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Background: Electroconvulsive therapy (ECT) is one of the most effective treatments for depressive disorders. However, ECT has a number of limitations, such as significant side effects in the neurocognitive domain and the requirement for general anesthesia. Transcranial magnetic stimulation (TMS) is an intervention that applies electric stimulation to the brain without causing convulsions, thus representing an attractive alternative to ECT. The aim of our study is to review systematic reports of the effectiveness of ECT and TMS in the treatment of depressive spectrum disorders., Subjects and Methods: We performed search queries in PubMed and eLibrary databases, which retrieved 391 articles, of which 14 met our inclusion criteria for the analysis. The articles comprised three comparisons: TMS vs SHAM, ECT vs sham ECT (SECT), and ECT vs PHARM. The protocol parameters analyzed for TMS were coil type, targeted brain area, amplitude of resting motor threshold, duration of session, number of sessions in total and per week, number and pulses per session and inter-train pause. For ECT, we evaluated the type of ECT device, targeted brain area, type of stimuli, and for ECT vs PHARM we recorded types of anesthesia and antidepressant medication., Results: Three of 6 studies showed a therapeutic effect of TMS compared to placebo; efficacy was greater for TMS frequency exceeding 10 Hz, and with stimulation of two areas of cerebral cortex rather than a single area. There was insufficient data to identify a relationship between the success of TMS and intertrain pause (IP). Three of four studies showed a therapeutic effect of ECT compared to placebo. Three studies of bilateral ECT showed a significant reduction in depression scores compared to the SECT groups. ECT protocols with brief pulses were generally of lesser efficacy. Four of 5 ECT vs PHARM studies showed superior efficacy of ECT compared to PHARM. Among several antidepressants, only the ketamine study showed greater efficacy compared to ECT., Conclusions: There of six TMS studies and 7 of 9 ECT studies showed efficacy in reducing depressive symptoms. A prospective study of crossover design might reveal the relative efficacies of ECT and TMS.

Background: Neuropathic pain (NP) affects approximately 7% of the general population and is often accompanied by depressive symptoms with up to 85% of NP patients are suffering from comorbid depression (CD). The noninvasive neuromodulation technique of transcranial magnetic stimulation (TMS) is an established proven clinically effective nonpharmacological treatment for depression, and considered a highly promising option also for reducing the burden of NP by relieving pain perception and increasing patients' quality of life. In this article, we systematically review the various clinical protocols used in TMS treatments in patients suffering from NP and comorbid depression., Subjects and Methods: Using Scopus, Elsevier, and PubMed databases, our keyword search identified 639 articles, of which 22 were selected for detailed analysis based on the inclusion criteria and in consideration of the heterogeneous study design of the majority of small trials. We evaluated the clinical efficacy in NP and comorbid depression, in relation to various TMS protocol parameters including coil type, target brain area, locus of increased evoked motor potential, amplitude of stimulation, duration of session, number of sessions per day/month, as well as inter-session-intervals, number and frequency of trains, and number and frequency of pulses., Results: The most effective TMS protocols for treating comorbid NP and depression, as marked by decreased pain and depression scores proved to entail figure-of-8 coils targeting the primary motor area (M1), and applying at least ten daily rTMS sessions using high frequency stimulation (10-20 Hz) with a sub threshold intensity of 80-90% RMT and a total number of pulses of at least 1500 per session. Performing an additional maintenance phase after the acute treatment phase may strengthen and prolong the therapeutic effects of rTMS., Conclusions: Our database analysis suggests that a specific combination of TMS parameters is most effective for treating NP and comorbid depression. Although results are promising, the heterogeneity within the literature is such that many underpowered studies contribute rather little to the outcome, as evident by our inclusion / exclusion analysis. Moreover, we see a need for consensus on clinical protocols and inclusion of much larger clinical samples. Furthermore, we conclude that future research should entail advanced TMS procedures with multiple brain region stimulation (sequential or concurrent), and address issues of TMS maintenance and improved coil engineering for targeting deeper structures.