Network meta-analysis on non-invasive brain stimulation for acute major depressive episode treatment

114 

Abstract Submission 

Ping Wang¹, Yingxue Gao¹, Shuangwei Chai¹, Jiawen Tian¹, Zilin Zhou¹, Hailong Li¹, Lianqing Zhang¹, Weijie Bao¹, Xinyue Hu¹, Yidan Wang¹, Xiaoqi Huang¹

¹Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University, Chengdu, China

Ping Wang  
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, China

Yingxue Gao  
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, China

Shuangwei Chai  
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, China

Jiawen Tian  
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, China

Zilin Zhou  
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, China

Hailong Li  
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, China

Lianqing Zhang  
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, China

Weijie Bao  
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, China

Xinyue Hu  
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, China

Yidan Wang  
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, China

Xiaoqi Huang  
Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University
Chengdu, China

Major depressive disorder (MDD) is a highly prevalent illness worldwide, with more than 264 million people affected. Its clinical course is often recurrent and can become chronic, with relapse rates of up to 80% within one year of remission. Although there are effective pharmacological and psychological therapies for MDD, even with a full course of treatment, at least one third of patients fail to achieve remission. Non-invasive brain stimulation (NIBS) therapies, such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), offer a potential alternative or add-on treatment strategy. Previous meta-analyses provide limited insights into the overall treatment hierarchy because treatment effects are estimated from, and presented for, a subset of relevant treatment comparisons only. We sought to perform a systematic review and meta-analysis of the antidepressant efficacy and tolerability of non-invasive neuromodulation in treating current depressive episode in major depressive disorder from randomized sham-controlled trials (RCTs), to estimate the comparative clinical efficacy and acceptability of NIBS for the acute treatment of major depressive episodes in adults.

The databases PubMed, Embase, and Web of Science were searched for randomized controlled trials (RCTs) reporting on the therapeutic efficacy of transcranial magnetic stimulation (repetitive (rTMS), accelerated, priming, deep, and synchronised), theta burst stimulation (bilateral, intermittent, continuous), transcranial direct current stimulation (tDCS) for MDD compared to sham, published until October 2023. Study and sample demographic characteristics as well as all of the above non-invasive brain stimulation parameters and outcome variables were extracted. Effect sizes were calculated for change in depression score and risk ratios for response and discontinuation.

95 RCTs (202 treatment arms) that randomised 5385 patients (mean age 45.6 years; 54.1% women) with major depressive disorder met the inclusion criteria and were included in this meta-analysis. We analyzed effects on response, all-cause discontinuation rates and continuous depression severity measures. The most studied treatment comparisons were high frequency left rTMS and tDCS versus sham therapy, whereas recent studies have gradually turned to focus on cognitive function in the past five years. In network meta-analysis, 12 out of 13 treatment strategies were associated with higher response compared with sham therapy: priming transcranial magnetic stimulation (summary odds ratio 3.67, 95% confidence interval 1.19 to 11.36), bilateral theta burst stimulation (3.67, 1.43 to 9.49), low frequency right repetitive TMS (3.10, 1.73 to 5.53), bilateral TMS (3.03, 1.73 to 5.37), high frequency right repetitive TMS (2.61, 0.66 to 10.28), high frequency left repetitive TMS (2.51, 1.92 to 3.29), and synchronized TMS (2.27, 0.79 to 6.49). It's worth noting that one of the most efficacious treatment bilateral theta burst stimulation also accompanied the highest all-cause discontinuation rates, meanwhile most other treatment strategies were at least as tolerable as sham therapy.

As far as we know, our study is the largest and most comprehensive network meta-analysis of NIBS for MDD so far. We found that there is strong evidence for the application of non-invasive brain stimulation techniques as alternative or add-on treatments for adults with major depressive episodes. Our findings also highlight important research priorities in the specialty of brain stimulation, such as the need to conduct further randomized controlled trials for novel treatment protocols such as tDCS or pTMS, to warrant more direct comparisons between different treatment modalities, and to examine what biomarkers are available to predict cognitive response in MDD patients.

TDCS

TMS ¹

Psychiatric (eg. Depression, Anxiety, Schizophrenia) ²

Affective Disorders

Meta- Analysis

Transcranial Magnetic Stimulation (TMS)

Treatment

Other - transcranial direct current stimulation