Repetitive Transcranial Magnetic Stimulation (rTMS) in Combination with Escitalopram in Patients with Treatment-Resistant Major Depression. A Double-Blind, Randomised, Sham-Controlled Trial

Mar 4, 2008Pharmacopsychiatry

Repeated brain stimulation combined with escitalopram in patients with hard-to-treat major depression: a double-blind, placebo-controlled trial

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Abstract

Active, high-frequency rTMS over the left cortex resulted in an effect size above 0.70 on the HAM-D(6) scale in patients with major depression.

Forty-five patients with medication-resistant major depression were included in the randomized trial.
Patients received either sham TMS or active rTMS alongside daily escitalopram.
The active rTMS demonstrated a statistically and clinically significant effect compared to sham TMS.
Most participants had previously failed two non-tricyclic antidepressant treatments.
Both the rTMS and escitalopram were reported to be well-tolerated.

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BACKGROUND: The role of high-frequency rTMS over the left cortex as an add-on strategy in the treatment of major depression is still uncertain even in patients resistant to pharmacotherapy. We had planned a large sham TMS controlled study in the acute phase with a placebo-controlled relapse-prevention phase with escitalopram. However, because a recent meta-analysis showed only a small effect size of rTMS over sham TMS in the acute treatment phase of depressed patients, we decided to make an interim analysis.

METHOD: In patients with medication-resistant major depression we administered in a randomised trial 15 sessions of sham-controlled rTMS over three weeks in combination with 20 mg escitalopram daily. After the last rTMS, the patients were followed for another 9 weeks on 20 mg escitalopram daily. The antidepressant effect was measured by the HAM-D(6) as primary outcome scale.

RESULTS: A total of 45 patients with complete data were randomised so that 23 patients received sham TMS and 22 patients received active, high-frequency rTMS over the left cortex. Over the 3 weeks, the active rTMS treatment was superior to sham TMS with effect sizes on the HAM-D(6) above 0.70, which indicates not only a statistically but also a clinically significant effect. The patients had typically been through two failed antidepressant treatment attempts with non-tricyclics before inclusion in the study. Both the rTMS and escitalopram were well-tolerated.

CONCLUSION: High-frequency rTMS over the left cortex is an add-on strategy of clinical significance in combination with escitalopram in patients with major depression resistant to non-tricyclic antidepressants.

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Repetitive Transcranial Magnetic Stimulation (rTMS) in Combination with Escitalopram in Patients with Treatment-Resistant Major Depression. A Double-Blind, Randomised, Sham-Controlled Trial

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