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Citalopram for continuation therapy after repetitive transcranial magnetic stimulation in vascular depression.

ABSTRACT: The authors previously reported that repetitive transcranial magnetic stimulation (rTMS) produced a response rate of 39.4% among 62 patients with treatment resistant vascular depression. This study was undertaken to assess the outcome of continuation therapy to prevent relapse among these patients during 9 weeks after completion of rTMS.Patients were randomly assigned to 18,000 pulses of rTMS given over 3 weeks or sham treatment using double blind methods. After rTMS, all patients were given 20 mg/day of citalopram for 9 weeks and reevaluated at 3, 6, and 9 weeks.Outpatient continuation treatment trial.Patients with vascular depression (N = 62), as determined by magnetic resonance imaging hyperintensities and three or more clinical risk factors for vascular disease without other major medical illness, were recruited. They had onset of major depression after age 50 and failed at least one trial of antidepressants.After rTMS or sham treatment, all treatment responders were given citalopram for 9 weeks.Among the 33 patients who were given rTMS, 13 responded (i.e., >50% decline in Hamilton Depression Scale score). Of these 13, all completed the 9 weeks of continuation treatment. There were nine patients who continued to be responders and four who had a relapse of depression.More effective methods are needed to treat elderly patients with treatment resistant vascular depression and to prevent relapse among treatment responders.

SUBMITTER: Robinson RG

PROVIDER: S-EPMC2758492 | biostudies-literature | 2009 Aug

REPOSITORIES: biostudies-literature

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Citalopram for continuation therapy after repetitive transcranial magnetic stimulation in vascular depression.

Robinson Robert G RG Tenev Veselin V Jorge Ricardo E RE

The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry 20090801 8

<h4>Objectives</h4>The authors previously reported that repetitive transcranial magnetic stimulation (rTMS) produced a response rate of 39.4% among 62 patients with treatment resistant vascular depression. This study was undertaken to assess the outcome of continuation therapy to prevent relapse among these patients during 9 weeks after completion of rTMS.<h4>Design</h4>Patients were randomly assigned to 18,000 pulses of rTMS given over 3 weeks or sham treatment using double blind methods. After ...[more]

PMID: 19625785

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Project description:BackgroundRepetitive transcranial magnetic stimulation (rTMS) can target specific neural circuits, which may allow for personalized treatment of depression. Treatment outcome is typically determined using sum scores from validated measurement scales; however, this may obscure differential improvements within distinct symptom domains. The objectives for this work were to determine: (1) whether a standard depression measure can be represented using a four symptom cluster model and (2) whether these symptom clusters had a differential response to rTMS treatment.MethodsData were obtained from two multi-centre randomized controlled trials of rTMS delivered to the left dorsolateral prefrontal cortex (DLPFC) for participants with treatment-resistant depression (TRD) conducted in Canada (THREE-D [Conducted between Sept 2013, and Oct 2016] and CARTBIND [Conducted between Apr 2016 and Feb 2018]). The first objective used confirmatory factor analytic techniques, and the second objective used a linear mixed effects model. Trial Registration: NCT01887782, NCT02729792.FindingsIn the total sample of 596 participants with TRD, we found a model consisting of four symptom clusters adequately fit the data. The primary analysis using the THREE-D treatment trial found that symptom clusters demonstrated a differential response to rTMS treatment (F(3,5984) = 31.92, p < 0.001). The anxiety symptom cluster was significantly less responsive to treatment than other symptom clusters (t(6001) = -8.02, p < 0.001). These findings were replicated using data from the CARTBIND trial.InterpretationThere are distinct symptom clusters experienced by individuals with TRD that have a differential response to rTMS. Future work will determine whether differing rTMS treatment targets have distinct patterns of symptom cluster responses with the eventual goal of personalizing rTMS protocols based on an individual's clinical presentation.FundingCanadian Institutes of Health Research, Brain Canada.

Project description:ObjectivesTo evaluate the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT), and combining both treatments in a stepped care pathway for patients with treatment-resistant depression (TRD) in Ontario.MethodsA cost-utility analysis evaluated the lifetime costs and benefits to society of rTMS and ECT as first-line treatments for TRD using a Markov model, which simulates the costs and health benefits of patients over their lifetime. Health states included acute treatment, maintenance treatment, remission, and severe depression. Treatment efficacy and health utility data were extracted and synthesized from randomized controlled trials and meta-analyses evaluating these techniques. Direct costing data were obtained from national and provincial costing databases. Indirect costs were derived from government records. Scenario, threshold, and probabilistic sensitivity analyses were performed to test robustness of the results.ResultsrTMS dominated ECT, as it was less costly and produced better health outcomes, measured in quality-adjusted life years (QALYs), in the base case scenario. rTMS patients gained an average of 0.96 additional QALYs (equivalent to approximately 1 year in perfect health) over their lifetime with costs that were $46,094 less than ECT. rTMS remained dominant in the majority of scenario and threshold analyses. However, results from scenarios in which the model's maximum lifetime allowance of rTMS treatment courses was substantially limited, the dominance of rTMS over ECT was attenuated. The scenario that showed the highest QALY gain (1.19) and the greatest cost-savings ($46,614) was when rTMS nonresponders switched to ECT.ConclusionFrom a societal perspective utilizing a lifetime horizon, rTMS is a cost-effective first-line treatment option for TRD relative to ECT, as it is less expensive and produces better health outcomes. The reduced side effect profile and greater patient acceptability of rTMS that allow it to be administered more times than ECT in a patient's lifetime may contribute to its cost-effectiveness.

Dataset Information

Citalopram for continuation therapy after repetitive transcranial magnetic stimulation in vascular depression.

Publications

Citalopram for continuation therapy after repetitive transcranial magnetic stimulation in vascular depression.

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