Elsevier

Journal of Psychiatric Research

Volume 152, August 2022, Pages 384-396
Journal of Psychiatric Research

A transdiagnostic review of safety, efficacy, and parameter space in accelerated transcranial magnetic stimulation

https://doi.org/10.1016/j.jpsychires.2022.06.038Get rights and content
Under a Creative Commons license
open access

Highlights

  • This review reports the safety, efficacy, and parameter space of accelerated transcranial magnetic stimulation (aTMS).

  • Accelerated TMS is safe and well tolerated, with similar rates of seizure and side effects as once daily rTMS.

  • In aTMS for depression, the average response rate was 42.4% and average remission rate was 28.4% (range = 0–90.5% for both).

  • Number of sessions/day, intersession interval, and total sessions may impact treatment response.

  • Future directions include investigating the safety profile, durability of response, and optimization of parameters in aTMS.

Abstract

Background

Accelerated transcranial magnetic stimulation (aTMS) is an emerging delivery schedule of repetitive TMS (rTMS). TMS is “accelerated” by applying two or more stimulation sessions within a day. This three-part review comprehensively reports the safety/tolerability, efficacy, and stimulation parameters affecting response across disorders.

Methods

We used the PubMed database to identify studies administering aTMS, which we defined as applying at least two rTMS sessions within one day.

Results

Our targeted literature search identified 85 aTMS studies across 18 diagnostic and healthy control groups published from July 2001 to June 2022. Excluding overlapping populations, 63 studies delivered 43,873 aTMS sessions using low frequency, high frequency, and theta burst stimulation in 1543 participants. Regarding safety, aTMS studies had similar seizure and side effect incidence rates to those reported for once daily rTMS. One seizure was reported from aTMS (0.0023% of aTMS sessions, compared with 0.0075% in once daily rTMS). The most common side effects were acute headache (28.4%), fatigue (8.6%), and scalp discomfort (8.3%), with all others under 5%. We evaluated aTMS efficacy in 23 depression studies (the condition with the most studies), finding an average response rate of 42.4% and remission rate of 28.4% (range = 0–90.5% for both). Regarding parameters, aTMS studies ranged from 2 to 10 sessions per day over 2–30 treatment days, 10–640 min between sessions, and a total of 9–104 total accelerated TMS sessions per participant (including tapering sessions). Qualitatively, response rate tends to be higher with an increasing number of sessions per day, total sessions, and total pulses.

Discussion

The literature to date suggests that aTMS is safe and well-tolerated across conditions. Taken together, these early studies suggest potential effectiveness even in highly treatment refractory conditions with the added potential to reduce patient burden while also expediting response time. Future studies are warranted to systematically investigate how key aTMS parameters affect treatment outcome and durability.

Keywords

Accelerated TMS (aTMS)
Intensive rTMS
High dose rTMS
Transcranial magnetic stimulation
Theta burst stimulation
Transdiagnostic review

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