Optimizing transcranial magnetic stimulation for depression: A multinational registry study identifying predictors of response and remission
Che-Sheng Chu, Cheng Ruey Jou, Galen Chin-Lun Hung, Guan-Wei Chen, Pao-Yuan Ching, Leo Chen, Elizabeth H. X. Thomas, Jonathan Jie Lee, Shih Ee Goh, Cheng-Ta Li, Chih-Ming Cheng, Ryota Osawa, Yuya Takeda, Yuka Saijo, Ryosuke Kitahata, Hsin-An Chang, Chun-Hung Chang, Kuan-Pin Su, Yi Hang Tay, Nguyễn Trung Nghĩa, Nguyễn Văn Giáp, Takashi Saeki, Phern Chern Tor, Danilo Rocha de Jesus, Reza Zomorrodi, Mihoko Yoshie, Daniel M. Blumberger, Yoshihiro NodaAbstract
Background
Real-world outcomes of repetitive transcranial magnetic stimulation (rTMS) for depressive disorders vary, and generalizable predictors of response and remission remain unclear.
Objective
To identify demographic, clinical, and treatment-related predictors of rTMS outcomes using a multinational registry.
Methods
We pooled registry data from six countries between January 2017 and April 2026. Patients with depression treated with rTMS were included. Primary outcomes were response and remission. Predictors were evaluated using hierarchical logistic regression. Model 1 was the primary complete-case core model, with sensitivity analyses using multiple imputation and excluding clinical-trial-derived patients. Model 2 incorporated treatment-dose and medication variables, whereas Model 3 explored clinical and sociodemographic variables with substantial missingness and was considered hypothesis-generating. Clinician-rated and patient-reported outcomes were also analyzed separately.
Results
Among 2,015 cases, 1,691 were analyzed. Response and remission rates were 43.6% and 28.7%, respectively. More treatment sessions were associated with higher odds of response (adjusted odds ratio (aOR) = 1.02 per session, p = 0.002), whereas lower baseline depression severity was consistently associated with higher odds of remission (aOR = 0.33, p < 0.001). Intermittent theta-burst stimulation was associated with lower odds of remission than high-frequency rTMS (aOR = 0.39, p < 0.001), although this association varied by outcome rater and protocol effects for response were non-significant. Country-level differences were observed, whereas medication-related and sociodemographic associations were inconsistent.
Conclusions
Treatment exposure and baseline severity were the most stable predictors of rTMS outcomes. Protocol and regional variations warrant standardized prospective studies to define personalized rTMS strategies.