rafeya Shami; Isabella J Sewell; Xingshan Cao; Peter Giacobbe; Jennifer S Rabin; Maged Goubran; Clement Hamani; Walter Swardfager; Benjamin Davidson; Nir Lipsman; Sean M Nestor

doi:10.1016/j.eclinm.2024.102760

Antidepressant class and concurrent rTMS outcomes in major depressive disorder: a systematic review and meta-analysis

EClinicalMedicine. 2024 Jul 27:75:102760. doi: 10.1016/j.eclinm.2024.102760. eCollection 2024 Sep.

Authors

Alina Zaidi^{1

2

3}, Rafeya Shami^{1

2}, Isabella J Sewell^{1

2}, Xingshan Cao⁴, Peter Giacobbe^{1

2

3

5}, Jennifer S Rabin^{1

2

6

7}, Maged Goubran^{1

2

8}, Clement Hamani^{1

2

9}, Walter Swardfager^{1

2

10}, Benjamin Davidson^{1

2

9}, Nir Lipsman^{1

2

3

5

9}, Sean M Nestor^{1

2

3

5}

Affiliations

¹ Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada.
² Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
³ Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
⁴ Research Design and Biostatistics, Sunnybrook Research Institute, Toronto, ON, Canada.
⁵ Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
⁶ Department of Neurology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
⁷ Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.
⁸ Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.
⁹ Department of Neurosurgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
¹⁰ Department of Pharmacology & Toxicology, University of Toronto, Toronto, ON, Canada.

Abstract

Background: Repetitive transcranial magnetic stimulation (rTMS) is frequently used as an adjunctive treatment with antidepressants for depression. We aimed to evaluate the clinical efficacy and safety of antidepressant classes when administered concurrently with rTMS for the management of major depressive disorder (MDD).

Methods: In this systematic review and meta-analysis, MEDLINE, Embase, PsycINFO, and the Cochrane Library were searched from inception to April 12th 2024 for terms relating to medication, depression, and rTMS and appraised by 2 independent screeners. All randomized clinical trials that prospectively evaluated a specific antidepressant adjunctively with sham rTMS as a control in MDD were included. The study was registered with PROSPERO (CRD42023418435). The primary outcome measure assessed symptomatic improvement measured by formal depression scales. We used a random-effects model with pooled Standardized Mean Differences (SMDs) and log odds ratios (OR). All studies were assessed for their methodological quality and bias using the Cochrane Collaboration Risk of Bias tool version 2 (RoB2).

Findings: 14 articles from 5376 identified studies were included in the systematic review and meta-analysis. There was only sufficient trial data to evaluate the effects of rTMS and combination therapy with selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs). Across studies, 848 participants (mean [SD] age:41.1 [18.7] years for SSRIs, 51.8 [3.8] years for SNRIs) prospectively examined the efficacy of antidepressant medication with rTMS. Combining rTMS with SSRIs led to significantly lower depression scores, (SMD [CI] of -0.65 [-0.98, -0.31], p = 0.0002, I² = 66.1%), higher response (OR = 0.97 [0.50, 1.44], p < 0.0001, I² = 25.33%) and remission rates (OR = 1.04 [0.55, 1.52], p < 0.0001, I² = 0.00%) than medication with sham rTMS. No additive benefit was found for SNRIs with rTMS (SMD of 0.10 [-0.14, 0.34], p = 0.42, I² = 0.00%; OR = 0.12 [-0.39, 0.62], p = 0.64, I² = 0.00%; OR = -0.31 [-0.90, 0.28], p = 0.86, I² = 39.9%). The overall risk of bias for the included studies ranged from low to high, with 1 study having a high risk of bias.

Interpretation: The combination of rTMS with SSRIs, but not SNRIs, significantly reduced depression severity, increasing response and remission rates. Some analyses demonstrated high heterogeneity, which was influenced by an SSRI trial with a high effect size. Overall, these results suggest that not all antidepressant combination therapies are alike, and SSRIs should be considered when initiating rTMS.

Funding: Donald T. Stuss Young Investigator Research Innovation Award from the Sandra Black Centre for Brain Resilience & Recovery and the Harquail Centre for Neuromodulation through the Sunnybrook Foundation.

Keywords: Antidepressant; Major depressive disorder; Selective serotonin reuptake inhibitors; Serotonin norepinephrine reuptake inhibitors; Transcranial magnetic stimulation.