HAS and transcranial magnetic stimulation: an electric shock for psychiatrists
Paris, Thursday, November 24, 2022 – The interest of repeated transcranial magnetic stimulation (rTMS) in the management of resistant depression in adults is the subject of a long-standing controversy that agitates psychiatrists around the world. A large number of works have been published on the subject which have themselves been identified in several meta-analyses, in no way allowing a consensus to be reached.
The discussions concern both the proof of the benefit of rTMS compared to existing alternatives and the population that could benefit from it. We find these same questions within the psychiatric community in France. Thus, the High Authority for Health (HAS) recalled in a report published last June the results of a survey conducted in 2018 among these practitioners which showed that 54% of respondents had assessed the level of acceptability of this act of “low to moderate”while 51% felt that the observable effect of rTMS seemed mostly ‘placebo’.
Pragmatic foreign recommendations
International recommendations also reflect this controversy. Thus, in Great Britain, the National Institute for Health and Care Excellence gave a favorable opinion on the use of rTMS in resistant depression while noting however the existence of a “variable response between patients” and noting a “difficulty in correctly estimating the effect size despite the large number of patients in the published studies”.
In the same way, the Belgian authorities, while expressing reservations about the low levels of proof of the effectiveness of this method, judged that it could be considered as “a possible therapeutic option”. It should also be noted that in Australia, the latest recommendations are in favor of the use of rTMS “in acute phase of depression”but an unfavorable opinion was presented as to
“its prolonged use in the consolidation phase with the help of maintenance sessions”.
No statistically proven effects
It is in this context that the HAS in turn looked into this therapeutic indication of rTMS in resistant depression. His conclusions, which were based on a “systematic research of recent synthetic literature”
and on the advice of experts is against this therapy.
“Data from the meta-analysis suggest that in the acute phase of depression, rTMS (conventional protocol) has a low magnitude of effect, without significant clinical translation (…). Overall, in the indication for the treatment of resistant depression in adults, despite a reassuring safety profile, the data retained relating to rTMS do not show a favorable clinical impact (absence of relevant clinical added value compared to a sham procedure, lack of determination of its place in relation to the existing reference strategy of pharmacological optimization, non-acceptable alternative to tremor therapy)” wrote at the beginning of the summer the experts of the HAS.
This conclusion constituted an electric shock (!) for a large number of psychiatrists who, without seeing rTMS as a miracle method, nevertheless considered it as a relevant and interesting therapeutic alternative, in a context where innovations remain rare. This is the position expressed today in Le Monde by five psychiatrists David Szekely, deputy head of the psychiatry department, Princess Grace Hospital Center (Monaco), Emmanuel Haffen, head of the psychiatry department, Besançon University Hospital, Raphael Gaillard, head of hospital-university center of psychiatry at Sainte-Anne Hospital (Paris), Emmanuel Poulet, head of the emergency psychiatry department, Civil Hospitals of Lyon and Anne Sauvaget, professor of psychiatry, Nantes University Hospital.
These specialists challenge the HAS assessment methods: “Thus, regarding the place of rTMS in the treatment of depression, the HAS experts took the wrong path: in the framework letter of June 2, 2019, the HAS took ECT as the reference therapy. However, the population covered by rTMS is different from that covered by ECT: extreme depressive states during which the patients no longer eat, are prostrate, and sometimes very suicidal, or very resistant depressions (after the failure four or five antidepressants), necessarily requiring hospitalization. Conversely, rTMS is mainly aimed at less severely depressed patients, often treated on an outpatient basis, sometimes in professional activity. they recall.
Some specialists not consulted
Recalling that“about 150 rTMS centers have nevertheless been structured, mostly in public hospitals, to meet a major public health need”they regret that this advice risks depriving some patients of an effective and well-tolerated therapeutic alternative.
“A framework for the conditions of recourse and use of rTMS is essential in the interest of patients. The recognition of a specific therapeutic act making it possible to enhance the activity at the hospital level, even without associated reimbursement, would have made it possible to circumvent the fears of an explosion in health costs while authorizing and regulating the use of rTMS. Hospital-university and hospital psychiatrists, practitioners of rTMS in France, were excluded from the reflections of the HAS expert group on this subject. They are ready to find together an intelligent solution in the interest of patients and hospitals to promote innovations in the field of mental health, a great national cause that cannot be considered on the margins of the international scientific community. they conclude.
Several readings of this appeal seem possible: new questioning of the reliability of the HAS opinions, persistence of an old controversy, desire of certain psychiatrists to protect their activity or lack of pragmatism on the part of the health authorities when the management of patients requires it… The interpretations are vast.
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