A sham controlled study of repetitive transcranial magnetic stimulation for posttraumatic stress disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a commonly occurring and often debilitating psychiatric condition. There currently is not definitive information regarding the efficacy of repetitive transcranial magnetic stimulation (rTMS) for PTSD. OBJECTIVE: This study seeks to examine the efficacy of rTMS for PTSD. METHODS: Twenty subjects with PTSD were randomly assigned to receive either 10 rTMS sessions delivered at 1 Hz to the right dorsolateral prefrontal cortex (DLPRC) or 10 sham rTMS sessions to the same area. A blinded rater assessed PTSD, depressive, anxiety, and neurocognitive symptoms before treatment, after the treatment series, and during a 2-month follow-up period. RESULTS: Trancranial magnetic stimulation delivered at 1 Hz to the right DLPRC resulted in statistically and clinically significant improvements in core PTSD symptoms and depressive symptoms compared with sham treatments. The effectiveness showed some degradation during the 2 months after treatments were stopped. CONCLUSIONS: This blinded sham controlled trial supports the efficacy of 10 sessions of right DLPRC rTMS delivered at 1 Hz for the treatment of PTSD symptoms.

An examination of mortality and other adverse events related to electroconvulsive therapy using a national adverse event report system.

BACKGROUND: : There is currently an incomplete understanding of adverse events related to electroconvulsive therapy (ECT) treatments. Much of the published literature is based either on a limited number of ECT providers or reports not representative of modern ECT practice. METHODS: : We searched the Veterans Affairs (VA) National Center for Patient Safety database for reports of adverse events related to ECT. The type and the cause of the events were determined and aggregated. The number of ECT treatments given in the VA was used to develop estimated rates of mortality associated with ECT. RESULTS: : There were no deaths associated with ECT reported in any VA hospital between 1999 and 2010. Based on the number of treatments given, we estimate the mortality rate associated with ECT as less than 1 death per 73,440 treatments. The most common reported adverse events related to ECT were injury to the mouth (including dental and tongue injury) and problems related to paralysis. CONCLUSIONS: : Based on this VA data, ECT may be safer than is widely reported. The reported adverse events were generally rare and typically minor in severity. Simple steps may possibly result in further enhancements to ECT safety.

Retrospective evaluation of the dexamethasone suppression test as a predictor of response to electroconvulsive therapy in patients with comorbid major depressive disorder and posttraumatic stress disorder.

BACKGROUND: There is evidence that response to dexamethasone suppression test (DST) can be predictive of treatment outcomes in major depressive disorder (MDD). The purpose of this study was to explore if DST response, at both 1 and 0.5 mg of dexamethasone doses, is predictive of the effectiveness of electroconvulsive therapy (ECT) in depression symptom reduction in patients with comorbid posttraumatic stress disorder (PTSD) and MDD who are treated with ECT. METHODS: We performed a chart review of all patients with both PTSD and MDD receiving ECT from January 2002 through December 2008, who had DST performed before starting ECT. A total of 32 patients meeting these criteria were identified. Those patients were divided into 3 groups based on their response to the DST: enhanced suppressors (n = 13), normal suppressors (n = 14), and nonsuppressors (n = 5). Posttraumatic stress disorder and MDD outcomes after completion of the primary ECT treatment series were measured. Results were stratified by pretreatment DST responses. RESULTS: Nonsuppressors showed significantly more response to ECT, in both MDD and PTSD symptom scales, as compared with normal suppressors and enhanced suppressors. Normal suppressors showed significantly more response to ECT than enhanced suppressors. Electroconvulsive therapy did not appear to be effective in depression symptom reduction for enhanced suppressors. CONCLUSIONS: This study suggests that DST results may be predictive of depression symptom reduction in response to ECT in patients with comorbid PTSD and MDD, with patients suppressing morning cortisol production in response to 0.5 mg of dexamethasone showing little improvement. In addition, this study lends further evidence that ECT is an effective treatment for some patients with comorbid MDD and PTSD.

Access to what? An evaluation of the key ingredients to effective advanced mental health access at a VA medical center and its affiliated community-based outreach clinics.

Initial evaluation of an advanced access clinic developed at a VA medical center (VAMC) found decreased Mental Health wait times and improved quality of care for veterans with depression. Subsequently, modified advanced access models were implemented at affiliated community-based outreach clinics (CBOCs). By comparing each site, we sought to determine whether less resource-intensive models could improve care to the same degree. We assessed contributions of the model's components to the improvement of care (i.e., wait times and depression treatment adequacy). The modified advanced access models led to significant improvements, although no such improvements were seen at 2 control sites. Six features related to rapid access, short-term treatment, and barrier-free access to mental health services accounted for most of the observed improvements. CBOCs can implement limited advanced mental health access models and derive similar improvements to those seen in more extensive models at the VAMCs to which they are affiliated.