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MRI-guided dmPFC-rTMS as a Treatment for Treatment-resistant Major Depressive Disorder
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Treatment-resistant depression and suicidality.

Isidoor O Bergfeld1, Mariska Mantione2, Martijn Figee3

  • 1Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Brain and Cognition, Amsterdam, The Netherlands.

Journal of Affective Disorders
|April 18, 2018
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Summary

Treatment-resistant depression (TRD) patients face high suicide attempt and completion rates. However, advanced treatments like deep brain stimulation (DBS), vagal nerve stimulation (VNS), and electroconvulsive therapy (ECT) showed no significant difference in these incidences.

Keywords:
Depressive disorderMeta-analysisSuicideSystematic reviewTreatment-resistant

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Area of Science:

  • Neuroscience and Psychiatry
  • Clinical Research and Therapeutics

Background:

  • Thirty percent of patients with treatment-resistant depression (TRD) have a lifetime history of suicide attempts.
  • Limited understanding exists regarding suicide attempt and completion rates in TRD patients post-treatment initiation.
  • Uncertainty surrounds whether specific treatments influence suicide incidence in TRD.

Purpose of the Study:

  • To systematically investigate the incidence of suicide attempts and completed suicides in patients with TRD after initiating treatment.
  • To explore potential differences in suicide incidences among various TRD treatments, including deep brain stimulation (DBS), vagal nerve stimulation (VNS), and electroconvulsive therapy (ECT).

Main Methods:

  • Systematic PubMed search for studies on TRD patients followed for at least three months post-treatment initiation.
  • Poisson meta-analysis used to estimate attempted and completed suicide incidences.
  • Meta-regression employed to assess differences in incidences across treatments due to a lack of controlled comparisons.

Main Results:

  • Thirty studies involving 32 TRD samples were analyzed, covering treatments like DBS, VNS, ECT, treatment-as-usual, capsulotomy, cognitive behavioral therapy, ketamine, and epidural cortical stimulation.
  • Overall incidence rates were 0.47 per 100 patient-years for completed suicides and 4.66 per 100 patient-years for attempted suicides.
  • No significant differences in suicide incidences were observed between deep brain stimulation (DBS), vagal nerve stimulation (VNS), and electroconvulsive therapy (ECT).

Conclusions:

  • High incidences of completed (0.47/100 patient-years) and attempted (4.66/100 patient-years) suicides are noted in TRD patients.
  • Advanced treatments including DBS, VNS, and ECT did not demonstrate differential effects on suicide incidences.
  • Clinical trials for TRD should incorporate suicidality as an explicit outcome measure due to the significant risk.