Preliminary communication
High frequency repetitive transcranial magnetic stimulation as an augmenting strategy in severe treatment-resistant major depression: A prospective 4-week naturalistic trial

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Abstract

Background

Randomized, controlled trials (RCTs) have found repetitive transcranial magnetic stimulation (rTMS) to be effective for major depression, but its usefulness as an augmenting strategy for severe treatment-resistant depression (TRD) has yet to be firmly established.

Methods

In a naturalistic trial, 15 chronically depressed, severely treatment-resistant patients were treated with daily high frequency (HF) rTMS over the left dorsolateral prefrontal cortex (DLPFC) for 4 weeks as an augmenting strategy. Depressive and anxious symptoms (both subjective and objective), as well as quality of life (QOL) domains were measured pre-post rTMS treatment.

Results

Pre-post rTMS comparisons revealed significant reductions of both clinician-rated and selfreport depression and anxiety measures and increases in three (out of five) domains of subjective QOL (i.e., global, physical, and psychological).

Limitations

Small sample size and non-controlled design.

Conclusions

Our results suggest that HF rTMS, when used as an augmenting strategy, positively affects depressive and anxious symptoms as well as QOL in patients with severe TRD. However, further studies with larger samples and controlled designs are needed to better clarify our preliminary findings.

Section snippets

Depressed patients

The present study was approved by the Douglas Mental Health University Institute's (DMHUI) Research Ethics Board, and written informed consent was obtained from all participants. A total convenience sample of 15 depressed subjects (7 males and 8 females) were recruited between September 2008 and 2009 from the Depressive Disorders Program at the DMHIU — a tertiary care outpatient clinic providing specialized follow-up for individuals with moderate to severe MDD. All participants had a primary

Sample characteristics

Demographic and baseline clinical information are presented in Table 1, while subjects' current pharmacological treatments are described in Table 2.

Subjects' ages ranged from 33 to 61 years, with a mean age of 47 years (SD = 8.51). They had a mean of 3.53 (SD = 1.246) failed antidepressants and a mean of 2.27 (SD = 1.335) failed augmenting agents (e.g., lithium and atypical antipsychotics) in the current MDE. Mean baseline HAM-D21, IDS-SR30, HAM-A, BAI, and CGI-S scores were 29.87 (SD = 7.1), 47.93 (SD = 

Discussion

This prospective naturalistic study was designed to assess the effectiveness of HF rTMS as an augmenting strategy in a sample of subjects with severe TRD. Moreover, we sought to broaden our investigation to include variables beyond symptomatology, notably QOL.

As predicted, patients who were severely and chronically depressed with high levels of treatment resistance and psychiatric comorbidities presented with a clinically meaningful improvement in all measures of depression and anxiety.

Conclusions

The present study provides preliminary evidence that 4 weeks of daily HF rTMS over the left DLPFC is associated with clinically meaningful improvements in anxious and depressive symptoms, as well as in QOL in subjects with severe TRD. However, further randomized, controlled and double-blind trials should be carried out to better evaluate the usefulness of rTMS as an augmentation strategy in severe TRD.

Role of the funding source

We had no outside funding for this study.

Conflict of interest

The authors have no financial relationships or conflicts of interest to disclose.

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