June 2007

rTMS: Inferior to ECT?
Repetitive transcranial magnetic stimulation (rTMS) is not as efficacious as electroconvulsive therapy (ECT) in patients referred for ECT.

Psychotropics and Fracture Risk
Patients (especially elderly ones) taking psychiatric medications are at increased risk for fractures.

Riluzole Augmentation for Depression
Preliminary evidence suggests riluzole (Rilutek) may be helpful in treating mood and anxiety disorders.

CBT Beats Zopiclone for Insomnia in Elderly
Cognitive behavioral therapy (CBT) was superior to zopiclone (Ambien) for chronic primary insomnia.

Alternative Medicines Are Commonly Used
Surveys show alternative medicines used by more than half of US population.

Hyponatremia with Antidepressants
Hyponatremia reported in patients treated with escitalopram (Lexapro) or duloxetine (Cymbalta).

In Brief
Dosing Strategies for Risperidone Long-Acting Injection; Deaths Associated with Methadone Treatment for Pain

Prolactin Levels and Associated Side Effects with Risperidone
Initial elevation of prolactin levels with risperidone (Risperdal) returns to normal with long-term treatment.

Mifepristone for Psychotic Depression?
Treatment with mifepristone (Mifeprex) improves psychosis but not depression in patients with psychotic depression.

An NSAID for Schizophrenia?
Adjunctive celecoxib (Celebrex) may be beneficial for treating schizophrenia.

rTMS: Inferior to ECT?

June 2007

Although it is a mainstay for the treatment of severe and treatment-resistant depression, electroconvulsive therapy (ECT) is poorly accepted by many patients. In addition, ECT requires anesthesia and can produce cognitive side effects. By contrast, the brief magnetic pulses of repetitive transcranial magnetic stimulation (rTMS) do not usually cause seizures or cognitive side effects and require no anesthesia. Because rTMS appears to cost less and be more acceptable than ECT, Eranti and coworkers in the United Kingdom compared rTMS with ECT in patients with severe depression who were referred for ECT.1

Two hundred sixty patients were referred for ECT during the trial, but many refused ECT and became ineligible. Of those who were eligible, 46 consented to enter the study. Patients were randomly assigned to either a 15-day course of rTMS of the left dorsal lateral prefrontal cortex or twice-weekly ECT sessions with EEG monitoring.

At the end of treatment, scores on the Hamilton Depression Rating Scale were substantially and significantly (P = .002) lower among ECT-treated than rTMS-treated patients. Furthermore, in the ECT group, 59.1% achieved remission versus only 16.7% in the rTMS group. For some reason, by 6 months, the depression scores converged. In the rTMS group, depression appeared to improve between the end of treatment and the end of 6 months, while ECT-treated patients worsened over the same interval.

The authors conclude that rTMS is not equally efficacious to ECT among patients referred to ECT. Of course, selection bias may have been a confounding variable in the methodology of this study. Also, the apparent convergence of depression severity between the two treatment groups by 6 months is hard to explain. This remains yet another therapeutic area where the "jury is still out."

1Eranti S, Mogg A, Pluck G, Landau S, Purvis R, Brown RG, Howard R, Knapp M, Philpot M, Rabe-Hesketh S, Romeo R, Rothwell J, Edwards D, McLoughlin DM: A randomized, controlled trial with 6-month follow-up of repetitive transcranial magnetic stimulation and electroconvulsive therapy for severe depression. Am J Psychiatry 2007;164:73-81.