The priming effect of repetitive transcranial magnetic stimulation on clinical response to electroconvulsive therapy in treatment-resistant depression: a randomized, double-blind, sham-controlled study.

BACKGROUND: Electroconvulsive therapy (ECT) is one of the most effective treatments for treatment-resistant depression (TRD). However, due to response delay and cognitive impairment, ECT remains an imperfect treatment. Compared to ECT, repetitive transcranial magnetic stimulation (rTMS) is less effective at treating severe depression, but has the advantage of being quick, easy to use, and producing almost no side effects. In this study, our objective was to assess the priming effect of rTMS sessions before ECT on clinical response in patients with TRD. METHODS: In this multicenter, randomized, double-blind, sham-controlled trial, 56 patients with TRD were assigned to active or sham rTMS before ECT treatment. Five sessions of active/sham neuronavigated rTMS were administered over the left dorsolateral prefrontal cortex (20 Hz, 90% resting motor threshold, 20 2 s trains with 60-s intervals, 800 pulses/session) before ECT (which was active for all patients) started. Any relative improvements were then compared between both groups after five ECT sessions, in order to assess the early response to treatment. RESULTS: After ECT, the active rTMS group exhibited a significantly greater relative improvement than the sham group [43.4% (28.6%) v. 25.4% (17.2%)]. The responder rate in the active group was at least three times higher. Cognitive complaints, which were assessed using the Cognitive Failures Questionnaire, were higher in the sham rTMS group compared to the active rTMS group, but this difference was not corroborated by cognitive tests. CONCLUSIONS: rTMS could be used to enhance the efficacy of ECT in patients with TRD. ClinicalTrials.gov: NCT02830399.

A Retrospective Study of Postictal Suppression during Electroconvulsive Therapy.

BACKGROUND: electroconvulsive therapy (ECT) is the most effective treatment in treatment-resistant depression (TRD), but its response remains partial. Identifying useful indicators to guide decision making for treatment and improve clinical response remains a major issue. The objective of the present retrospective study was to determine if clinical response-early (after 5 ECT sessions) or longer-term (after 12 ECT sessions)-was associated with postictal suppression during the first ECT course and/or with postictal suppression frequency during the whole ECT course. METHODS: in a retrospective study, the data of 42 patients suffering from treatment-resistant depression and receiving at least 5 ECT sessions were collected. Two sessions per week of bitemporal brief-pulse ECT sessions were administered to patients. Each of the electroencephalography (EEG) recordings were assessed to determine the presence of postictal suppression. RESULTS: the postictal suppression from the first ECT session predicted a better long-term clinical response (after 12 ECT sessions), but not early clinical response (after only 5 ECT sessions). The postictal suppression frequency was associated with neither the short- nor the long-term clinical response. In addition, postictal suppression and short-term cognitive performances were not associated. CONCLUSIONS: this EEG indicator is clinically useful if it appears in the first ECT sessions, but it is no longer relevant in the following sessions.

Eleven Years of Clozapine Experience in Autism Spectrum Disorder: Efficacy and Tolerance.

BACKGROUND: Autism spectrum disorders (ASDs) are neurodevelopmental disorders that comprise wide graduated clinical expressions but similar core symptoms (repetitive, stereotyped behavior, and social communication disabilities). Many patients with ASD have disruptive behaviors like aggressiveness, temper tantrums, or self-injury that interfere with their socializations, their learning abilities, and their quality of life. These behaviors represent a common target for pharmacology. Beherec et al (J Clin Psychopharmacol. 2011;31:341-344) (first cohort), showed the efficacy of clozapine on disruptive behaviors in 6 patients with autism who were older than 16 years. The aim of this study was to assess the efficacy and tolerance of clozapine in a new cohort and the long-term effect in our first cohort. PROCEDURES: Concerning the replication study, we conducted a retrospective study of the changes of aggressive behaviors for all patients with ASD who were treated with clozapine from 2011 to 2017. Disruptive behaviors were monitored from 1 to 6 months before and after the initiation of the clozapine. RESULTS: All the patients of the first cohort were still on clozapine after an average of 11 + 2.6 years, with the same efficacy and no serious adverse effect was noted. For the replication study, 13 patients were included. Clozapine resulted in a significant decrease in the number of the days with aggression (65.2% + 32.6%). Once again, no serious adverse effect was notified. All the patients had a better quality of life. CONCLUSIONS: Our study confirms that clozapine could be an efficacious and well-tolerated treatment for ASD patients with disruptive behaviors who do not respond to other antipsychotics on the long term.