Electroconvulsive Therapy Versus Repetitive Transcranial Magnetic Stimulation in Patients With a Depressive Episode: A Register-Based Study.

To the Editor: Thank you for the opportunity to respond to the valuable comments on the study on relative effectiveness of electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS) (reference to the letter to the editor). Indeed, it is important to be reminded that this study, with its observational design, cannot, with certainty, answer the question about the superiority of ECT or rTMS, as randomized studies can.1 In order to respond to the comments, the still expanding registers were revisited, and further analyses were made that could shed more light on the relative effectiveness of ECT and rTMS. As noticed in the Letter to the Editor, the current study had a risk of being biased toward a higher chance for ECT to show positive effects in patients with depression because the majority of patients received ECT as the first treatment. Thus, we extracted a new dataset with a population of patients who received both rTMS and ECT and who were treated with rTMS first. All patients were assessed with the Montgomery-Åsberg Depression Rating Scale–Self-assessment (MADRS-S) before and after both treatments. In total, 128 patients were identified. Patients were treated between 2018 and 2023 (data extraction was done on the 15th of December 2023). The mean of the MADRS-S score before rTMS was 33.6 (SD, 7.4) and 28.3 (SD, 10.3) after rTMS. The mean of the MADRS-S score before ECT was 34.7 (SD, 7.7) and 20.8 (SD, 11.1) after ECT. A linear mixed model was used to analyze the significance of differences between MADRS-S change after rTMS and ECT while accounting for the intraindividual variability. The best-fitting model included a random intercept and a random slope. The interaction term between MADRS-S change and ECT versus MADRS-S change and rTMS was significant (P < 0.0001), meaning that patients improved significantly more after ECT compared with after rTMS. The new result of the new analysis suggests that the published study was not significantly biased because the majority of patients received ECT first. These results should also be seen in the broader context of the evidence based on randomized studies supporting the idea of the superiority of ECT over rTMS in treating major depression.2,3 However, more randomized studies are needed to compare the effects of these 2 treatment modalities in different subpopulations with depression. Considerations should include costs and patient preferences after balancing antidepressive effects with adverse effects. Katarzyna Popiolek, MDUniversity Health Care Research CentreFaculty of Medicine and HealthÖrebro UniversityÖrebro, Sweden[email protected]Tor Arnison, PhDUniversity Health Care Research CentreFaculty of Medicine and HealthÖrebro UniversityÖrebroSwedenRobert Boden, MD, PhDDepartment of Medical SciencesPsychiatryUppsala UniversityUppsalaSwedenCarl Johan Ekman, MD, PhDJohan Lundberg, MD, PhDCentre for Psychiatry ResearchDepartment of Clinical NeuroscienceKarolinska Institutet and Stockholm Health CareServicesRegion StockholmSwedenPontus StrandbergSchool of Medical SciencesÖrebro UniversityÖrebroSwedenAxel Nordenskjöld, MD, PhDUniversity Health Care Research CentreFaculty of Medicine and HealthÖrebro UniversityÖrebroSweden