Citalopram for continuation therapy after repetitive transcranial magnetic stimulation in vascular depression

Abstract

Objectives: The authors previously reported that repetitive transcranial magnetic stimulation (rTMS) produced a response rate of 39.4% among 62 patients with treatment resistant vascular depression. This study was undertaken to assess the outcome of continuation therapy to prevent relapse among these patients during 9 weeks after completion of rTMS.

Design: Patients were randomly assigned to 18,000 pulses of rTMS given over 3 weeks or sham treatment using double blind methods. After rTMS, all patients were given 20 mg/day of citalopram for 9 weeks and reevaluated at 3, 6, and 9 weeks.

Setting: Outpatient continuation treatment trial.

Participants: Patients with vascular depression (N = 62), as determined by magnetic resonance imaging hyperintensities and three or more clinical risk factors for vascular disease without other major medical illness, were recruited. They had onset of major depression after age 50 and failed at least one trial of antidepressants.

Intervention: After rTMS or sham treatment, all treatment responders were given citalopram for 9 weeks.

Results: Among the 33 patients who were given rTMS, 13 responded (i.e., >50% decline in Hamilton Depression Scale score). Of these 13, all completed the 9 weeks of continuation treatment. There were nine patients who continued to be responders and four who had a relapse of depression.

Conclusion: More effective methods are needed to treat elderly patients with treatment resistant vascular depression and to prevent relapse among treatment responders.

Figure 1. Responders to rTMS

Hamilton 17-item depression scores (mean±SD) for patients who responded to treatment with rTMS during the initial to 3 week period. From 3 to 12 weeks, patients were divided into those who relapsed, defined as meeting DSM-IV criteria for major or minor depression, with at least a 4 point increase in their HamD-17 score and those who did not relapse. Note that the relapsers did not have a “partial” response to rTMS and that the non-relapsers showed improvement (consolidation) with continued antidepressant treatment.

Figure 2. 9 weeks of citalopram after rTMS

The percent of patients who had a greater than 50% decline in Hamilton 17-item depression scores during 9 weeks of treatment with citalopram. Of the 13 patients who had responded to rTMS treatment, 4 of 13 were no longer responders after 9 weeks of citalopram, while 9 of 43 patients (20.9%) who failed to respond did respond to citalopram.