Type of transcranial magnetic stimulation is ineffective for mixed depression – 07/25/2021

Results of a survey conducted at the Institute of Psychiatry (IPq) of the Hospital das Clínicas (HC) of the Faculty of Medicine (FM) of USP rule out the use of transcranial magnetic stimulation, theta-burst modality (TBS), in the treatment of people with depression mixed – a subgroup of the disease with poor response to conventional treatment of depression, antidepressants.

The study, which lasted six weeks and included the participation of 90 volunteers with bipolar disorder and major depressive disorder (classic depression), showed an ineffectiveness in resolving symptoms in this type of depression, confirming other studies that show the resistance of these patients to conventional treatments.

The results obtained are of great importance because they will serve to guide the decision of physicians regarding the most appropriate protocols to treat patients with mixed symptoms of depression in real life. An article describing the study was published on June 30 in the journal Neuropsychopharmacology – Pubmed.

According to psychiatrist Diego Freitas Tavares, from IPq, author of the research and the first author of the article, mixed depression presents itself as a different picture in terms of clinical course, with high recurrence (more than three depressive episodes throughout life) and with less response to conventional treatments. It occurs both in people with classic depression and in people with bipolar disorder. In mixed depression, there is a varied combination of symptoms of depression and agitation, which brings more suffering to patients, reports Tavares to Jornal da USP.

The main symptoms include depressed mood (sadness, guilt and a feeling of worthlessness), reduced ability to enjoy things and lack of energy and motivation – typical of a common depression. Associated with these issues, the patient can also be affected by a large amount of thoughts, difficulty concentrating, irritability and increased impulsiveness – characteristic of activation. “In these situations, antidepressants tend to worsen depression, intensifying agitation, irritability, insomnia, anxiety, the amount of thoughts, difficulty concentrating and sadness, with the appearance of anguish and despair, and more behaviors compulsive (eating, smoking, drinking, spending, masturbating, etc.)”, he explains.

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Transcranial magnetic stimulation

According to the researcher, transcranial magnetic stimulation (TMS) is a non-pharmacological technique already widely used in the treatment of mood disorders (depression and bipolar disorder). It is considered a neuromodulation technique as it would have the ability to regulate brain function without the use of psychotropic drugs. The technique consists of using magnetic waves that will produce changes in brain neurocircuits, which modulate the regions involved with mood disorders, with limbic areas and associated with energy levels, impulse and thought, he explains.

More recently, a new modality of magnetic stimulation, TBS, was developed, whose main advantage would be the shorter duration of the session compared to conventional EMT: around 10 minutes in TBS, whereas conventional EMT lasts for about 45 minutes.

How the study was done

The research was conducted using a randomized, controlled and double-blind clinical trial methodology (method in which neither the research volunteer nor the investigator know what is being used) so that there is no tendency to bias the data evaluation.

Volunteers were recruited through social networks and had as criteria to have had moderate or severe severe depressive episodes with mixed characteristics and to have received at least one first or second-line pharmacological treatment, with no positive response. After this stage, and after a face-to-face screening for clinical and neuropsychological evaluation, the 90 patients who actually participated in the research were selected. The group consisted mostly of women aged between 18 and 65 years.

At the research center, patients were divided into two groups, half received the magnetic stimuli (active group) and the other not (simulated group), remembering that neither the patients nor the researchers knew which groups each patient was in. Likewise, all underwent the same procedure, with the difference that, for one of the groups, the equipment simulated the emission of the magnetic stimulus but did not do it.

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It took six weeks of research and observations. In the first three weeks, daily sessions were administered (one session per day, for five consecutive days) and in the following weeks, the technique was conducted more spaced (one session, two days a week) to minimize the effects of discontinuity of the interventions.


At the end of the six weeks, the researchers found that, although the technique has shown safety and good tolerance, there were no significant differences in the improvement of the depression picture between the patients in the two groups, including a tendency to worsen in the participants who belonged to the group. active. Active and simulated stimulations were similar in the rate of adverse events (headache, neck pain, scalp pain, scalp burning, hearing difficulty, difficulty concentrating, cognitive changes, mood swings and seizures) and severe (depression worsening and manic upset resulting from the treatment).

Diego Tavares said his initial hypothesis was that patients who received active TBS had a greater reduction in mixed depressive symptoms compared to those who received sham TBS, suggesting that TBS had a mood-stabilizing effect, but this result was not confirmed in practice.

Currently, the most suitable treatment for this type of depression is mood stabilizers, a class of drugs that includes some drugs such as lithium, anticonvulsants (valproic acid and carbamazepine) and antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, among others others), concludes the researcher.

Types of Depression

According to psychiatric doctor Diego Tavares, depression does not manifest itself identically in people and each spectrum of the disease requires careful evaluation and monitoring by a health professional.

  • In melancholic depression, the most common symptoms are sadness, guilt, feelings of worthlessness and hopelessness, insomnia, lack of appetite, a drop in concentration and a drop in libido.
  • In atypical depression, the symptoms of melancholic depression are reversed: instead of insomnia, the person has excessive sleep; instead of lack of appetite, there is also binge eating.
  • In anxious depression, the person has fear, worries and negative anticipation of the future. In mixed depression, thoughts are accelerated, there is greater irritability and compulsive shopping behaviors, sex and how to react to situations and to others.
  • In psychotic depression, in addition to the typical symptoms of depression, the person has delusions (unrealistic beliefs, such as being persecuted) and hallucinations (seeing or hearing things that others are not noticing).
  • Postpartum depression is linked to the drop in hormone production that occurs soon after childbirth.
  • And seasonal depression is associated with lack of sunlight and tends to affect people who live in countries with very cold climates, such as Norway, and in some places in Canada and the USA, where the availability of natural light is lower in periods of extreme winter. .
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