rTMS as add-on to escitalopram: a way to enhance antidepressant response? A randomized, placebo controlled trial

Context: In the treatment of major depression the clinical efficacy of escitalopram is well established. Moreover, contrary to other interventions escitalopram is known for its fast onset of action. Repetitive transcranial magnetic stimulation is a well-tolerated non-invasive method, which has also been proved to have antidepressant effects and is used as „add-on“-therapy in treating pharmaco-resistant major depression. May the antidepressant response be enhanced by a combination of both treatments? Objective: The efficacy of an Escitalopram- rTMS-combination-treatment was evaluated and compared to a placebo condition. Methods: We designed a four week-, randomized, rater blinded, placebo controlled, add-on study with two treatment arms. 33 depressed patients received either 20 sessions of rTMS as add-on to pharmacotherapy with escitalopram or escitalopram combined with sham rTMS. rTMS was applied at 20Hz over the left dorsolateral prefrontal cortex. Main outcome measures: Hamilton Depression Scale (HAM-D 28). Results: After four weeks of treatment both groups had a measurable benefit. However, the patients receiving escitalopram in combination with real rTMS did not improve significantly better than those receiving escitalopram in combination with sham stimulation. Conclusions: There are no hints for an enhanced response when using a combination of escitalopram and r TMS in comparison to using escitalopram as a monotherapy.