Magnetic Seizure Therapy for Suicidality in Treatment-Resistant Depression

Abstract

Importance: There is an unmet need for effective treatments for suicidality in mental disorders. Magnetic seizure therapy (MST) has been investigated as an alternative to electroconvulsive therapy, a known effective treatment for suicidality, in the management of treatment-resistant major depressive disorder, with promising findings. Yet, there are very limited data on the association of MST with suicidality directly. It is important to explore the potential of MST as a viable treatment alternative to electroconvulsive therapy for suicidality.

Objective: To determine the association of MST with suicidality in patients with treatment-resistant major depressive disorder.

Design, setting, and participants: This nonrandomized controlled trial took place at a single tertiary care psychiatric facility in Canada. It followed an open-label study design with consecutive treatment cohorts. Consecutive groupings of 67 patients with treatment-resistant major depressive disorder and with baseline suicidality present were treated for up to 24 treatments. The study was run from February 2012 through June 2019. Patients were followed up for 6 months at the end of the treatment period. This post hoc secondary analysis of the trial was performed from January to November 2019.

Interventions: MST was delivered at 100% stimulator output over the prefrontal cortex with low (25 Hz), moderate (50 or 60 Hz), or high (100 Hz) frequency, for a maximum of 24 sessions.

Main outcomes and measures: Remission from suicidality was measured as an end point score of 0 on the Beck Scale for Suicidal Ideation. A linear mixed model was used to assess the trajectory of Beck Scale for Suicidal Ideation scores.

Results: A total of 67 patients (mean [SD] age, 46.3 [13.6] years; 40 women [60.0%]) received a mean (SD) of 19.5 (5.1) MST treatments. The overall number of patients achieving remission was 32 (47.8%). Sixteen patients (55.2%) receiving low-frequency MST achieved remission, as well as 12 patients (54.5%) in the moderate-frequency group, and 4 patients (25.0%) in the high-frequency group. The linear mixed model revealed an association of time with Beck Scale for Suicidal Ideation scores (F8,293.95 = 5.73; P < .001).

Conclusions and relevance: These findings suggest that MST may be an effective treatment for suicidality, and sensitivity analysis shows this may be particularly so at low and moderate frequencies. Future studies should directly compare MST with electroconvulsive therapy for treating suicidality and should evaluate MST as a treatment for suicidality across mental disorders.

Trial registration: ClinicalTrials.gov Identifier: NCT01596608.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Blumberger reported receiving grants from Brain Canada, Canadian Institutes of Health Research (CIHR), National Institutes of Health (NIH), and the Temerty Family Foundation through the Centre for Addiction and Mental Health (CAMH) Foundation and the Campbell Family Research Institute; in-kind equipment support from MagVenture; research support and in-kind equipment support from Brainsway; and medication supplies for an investigator-initiated trial from Indivior outside the submitted work. Dr Voineskos reported receiving research training fellowship funding from the Ontario Mental Health Foundation, an American Psychiatric Association/Eli Lilly research fellowship, a CAMH postdoctoral fellowship, and support from the Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario. Dr Downar reported being a medical advisor for TMS Neuro Solutions and NeuroStim Health; receiving grants from NIH, CIHR, Brain Canada, Ontario Brain Institute, Arrell Family Foundation, and Buchan Family Foundation; and receiving nonfinancial support from MagVenture outside the submitted work. Dr Mulsant reported receiving research support from Brain Canada, CIHR, the CAMH Foundation, the Patient-Centered Outcomes Research Institute, NIH, Capital Solution Design (software used in a study founded by CAMH Foundation), HAPPYneuron (software used in a study founded by Brain Canada), Eli Lilly (medications for a NIH-funded clinical trial), and Pfizer (medications for a NIH-funded clinical trial) outside the submitted work and reported owning stock in General Electric (<$5000). Dr Rajji reported receiving research support from Brain Canada, Brain and Behavior Research Foundation, BrightFocus Foundation, Canada Foundation for Innovation, Canada Research Chair, CIHR, Centre for Aging and Brain Health Innovation, NIH, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research and Innovation, and the Weston Brain Institute; in-kind equipment support for an investigator-initiated study from Magstim; and in-kind research accounts from Scientific Brain Training Pro. Dr Fitzgerald reported receiving a Practitioner Fellowship grant from National Health and Medical Research Council (1078567); receiving equipment for research from MagVenture, Medtronic, Neurosoft, and Brainsway; serving on scientific advisory boards for Bionomics and LivaNova; and acting as a founder for TMS Australia. Dr Daskalakis reported receiving research grants and in-kind equipment support for an investigator-initiated study through Brainsway and MagVenture and receiving support from the Ontario Mental Health Foundation, CIHR, the National Institutes of Mental Health, and the Temerty Family and Grant Family through the CAMH Foundation and the Campbell Institute. No other disclosures were reported.

Figures

Figure 1.. Patient Flow Diagram

Adapted from Daskalakis et al, 2020. MST indicates magnetic seizure therapy. aPatients completed trial as per primary depression outcome.

Figure 2.. Rates of Remission From Suicidality Indexed by Beck Scale for Suicidal Ideation (SSI) Scores in the Adequate Trial Completers and Protocol Completer Groups

There were 67 patients in adequate trial completer group (ie, participants who completed ≥8 magnetic seizure therapy [MST] sessions) and 36 patients in the protocol completer group (ie, those who attained remission from depression or completed 24 MST sessions, which is the maximum). MST frequencies are defined as low (25 Hz), moderate (50 or 60 Hz), and high (100 Hz). Vertical lines and error bars indicate SEs.

Figure 3.. General Linear Mixed Model of Beck Scale for Suicidal Ideation (SSI) Total Scores by Treatment Frequency With Group-by-Time Interaction

Magnetic seizure therapy frequencies are defined as low (25 Hz), moderate (50 or 60 Hz), and high (100 Hz).