Demetrio O. Rumi

Transcranial magnetic stimulation accelerates the antidepressant effect of amitriptyline in severe depression: A double-blind placebo-controlled study

BACKGROUND Transcranial magnetic stimulation (TMS) is a noninvasive method to stimulate the cortex, and the treatment of depression is one of its potential therapeutic applications. Three recent meta analyses strongly suggest its benefits in the treatment of depression. The present study investigates whether repetitive TMS (rTMS) accelerates the onset of action and increases the therapeutic effects of amitriptyline. METHODS Forty-six outpatients meeting DSM-IV criteria for nonpsychotic depressive episode were randomly assigned to receive rTMS (n = 22) or sham repetitive TMS (sham) (n = 24) during 4 weeks over dorsolateral prefrontal cortex (DLPFC) in this double-blind controlled trial. All patients were concomitantly taking amitriptyline (mean dose 110 mg/d). The rTMS group received 20 sessions (5 sections per week) of 5 Hz rTMS (120% of motor threshold and 1250 pulses per session). Sham stimulation followed the same schedule, however, using a sham coil. The efficacy variables were the Hamilton Depression Rating Scale-17 items (HAM-D/17), the Montgomery-Asberg Depression Rating Scale (MADRS), a Visual Analogue Scale (VAS), and the Clinical Global Impression (CGI). Tolerability was assessed by clinical examination and a safety screening of TMS side effects. RESULTS Repetitive TMS had a significantly faster response to amitriptyline. There was a significant decrease in HAM-D/17 scores, already after the first week of treatment (p < .001 compared with baseline and p < .001 compared with sham). The decrease in HAM-D/17 scores in the rTMS group was significantly superior compared with the sham group throughout the study (p < .001 at fourth week). CONCLUSIONS Repetitive TMS at 5 Hz accelerated the onset of action and augmented the response to amitriptyline.

Effect of repetitive TMS and fluoxetine on cognitive function in patients with parkinson's disease and concurrent depression

Previous studies show that cognitive functions are more impaired in patients with Parkinsons disease (PD) and depression than in nondepressed PD patients. We compared the cognitive effects of two types of antidepressant treatments in PD patients: fluoxetine (20 mg/day) versus repetitive transcranial magnetic stimulation (rTMS, 15 Hz, 110% above motor threshold, 10 daily sessions) of the left dorsolateral prefrontal cortex. Twenty‐five patients with PD and depression were randomly assigned either to Group 1 (active rTMS and placebo medication) or to Group 2 (sham rTMS and fluoxetine). A neuropsychological battery was assessed by a rater blind to treatment arm at baseline and 2 and 8 weeks after treatment. Patients in both groups had a significant improvement of Stroop (colored words and interference card) and Hooper and Wisconsin (perseverative errors) test performances after both treatments. Furthermore, there were no adverse effects after either rTMS or fluoxetine in any neuropsychological test of the cognitive test battery. The results show that rTMS could improve some aspects of cognition in PD patients similar to that of fluoxetine. The mechanisms for this cognitive improvement are unclear, but it is in the context of mood improvement.

Comparison of repetitive transcranial magnetic stimulation and electroconvulsive therapy in unipolar non-psychotic refractory depression: a randomized, single-blind study

Repetitive transcranial magnetic stimulation (rTMS) can induce significant antidepressant effects and, for some patients, might be an alternative to electroconvulsive therapy (ECT). The results of studies comparing the efficacy of rTMS and ECT are mixed and, therefore, comparison of these two therapies needs to be further explored. Forty-two patients aged between 18 and 65 yr, referred to ECT due to unipolar non-psychotic depression refractoriness entered the trial. They were randomly assigned to receive either rTMS or ECT. Depressive symptom changes were blindly measured by Hamilton Depression Rating Scale, Visual Analogue Scale and Clinical Global Impression at baseline, after 2 wk and after 4 wk of treatment. There was no difference in the antidepressant efficacy of ECT and rTMS. Response rates were relatively low in both groups (40% and 50% respectively), with no significant difference between them (p=0.55). Remission rates were also low for both groups (20% and 10% respectively), also with no significant difference (p=0.631). There was no significant difference in the neuropsychological test performance after either one of these therapies. Both treatments were associated with a degree of improvement in refractory depression and therefore add to the literature that rTMS can be an effective option to ECT as it is a less costly treatment and is not associated with anaesthetic and other ECT risks.

Double-blind study to evaluate efficacy and safety of meloxicam 7.5 mg and 15 mg versus mefenamic acid 1500 mg in the treatment of primary dysmenorrhea

Objective.  Assessment of efficacy and safety of meloxicam 7.5 mg and 15 mg once a day (o.a.d.) compared with mefenamic acid 500 mg three times a day (t.i.d.), over a treatment period of 3–5 days, during three menstrual cycles, for primary dysmenorrhea.

Electrocardiographic and Blood Pressure Alterations During Electroconvulsive Therapy in Young Adults

OBJECTIVE To study cardiovascular alterations in young patients with no apparent organic disease who underwent electroconvulsive therapy. METHODS The study comprised 47 healthy patients (22 males and 25 females) with a mean age of 30.3 years, who underwent electroconvulsive therapy. Ambulatory blood pressure monitoring and continuous electrocardiographic monitoring (Holter monitor) were performed during 24 hours. Blood pressure and heart rate were assessed 4 hours prior to electric shock administration, during electric shock administration, and 3 hours after electric shock administration. Arrhythmias and alterations in the ST segment in 24 hours were recorded. RESULTS On electroconvulsive therapy, a significant increase in blood pressure and heart rate was observed and the measurements returned to basal values after 25 minutes. Three females had tracings with depression of the ST segment suggesting myocardial ischemia prior to and after electroconvulsive therapy. Coronary angiography was normal. No severe cardiac arrhythmias were diagnosed. CONCLUSION 1) Electroconvulsive therapy is a safe therapeutic modality in psychiatry; 2) it causes a significant increase in blood pressure and heart rate; 3) it may be associated with myocardial ischemia in the absence of coronary obstructive disease; 4) electroconvulsive therapy was not associated with the occurrence of severe cardiac arrhythmias.

Assessment of the cardiovascular effects of electroconvulsive therapy in individuals older than 50 years

To evaluate the impact of electroconvulsive therapy on arterial blood pressure, heart rate, heart rate variability, and the occurrence of ischemia or arrhythmias, 38 (18 men) depressive patients free from systemic diseases, 50 to 83 years old (mean: 64.7 +/- 8.6) underwent electroconvulsive therapy. All patients were studied with simultaneous 24-h ambulatory blood pressure and Holter monitoring, starting 18 h before and continuing for 3 h after electroconvulsive therapy. Blood pressure, heart rate, heart rate variability, arrhythmias, and ischemic episodes were recorded. Before each session of electroconvulsive therapy, blood pressure and heart rate were in the normal range; supraventricular ectopic beats occurred in all patients and ventricular ectopic beats in 27/38; 2 patients had non-sustained ventricular tachycardia. After shock, systolic, mean and diastolic blood pressure increased 29, 25, and 24% (P < 0.001), respectively, and returned to baseline values within 1 h. Maximum, mean and minimum heart rate increased 56, 52, and 49% (P < 0.001), respectively, followed by a significant decrease within 5 min; heart rate gradually increased again thereafter and remained elevated for 1 h. Analysis of heart rate variability showed increased sympathetic activity during shock with a decrease in both sympathetic and parasympathetic drive afterwards. No serious adverse effects occurred; electroconvulsive therapy did not trigger any malignant arrhythmias or ischemia. In middle-aged and elderly people free from systemic diseases, electroconvulsive therapy caused transitory increases in blood pressure and heart rate and a decrease in heart rate variability but these changes were not associated with serious adverse clinical events.

Assessment of memory complainers in São Paulo, Brazil Three-year results of a memory clinic

Memory clinics were established in the USA and European countries as services to attend patients who complain of cognitive deficits, referred by primary care doctors, specialists and other hospitals. Objective We aimed to describe the clinical and cognitive profile of consecutively evaluated subjects during the initial three years of service of a memory clinic from a university hospital. Methods Subjects were submitted to a clinical work-up for dementia, which included laboratory exams, cranial computerized tomography, cognitive tests, and a comprehensive neuropsychological battery. Diagnosis was made according to ICD-10 criteria. Results We evaluated 104 subjects (67.3% females and 32.7% males), with mean age of 59.1 years, 88.8% aged 50 years or above. Mean schooling was 9.9 years. Patients were classified into 10 different primary diagnostic categories, namely Depression (26.9%), Alzheimer’s disease (17.3%), Memory complaints without objective impairment (17.3%), Mild Cognitive Disorder – MCD (14.4%), and Anxiety (12.5%) the most frequent diagnosis. Comparing patients with dementia, MCD, Depression or Anxiety and Memory complainers, by age (below and above 60 years), dementia was more commonly diagnosed in older subjects, while a higher frequency of memory complainers was found in the younger group. Conclusions This preliminary report from an outpatient group of referred patients with cognitive complaints showed a higher frequency of psychiatric disorders in this sample. The memory clinic approach should be considered as a model of service which can evaluate subjects with cognitive complaints effectively and improve the quality of care delivered to this patient group.

Cardiovascular safety of the method of limits titration procedure for electroconvulsive therapy dosing: a retrospective study

The best way to select the charge to be given during electroconvulsive therapy (ECT) treatment is still controversial. Although the method of limits titration procedure developed by Sackeim et al. is generally accepted as the best one, being encouraged by the American Psychiatric Association, many practitioners have concerns regarding the cardiac safety of this method. Subthreshold stimuli used during titration induce parasympathetic autonomic release that is not compensated by the sympathetic response because of seizure induction and leads to bradycardia, sometimes with asystole . In the current study, we retrospectively evaluated the medical charts of all patients who have undergone ECT with the titration procedure in a Brazilian ECT Service (University of Sao Paulo) during the year of 2007. Special emphasis was devoted to analyze the incidence of cardiac complications, especially bradycardia and asystole.

Repetitive Transcranial Magnetic Stimulation in Augmentation of Antidepressant Drugs

Repetitive transcranial magnetic stimulation (rTMS) is a new technology which holds promise as a treatment in neuropsychiatry. Drugs and psychotherapy are inadequate for relieving depressive symptom

Estimulação magnética transcraniana de repetição associada a antidepressivo: início e intensidade da resposta antidepressiva

OBJETIVOS: Avaliar diferentes estudos que analisam o grau de eficacia da resposta antidepressiva entre a associacao de estimulacao magnetica transcraniana de repeticao (EMTr) com antidepressivos em pacientes deprimidos graves. METODOS: Os autores revisaram varios estudos em que a EMTr foi usada concomitantemente a antidepressivos em pacientes deprimidos graves. Adicionalmente, relatou-se um estudo feito no Instituto de Psiquiatria do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo. Estudo duplo-cego, randomizado, unicentrico, placebo-controlado com 46 pacientes atendendo aos criterios diagnosticos da DSM-IV para episodio depressivo severo. Os pacientes estavam em uso de amitriptilina. RESULTADOS: De forma geral, a maioria dos estudos mostra que a EMTr apresenta boa eficacia antidepressiva quando associada a antidepressivos. Ha grande diversidade de parâmetros tecnicos utilizados, tipos de bobina, diferentes tecnicas de placebo e uso de diferentes antidepressivos. O estudo realizado no Instituto de Psiquiatria mostrou que o emprego da EMTr de alta frequencia aumentou a resposta antidepressiva a amitriptilina e diminuiu o tempo para o inicio da resposta antidepressiva em relacao ao grupo placebo. CONCLUSOES: EMTr e um metodo novo, promissor e com grande potencial para o tratamento da depressao. Apesar disso, observa-se que nao ha ainda uniformidade no emprego dos parâmetros tecnicos, nem tampouco das tecnicas de placebo. O estudo realizado no Instituto de Psiquiatria do HC- FMUSP mostrou grandes taxas de resposta e remissao em relacao ao grupo com estimulacao sham e amitriptilna.