Repetitive transcranial magnetic stimulation and pharmacological treatment in patients with major depressive disorder

Introduction: Major depression is one of the leading causes of disease burden worldwide. Its impact on society with renard to human suffering and economic charge is enormous and is even projected to increase in upcoming decades. The World Health Organization (WHO) estimates that they will be the second most important cause of disability by the year 2020. Current approaches to the treatment of major depression, while effective, are nevertheless associated with substantial percentages of nonresponders or partial responders. Approximately 30% of depressed patients do not show sufficient improvements after the first course of adequate antidepressant treatment and a further 20% discontinue due to tolerability problems. Half of patients who do not respond adequately to a first course also fail to respond to a second antidepressant treatment trial. If several antidepressant treatment trials have been inefficient, even lower response rates after switching to other drugs may be observed. Because of relapses and recurrences, major depression tends to be a chronic illness. Given the pervasive nature of depression and the need for more effective, safer and more socially acceptable therapeutic strategies, alternative approaches are being investigated, such as repetitive Transcranial Magnetic Stimulation (rTMS). Several Clinical Trials on Repetitive Transcranial Magnetic Stimulation (rTMS) have shown its effectiveness in the treatment of depression proposing rTMS as an augmentation strategy [1,2]. Objectives: Object of this study was to compare the effectiveness of rTMS associated with pharmacotherapy and single drug treatment in pharmacotherapy-resistant major depressive patients. Methods: A sample of 20 outpatients was randomly assigned to one of two treatment groups. Inclusion criteria: age between 45 and 65; diagnosis of major depressive disorder (according to the criteria of DSM-IV-TR); score 20 at the 21-item HDRS score 25 or the MADRS; drug resistance to at least three adequate courses of at least 2 different classes of antidepressants; serious neurological evaluation was excluded performing CT or MRI. Group I was treated with drugs and high-frequency rTMS over the left dorso-lateral-prefrontal-cortex. Group II was treated only with drugs. Effectiveness data was gathered at baseline and at week 4. Clinician-rating of depressive symptoms included the Hamilton Depression Rating Scale and the Montgomery Asberg Depression Rating Scale. All patients underwent an evaluation of neuropsychological battery for the evaluation of different frontal lobe abilities, both before and after rTMS, including the Frontal Assessment Battery and the Stroop Color Word Test interference. Results: Comparison of the two group treatment revealed statistically significant mood improvements in the first group as indexed by a reduction of more than 40% on the Hamilton Rating Scale for Depression and on Montgomery Asberg Depression Rating Scale. Conclusion: Left prefrontal rTMS as combined therapy with drugs produced statistically significant and clinically meaningful antidepressant therapeutic effects greater than single drug treatment [3].