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The authors respond.

We appreciate Dr. Feldman noting our technical error. He is correct that TMS is FDA-approved for treating unipolar depression in individuals who had failed 1 adequate antidepressant trial during their current episode. However, Dr. Feldman is not correct that by no definition would this constitute TRD. For example, Fava (1) stated TRD "typically refers to inadequate response to at least one antidepressant trial of adequate doses and duration."

Based on the research literature, we also disagree with Dr. Feldman's assertion of "questionable utility" of TMS in TRD. As part of research presented to the FDA, O'Reardon et al. (2) characterized the study sample as having failed an overage of 7.6 adequate antidepressant treatment trial, with approximately one-half having failed [greater than or equal to] 2 treatments in their current episode. Connolly et al (3) described results in treating 100 consecutive depressed patients with TMS as equivalent to research findings. Most patients had >1 failed adequate antidepressant trial in their current episode. The Agency for Healthcare Research and Quality concluded that evidence supported use of TMS. (4) Overall, the panel concluded that there is a substantial and well-replicated body of evidence that TMS is beneficial compared with controls in severity of symptoms, response rate, and remission rate. In a head-to-head comparison with electroconvulsive therapy, TMS was equally effective. TMS is a valuable addition to the therapeutic armamentarium that can help patients early in an illness not fall into a treatment-resistant state, and can offer another chance for those who have.


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(1.) Fava M. Diagnosis and definition of treatment-resistant depression. Biol Psychiatry. 2003;53(8): 649-659.

(2.) O'Reardon JP, Solvason HB, Janicak PG, et al. Reply regarding "efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial." Biol Psychiatry 2010;67(2):e15-e7.

(3.) Connolly RK, Helmer A, Cristancho MA, et al. Effectiveness of transcranial magnetic stimulation in clinical practice post-FDA approval in the United States: results observed with the first 100 consecutive cases of depression at an academic medical center. J Clin Psychiatry 2012; 73(4):e567-e573.

(4.) U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality Nonpharmacologic interventions for treatment-resistant depression in adults. Published September 23, 2011. Accessed July 12, 2012.

Gordon Baumbacher MD

Caroline Mulder, MD

Private Practice Corte Madera, CA

Richard Bermudes, MD

Private Practice Sacramento, CA

Jennifer Beck, MD

Private Practice Santa Rosa, CA

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Title Annotation:Comments&Controversies
Publication:Current Psychiatry
Geographic Code:1USA
Date:Sep 1, 2012
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