After 2 antidepressant trials, TMS or esketamine offers faster relief and durable remission—see why clinicians switch sooner.
Treatment-resistant depression is often defined clinically as failure of, or intolerance to, at least 2 oral medications. Remission rates fall with each successive monoaminergic agent, according to studies, leading clinicians to consider options beyond medication. Ryan Wakim, MD, highlighted, "the chances of remission for handing someone that third monoaminergic option drops all the way down to less than 15% chance of remission."1 Only about 25% of patients achieved remission with a 2nd agent, and about 65% of those who remitted with a 3rd agent relapsed within 3 months, on average. Wakim said this pattern supported earlier consideration of interventional care.
Wakim advocated raising interventional options—electroconvulsive therapy, transcranial magnetic stimulation (TMS), and esketamine (Spravato)—by the time of the 2nd medication trial. The American Psychiatric Association considered TMS safe and effective enough for use as a 2nd-line treatment, although insurers may not cover interventional treatment until after a 2nd failure. Wakim noted that informed consent discussions have led some patients to pay out of pocket for TMS or Spravato rather than wait for a 3rd or subsequent medication trial and its potential adverse effects.
Choice among options depended first on contraindications: ferrous metal in the head or neck precluded TMS, and a history of stroke or brain aneurysm precluded Spravato. Onset also differed: Spravato produced benefit within 24 to 48 hours, TMS within 15 to 20 treatments (3 to 4 weeks), and oral medications within 4 to 8 weeks or longer. Spravato may be favored for acute presentations, including suicidality, marked apathy or amotivation, and frequent hospitalizations, because of its activating effects and rapid onset.
TMS might be favored for patients with poor durability of response to medication, intolerable adverse effects, or difficulty with daily pill adherence. Wakim said, "TMS is a monotherapy. You can use it as standalone. And it actually has a very high durability rate." After a 36-treatment course, 65% to 70% of patients remained in remission for up to 12 months, and response or remission rates were 65% to 75%.2
Dr Wakim is the chief medical officer at Transformations Care Network.
References
1. Rush AJ, Trivedi MH, Wisniewski SR, et al.
2. Dunner DL, Aaronson ST, Sackeim HA, et al.
