- Design
- Observational individual-participant analysis of two randomised trials, propensity weighted
- Population
- 758 adults aged 60 or older with treatment-resistant depression
- Primary outcome
- MADRS score at 10 weeks
- Effect
- rTMS lower by 4.16 (vs aripiprazole), 6.08 and 6.36 points (vs bupropion strategies)
This analysis pooled individual data from two trials in adults aged 60 or older with treatment-resistant depression: 758 people in all. One trial gave once-daily bilateral rTMS for 4 to 6 weeks; the other compared aripiprazole augmentation, bupropion augmentation and switching to bupropion. Propensity weighting and regression were used to make the groups comparable.
At 10 weeks, rTMS was associated with MADRS scores 4.16 points lower than aripiprazole augmentation, 6.08 lower than bupropion augmentation and 6.36 lower than a bupropion switch. Response was more likely with rTMS, with adjusted odds ratios of about 3.8 to 4.9, though the intervals were wide. Headache was more common with rTMS.
Because the two treatments came from different trials, this is a comparison of cohorts, not a randomised head-to-head. Even so, the gap is large enough that rTMS deserves to be discussed alongside augmentation, not reserved for after several drug failures — particularly in older adults for whom another drug adds interaction and fall risk.
- Discuss rTMS as an option at the point of choosing augmentation in older adults with resistant depression
- Weigh drug interactions, falls and sedation risk when comparing augmentation with neurostimulation
- Warn patients that headache is the commonest side effect of rTMS
- Check local access and waiting times for rTMS before offering it as the next step
Why it matters
It challenges the habit of trying several drug strategies in older adults before considering neurostimulation.
Don't overread it
This compares people from two different trials — it is not a randomised comparison of rTMS with medication.
The statistics, in plain English
A 4 to 6 point difference on the MADRS is roughly the size of a meaningful clinical change. The odds ratios for response look large, but the confidence intervals run from about 1.1 to over 13, so the true size of the advantage is uncertain.
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