Appraising the effectiveness of electrical and magnetic brain stimulation techniques in acute major depressive episodes: an umbrella review of meta-analyses of randomized controlled trials

Laís B Razza, Leonardo Afonso Dos Santos, Lucas Borrione, Helena Bellini, Luis C Branco, Eric Cretaz, Dante Duarte, Ygor Ferrão, Ricardo Galhardoni, João Quevedo, Marcel Simis, Felipe Fregni, Christoph U Correll, Frank Padberg, Alisson Trevizol, Zafiris J Daskalakis, Andre F Carvalho, Marco Solmi, André R Brunoni, Laís B Razza, Leonardo Afonso Dos Santos, Lucas Borrione, Helena Bellini, Luis C Branco, Eric Cretaz, Dante Duarte, Ygor Ferrão, Ricardo Galhardoni, João Quevedo, Marcel Simis, Felipe Fregni, Christoph U Correll, Frank Padberg, Alisson Trevizol, Zafiris J Daskalakis, Andre F Carvalho, Marco Solmi, André R Brunoni

Abstract

Electrical and magnetic brain stimulation techniques present distinct mechanisms and efficacy in the acute treatment of depression. This was an umbrella review of meta-analyses of randomized controlled trials of brain stimulation techniques for managing acute major depressive episodes. A systematic review was performed in the PubMed/MEDLINE databases from inception until March 2020. We included the English language meta-analysis with the most randomized controlled trials on the effects of any brain stimulation technique vs. control in adults with an acute depressive episode. Continuous and dichotomous outcomes were assessed. A Measurement Tool to Assess Systematic Reviews-2 was applied and the credibility of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework. Seven meta-analyses were included (5,615 patients), providing evidence for different modalities of brain stimulation techniques. Three meta-analyses were evaluated as having high methodological quality, three as moderate, and one as low. The highest quality of evidence was found for high frequency-repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation, and bilateral rTMS. There is strong clinical research evidence to guide future clinical use of some techniques. Our results confirm the heterogeneity of the effects across these techniques, indicating that different mechanisms of action lead to different efficacy profiles.

Conflict of interest statement

CUC has been a consultant and/or advisor to or has received honoraria from Acadia, Alkermes, Allergan, Angelini, Axsome, Gedeon Richter, Gerson Lehrman Group, IntraCellular Therapies, Janssen/J&J, LB Pharma, Lundbeck, MedAvante-ProPhase, Medscape, Neurocrine, Noven, Otsuka, Pfizer, Recordati, Rovi, Sumitomo Dainippon, Sunovion, Supernus, Takeda, and Teva; has provided expert testimony for Janssen and Otsuka; has served on a Data Safety Monitoring Board for Lundbeck, Rovi, Supernus, and Teva; has received grant support from Janssen and Takeda; has received royalties from UpToDate; and is a stock option holder of LB Pharma. FP is a member of the European Scientific Advisory Board of Brainsway Inc., Jerusalem, Israel; has received speaker’s honoraria from Mag & More GmbH and the neuroCare Group; his lab has received support with equipment from neuroConn GmbH, Ilmenau, Germany, Mag & More GmbH, and Brainsway Inc., Jerusalem, Israel. ARB is chief medical advisor of Flow™ and has small equity in the company. The other authors report no conflicts of interest.

Figures

Figure 1. Flowchart of the included meta-analyses.…
Figure 1. Flowchart of the included meta-analyses. MA = meta-analysis; RCTs = randomized controlled trials; SR = systematic-review.

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