Objective: Late-life depression is often associated with treatment-resistance, poor long-term outcome and progressive disability in daily functioning. Controlled studies show antidepressant effects after repetitive transcranial magnetic stimulation (rTMS) in patients with drug-refractory depression. There are no descriptions of clinical dimensions modified by rTMS. The aim of the present study is to assess the clinical profile of responders in elderly depressive subjects.
Design: Open trial.
Patients: 6 patients with drug-refractory DSM-IV major depression were included: 2 females and 4 males. All were right-handed. They had no psychiatric or significant somatic comorbidity. All patients gave their written informed consent. The study was approved by the local ethics committee.
Treatment: A Magstim Rapid Stimulator (MAGSTIM Innomed TM) with a focal, figure 8-shaped 70-mm coil was used for rTMS. The motor threshold (MT) for the right abductor pollicis brevis muscle (APBM) was determined according to the method of limits. As in prior studies, the position of the left dorso-lateral pre-frontal cortex (DLPFC) was defined as 5 cm anterior to the scalp position for optimal stimulation of the right APBM. rTMS was applied at 90% or 100% of MT, using 1600 stimuli per day (10 Hz) for 10 consecutive days during 2 weeks.
Design and rating: Severity of depression was rated with a 21-item version of the Hamilton Depression Rating Scale(HDRS). Raters were experienced psychiatrists. Patients also self-rated their symptoms using the Symptom-Check-List of Derogatis(SCL-90R)and the Beck Depression Inventory (BDI). All patients were rated at the same time of the day, at baseline (day 0), and after the last rTMS treatment (day 10). The clinical response is defined by a decrease of the HDRS mean global score by 30%.
Statistical Analysis: Scores on factors from 2 separate factorial analyses (Fleck et al, 1995; O'Brien et al, 1988) were computed using a non-parametric rank statistical test (Wilcoxon). Scores on individual items were classified according to degree and frequency of change.
Clinicians' ratings: After rTMS sessions, HDRS mean global score decreased by 57%(+/-9)(p < 0,03). HDRS score on a core depressive factor(F1)(in Fleck et al. analysis) decreased from pre-treatment to post-treatment (p < 0,03).
Self-rating: "Work and activities" item (HDRS) improved in all patients. Scores on other items were not significantly modified between pre- and post-measurements.
Side-effects: In general, rTMS was well tolerated and compliance was excellent.
Conclusion: In this preliminary open study, core depressive symptoms were significantly alleviated after rTMS in an elderly population. Daily functioning seems to be particularly sensitive to rTMS treatment. rTMS appear to be a promising therapeutic in the management of refractory-depression in the elderly.
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