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Transcranial Magnetic Stimulation in the Treatment of Depression
A Double-blind, Placebo-Controlled Trial
Paul B. Fitzgerald, MBBS, MPM, FRANZCP;
Timothy L. Brown, GradDipClinNurse (Psych);
Natasha A. U. Marston, BA;
Z. Jeff Daskalakis, MD, FRCP(C);
Anthony de Castella, BA, DipAppSci;
Jayashri Kulkarni, MBBS, MPM, FRANZCP, PhD
Arch Gen Psychiatry. 2003;60:1002-1008.
Background High-frequency left-sided repetitive transcranial magnetic stimulation (HFL-TMS) has been shown to have antidepressant effects in double-blind trials. Low-frequency stimulation to the right prefrontal cortex (LFR-TMS) has also shown promise, although it has not been assessed in treatment-resistant depression and its effects have not been compared with those of HFL-TMS.
Objective To prospectively evaluate the efficacy of HFL-TMS and LFR-TMS in treatment-resistant depression and compared with a sham-treated control group.
Design A double-blind, randomized, sham-controlled trial.
Setting Two general psychiatric services.
Participants Sixty patients with treatment-resistant depression who had failed to respond to therapy with multiple antidepressant medications were divided into 3 groups of 20 that did not differ in age, sex, or any clinical variables. All patients completed the double-blind phase of the study.
Interventions Twenty 5-second HFL-TMS trains at 10 Hz and five 60-second LFR-TMS trains at 1 Hz were applied daily. Sham stimulation was applied with the coil angled at 45° from the scalp, resting on the side of one wing of the coil.
Main Outcome Measure Score on the Montgomery-Åsberg Depression Rating Scale.
Results There was a significant difference in response among the 3 groups (F56,2 = 6.2), with a significant difference between the HFL-TMS and sham groups and between the LFR-TMS and sham groups (P<.005 for all) but not between the 2 treatment groups. Baseline psychomotor agitation predicted successful response to treatment.
Conclusions Both HFL-TMS and LFR-TMS have treatment efficacy in patients with medication-resistant major depression. Treatment for at least 4 weeks is necessary for clinically meaningful benefits to be achieved. Treatment with LFR-TMS may prove to be an appropriate initial repetitive TMS strategy in depression taking into account safety, tolerability, and efficacy considerations.
From the Alfred Psychiatry Research Centre, The Alfred Hospital, and the Department of Psychological Medicine, Monash University, Melbourne, Australia (Drs Fitzgerald and Kulkarni, Messrs Brown and de Castella, and Ms Marston); and the Clarke Division, Centre for Addiction and Mental Health, Toronto, Ontario (Dr Daskalakis).
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