• Jerome A Yesavage, J Kaci Fairchild, Zhibao Mi, Kousick Biswas, Anne Davis-Karim, Ciaran S Phibbs, Steven D Forman, Michael Thase, Leanne M Williams, Amit Etkin, Ruth O'Hara, Gerald Georgette, Tamara Beale, Grant D Huang, Art Noda, Mark S George, and VA Cooperative Studies Program Study Team.
• Department of Veterans Affairs, Sierra-Pacific Mental Illness Research Educational and Clinical Center, Palo Alto, California.
• JAMA Psychiatry. 2018 Sep 1; 75 (9): 884-893.

ImportanceTreatment-resistant major depression (TRMD) in veterans is a major clinical challenge given the high risk for suicidality in these patients. Repetitive transcranial magnetic stimulation (rTMS) offers the potential for a novel treatment modality for these veterans.ObjectiveTo determine the efficacy of rTMS in the treatment of TRMD in veterans.Design, Setting, And ParticipantsA double-blind, sham-controlled randomized clinical trial was conducted from September 1, 2012, to December 31, 2016, in 9 Veterans Affairs medical centers. A total of 164 veterans with TRD participated.InterventionsParticipants were randomized to either left prefrontal rTMS treatment (10 Hz, 120% motor threshold, 4000 pulses/session) or to sham (control) rTMS treatment for up to 30 treatment sessions.Main Outcomes And MeasuresThe primary dependent measure of the intention-to-treat analysis was remission rate (Hamilton Rating Scale for Depression score ≤10, indicating that depression is in remission and not a clinically significant burden), and secondary analyses were conducted on other indices of posttraumatic stress disorder, depression, hopelessness, suicidality, and quality of life.ResultsThe 164 participants had a mean (SD) age of 55.2 (12.4) years, 132 (80.5%) were men, and 126 (76.8%) were of white race. Of these, 81 were randomized to receive active rTMS and 83 to receive sham. For the primary analysis of remission, there was no significant effect of treatment (odds ratio, 1.16; 95% CI, 0.59-2.26; P = .67). At the end of the acute treatment phase, 33 of 81 (40.7%) of those in the active treatment group achieved remission of depressive symptoms compared with 31 of 83 (37.4%) of those in the sham treatment group. Overall, 64 of 164 (39.0%) of the participants achieved remission.Conclusions And RelevanceA total of 39.0% of the veterans who participated in this trial experienced clinically significant improvement resulting in remission of depressive symptoms; however, there was no evidence of difference in remission rates between the active and sham treatments. These findings may reflect the importance of close clinical surveillance, rigorous monitoring of concomitant medication, and regular interaction with clinic staff in bringing about significant improvement in this treatment-resistant population.Trial RegistrationClinicalTrials.gov Identifier: NCT01191333.

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