Focus of the Report: The focus of this Health Technology Assessment is to evaluate the effectiveness and safety of repetitive transcranial magnetic stimulation (rTMS) for the treatment of adult patients with bipolar disorder (BD).

Technology Description: Transcranial magnetic stimulation (TMS) works by passing electrical energy through a coil to generate an electromagnetic field. When placed over the scalp, the stimulation coil focuses a pulse of electrical current that penetrates the cortical surface and directly alters local superficial neuronal activity. For clinical purposes, TMS is typically delivered in a train of pulses, a process also known as rTMS, which is thought to yield more persistent changes in cortical excitability and plasticity. In the context of BD treatment, rTMS generally targets the dorsolateral prefrontal cortex, a region important for high-order executive functions. For acute rTMS treatment, sessions typically last 30 to 40 minutes. rTMS treatment is delivered in up to 5 sessions per week for 2 to 6 weeks (i.e., 20 to 30 total treatment sessions).

Controversy: Many studies have investigated rTMS as a modality for the treatment of patients with treatment-resistant unipolar major depressive disorder (MDD). Although patients with MDD and depression associated with BD often experience similar symptoms, the underlying pathophysiology of these disorders likely differs. Furthermore, patients with BD may exhibit a mixed presentation with symptoms of mania or hypomania during, before, or after a depressive state. Therefore, the potential efficacy and safety of rTMS for the treatment of patients with BD remains unclear, especially for patients in varying states of BD.

Key Questions:

  1. Is rTMS effective for the treatment of depression associated with BD in adults?

  2. How does rTMS compare with alternative therapies for the treatment of depression associated with BD?

  3. Is rTMS in adults with BD safe?

  4. Have definitive patient selection criteria been identified for rTMS for the treatment of depression associated with BD?

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