Low-frequency transcranial magnetic stimulation in patients with fibromyalgia and major depression.

OBJECTIVE: To study the efficacy of low-frequency transcranial magnetic stimulation in patients with fibromyalgia and major depression. DESIGN: Twenty-eight patients were randomly assigned to receive 20 sessions of real or sham transcranial magnetic stimulation of the right dorsolateral prefrontal cortex. The main stimulation parameters were 15 trains at 110% of the motor threshold for 60 seconds at a frequency of 1 Hz. Blinded external evaluators administered the fibromyalgia scales (FibroFatigue, Likert pain) and the depression scales (Hamilton Depression Rating Scale, Clinical Global Impression) during the study. RESULTS: Both treatment groups (real and sham) improved their scores in some of the scales (FibroFatigue and Clinical Global Impression), although there were no differences between them. No improvements were observed in the Likert Pain Scale in either of the groups. CONCLUSION: With the methodology used in this study, patients with fibromyalgia and major depression who received real magnetic stimulation did not present significant differences in symptoms with respect to those who received sham magnetic stimulation.

Biopsychosocial model in Depression revisited.

There are two fundamental etiological perspectives about mental disorders; biomedical and psychosocial. The biopsychosocial model has claimed to integrate these two perspectives in a scientific way, signalling their interconnection and interdependence. To that end, it used a systemic conceptual framework, taking advantage of the possibilities which it offers to establish general principles for diverse systems, independently of their physical, biological or sociological nature. In recent years, drawing on the theory of systems, theories have been developing of the dynamic non-linear systems, applicable to networks of a large quantity of densely interconnected elements (also called complex systems), like the mind or the brain. We believe that this revised systemic conceptual framework can bring integrative ideas to apply to Depression, such as the "binding dysfunction" concept we use in this article. According to this, vulnerability or predisposition to Depression would be associated with the imbalance between activating and inhibiting interactions (between some cognitions and emotions at a mental level, and between certain neuronal groups at a cerebral level). Precipitating factors would imply the increase of the activation level over this pattern of cognitions and emotions, or over those neuronal systems. When stress goes beyond the vulnerability threshold an excessive positive feedback between cognitions and emotions would appear (and between groups of neurons) with insufficient inhibitory control to mitigate it, which would imply a mental/cerebral dissociation in dominions of different level of activation. As a consequence, the generation and dissolution of patterns of cerebral and mental activation will no longer have the dynamism and flexibility that permits an optimal interaction with the environment ("binding dysfunction"). Therefore, our hypothesis is that the person with Depression will suffer at a cerebral level a functional dissociation in neural dominions (some rigidly hyperactive and others rigidly hypoactive) in determined locations, which would be a different combination from those found in other mental disorders. At a mental level, this would correlate with a functional dissociation in several cognitive-emotive dominions; some corresponds to over activated patterns of "depressive" cognitions and emotions that for that reason invade the consciousness frequently, intrusively and repetitively; meanwhile there are other alternative hypoactive emotions and cognitions that do not manage to become powerful enough to avoid the consequent distortion in the communication with the environment.

High (20-Hz) and low (1-Hz) frequency transcranial magnetic stimulation as adjuvant treatment in medication-resistant depression.

Studies of repetitive transcranial magnetic stimulation (rTMS) in depression have found antidepressant effects when high frequency stimulation (HF-rTMS; >1 Hz) is applied over the left prefrontal cortex (LPF). A few studies have also reported success with low frequency stimulation (LF-rTMS) to the right prefrontal cortex (RPF). Both HF-rTMS and LF-rTMS have been reported to work better in areas with cerebral hypometabolism or hypermetabolism, respectively. Thirty medication-resistant patients with major depression were randomized into three groups. The first group received sham rTMS and the second group received active rTMS (20-Hz rTMS to the LPF and 1-Hz rTMS to the RPF). The third group, however, received active rTMS that was focused on different regions of the brain after examination with single photon emission computed tomography (20-Hz rTMS to an area of relatively low activity and 1-Hz rTMS to an area showing relatively high activation). Patients and raters were blind to the treatment condition. Comparison of the sham rTMS group with the overall group that received active rTMS revealed statistically significant changes on the Hamilton Rating Scale for Depression after 10 sessions. This study demonstrated that combined 20+1-Hz rTMS was effective, but no additional advantages were obtained by focusing rTMS on areas identified by single photon emission tomography as showing high versus low levels of functional activity.

Age predicts low-frequency transcranial magnetic stimulation efficacy in major depression.

BACKGROUND: Transcranial magnetic stimulation (TMS) effectiveness in major depression has so far been studied mainly with high-frequency (>1 Hz) administration (HF-TMS). However, some available studies with low-frequency TMS (LF-TMS) have provided similar response rates to HF-TMS with better tolerance, but the evidence is mixed and controversial. METHODS: Randomized, controlled, two arm, clinical trial. 34 Major Depression patients were randomly assigned to receive 20 sessions of real or sham TMS of the right dorsolateral prefrontal cortex as adjuvant treatment to pharmacotherapy. The main stimulation parameters were 20 trains at 110% of the motor threshold for 60 s at a frequency of 1 Hz. Blinded external evaluators administered the Hamilton Depression Rating Scale. RESULTS: Both treatment groups significantly improved, although there were no statistical differences between them. In the real TMS group patients age inversely correlated with improvement of depressive symptoms at the end of the study (r=-0683 p=0.002). The percentage of decrease in scores on the Hamilton Scale was greater in subjects younger than 45 years old vs. others (41.3 +/- 22.6 vs. 15.1 +/- 15.8; t=2.8 df=16, p=0.011). These real TMS subgroups did not differ significantly in their history of previous depressive disorders, or in the refractoriness indicators of the current episode. LIMITATIONS: Small size and highly refractory sample. CONCLUSION: Only younger patients benefited from LF-rTMS as adjuvant treatment to antidepressants in this study.