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Transcranial Magnetic Stimulation vs. ECT in Psychotic and Nonpsychotic Depression

Repetitive transcranial magnetic stimulation (rTMS) applied to the left dorsolateral prefrontal cortex has received increasing scrutiny as a possible substitute for electroconvulsive therapy (see JW Psychiatry, Jun 1999, p. 48, and Arch Gen Psychiatry 1999; 56:315). This open Israeli study randomly assigned 40 ECT candidates with major depression (19 with psychosis) to rTMS or ECT; its findings suggest that rTMS may be as effective as ECT for nonpsychotic depression, but not for psychotic depression.

ECT patients received right unilateral ECT at 2.5 times the seizure threshold (mean number of ECTs, 9.6); 8 were switched to bilateral placement after not responding to 6 treatments. rTMS was administered 5 times per week for 4 weeks; stimulation occurred at 10 Hz for 20 trains at 2 seconds (8 patients) or 6 seconds (final 12 patients). ECT patients continued antidepressive medications; rTMS patients received only clonazepam. ECT was clearly superior to rTMS for psychotic major depression, whereas patients with nonpsychotic major depression responded equally well to both treatments. In patients with a definite early response, continuing rTMS for 4 weeks increased overall treatment response; however, patients with minimal improvement after 2 weeks of rTMS did not improve after continued treatment.

Comment: This study is limited by open outcome assessments, lack of a placebo group, and use of concomitant psychotropic medications by ECT patients but only clonazepam by patients receiving transcranial magnetic stimulation. Higher-frequency rTMS may have been more effective than lower-frequency rTMS for psychotic depression, but high-frequency treatment carries a greater risk for spontaneous seizures and is not yet approved in the U.S.

— S Dubovsky

Published in Journal Watch Psychiatry June 1, 2000

Citation(s):

Grunhaus L et al. Repetitive transcranial magnetic stimulation is as effective as electroconvulsive therapy in the treatment of nondelusional major depressive disorder: An open study. Biol Psychiatry 2000 Feb 15 47 314-324.

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