Dumas R, Padovani R, Richieri R, Lançon C
Pôle universitaire de psychiatrie, hôpital Sainte-Marguerite, Marseille cedex, France.
Encephale. 2012 Sep;38(4):360-8. doi: 10.1016/j.encep.2011.08.004. Epub 2011 Oct 11.
Repetitive transcranial magnetic stimulation (rTMS) is a brain stimulation technique that has been investigated as a novel treatment for psychiatric disorders, notably in major depression, and has shown statistically significant effects. The authors found it necessary to propose an up-to-date review of positive predictors for antidepressive response to repetitive transcranial magnetic stimulation.
Based on an exhaustive consultation of Medline data, supplemented by a manual research, only works evaluating response factors of rTMS in major depression were retained.
Twenty-nine studies were retained, including meta-analyses, reviews, randomized controlled trials and open trials. The most concordant data clearly indicate that a high score of treatment resistance, a long duration of current episode, advanced age, and psychotic symptoms are negative predictors for treatment response to rTMS. In the older patients, menopausal women are especially concerned. However, some parameters should be adapted to the degree of cortical atrophy such as intensity of stimulation or total number of rTMS sessions. Previous response to rTMS therapy seems to be a good predictor contrary to non-response to electroconvulsive therapy. Adjunctive antidepressant treatment shows greater responsiveness to rTMS contrary to benzodiazepine or anticonvulsant treatment. To our knowledge, no study compares unipolar and bipolar depression, the profile of depression is not established yet. Imaging studies show that TMS antidepressant responders differed from non-responders in inferior frontal activity, at baseline, and even more so following treatment. Furthermore, reduced baseline cerebral metabolism in cerebellar, temporal, anterior cingulate and occipital regions of the brain was correlated with improvement after two weeks of fast (20Hz) left dorsolateral prefrontal cortex (DLPFC) rTMS. Additionally, a right frontal region emerges with divergent polarity in the metabolic prediction of response to low rTMS. Inhibiting right DLPFC or stimulating DLPFC shows similar results, the choice on the side of stimulation does not seem determining. Bilateral stimulation for the moment does not seem superior to unilateral stimulation. Parameters of stimulation associated with effectiveness of rTMS are an intensity of stimulation higher than 100% of the motor threshold, a number of stimulations per sessions superior to 1000, and a full number of days of treatment greater than 10.
Parameters of stimulation must be adapted according to the treated patients. For example, older patients who present cortical atrophy need higher intensity of stimulation. Other criteria could influence effectiveness of rTMS in the same way. Would it be necessary, for example, to adapt the duration or the intensity of stimulation according to the severity of the depressive episode or its duration of evolution? Do antecedents of resistance to a pharmacological treatment oblige us to stimulate differently? Few studies exceed 10 days of treatment; will longer duration of treatment be more effective? Also, we did not find any data on the interest of maintenance treatment among responders. Should the characteristics of the depressive disorder or its evolution require maintenance treatment? What will be its rhythm and its duration? Should we adapt rTMS parameters to abnormalities highlighted by functional neuroimagery? The prospects for work remain numerous.
重复经颅磁刺激（rTMS）是一种脑刺激技术，已被研究作为治疗精神疾病的新方法，尤其是在重度抑郁症中，并已显示出统计学上的显著效果。作者认为有必要对重复经颅磁刺激抗抑郁反应的阳性预测因素进行最新综述。
在对Medline数据进行详尽查询并辅以手工检索的基础上，仅保留评估rTMS在重度抑郁症中反应因素的研究。
共保留29项研究，包括荟萃分析、综述、随机对照试验和开放试验。最一致的数据清楚表明，高治疗抵抗评分、当前发作持续时间长、高龄和精神病性症状是rTMS治疗反应的阴性预测因素。在老年患者中，绝经后女性尤其受关注。然而，一些参数应根据皮质萎缩程度进行调整，如刺激强度或rTMS疗程总数。与电休克治疗无反应相反，既往对rTMS治疗的反应似乎是一个良好的预测因素。辅助抗抑郁治疗对rTMS的反应性更高，与苯二氮䓬类或抗惊厥治疗相反。据我们所知，尚无研究比较单相和双相抑郁症，抑郁症的特征尚未确立。影像学研究表明，在基线时，rTMS抗抑郁反应者与无反应者在下额叶活动方面存在差异，治疗后差异更大。此外，大脑小脑、颞叶、前扣带回和枕叶区域基线脑代谢降低与快速（20Hz）左侧背外侧前额叶皮质（DLPFC）rTMS治疗两周后的改善相关。此外，在低强度rTMS反应的代谢预测中，右额叶区域出现了不同的极性。抑制右DLPFC或刺激DLPFC显示出相似的结果，刺激侧的选择似乎不起决定性作用。目前双侧刺激似乎并不优于单侧刺激。与rTMS有效性相关的刺激参数包括高于运动阈值100%的刺激强度、每次疗程超过1000次的刺激次数以及超过10天的完整治疗天数。
刺激参数必须根据所治疗的患者进行调整。例如，存在皮质萎缩的老年患者需要更高的刺激强度。其他标准可能以同样的方式影响rTMS的有效性。例如，是否有必要根据抑郁发作的严重程度或其演变持续时间来调整刺激的持续时间或强度？药物治疗抵抗史是否迫使我们采用不同的刺激方式？很少有研究超过10天的治疗；更长的治疗时间会更有效吗？此外，我们未找到关于反应者维持治疗益处的任何数据。抑郁症的特征或其演变是否需要维持治疗？其节奏和持续时间会是怎样？我们是否应根据功能神经影像学突出显示的异常来调整rTMS参数？研究前景仍然广阔。
