High-frequency repetitive TMS for suicidal ideation in adolescents with depression

Abstract

Background: This exploratory study sought to examine the effect of an acute course of high-frequency repetitive TMS on suicidal ideation in adolescents.

Methods: Data were pooled from 3 prior protocols providing a 30-session course of open-label TMS treatment for adolescents with treatment-resistant depression. All participants (n = 19) were outpatients taking antidepressant medication, with TMS provided as adjunctive treatment. Suicidality was assessed at baseline, after 10 treatments, after 20 treatments, and after 30 treatments. Outcome measures of suicidal ideation included the Columbia Suicide Severity Rating Scale (C-SSRS) "Intensity of Ideation" subscale and Item 13 "Suicidality" on the Children's Depression Rating Scale, Revised (CDRS-R).

Results: The predicted odds of suicidal ideation (CDRS-R Item 13 and C-SSRS Intensity of Ideation subscale) significantly decreased over 6 weeks of acute TMS treatment without adjustments for illness (depression) severity. However, the magnitude of the decrease in the predicted odds of suicidal ideation across 6 weeks of treatment was attenuated and rendered non-significant in subsequent analyses that adjusted for illness (depression) severity.

Limitations: This was an exploratory study with a small sample size and no sham control. Regulatory and ethical barriers constrained enrollment of adolescents with severe suicidality.

Conclusions: The present findings suggest that open-label TMS mitigated suicidal ideation in adolescents through the treatment and improvement of depressive symptom severity. Although caution is warranted in the interpretation of these results, the findings can inform the design and execution of future interventional trials targeting suicidal ideation in adolescents.

Keywords: Adolescent; Brain stimulation; Depression; Suicidal ideation; Suicidality; Transcranial magnetic stimulation.

Copyright © 2018 Elsevier B.V. All rights reserved.

Figures

Figure 1.

Forest plot, from the ordinal logistic regression (CDRS-R Item 13) and binary logistic regression (C-SSRS), showing the change (or decrease) in the predicted odds of suicidal ideation over the 6 weeks of acute TMS treatment with/without adjusting for the change in illness (depression) severity as a time-varying covariate. The cumulative probabilities were modeled over the higher-ordered suicidal ideation scale score (more suicidal ideation) in the ordinal logistic model for CDRS-R Item 13 and the probability of suicidal ideation was modeled in the binary logistic model for C-SSRS. An estimated Odds Ratio

Figure 2.

Mosaic plots of the observed cumulative frequency distribution for measures of suicidal ideation by TMS visit week. A) The ordinal-scaled suicidal ideation (CDRS-R Item 13) outcome (Rank 1=no suicidal ideation, Rank 6=recurrent thoughts of suicide). B) The binary suicidal ideation outcome (C-SSRS).