Study identifies an optimal rTMS treatment regimen for older adults

A new study published in Frontiers in Aging Neuroscience is the first to identify an optimal Repetitive Transcranial Magnetic Stimulation (rTMS) treatment regimen for older adults with treatment-resistant depression, according to researchers at Hinda and Arthur Marcus Institute for Aging Research and the Deanna and Sidney Wolk Center for Memory Health at Hebrew SeniorLife. A noninvasive procedure, TMS uses magnetic fields to stimulate nerve cells in a specific part of the brain to successfully treat depression, but the study found the treatment response can be slower and take a larger number of rTMS treatment sessions in older adults than with younger individuals. This has implications for best practices as well as healthcare policy.

Major Depressive Disorder (MDD) is a leading cause of disability worldwide, and is common in older adults, affecting up to one third of the population. In order adults, MDD is often resistant to treatment, and treatment is frequently complicated by medical comorbidities and polypharmacy, according to a study conducted by Marcus Institute and Wolk Center researchers published earlier in the year in Ageing Research Reviews. Brain stimulation strategies, and specifically rTMS, have been considered an effective antidepressant treatment for those who do not respond or tolerate other treatment strategies but other studies suggested that rTMS was less effective in older adults. The publication in Ageing Research Reviews showcased a set of novel approaches for the optimization of the TMS protocol for depression and discussed the possibility for a standardized TMS protocol tailored for the treatment of geriatric depression.

The new study, titled "In Older Adults the Antidepressant Effect of Repetitive Transcranial Magnetic Stimulation is Similar but Occurs Later Than in Younger Adults," evaluated the rTMS treatment outcomes in a large international multicenter cohort of more than 500 patients, and specifically compared the response to rTMS in adults younger than 65 compared to those older than 65. Researchers found there is an initial slower response to treatment for older adults than younger adults but that after six weeks, the degree of improvement in older and younger adults is the same. Therefore, the new study provides experimental evidence that while more sessions may be needed in older adult patients to improve depression severity, the efficacy of rTMS is clear and it offers a valuable therapeutic option to an otherwise extremely disabling disease.

Alvaro Pascual-Leone, M.D., Ph.D., Medical Director of the Deanna and Sidney Wolk Center for Memory Health and Senior Scientist at the Hinda and Arthur Marcus Institute for Aging Research at Hebrew Senior Life, is the lead author. "The findings are significant from a healthcare policy perspective because many major insurance providers in the U.S. have coverage policies that hinge on a clinical response within four weeks. They need to expand coverage to at least beyond six weeks of treatment to ensure maximal benefit for older adults who are in particular need of effective treatment option for major depression. It brings new hope to patients and their families that TMS can relieve treatment- resistant depression."

Berenson-Allen Center for Noninvasive Brain Stimulation in Boston, University of Iowa Center for Noninvasive Brain Stimulation in Iowa City, and Champalimaud Foundation Neuropsychiatry Unit in Lisbon, Portugal, collaborated in this study.

This study was funded by Fundação para a Ciência e Tecnologia (FCT; Portugal) through a PhD Scholarship (SFRH/BD/130210/2017); the National Institutes of Health (NIH) (NS114405-02, MH120441-01); FCT (Portugal) through a Junior Research and Career Development Award from the Harvard Medical School – Portugal Program (HMSP-ICJ/0020/2011); PTDC/MED-NEU/31331/2017 and PTDC/MED-NEU/30302/2017. The study also received national funds from FCT/MCTES and co-funded by FEDER, under the Partnership Agreement Lisboa 2020 - Programa Operacional Regional de Lisboa, and from a Starting Grant from the European Research Council under the European Union's Horizon 2020 research and innovation programme (grant agreement no. 950357).

Other authors included: Gonçalo Cotovio, M.D., Ph.D.-candidate, Champalimaud Research & Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal, NOVA Medical School, NMS, Universidade Nova de Lisboa, Lisbon, and Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisbon; Aaron D. Boes, M.D., Ph.D., assistant professor, Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, and associate professor of Pediatrics-General Neurology, the University of Iowa Carver College of Medicine; Daniel Z. Press, M.D., Chief, Division of Cognitive Neurology, and associate professor of Neurology at the Harvard Medical School and the Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center; and Albino J. Oliveira-Maia, M.D., M.P.H., Ph.D., Director of Neuropsychiatry, Champalimaud Research & Clinical Centre, Champalimaud Centre for the Unknown, Lisbon.