Comparative Efficacy and Acceptability of 3 Repetitive Transcranial Magnetic Stimulation Devices for Depression: A Meta-Analysis of Randomized, Sham-Controlled Trials

<b><i>Introduction:</i></b> Repetitive transcranial magnetic stimulation (rTMS) has been employed worldwide for therapy-resistant depression. The Food and Drug Administration has approved a number of therapeutic devices for treating major depressive disorder; however, no studies have examined the differences in efficacy and acceptability among commercially available stimulation devices. The aim of our study was to compare the efficacy and acceptability of 3 stimulation devices (NeuroStar, MagPro, and Magstim) for depressive disorders. <b><i>Methods:</i></b> Our study included 31 randomized sham-controlled trials of high-frequency rTMS included in the network meta-analysis by Brunoni. We calculated the risk ratio and 95% confidence intervals, comparing each device with sham for the endpoints of response rate, remission rate, and all-cause discontinuation. We then analyzed the differences among the devices in effect size for those endpoints. <b><i>Results:</i></b> After determining the effect sizes for the endpoints, we found no statistically significant subgroup differences in the response rates, all-cause discontinuation, or remission rates among the devices (<i>p</i> = 0.12, <i>p</i> = 0.84, and <i>p</i> = 0.07, respectively). <b><i>Conclusion:</i></b> Our results suggest similar efficacy and acceptability for the 3 stimulation devices. Future studies need to perform head-to-head comparisons of the efficacy and acceptability of the stimulation devices for treating depression using the same stimulation protocols.

Gradient of electro-convulsive therapy’s antidepressant effects along the longitudinal hippocampal axis

Despite decades of successful treatment of therapy-resistant depression and major scientific advances in the field, our knowledge about electro-convulsive therapy’s (ECT) mechanisms of action is still scarce. Building on strong empirical evidence for ECT-induced hippocampus anatomy changes, we sought to test the hypothesis that ECT has a differential impact along the hippocampus longitudinal axis. We acquired behavioural and brain anatomy magnetic resonance imaging (MRI) data in patients with depressive episode undergoing ECT (n = 9) or pharmacotherapy (n = 24) and healthy controls (n = 30) at two time points 3 months apart. Using whole-brain voxel-based statistical parametric mapping and topographic analysis focused on the hippocampus, we observed ECT-induced gradient of grey matter volume increase along the hippocampal longitudinal axis with predominant impact on its anterior portion. Clinical outcome measures showed strong correlations with both baseline volume and rate of ECT-induced change exclusively for the anterior, but not posterior hippocampus. We interpret our findings confined to the anterior hippocampus and amygdala as additional evidence of the regional specific impact of ECT that unfolds its beneficial effect on depression via the “limbic” system. Main limitations of the study are patients’ polypharmacy, heterogeneity of psychiatric diagnosis, and long-time interval between scans.

Characteristics of patients expressing an interest in ketamine treatment: results of an online survey

BackgroundOff-label ketamine treatment has shown acute antidepressant effects that offer hope for patients with therapy-resistant depression. However, its potential for integration into treatment algorithms is controversial, not least because the evidence base for maintenance treatment with repeated ketamine administration is currently weak. Ketamine is also a drug of misuse, which has raised concerns regarding the target population. Little is known about which patients would seek ketamine treatment if it were more widely available.AimsTo explore some of the characteristics of the patients actively seeking ketamine treatment.MethodAn online survey containing questions about duration of current depressive episode, number of antidepressants used and other comments was completed by patients who were exploring the internet regarding the possibility of ketamine for depression.ResultsOf the 1088 people who registered their interest, 93.3% reported depression, 64.3% reported a chronic course of their symptoms and in the past 10 years, 86.3% had tried at least two antidepressants. Desperation was a common theme, but this appeared to be competently expressed. A small minority (<8%) reported experience of illegal ketamine use.ConclusionsIt cannot be ruled out that patients with different degrees of treatment resistance and comorbidities will seek treatment with ketamine. This stresses the urgency to perform larger randomised controlled trials as well as to systematically monitor outcomes and adverse effects of ketamine, that is currently prescribed off-label for patients in need.Declaration of interestR.M. is consulting and is Principal Investigator for Janssen trials of esketamine and is consulting for Eleusis.

The choice of anesthetics and the effect on the Hamilton depression rating scale in therapy resistant depression

IntroductionThe Dutch guideline ECT does not favor any anesthetic drug during electroconvulsive therapy. Although there are differences in seizure duration which may influence the effect of ECT, ethomidate, methohexital and propofol are “equal”. The influence of switching anesthetics during ECT is unknown. The reason for switching anesthetics is insufficient improvement in depressive symptomatology which is based on clinical picture. The Hamilton is a multiple item questionnaire which can give an indication of depression and which can evaluate recovery.ObjectivesDoes the choice of anesthetics or switching anesthetics influence the effect of ECT on the Hamilton depression rating scale?AimsTo determine whether the choice of anesthetic drugs in the case of switching influences the effect on the Hamilton depression rating scale.MethodsWe collected data of patients who received ECT for therapy resistant depression over the past five years. Choice of anesthetics, eventually switch and the score on the HDRS before and after ECT were included. The data was statistical analyzed.Results50 patients received ECT during past 5 years. ECT gives an improvement on the HDRS in all cases, whether there was a switch or not. Switching from methohexital to ethomidate when shock duration is less than 21 seconds gives a significant difference in improvement on the HDRS (BI 1.288 to 13.538) compared to patients who did not switch.ConclusionsThere are no significant differences on HDRS effect between the different anesthetics. Switching from methohexital to ethomidate gives a significant improvement on HDRS compared with no switch.Disclosure of interestThe authors have not supplied their declaration of competing interest.