A sham-controlled trial of the efficacy and safety of twice-daily rTMS in major depression

BACKGROUND: Studies of repetitive transcranial magnetic stimulation (rTMS) in depression have mostly involved once-daily treatment, with positive but modest clinical results. This study tested the efficacy and safety of twice-daily rTMS over 2 weeks. METHOD: Thirty-eight depressed subjects enrolled in a double-blind, sham-controlled trial of twice-daily rTMS (left prefrontal cortex, 10 Hz, 110% intensity, 1500 stimuli per session) over 2 weeks. Mood and neuropsychological functioning were assessed weekly by blind raters, using the Montgomery-Asberg Depression Rating Scale (MADRS) as the primary outcome measure, plus the Hamilton Rating Scale for Depression (HRSD) and self-report measures. After the blind period, 22 subjects continued with once-daily rTMS to receive a total of 6 weeks of active rTMS. RESULTS: Subjects were moderately treatment resistant. Active treatment resulted in significantly greater improvement than sham over the 2-week blind period on one outcome measure only (MADRS p<0.05). Subjects showed further improvement over the 6 weeks of active rTMS. Neuropsychological test scores did not change significantly. CONCLUSIONS: rTMS given twice daily was effective and safe, with no adverse neuropsychological effects.     

Cost-effectiveness of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: a decision-making approach

BACKGROUND: Deliberate self-harm can be costly, in terms of treatment and subsequent suicide. Any intervention that reduces episodes of self-harm might therefore have a major impact on the costs incurred by service providers and the productivity losses due to illness or premature death. METHOD: Four hundred and eighty patients with a history of recurrent deliberate self-harm were randomized to manual-assisted cognitive behaviour therapy (MACT) or treatment as usual. Economic data were collected from patients at baseline, 6 and 12 months, and these data were complete for 397 patients. Incremental cost-effectiveness was explored using the primary outcome measure, proportion of patients having a repeat episode of deliberate self-harm, and quality of life. The uncertainty surrounding costs and effects was represented using cost-effectiveness acceptability curves. RESULTS: Differences in total cost per patient were statistically significant at 6 months in favour of MACT (pounds sterling -897, 95 % CI -1747 to -48, P=0.04), but these differences did not remain significant at 12 months (pounds sterling -838, 95% CI -2142 to 466, P=0.21). Nevertheless, exploration of the uncertainty surrounding these estimates suggests there is >90% probability that MACT is a more cost-effective strategy for reducing the recurrence of deliberate self-harm in this population over 1 year than treatment as usual. The results for quality of life were not conclusive. CONCLUSION: Cost-effectiveness acceptability curves demonstrate that, based on the evidence currently available, to reject MACT on traditional grounds of statistical significance and to continue funding current practice has <10% chance of being the correct decision in terms of cost-effectiveness.     

Evidence of cost-effective treatments for depression: a systematic review

BACKGROUND: High levels of public spending, rising costs of treatments and scarcity of mental health resources have intensified the need for information on the cost-effectiveness of interventions for depression. There have been few reviews that consider the cost-effectiveness of all treatments for depression together. METHODS: Systematic review of published economic evaluations of interventions for depression to identify where evidence of cost-effectiveness exists and where ambiguity remains. RESULTS: Fifty-eight papers met the criteria and were included in the review. The quality of the evaluations varied greatly. Evidence establishing the cost-effectiveness of interventions for depression is accumulating; selective serotonin reuptake inhibitors (SSRI) and the newer antidepressants venlafaxine, mirtazepine and nefazodone appear cost-effective compared with older drugs. Despite the availability of high quality economic evaluations of psychological therapies compared to usual care, there is limited evidence of their cost-effectiveness particularly when compared directly to pharmacotherapies. Changes to health systems have been found to be cost-effective in some patient groups, but there is no evidence that screening in primary care populations is a cost-effective strategy. LIMITATIONS: Vastly different interventions, outcome measures and cost perspectives meant a meta-analysis of costs and effects was not considered possible. CONCLUSIONS: On the basis of available evidence, it is not possible to identify the most cost-effective strategy for alleviating the symptoms of depression, although the SSRIs and newer antidepressants consistently appear more cost-effective than tricyclic antidepressants in many patient groups. Better quality economic evidence is needed.     

Adjuvant occupational therapy for work-related major depression works: randomized trial including economic evaluation

BACKGROUND: Major depression has far-reaching consequences for work functioning and absenteeism. In most cases depression is treated by medication and clinical management. The addition of occupational therapy (OT) might improve outcome. We determined the cost-effectiveness of the addition of OT to treatment as usual (TAU). METHOD: Sixty-two adults with major depression and a mean absenteeism of 242 days were randomized to TAU (out-patient psychiatric treatment) or TAU+OT [6 months, including (i) diagnostic phase with occupational history and work reintegration plan, and (ii) therapeutic phase with individual sessions and group sessions]. Main outcome domains were depression, work resumption, work stress and costs. Assessments were at baseline and at 3, 6, 12 and 42 months. RESULTS: The addition of OT to TAU: (i) did not improve depression outcome, (ii) resulted in a reduction in work-loss days during the first 18 months, (iii) did not increase work stress, and (iv) had a 75.5% probability of being more cost-effective than TAU alone. CONCLUSION: Addition of OT to good clinical practice does not improve depression outcome, improves productivity without increasing work stress and is superior to TAU in terms of cost-effectiveness.     

A prospective follow-up study of ECT outcome in older depressed patients

BACKGROUND: This study examined the relationship between age and outcome of electroconvulsive therapy (ECT). METHOD: This was a naturalistic, prospective follow-up of 81 consecutive in-patients with primary major depression. ECT outcome was compared for three age groups - under 65, 65-74 and 75 years and over - on the Hamilton Rating Scale for Depression (HRSD), Global Assessment of Functioning scale (GAF) and clinical outcome rating scale. Assessments were performed pre-ECT, immediately post-ECT, 1-3 years later and, for patients suspected of having dementia, 5 years later. RESULTS: At post-ECT and follow-up, improvement on HRSD and clinical outcome ratings were comparable for patients in the three age groups. Improvements on GAF were also comparable post-ECT, but not between post-ECT and follow-up. At follow-up, 35.7% of the oldest group had dementia. Importantly, patients who did and did not develop dementia were clinically indistinguishable prior to ECT. The number and severity of common adverse events were similar pre- and post-ECT and were not associated with age. CONCLUSIONS: Depressive outcome and adverse effects of ECT are largely independent of age. Older patients receiving ECT appear to have a higher risk of developing dementia, possibly underpinned by cerebrovascular disease.     

"Side effects" of ECT are mainly depressive phenomena and are independent of age

BACKGROUND: The aetiology of reported side effects of electroconvulsive therapy (ECT) is unclear. We examined the interaction of depression and age on adverse neuropsychological and putative side effects of ECT. METHOD: Inpatients (N=81; median age 70 years) with major depression were assessed prospectively pre-ECT, immediately post-ECT and 1-3 years later. Patients were administered the Hamilton Rating Scale for Depression (HRSD), the Global Assessment of Functioning scale (GAF) and neuropsychological tests from the Wechsler Memory Scale. Side effects and total burden scores were rated pre- and post-treatment. RESULTS: HRSD and GAF scores improved with treatment after ECT, but the prevalence and total burden of side effects were unchanged. Side effect burden was related to depression level before and after ECT. Improvement in depression correlated with reduction in side effect burden. There was a significant decline in side effect burden after controlling for change in depression. Patients' scores on neuropsychological measures did not appear to change after ECT or between pre-ECT and follow-up. Re-analysis, allowing for age, chronicity of depression, medication use and development of dementia, did not alter the findings. LIMITATIONS: lack of a control group, lack of information on ECT technique, incomplete data sets and limited neuropsychological testing. CONCLUSIONS: ECT, an effective treatment for depression, does not cause significant side effects or neuropsychological impairment, which are more likely to be depressive phenomena. ECT appears to be safe for old (> or =65 years) and very old (> or =75 years) patients, who do not appear to be more susceptible to adverse effects.     

Acute effects of electroconvulsive therapy on lymphocyte natural killer cell activity in patients with major depression

BACKGROUND: Major depression has been associated with a reduction in lymphocyte natural killer cell activity (NKCA). The effects of biological treatment of depression on the immune system have not been systematically investigated. The present study addresses the acute effects of electroconvulsive therapy (ECT) on NKCA. METHODS: Thirteen patients undergoing ECT for major depression were studied. NKCA at four different effector:target (E:T) ratios (E:T = 50:1; 25:1; 12.5:1 and 6.25:1, respectively) was assessed serially in relation to the first ECT session prior to and up to 1 h following treatment (-30', -10', -3' before ECT and +3', +10', +30' and +60' following ECT). On several patients, NKCA data were also available in relation to the sixth ECT session. Comparisons between mean NKCA values for each of the E:T ratios at the different time points were made using ANOVA. RESULTS: There were significant changes in NKCA values with time at E:T=25:1 (P < 0.05). Mean NKCA values for the 30 min following ECT were significantly higher than the mean NKCA values for the 30 min preceding ECT for all four E:T ratios used (P < 0.05). Differences in NKCA values between ECT no. 1 and ECT no. 6 were small and not statistically significant. CONCLUSION: ECT is associated with a significant albeit transient increase in NKCA. The clinical implications of these findings are unknown at the present time. LIMITATIONS: A small number of patients has been investigated, particularly for the sixth ECT session. No control group for ECT was available. No correlations with clinical outcome variables have been obtained.     

Cost-Effectiveness Analysis of Trauma-Focused Cognitive Behavioral Therapy: A Randomized Control Trial among Norwegian Youth

Traumatic events by young people can adversely affect their psychological and social well-being when left untreated. This can result in high costs for society. In this study, we aimed to evaluate whether trauma-focused cognitive behavioral therapy (TF-CBT) is a cost-effective alternative to therapy as usual (TAU). Individual-level data were collected from 2008 to 2013, as part of a randomized control trial in Norwegian youth, 10–18 years of age, presenting with symptoms of posttraumatic stress (N = 156). Health outcomes, costs, and patient and family characteristics were recorded. Health-related quality of life (HRQoL) was measured with the 16D instrument, and quality-adjusted life-years (QALYs) were derived; total costs included the costs of therapy, and last we calculated the incremental cost-effectiveness ratio (ratio of differences in costs and QALYs gained). We performed nonparametric bootstrapping and used the results to draw a cost-effectiveness acceptability curve depicting the probability that TF-CBT is cost-effective. HRQoL increased in both treatment groups, whereas no significant differences in QALYs were observed. Resource use measured in minutes per session was significantly higher in the TF-CBT group; however, total minutes of therapy and costs were not significantly different between the two groups. In addition, use of resources, such as psychological counseling services, welfare services, and medication, was lower in the TF-CBT group posttreatment. The likelihood of TF-CBT being cost-effective varied from 91% to 96%. TF-CBT is likely to be a cost-effective alternative to standard treatment and should be recommended as the guideline treatment for youth with posttraumatic stress disorder.     

ECT response in delusional versus non-delusional depressed inpatients

BACKGROUND: ECT is often considered more effective in delusional than in non-delusional depressives, although the literature does not support this view. METHODS: We reviewed the records of 55 consecutive inpatients with major depression according to the DSM-III-R criteria and distinguished two subtypes: patients with delusions and those without. We examined whether the deluded patients showed a higher response rate. RESULTS: using 50% reduction on the Hamilton Rating Scale for Depression (HRSD) as response criterion, the efficacy of ECT was higher in patients with delusional depression (92% response) than in the non-deluded patients (55% response). Considering a post-ECT HRSD score of < or =7 as response criterion, patients with delusions again showed a higher response rate (57% versus 24%). LIMITATIONS: this study has a retrospective nature and a rather homogeneous sample. CONCLUSION: ECT appears to be an effective treatment for severely depressed inpatients, both with and without delusions. The efficacy of ECT was superior in patients with delusional depression, considering the number of patients achieving partial remission as well as full remission.     

Influence of resistance to antidepressant pharmacotherapy on short-term response to electroconvulsive therapy

BACKGROUND: Few studies assessing the influence of resistance to antidepressant pharmacotherapy on the response to subsequent electroconvulsive therapy (ECT) are found in the literature. Results are somewhat conflicting and may not be applicable to the population of depressed patients in The Netherlands. The aim of this study is to assess the influence of medication resistance on the short-term response to ECT in a population of severely depressed inpatients in The Netherlands, where ECT is an exceptional treatment, often used as a final treatment option. METHODS: We reviewed the records of 41 consecutive inpatients with major depression according to DSM-III-R criteria and rated each patients' antidepressant pharmacotherapy prior to ECT. We examined the extent to which medication resistance was related to short-term response to ECT. RESULTS: When a reduction of at least 50% on the Hamilton Rating Scale for Depression (HRSD) post-ECT compared to pre-ECT (partial remission) is used as response criterion, medication resistant patients and patients without established medication resistance were equally likely to respond to subsequent ECT. When a post-ECT HRSD score < or = 7 (full remission) is used as response criterion, medication resistant patients were less likely to respond to subsequent ECT (8/29=27.6%) than patients who did not receive adequate antidepressant pharmacotherapy prior to ECT (6/12=50.0%), although the difference in response rate was not statistically significant. LIMITATIONS: This study has a retrospective nature and a relatively small sample size. CONCLUSION: Antidepressant medication resistance does not seem to have an influence on the short-term response to subsequent ECT. However, when the number of patients achieving full remission is concerned, a substantial percentage of antidepressant medication resistant patients respond to ECT, although their response rate was nearly half compared to that of patients without prior adequate treatment with antidepressants. This difference in response rate was not statistically significant. ECT seems to be an effective treatment for both patients with and without prior adequate treatment with antidepressants in this Dutch population.     

Influence of episode duration of major depressive disorder on response to electroconvulsive therapy

BACKGROUND: Longer duration of major depressive episode is supposed to decrease response to electroconvulsive therapy (ECT). Most studies on the subject are dated and their population differs from ours, therefore their results may not be applicable to our population of severely depressed inpatients. METHODS: We reviewed the records of 56 consecutive inpatients with major depressive disorder according to DSM-III-R criteria and assessed each patient's episode duration. We examined whether episode duration has an effect on response to ECT. RESULTS: Episode duration has no significant effect on response to ECT, according to both a reduction on the Hamilton Rating Scale for Depression (HRSD) of at least 50% and a post-treatment HRSD score 相似文献   

Cost-effectiveness of cognitive behavioural therapy, graded exercise and usual care for patients with chronic fatigue in primary care

BACKGROUND: Chronic fatigue is a common condition, frequently presenting in primary care. The aim of this study was to compare the cost-effectiveness of cognitive behavioural therapy (CBT) and graded exercise therapy (GET), and to compare therapy with usual care plus a self-help booklet (BUC). METHOD: Patients drawn from general practices in South East England were randomized to CBT or GET. The therapy groups were then compared to a group receiving BUC recruited after the randomized phase. The main outcome measure was clinically significant improvements in fatigue. Cost-effectiveness was assessed using the net-benefit approach and cost-effectiveness acceptability curves. RESULTS: Costs were available for 132 patients, and cost-effectiveness results for 130. Costs were dominated by informal care. There were no significant outcome or cost differences between the therapy groups. The combined therapy group had significantly better outcomes than the standard care group, and costs that were on average 149 pounds higher (a non-significant difference). Therapy would have an 81.9% chance of being cost-effective if society were willing to attach a value of around 500 pounds to each four-point improvement in fatigue. CONCLUSION: The cost-effectiveness of cognitive behavioural therapy and graded exercise were similar unless higher values were placed on outcomes, in which case CBT showed improved cost-effectiveness. The cost of providing therapy is higher than usual GP care plus a self-help booklet, but the outcome is better. The strength of this evidence is limited by the use of a non-randomized comparison. The cost-effectiveness of therapy depends on how much society values reductions in fatigue.     

Discontinuation of antidepressant drugs during electroconvulsive therapy: a controlled study

BACKGROUND: The concurrent use of antidepressant drugs with ECT is recommended by a recent ECT guideline. The study aimed to examine differential therapeutic and side effect responses when antidepressants are discontinued or not during ECT. METHODS: This study compared the effectiveness and side effect profile of unilateral ECT with antidepressant drugs (Group-1) or unilateral ECT with drug placebo (Group-2) in 30 major depressive disorder (DSM-IV) patients on antidepressants using a prospective randomised trial. Hamilton Rating Scale for Depression (HRSD), Montgomery Asberg Depression Rating Scale (MADRS), UKU scale, Columbia ECT side effect check list were used. The assessments were carried out before starting ECTs and at fixed intervals thereafter for four weeks. In addition, at six weeks a follow-up assessment was carried out using HRSD. ECTs were stopped after four weeks or earlier if patient obtained HRSD scores <8 and remained so for one week. RESULTS: Continuation of antidepressant drugs with ECT conferred no therapeutic advantage. Barring tricyclic antidepressant induced anticholinergic side effects, no differential side effect profile was noted. At follow-up none relapsed in Group-2 and the mean HRSD scores between the groups did not differ. Limitation: The antidepressant treatment prior to ECT was uncontrolled. In addition, the design was not strictly double-blind. CONCLUSION: The study failed to support an advantage with antidepressant continuation during an ECT course in major depressive disorder.     

Cost-effectiveness of a home-based environmental intervention for inner-city children with asthma

BACKGROUND: Exposure to indoor allergens contributes to increased asthma morbidity. The Inner-City Asthma Study, a randomized trial involving home environmental allergen and irritant remediation among children aged 6 through 11 years with moderate-to-severe asthma, successfully reduced asthma symptoms. A cost-effectiveness analysis can help stakeholders to evaluate the potential costs and benefits of adopting such a program. OBJECTIVE: We sought to assess the cost-effectiveness of the environmental intervention of the Inner-City Asthma Study. METHODS: Incremental cost-effectiveness ratios for a 2-year study period were calculated. Health outcome was measured as symptom-free days. Resource use measures included ambulatory visits, hospitalizations, and pharmaceutical use. CIs were obtained by using bootstrapping. RESULTS: The intervention, which cost $1469 per family, led to statistically significant reductions in symptom days, unscheduled clinic visits, and use of beta-agonist inhalers. Over the year of the intervention and a year of follow-up, the intervention cost was $27.57 per additional symptom-free day (95% CI, $7.46-$67.42). Subgroup analysis showed that targeting the intervention to selected high-risk subgroups did not reduce the incremental cost-effectiveness ratio. CONCLUSIONS: A targeted home-based environmental intervention improved health and reduced service use in inner-city children with moderate-to-severe asthma. The intervention is cost-effective when the aim is to reduce asthma symptom days and the associated costs.     

When the cradle falls II: The cost-effectiveness of treating postnatal depression in a psychiatric day hospital compared with routine primary care

BACKGROUND: This prospective cohort study assessed the cost-effectiveness of treating 30 women with postnatal depression (PND) at a specialised psychiatric Parent and Baby Day Unit (PBDU), compared to 30 women treated using routine primary care (RPC). METHODS: Following recruitment, the women were assessed on three occasions (initially, 3- and 6-months), using a variety of social and psychiatric outcome measures. Direct and indirect costs were collated using structured interviews, retrospective analysis of case notes and routinely collated NHS cost data. Sensitivity analysis was also carried out. RESULTS: There was no significant difference between the women in the two groups initially in terms of their socio-demographic characteristics, or scores on the outcome measures. However, at 6-months, 21 women in the PBDU group were no longer depressed compared to only seven women in the RPC group. The total cost was 46,211 pounds for the PBDU group and 18,973 pounds for the RPC group. Moving from RPC to a PBDU would involve an additional expenditure of 27,238 pounds (46,211-18,973) whilst delivering 14 more positive outcomes. The move from RPC to PBDU would incur an additional cost per successfully treated woman of 1945 pounds (27,238/14). This compares favourably with the current cost per successfully treated woman in the RPC group of 2710 pounds (18,973/7). CONCLUSIONS: RPC is dominated on the grounds of cost-effectiveness by PBDU treatment and so PBDU treatment should be recommended to health care decision-makers. LIMITATIONS OF THE STUDY: The results were sensitive to the inclusion of primary care contacts and the costs of medication.     

重复经颅磁刺激和无抽搐电痉挛治疗抑郁症的初步比较

目的探讨重复经颅磁刺激和无抽搐电痉挛治疗抗抑郁疗效的差异。方法纳入分别接受重复经颅磁刺激治疗(rTMS组)和无抽搐电痉挛治疗(MECT组)的难治性抑郁症患者各30例,采用汉密尔顿抑郁量表在治疗前和治疗结束时评估患者临床症状,比较两组患者的疗效差异。结果 rTMS和MECT均能显著改善患者抑郁症状(rTMS组:t=0.34,P=0.02;MECT组:t=0.23,P=0.00)。rTMS组在汉密尔顿量表睡眠障碍因子分改善方面显著高于MECT组,差异有显著统计学意义(t=7.88,P=0.01),MECT在改善自杀因子方面优于rTMS,差异有显著统计学意义(t=3.87,P=0.00)。结论 rTMS和ECT在短期内均能有效改善抑郁症状,MECT的抗抑郁作用强于rTMS。在改善睡眠障碍方面,rTMS优于MECT;在改善自杀因子方面,MECT组作用更强。     

rTMS for pharmacoresistant major depression in the clinical setting of a psychiatric hospital: Effectiveness and effects of age

Background

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive method of brain stimulation used in the treatment of drug-resistant major depressive disorder (MDD). It has been suggested that the efficacy of rTMS decreases with the age of the patient, but the data are contradictory. Here, we analyze in our clinical setting the efficacy of a 3-week rTMS treatment in drug-resistant MDD during a 3 month period and the potential influence of age on this efficacy.

Methods

Stimulation consisted of 15 sessions of rTMS over the dorsolateral prefrontal cortex. Clinical evaluations included the Hamilton Depression Rating Scale (HDRS), and the Beck Depression Inventory (BDI) at baseline, after 3 weeks of treatment, and 1 month and 3 months after the last session.

Results

Data from 93 patients issued from the 178 patients active file were analyzed. The antidepressant effect observed in the two age groups (<65 and ≥65) did not differ at the end of the treatment and 3 months later, with a comparable number of responders (50% decrease in HDRS score from baseline) (53.3% for age <65 versus 46.7% for age ≥65, p=0.51). The treatment had a significant effect over time. We found no evidence of the age affecting outcome at 3 months after the last session.

Limitations

Previous antidepressant treatments, and therapeutic drug use modifications after rTMS treatment, degree of pharmaco-resistance or duration of current episode are not reported.

Conclusion

RTMS of the DFPLC is effective as an add-on treatment for cases of pharmacologically refractory major depression, independent of the patient age.     

Effectiveness and cost-effectiveness of antidepressant treatment in primary health care: a six-month randomised study comparing fluoxetine to imipramine

BACKGROUND: Over the past decade, studies of the effectiveness of pharmacological treatment for depression have often been based on research designs intended to measure efficacy, and for this reason the results are of limited generalizability. Research is needed comparing the clinical and economic outcomes of antidepressants in day-to-day clinical practice. METHODS: A six-month randomised prospective naturalistic study comparing fluoxetine to imipramine carried out in three primary care health centres. Outcome measures were the Montgomery Asberg Depression Rating Scale (MADRS), direct costs, indirect costs and total costs. Subjects were evaluated at the beginning of treatment and at one, three and six months thereafter. RESULTS: Of the 103 patients, 38.8% (n = 40) were diagnosed with major depressive disorder, 14.6% (n = 15) with dysthymic disorder, and 46.6% (n = 48) with depressive disorder not otherwise specified. Patients with major depressive disorder or dysthymic disorder achieved similar clinical improvement in both treatment groups (mean MADRS ratings decrease in major depressive disorder from baseline to 6 months of 18.3 for imipramine and 18.8 for fluoxetine). For patients with major depressive disorder and dysthymic disorder, the imipramine group had fewer treatment-associated costs (imipramine 469.66 Euro versus fluoxetine 1,585.93 Euro in major depressive disorder, p < 0.05; imipramine 175.39 Euro versus fluoxetine 2,929.36 Euro in dysthymic disorder, p < 0.05). The group with depressive disorder not otherwise specified did not experience statistically significant differences in clinical and costs outcomes between treatment groups. LIMITATIONS: Exclusion criteria, participating physicians may not represent GPs. CONCLUSIONS: In a primary care context, imipramine may represent a more cost-effective treatment option than fluoxetine for treating major depressive disorder or dysthymic disorder. There were no differences in cost-effectiveness in the treatment of depressive disorder not otherwise specified.     

Serial dexamethasone suppression tests in depressed patients treated only with electroconvulsive therapy

Several systematic studies have evaluated serial dexamethasone suppression tests (DST) in patients with major depression who were treated with antidepressant medications. DST changes were noted to parallel clinical improvement in most recovering patients. If serial DSTs are a valid state-related correlate of depressive pathophysiology, all types of effective antidepressant treatment should result in DST 'normalization'. However, no treatment modalities other than antidepressant medications have been studied serially with systematic assessments. To test whether serial DSTs reflect clinical progress in depressives treated solely with electroconvulsive therapy (ECT), we studied weekly DSTs and Hamilton Rating Scales for Depression (HRSD) in 22 drug-free depressed patients. We observed progressive DST 'normalization' in most patients and moderately high correlations between weekly DST and HRSD values throughout treatment. Most patients receiving ECT became DST suppressors. In most patients the DST appeared to reflect the severity of depressive pathophysiology, perhaps providing serial feedback to clinicians monitoring the progress of treatment with ECT.     

Repetitive Transcranial Magnetic Stimulation (rTMS) in the treatment of panic disorder (PD) with comorbid major depression

BACKGROUND: Studies suggest that the dorsolateral prefrontal cortex (DLPFC) participates in neural circuitry that is dysregulated in Panic Disorder (PD) and Major Depressive Disorder (MDD). We tested whether low-frequency repetitive Transcranial Magnetic Stimulation (rTMS) could normalize the overactivity of right frontal regions and thereby improve symptoms. METHODS: Six patients with PD and comorbid MDD were treated with daily active 1-Hz rTMS to the right DLPFC for 2 weeks in this open-label trial. RESULTS: Clinical improvements were apparent as early as the first week of treatment. After the second week, 5/6 of patients showed improvements in panic and anxiety, and 4/6 showed a decrease in depression, with sustained improvement at 6 months of follow-up. Right hemisphere resting motor threshold increased significantly after rTMS. LIMITATIONS: Limitations of this study are the open design and the small sample size. CONCLUSIONS: Slow rTMS to the right DLPFC resulted in significant clinical improvement and reduction of ipsilateral motor cortex excitability. Replications in larger sample will help to clarify the relevance of this preliminary data and to define the potential role of right DLPFC rTMS in panic with major depression.