HAS and transcranial magnetic stimulation: electric shock for psychiatrists

Paris, Thursday, November 24, 2022 – The interest in repetitive transcranial magnetic stimulation (rTMS) in the management of refractory depression in adults has been a long-running topic of controversy of concern to psychiatrists worldwide. A large number of works have been published on this topic that have been identified in several meta-analyses, in no way allowing for a consensus to be reached.

The discussions concern both the demonstration of benefit of rTMS compared to current alternatives and the populations that could benefit from it. We find these same questions in the psychiatric community in France. Accordingly, the Supreme Authority for Health, in a report published last June, referred to the results of a survey conducted in 2018 among these practitioners, as it showed that 54% of the respondents assessed the level of acceptance of this act. “low to medium”while 51% felt that the observed effect of rTMS seemed mostly a ‘placebo’.

Practical external recommendations

International recommendations also reflect this controversy. Thus, in Great Britain the National Institute for Health and Care Excellence gave a positive opinion on the use of rTMS in refractory depression noting “variable response among patients” and noting 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 proving the efficacy of this method, held that it could be considered as ‘Potential treatment option’. It should also be noted that the most recent recommendations in Australia favor the use of rTMS In the acute phase of depressionbut an unfavorable opinion was submitted
“Using it for long periods in the consolidation phase with the help of maintenance sessions”.

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There are no statistically proven effects

In this context, HAS in turn investigated this therapeutic indication for rTMS in refractory depression. His conclusions, which were based on a Systematic research of modern synthetic literature.
And based on expert advice against this treatment.

“The data from the meta-analysis indicate that in the acute phase of depression the effect of rTMS (the traditional protocol) is low, without significant clinical translation (…). Definition of reassuring safety, archival data regarding rTMS do not show a positive clinical effect (no relevant clinical added value compared to placebo, no placement in relation to current reference strategy for pharmacological optimization, unacceptable alternative for treatment of tremor)” Written at the beginning of the summer HAS experts.

wrong indicators

This conclusion constituted an electric shock (!) to a large number of psychiatrists who, without regard to the miraculous method of repetitive transcranial magnetic stimulation, considered it an interesting and convenient therapeutic alternative, in a context in which innovations are still scarce. This is the position expressed today in Le Monde by five psychiatrists David Szeckley, Deputy Head of the Department of Psychiatry, Princess Grace Hospital Center (Monaco), Emmanuelle Haven, Head of the Department of Psychiatry, University Hospital of Besançon, Raphael Gaillard, Head of the Hospital-University Center for Medicine Psychiatrist at the Hospital Sainte-Anne (Paris), Emmanuelle Boullet, Head of Emergency Psychiatry, Hospitals Civic de Lyon and Anne Sauvaget, Professor of Psychiatry, University Hospital of Nantes.

These specialists challenge HAS assessment methods: Thus, regarding the place of rTMS in the treatment of depression, HAS experts took the wrong path: in the frame letter of June 2, 2019, HAS took ECT as the reference treatment. However, the populations included in rTMS are different from those included in ECT: severe depressive states during which patients no longer eat, prostrate, and sometimes suicidal or highly refractory depressive states (after failing four or five antidepressants). For depression), which necessarily require hospitalization. On the contrary, rTMS is primarily targeted at less severely depressed patients, often treated in an outpatient setting, and occasionally in a professional setting. They remember.

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Some specialists were not consulted

indicating thatHowever, about 150 rTMS centers, mostly in public hospitals, have been organized to meet major public health needs.They regret that this view may deprive some patients of an effective and well-tolerated treatment alternative.

“The framework of asylum conditions and the use of repetitive transcranial magnetic stimulation (rTMS) is essential for the benefit of patients. Recognition of a specific therapeutic action that makes it possible to promote activity at the hospital level, even without the associated reimbursement, would make it possible to circumvent fears of a blowout.” In health costs while allowing and regulating the use of rTMS.Hospital psychiatrists, universities and hospitals, practicing rTMS in France, were excluded from the reflections of the HAS expert group on this topic.They are ready to find a smart solution together for the benefit of patients and hospitals to promote innovations in the field of mental health, It is a great national issue that cannot be considered on the sidelines of the international scientific community. they conclude.

Several readings of this appeal seem possible: the new questioning about the credibility of HAS views, the persistence of an old controversy, the desire of some psychiatrists to protect their activism, or the lack of pragmatism on the part of health authorities when managing patients requires it. … the interpretations are wide.

Aurelie Haroche

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