Prefrontal rTMS for treating depression: Location and intensity results from the OPT-TMS multi-site clinical trial

Kevin A. Johnson; Mirza Baig; Dave Ramsey; Sarah H. Lisanby; David Avery; William M. McDonald; Xingbao Li; Elisabeth R. Bernhardt; David R. Haynor; Paul E. Holtzheimer; Harold A. Sackeim; Mark S. George; Ziad Nahas

doi:10.1016/j.brs.2012.02.003

Prefrontal rTMS for treating depression: Location and intensity results from the OPT-TMS multi-site clinical trial

Kevin A. Johnson, Mirza Baig, Dave Ramsey, Sarah H. Lisanby, David Avery, William M. McDonald, Xingbao Li, Elisabeth R. Bernhardt, David R. Haynor, Paul E. Holtzheimer, Harold A. Sackeim, Mark S. George, Ziad Nahas

Psychiatry & Behavioral Sciences

Research output: Contribution to journal › Article › peer-review

87 Scopus citations

Abstract

Background: Motor cortex localization and motor threshold determination often guide Transcranial Magnetic Stimulation (TMS) placement and intensity settings for non-motor brain stimulation. However, anatomic variability results in variability of placement and effective intensity. Objective: Post-study analysis of the OPT-TMS Study reviewed both the final positioning and the effective intensity of stimulation (accounting for relative prefrontal scalp-cortex distances). Methods: We acquired MRI scans of 185 patients in a multi-site trial of left prefrontal TMS for depression. Scans had marked motor sites (localized with TMS) and marked prefrontal sites (5 cm anterior of motor cortex by the "5 cm rule"). Based on a visual determination made before the first treatment, TMS therapy occurred either at the 5 cm location or was adjusted 1 cm forward. Stimulation intensity was 120% of resting motor threshold. Results: The "5 cm rule" would have placed stimulation in premotor cortex for 9% of patients, which was reduced to 4% with adjustments. We did not find a statistically significant effect of positioning on remission, but no patients with premotor stimulation achieved remission (0/7). Effective stimulation ranged from 93 to 156% of motor threshold, and no seizures were induced across this range. Patients experienced remission with effective stimulation intensity ranging from 93 to 146% of motor threshold, and we did not find a significant effect of effective intensity on remission. Conclusions: Our data indicates that individualized positioning methods are useful to reduce variability in placement. Stimulation at 120% of motor threshold, unadjusted for scalp-cortex distances, appears safe for a broad range of patients.

Original language	English (US)
Pages (from-to)	108-117
Number of pages	10
Journal	Brain Stimulation
Volume	6
Issue number	2
DOIs	https://doi.org/10.1016/j.brs.2012.02.003
State	Published - Mar 2013

Bibliographical note

Funding Information:
Sarah H. Lisanby: Dr. Lisanby reports no speaking fees and no advisory board work. She reports research grants from Advanced Neuromodulation Systems/St Jude, Brainsway, Cyberonics (past), Neuronetics (past), and equipment support from Magstim and Magventure. Columbia University has a patent application on TMS technology (unrelated to this manuscript) on which Dr. Lisanby is a co-inventor but receives no proceeds.

Keywords

Depression
Imaging (MRI)
Motor cortex
Prefrontal cortex
Transcranial magnetic stimulation (TMS)

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10.1016/j.brs.2012.02.003

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Johnson, K. A., Baig, M., Ramsey, D., Lisanby, S. H., Avery, D., McDonald, W. M., Li, X., Bernhardt, E. R., Haynor, D. R., Holtzheimer, P. E., Sackeim, H. A., George, M. S., & Nahas, Z. (2013). Prefrontal rTMS for treating depression: Location and intensity results from the OPT-TMS multi-site clinical trial. Brain Stimulation, 6(2), 108-117. https://doi.org/10.1016/j.brs.2012.02.003

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title = "Prefrontal rTMS for treating depression: Location and intensity results from the OPT-TMS multi-site clinical trial",

abstract = "Background: Motor cortex localization and motor threshold determination often guide Transcranial Magnetic Stimulation (TMS) placement and intensity settings for non-motor brain stimulation. However, anatomic variability results in variability of placement and effective intensity. Objective: Post-study analysis of the OPT-TMS Study reviewed both the final positioning and the effective intensity of stimulation (accounting for relative prefrontal scalp-cortex distances). Methods: We acquired MRI scans of 185 patients in a multi-site trial of left prefrontal TMS for depression. Scans had marked motor sites (localized with TMS) and marked prefrontal sites (5 cm anterior of motor cortex by the {"}5 cm rule{"}). Based on a visual determination made before the first treatment, TMS therapy occurred either at the 5 cm location or was adjusted 1 cm forward. Stimulation intensity was 120% of resting motor threshold. Results: The {"}5 cm rule{"} would have placed stimulation in premotor cortex for 9% of patients, which was reduced to 4% with adjustments. We did not find a statistically significant effect of positioning on remission, but no patients with premotor stimulation achieved remission (0/7). Effective stimulation ranged from 93 to 156% of motor threshold, and no seizures were induced across this range. Patients experienced remission with effective stimulation intensity ranging from 93 to 146% of motor threshold, and we did not find a significant effect of effective intensity on remission. Conclusions: Our data indicates that individualized positioning methods are useful to reduce variability in placement. Stimulation at 120% of motor threshold, unadjusted for scalp-cortex distances, appears safe for a broad range of patients.",

keywords = "Depression, Imaging (MRI), Motor cortex, Prefrontal cortex, Transcranial magnetic stimulation (TMS)",

author = "Johnson, {Kevin A.} and Mirza Baig and Dave Ramsey and Lisanby, {Sarah H.} and David Avery and McDonald, {William M.} and Xingbao Li and Bernhardt, {Elisabeth R.} and Haynor, {David R.} and Holtzheimer, {Paul E.} and Sackeim, {Harold A.} and George, {Mark S.} and Ziad Nahas",

note = "Funding Information: Sarah H. Lisanby: Dr. Lisanby reports no speaking fees and no advisory board work. She reports research grants from Advanced Neuromodulation Systems/St Jude, Brainsway, Cyberonics (past), Neuronetics (past), and equipment support from Magstim and Magventure. Columbia University has a patent application on TMS technology (unrelated to this manuscript) on which Dr. Lisanby is a co-inventor but receives no proceeds. ",

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TY - JOUR

T1 - Prefrontal rTMS for treating depression

T2 - Location and intensity results from the OPT-TMS multi-site clinical trial

AU - Johnson, Kevin A.

AU - Baig, Mirza

AU - Ramsey, Dave

AU - Lisanby, Sarah H.

AU - Avery, David

AU - McDonald, William M.

AU - Li, Xingbao

AU - Bernhardt, Elisabeth R.

AU - Haynor, David R.

AU - Holtzheimer, Paul E.

AU - Sackeim, Harold A.

AU - George, Mark S.

AU - Nahas, Ziad

N1 - Funding Information: Sarah H. Lisanby: Dr. Lisanby reports no speaking fees and no advisory board work. She reports research grants from Advanced Neuromodulation Systems/St Jude, Brainsway, Cyberonics (past), Neuronetics (past), and equipment support from Magstim and Magventure. Columbia University has a patent application on TMS technology (unrelated to this manuscript) on which Dr. Lisanby is a co-inventor but receives no proceeds.

PY - 2013/3

Y1 - 2013/3

N2 - Background: Motor cortex localization and motor threshold determination often guide Transcranial Magnetic Stimulation (TMS) placement and intensity settings for non-motor brain stimulation. However, anatomic variability results in variability of placement and effective intensity. Objective: Post-study analysis of the OPT-TMS Study reviewed both the final positioning and the effective intensity of stimulation (accounting for relative prefrontal scalp-cortex distances). Methods: We acquired MRI scans of 185 patients in a multi-site trial of left prefrontal TMS for depression. Scans had marked motor sites (localized with TMS) and marked prefrontal sites (5 cm anterior of motor cortex by the "5 cm rule"). Based on a visual determination made before the first treatment, TMS therapy occurred either at the 5 cm location or was adjusted 1 cm forward. Stimulation intensity was 120% of resting motor threshold. Results: The "5 cm rule" would have placed stimulation in premotor cortex for 9% of patients, which was reduced to 4% with adjustments. We did not find a statistically significant effect of positioning on remission, but no patients with premotor stimulation achieved remission (0/7). Effective stimulation ranged from 93 to 156% of motor threshold, and no seizures were induced across this range. Patients experienced remission with effective stimulation intensity ranging from 93 to 146% of motor threshold, and we did not find a significant effect of effective intensity on remission. Conclusions: Our data indicates that individualized positioning methods are useful to reduce variability in placement. Stimulation at 120% of motor threshold, unadjusted for scalp-cortex distances, appears safe for a broad range of patients.

AB - Background: Motor cortex localization and motor threshold determination often guide Transcranial Magnetic Stimulation (TMS) placement and intensity settings for non-motor brain stimulation. However, anatomic variability results in variability of placement and effective intensity. Objective: Post-study analysis of the OPT-TMS Study reviewed both the final positioning and the effective intensity of stimulation (accounting for relative prefrontal scalp-cortex distances). Methods: We acquired MRI scans of 185 patients in a multi-site trial of left prefrontal TMS for depression. Scans had marked motor sites (localized with TMS) and marked prefrontal sites (5 cm anterior of motor cortex by the "5 cm rule"). Based on a visual determination made before the first treatment, TMS therapy occurred either at the 5 cm location or was adjusted 1 cm forward. Stimulation intensity was 120% of resting motor threshold. Results: The "5 cm rule" would have placed stimulation in premotor cortex for 9% of patients, which was reduced to 4% with adjustments. We did not find a statistically significant effect of positioning on remission, but no patients with premotor stimulation achieved remission (0/7). Effective stimulation ranged from 93 to 156% of motor threshold, and no seizures were induced across this range. Patients experienced remission with effective stimulation intensity ranging from 93 to 146% of motor threshold, and we did not find a significant effect of effective intensity on remission. Conclusions: Our data indicates that individualized positioning methods are useful to reduce variability in placement. Stimulation at 120% of motor threshold, unadjusted for scalp-cortex distances, appears safe for a broad range of patients.

KW - Depression

KW - Imaging (MRI)

KW - Motor cortex

KW - Prefrontal cortex

KW - Transcranial magnetic stimulation (TMS)

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Prefrontal rTMS for treating depression: Location and intensity results from the OPT-TMS multi-site clinical trial

Abstract

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