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World J Psychiatr. Jun 22, 2015; 5(2): 170-181
Published online Jun 22, 2015. doi: 10.5498/wjp.v5.i2.170
Transcranial magnetic stimulation for geriatric depression: Promises and pitfalls
Priyadharshini Sabesan, Sudheer Lankappa, Najat Khalifa, Vasudevan Krishnan, Rahul Gandhi, Lena Palaniyappan
Priyadharshini Sabesan, Sudheer Lankappa, Najat Khalifa, Vasudevan Krishnan, Rahul Gandhi, Lena Palaniyappan, Nottingham Neuromodulation Unit, Nottinghamshire Healthcare NHS Trust ECT Suite, South Block - A Floor Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
Najat Khalifa, Section of Forensic Mental Health, Division of Psychiatry and Applied Psychology, University of Nottingham, NG7 2TU Nottingham, United Kingdom
Lena Palaniyappan, Translational Neuroimaging for Mental Health, Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham NG7 2TU, United Kingdom
Author contributions: All author contributed to this manuscript.
Supported by Transformational funding support from the National Health Services, Nottinghamshire Healthcare NHS Trust; Lena Palaniyappan received benefit in kind to speak at a conference organised by Magstim Limited.
Conflict-of-interest: All other authors report no conflicts pertaining to this work.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Lena Palaniyappan, Associate Professor in Translational Neuroimaging, Translational Neuroimaging for Mental Health, Division of Psychiatry and Applied Psychology, University of Nottingham, C-09, Institute of Mental Health, Triumph Road, Nottingham NG7 2TU, United Kingdom. lena.palaniyappan@nottingham.ac.uk
Telephone: +44-115-8230421 Fax: +44-115-8230433
Received: November 17, 2014
Peer-review started: November 18, 2014
First decision: December 26, 2014
Revised: March 18, 2015
Accepted: April 10, 2015
Article in press: April 14, 2015
Published online: June 22, 2015
Processing time: 213 Days and 19.2 Hours
Abstract

As the global population gets older, depression in the elderly is emerging as an important health issue. A major challenge in treating geriatric depression is the lack of robust efficacy for many treatments that are of significant benefit to depressed working age adults. Repetitive transcranial magnetic stimulation (rTMS) is a novel physical treatment approach used mostly in working age adults with depression. Many TMS trials and clinics continue to exclude the elderly from treatment citing lack of evidence in this age group. In this review, we appraise the evidence regarding the safety and efficacy of rTMS in the elderly. A consistent observation supporting a high degree of tolerability and safety among the elderly patients emerged across the Randomised Controlled Trials and the uncontrolled trials. Further, there is no reliable evidence negating the utility of rTMS in the elderly with depression. We also identified several factors other than age that moderate the observed variations in the efficacy of rTMS in the elderly. These factors include but not limited to: (1) brain atrophy; (2) intensity and number of pulses (dose-response relationship); and (3) clinical profile of patients. On the basis of the current evidence, the practice of excluding elderly patients from TMS clinics and trials cannot be supported.

Keywords: Transcranial magnetic stimulation; Depression; Geriatric; Treatment resistance; Treatment resistant depression; Repetitive transcranial magnetic stimulation; Neuromodulation

Core tip: Depression in the elderly (geriatric depression) is an emerging global concern. A major challenge in treating geriatric depression is the lack of robust efficacy for many treatments that are of significant benefit to depressed working age adults. An emerging intervention that shows promise in refractory depression is repetitive transcranial magnetic stimulation (rTMS). To date, most of the evidence for TMS in depression pertains to working age adults. We review the evidence regarding the safety and efficacy of rTMS in geriatric depression. In addition, we also review the literature on possible moderators of differential efficacy of rTMS in geriatric depression.