Shannon Brode

Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression: A Systematic Review and Meta-Analysis

OBJECTIVE To evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with major depressive disorder (MDD) and 2 or more prior antidepressant treatment failures (often referred to as treatment-resistant depression [TRD]). These patients are less likely to recover with medications alone and often consider nonpharmacologic treatments such as rTMS. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Library, PsycINFO, and the International Pharmaceutical Abstracts for studies comparing rTMS with a sham-controlled treatment in TRD patients ages 18 years or older. STUDY SELECTION We included 18 good- or fair-quality TRD studies published from January 1, 1980, through March 20, 2013. DATA EXTRACTION We abstracted relevant data, assessed each studys internal validity, and graded strength of evidence for change in depressive severity, response rates, and remission rates. RESULTS rTMS was beneficial compared with sham for all outcomes. rTMS produced a greater decrease in depressive severity (high strength of evidence), averaging a clinically meaningful decrease on the Hamilton Depression Rating Scale (HDRS) of more than 4 points compared with sham (mean decrease = -4.53; 95% CI, -6.11 to -2.96). rTMS resulted in greater response rates (high strength of evidence); those receiving rTMS were more than 3 times as likely to respond as patients receiving sham (relative risk = 3.38; 95% CI, 2.24 to 5.10). Finally, rTMS was more likely to produce remission (moderate strength of evidence); patients receiving rTMS were more than 5 times as likely to achieve remission as those receiving sham (relative risk = 5.07; 95% CI, 2.50 to 10.30). Limited evidence and variable treatment parameters prevented conclusions about which specific treatment options are more effective than others. How long these benefits persist remains unclear. CONCLUSIONS For MDD patients with 2 or more antidepressant treatment failures, rTMS is a reasonable, effective consideration.

Systematic Review: Effective Characteristics of Nursing Homes and Other Residential Long-Term Care Settings for People with Dementia

In response to the need for an evidence‐based review of factors within long‐term care settings that affect the quality of care, this review compared characteristics of nursing homes and other residential long‐term care settings for people with dementia and their informal family caregivers with respect to health and psychosocial outcomes.

Impact of genotype-guided dosing on anticoagulation visits for adults starting warfarin: A randomized controlled trial

AIM This study aimed to assess the effectiveness of genotype-guided warfarin dosing. PATIENTS & METHODS A total of 109 adults were randomized to receive initial dosing as determined by an algorithm containing genetic (VKORC1 and CYP2C9) plus clinical information or only clinical information. Primary end points were the number of anticoagulation visits and the time in therapeutic range (TTR) over 90 days. Secondary end points included time to therapeutic dose, International Normalized Ratios of >4, emergency visits, hospitalizations, hemorrhagic events, thrombotic events and mortality. RESULTS Neither primary end point was significantly different between groups (anticoagulation visits: 6.96 vs 6.37, p = 0.51; TTR: 0.40 vs 0.43, p = 0.59). Fewer emergency visits, hospitalizations, major hemorrhagic events, thrombotic events and deaths occurred in the genetic plus clinical group than in the clinical only group, but these differences were not statistically significant. CONCLUSION Genotype-guided dosing did not decrease the number of anticoagulation visits or improve TTR. Our trial was not powered to detect anything but large differences for utilization and health outcomes.

Identifying Priorities for Patient-Centered Outcomes Research for Serious Mental Illness

OBJECTIVE The purpose of this project was to engage a diverse group of stakeholders (N=38) to help establish priorities to guide patient-centered outcomes research (PCOR) in serious mental illness. METHODS Three meetings, two Web-based and one on site, were held to generate and prioritize an initial list of topics. Topics were then sorted and organized into common themes. RESULTS About 140 topics were identified and sorted into 21 main themes, ranked by priority. Three of the top four themes focused on how research was conducted, particularly the need to develop consensus measurement and outcomes definitions; improving infrastructure for research, longitudinal studies, and new data sets and investigators; and developing PCOR methodology. Stakeholders also identified a need to focus on service delivery, treatment settings, and structure of the delivery of care. CONCLUSIONS Engagement by a broad group of stakeholders in a transparent process resulted in the identification of priority areas for PCOR. Stakeholders clearly indicated a need to fundamentally change how research on serious mental illness is conducted and a critical need for the development of methodology and infrastructure. Most current PCOR has been focused on relatively short-term outcomes, but real world, long-term studies providing guidance for treatment over the lifetime of a serious mental illness are needed.