title: Repetitive transcranial magnetic stimulation for treatment-resistant depression: a systematic review and meta-analysis.
abstract: OBJECTIVE
  To evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with major depressive disorder (MDD) and 2 or more prior antidepressant treatment failures (often referred to as treatment-resistant depression [TRD]). These patients are less likely to recover with medications alone and often consider nonpharmacologic treatments such as rTMS.
  
  
  METHODS
  We searched MEDLINE, EMBASE, the Cochrane Library, PsycINFO, and the International Pharmaceutical Abstracts for studies comparing rTMS with a sham-controlled treatment in TRD patients ages 18 years or older.
  
  
  METHODS
  We included 18 good- or fair-quality TRD studies published from January 1, 1980, through March 20, 2013.
  
  
  METHODS
  We abstracted relevant data, assessed each study's internal validity, and graded strength of evidence for change in depressive severity, response rates, and remission rates.
  
  
  RESULTS
  rTMS was beneficial compared with sham for all outcomes. rTMS produced a greater decrease in depressive severity (high strength of evidence), averaging a clinically meaningful decrease on the Hamilton Depression Rating Scale (HDRS) of more than 4 points compared with sham (mean decrease = -4.53; 95% CI, -6.11 to -2.96). rTMS resulted in greater response rates (high strength of evidence); those receiving rTMS were more than 3 times as likely to respond as patients receiving sham (relative risk = 3.38; 95% CI, 2.24 to 5.10). Finally, rTMS was more likely to produce remission (moderate strength of evidence); patients receiving rTMS were more than 5 times as likely to achieve remission as those receiving sham (relative risk = 5.07; 95% CI, 2.50 to 10.30). Limited evidence and variable treatment parameters prevented conclusions about which specific treatment options are more effective than others. How long these benefits persist remains unclear.
  
  
  CONCLUSIONS
  For MDD patients with 2 or more antidepressant treatment failures, rTMS is a reasonable, effective consideration.
authors.affiliation: Department of Psychiatry, CB #7160, 304 MacNider Hall, Room J, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7160 bgaynes@med.unc.edu.
authors.forename: Bradley N
authors.initials: BN
authors.lastname: Gaynes
authors.forename: Stacey W
authors.initials: SW
authors.lastname: Lloyd
authors.forename: Linda
authors.initials: L
authors.lastname: Lux
authors.forename: Gerald
authors.initials: G
authors.lastname: Gartlehner
authors.forename: Richard A
authors.initials: RA
authors.lastname: Hansen
authors.forename: Shannon
authors.initials: S
authors.lastname: Brode
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Jonas
authors.forename: Tammeka
authors.initials: T
authors.lastname: Swinson Evans
authors.forename: Meera
authors.initials: M
authors.lastname: Viswanathan
authors.forename: Kathleen N
authors.initials: KN
authors.lastname: Lohr
mesh_terms: D003865:Major Depressive Disorder / Q000628:therapy*; D061218:Depressive Disorder, Treatment-Resistant / Q000628:therapy*; D006801:Humans; D050781:Transcranial Magnetic Stimulation / Q000379:methods*