Bilateral Repetitive Transcranial Magnetic Stimulation Decreases Suicidal Ideation in Depression
Abstract
Objective The purpose of this study was to evaluate the effects of repetitive transcranial magnetic stimulation (rTMS) on suicidal ideation in patients with treatment-resistant major depression (TRD) (patients who failed to clinically respond to at least 2 medication trials). Methods We pooled data from 2 published prospective randomized controlled trials of rTMS applied to the dorsolateral prefrontal cortex in patients with TRD. We compared the effect of bilateral, left unilateral, and sham rTMS on suicidal ideation as measured by the suicide item of the 17-item Hamilton Depression Rating Scale (HDRS) (N = 156). Results Suicidal ideation resolved in 40.4%, 26.8%, and 18.8% of participants randomized to bilateral, left unilateral, and sham rTMS, respectively. The difference between bilateral and sham was significant (OR = 3.03; 95% CI, 1.19-7.71; P = .02), unlike the difference between left unilateral and sham (OR = 1.59; 95% CI, 0.61-4.12; P = .33). There was a modest correlation between change in suicidal ideation and change in depression severity (Pearson r = 0.38; P Conclusions Bilateral rTMS was superior to sham rTMS in reducing suicidal ideation in patients with TRD. Only a small portion of the reduction in suicidal ideation was attributable to the reduction in depressive symptoms. These data suggest that suicidal ideation could be a specific target symptom construct for rTMS. Trial registration ClinicalTrials.gov identifiers: NCT01515215 and NCT00305045.
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A study of pooled sham-controlled trials reported that bilateral TMS is associated with a decline in SI.
“In addition, a study of pooled sham-controlled trials reported that bilateral TMS is associated with a decline in SI [74].”
Several repetitive TMS trials among individuals with suicidal ideation and major depression have shown reductions in suicidality.
“Several repetitive TMS (the precursor to iTBS) trials among individuals with SI and major depression have shown reductions in suicidality [71-74].”
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Self-citationTranscranial magnetic stimulation to reduce suicidality – A review and naturalistic outcomes
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“Eight studies utilized figure-of-eight TMS coils with parameters used in the treatment of depression (Croarkin et al., 2018; George et al., 2014; Hadley et al., 2011; Keshtkar et al., 2011; Rao et al., 2019; Weissman et al., 2018; Yesavage et al., 2018), two utilized intermittent theta burst stimulation (iTBS) (Cole e…”
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“They found a significant superiority of bilateral rTMS to sham rTMS in reducing suicidal ideation, with only a small portion of this reduction in suicidal ideation attributable to the improvement of overall depressive symptoms (59).”
BackgroundAaronson, S. T., Carpenter, L. L., Hutton, T. M., Kraus, S., Mina, M., Pages, K., Shi, L., West, W. S., & Sackeim, H. A. (2022) · Brain Stimulation · doi:10.1016/j.brs.2022.01.006 · Cited by 50 · see citing works
“In a study pooling data from two RCTs, SBL TMS was superior to both sham and HF-LUL stimulation in reducing suicidal ideation, and the change in suicidal ideation was only modestly associated with the change in depressive symptoms [36].”
MethodRepetitive transcranial magnetic stimulation and its role in suicidality - A systematic review.
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“There is evidence of limited reduction in suicidal ideation among those with TRD using pharmacotherapy(78) and more promising results using bilateral rTMS versus sham.(79) Our data do not support such an impact using accelerated iTBS applied to the left DLPFC.”
ResultMagnetic Seizure Therapy for Suicidality in Treatment-Resistant Depression
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Self-citationEffects of repetitive transcranial magnetic stimulation on suicidal behavior: A systematic review.
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“Bilateral TMS resulted instead effective when compared with placebo (Weissman et al., 2018).”
ResultSelf-citationChen, G.-W., Hsu, T.-W., Ching, P., Pan, C.-C., Chou, P.-H., & Chu, C.-S. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.884390 · Cited by 30 · see citing works
“Regarding method of targeting, several different kinds of methods were used, including neuro-navigation (37, 38, 46), 5-cm rule (41), mixed 5-cm rule and neuro-navigation (39), and the International 10–20 System for Electrode Placement (43, 47).”
BackgroundMethodInfluentialLin, C., Park, C., & McIntyre, R. S. (2019) · Journal of Affective Disorders · doi:10.1016/j.jad.2019.04.082 · Cited by 34 · see citing works
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Self-citationA Systematic Review of Neuromodulation Treatment Effects on Suicidality
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“Another sham-controlled randomized trial included 108 patients receiving sequential, bilateral (n = 52), or unilateral (n = 56) rTMS for TRD and 48 control patients matched for age, sex, and diagnosis receiving sham treatment (Weissman et al., 2018).”
BackgroundMethodTrevizol, A., & Blumberger, D. (2019) · Clinical pharmacology and therapy · doi:10.1002/cpt.1550 · Cited by 22 · see citing works
“Therefore, bilateral rTMS may address one of the factors that contribute to the variability in response rates in rTMS for MDD—not stimulating the involved cortical region.(12,13) Although a recent network meta-analysis(4) demonstrated a robust superiority of bilateral rTMS over sham (OR, 3.”
BackgroundSelf-citationWeissman, C., Hadas, I., Yu, D., Jones, B. D. M., Kong, D., Mulsant, B., Blumberger, D., & Daskalakis, Z. (2021) · Neuropsychopharmacology · doi:10.1038/s41386-020-00953-9 · Cited by 19 · see citing works
Self-citationMultimodal Elements of Suicidality Reduction After Transcranial Magnetic Stimulation
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“Similarly, a study pooling data from multiple sham-controlled RCTs found that bilateral TMS was associated with reductions in suicidal ideation (17).”
BackgroundLiu, J., Shu, Y., Wu, G., Hu, L., & Cui, H. (2024) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1321660 · Cited by 12 · see citing works
“Some new studies showed that bilateral rTMS treatment was more effective for treating depressive symptoms than unilateral, sham stimulation or medicine only (19, 20).”
BackgroundZhang, T.-H., Zhu, J.-J., Wang, J.-J., Tang, Y.-Y., Xu, L.-H., Tang, X.-C., Hu, Y.-G., Wei, Y.-Y., Cui, H.-R., Liu, X.-H., et al. (2020) · Journal of ECT · doi:10.1097/yct.0000000000000739 · Cited by 15 · see citing works
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“Supplementally, rTMS has shown efficacy for reducing SI in approximately 40% of individuals with treatment-resistant depression.(92) Significant reductions in SI have also been seen at the end of ECT treatment, in up to 80% of patients with depression.”
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“…protocol were not specified in twelve studies (Berlim et al., 2014; George et al., 2014; Hadley et al., 2011; Hunt et al., 2011; Keshtkar et al., 2011; Liang et al., 2017; MunkOlsen et al., 2007; Nordenskjöld et al., 2013; Popiolek et al., 2018; Sun et al., 2016, 2018; Weissman et al., 2018).”
BackgroundMethodResultInfluentialThe functional relevance of right DLPFC and VMPFC in risk-taking behavior.
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“TMS been applied in various clinical studies where the rates of suicidal ideation among participants with major depression disorder could significantly be reduced through prefrontal TMS (Croarkin et al., 2018; Cui et al., 2022; Weissman et al., 2018).”
MethodAdding Cognitive Therapy to Antidepressant Medications Decreases Suicidal Ideation
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“We therefore used single-item measures, following the lead of previous studies (Kellner et al., 2005; Kowal et al., 2014; Szanto et al., 2003; Weissman et al., 2018; Weitz et al., 2014), as well as studies showing the validity of this approach (Desseilles et al.”
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“Future studies should therefore consider the right DLPFC as potential treatment target as suggested by Weissman and colleagues [36].”
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“Regarding optimal sequence in this population, low-frequency (1 Hz) TMS offers advantages for safety and tolerability, while achieving similar therapeutic effects to other protocols against depression and anxiety [9] and potentially superior effects against suicidality [10].”
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“Superior effects of bilateral versus left unilateral DLPFC-TMS on anxiety and suicidality have previously been reported in adults [9].”
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“In addition, a study of pooled sham-controlled trials reported that bilateral TMS is associated with a decline in SI [74].”
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“4, 26.8, and 18.8% of participants randomized to bilateral, left unilateral, and sham rTMS, respectively [24].”
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“…DLPFC and excitatory stimulation to the left DLPFC, perhaps due in part to the DLPFC exerting executive and cognitive control of negative emotion [14]. rTMS is also being increasingly explored as a treatment option for OUD, with some early clinical trials demonstrating a reduction of opioid…”
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“…(L-DLPFC) has been associated with negative affective judgments, 190 whereas the right dorsolateral prefrontal cortex (R-DLPFC) shows an association with suicidal ideation (SI); 191 the VMPFC plays a pivotal role in emotion processing and is particularly sensitive to reward and value functions.”
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Emerging pharmacological and neuromodulation interventions for suicidal ideation and behaviour.
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“Both studies applied 1Hz to the right dlPFC, and 10Hz to the left dlPFC, at 100-120% MT. Weissman et al. (2018) found bilateral rTMS reduced STB in the active treatment arm, and this differed significantly to the sham arm ( p =.020) and differed to their null finding for left dlPFC rTMS."Treatments…”
InfluentialNon-invasive Brain Stimulation in the Management of Suicidal Behavior
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- Authors
- Weissman, C. R., Blumberger, D. M., Brown, P. E., Isserles, M., Rajji, T. K., Downar, J., Mulsant, B. H., Fitzgerald, P. B., & Daskalakis, Z. J.
- Affiliations
- Centre for Addiction and Mental Health (CA)
- University of Toronto (CA)
- University Health Network (CA)
- Monash Alfred Psychiatry Research centre (AU)
- ORCID
- Venue
- The Journal of Clinical Psychiatry
- Publisher
- Physicians Postgraduate Press, Inc
- Published
- 2018-06-27
- Volume
- 79
- Issue
- 3
- ISSN
- 0160-6689 (ISSN-L)
- OpenAlex
- W2801724856
- Cited by
- 67
- References
- 0
- Citations by year
- 2026: 5 · 2025: 11 · 2024: 11 · 2023: 2 · 2022: 12 · 2021: 10 · 2020: 11 · 2019: 5
- FWCI
- 2.85
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Clinical Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Life Sciences › Neuroscience › Neurology › Transcranial Magnetic Stimulation Studies
- Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
- Health Sciences › Medicine › Psychiatry and Mental health › Electroconvulsive Therapy Studies
- Keywords
- repetitive transcranial magnetic stimulation, suicidal ideation, treatment-resistant depression, dorsolateral prefrontal cortex, sham rTMS, depression severity, Hamilton Depression Rating Scale
- MeSH terms
- Adolescent, Adult, Aged, Aged, 80 and over, Major Depressive Disorder, Female, Humans, Male, Middle Aged, Severity of Illness Index, Randomized Controlled Trials as Topic, Outcome Assessment, Health Care, Prefrontal Cortex, Transcranial Magnetic Stimulation, Young Adult, Suicidal Ideation, Depressive Disorder, Treatment-Resistant
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