Journal of ECT • Volume 30, Number 4, December 2014
Lars Helgeson, MD Department of Anesthesiology Yale School of Medicine New Haven, CT
Robert B. Ostroff, MD Department of Psychiatry Yale School of Medicine New Haven, CT
The authors have no conflicts of interest or financial disclosures to report. REFERENCES 1. Drop LJ, Bouckoms AJ, Welch CA. Arterial hypertension and multiple cerebral aneurysms in a patient treated with electroconvulsive therapy. J Clin Psychiatry. 1988;49:280–282. 2. Bader GM, Silk KR, Dequardo JR, et al. Electroconvulsive therapy and intracranial aneurysm. Convuls Ther. 1995;11:139–143. 3. Hunt SA, Kaplan E. ECT in the presence of a cerebral aneurysm. J ECT. 1998;14:123–124. 4. Kolano JE, Chhibber A, Calalang CC. Use of esmolol to control bleeding and heart rate during electroconvulsive therapy in a patient with an intracranial aneurysm. J Clin Anesth. 1997;9:493–495. 5. Najjar F, Guttmacher LB. ECT in the presence of intracranial aneurysm. J ECT. 1998;14: 266–271. 6. Gardner MW, Kellner CH. Safe use of ECT with an intracranial aneurysm. J ECT. 1998;14: 290–292. 7. Viguera A, Rordorf G, Schouten R, et al. Intracranial haemodynamics during attenuated responses to electroconvulsive therapy in the presence of an intracerebral aneurysm. J Neurol Neurosurg Psychiatry. 1998;64:802–805. 8. Salaris S, Szuba MP, Traber K. ECT and intracranial vascular masses. J ECT. 2000;16: 198–203. 9. Husum B, Vester-Andersen T, Buchmann G, et al. Electroconvulsive therapy and intracranial aneurysm. Prevention of blood pressure elevation in a normotensive patient by hydralazine and propranolol. Anaesthesia. 1983;38:1205–1207. 10. Farah A, McCall WV, Amundson RH. ECT after cerebral aneurysm repair. Convuls Ther. 1996;12:165–170. 11. Power-Connon M, Pridmore S. Electroconvulsive therapy post cerebral aneurysm repair. Aust N Z J Psychiatry. 2003; 37:244. 12. Sharma A, Ramaswamy S, Bhatia SC. Electroconvulsive therapy after repair of cerebral aneurysm. J ECT. 2005;21:180–181. 13. Okamura T, Kudo K, Sata N, et al. Electroconvulsive therapy after coil embolization of cerebral aneurysm: a case report and literature review. J ECT. 2006;22: 148–149.
© 2014 Lippincott Williams & Wilkins
14. The International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. International Study of Unruptured Intracranial Aneurysms Investigators. N Engl J Med. 1998; 339:1725–1733. 15. Morita A, Kirino T, Hashi K, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med. 2012;366: 2474–2482. 16. Wiebers DO, Whisnant JP, Huston J 3rd, et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003;362: 103–110. 17. Vlak MH, Rinkel GJ, Greebe P, et al. Risk of rupture of an intracranial aneurysm based on patient characteristics: a case-control study. Stroke. 2013;44:1256–1259. 18. Tada Y, Wada K, Shimada K, et al. Roles of hypertension in the rupture of intracranial aneurysms. Stroke. 2014;45:579–586.
Electroconvulsive Therapy Service Provision at Zomba Mental Hospital, Malawi To the Editor: omba Mental Hospital (ZMH) is the only tertiary psychiatric government referral hospital and is located in the southern region of Malawi. It has a bed capacity of 333, with an average admission per year of 2000 patients. It offers the following services: long-stay care, forensic care, acute inpatient care, community care, rehabilitation services, occupation therapy, outpatient care, and electroconvulsive therapy (ECT) services. This is 1 of the 2 facilities in the country among the 3 psychiatric units that provide ECT services. The hospital acquired a donation of 2 ECT machines (Mecta SR models) from Scotland. Modified ECT was introduced at ZMH in the first week of September in 2007. Electroconvulsive therapy takes place 3 times per week, with a maximum of 5 patients per day. Patients may receive ECT up to 3 times per week. A previous study in Malawi suggests that modification of ECT approaching Western standards was possible with clear ECT guidelines, consent procedures, and adequate monitoring of adverse effects.1 It is against this background that there was a need to conduct an audit at ZMH to assess the provision of care with regard to ECT services. The main objective was to determine the quality of care in terms of ECT provision to patients at ZMH in Malawi since adaptation of the modified ECT. The specific objectives were as follows:
Z
Letters to the Editor
1. to audit deficiencies in the current ECT services against the standards, 2. to redesign the ECT ordering and administration form and increase compliance with standards, and 3. to implement the new ECT ordering and administration form.
A baseline audit was performed by reviewing the case files of all patients who received ECT between August 2008 and December 2008. The patients’ ECT records were audited against the standards set for ECT provision at ZMH. Thirty case files of the 60 patient files belonging to the patients who were previously admitted at ZMH and underwent ECT between August and December 2008 were sampled using systematic sampling, and the results were analyzed statistically using Excel. The 30 case files were reviewed, with a few having missing data on other variables. The female patients dominated the sample, thus 24 females and 6 males. Their ages ranged from 16 to 54 years. Ten (33%) patients were diagnosed with a bipolar disorder; 5 (17%) patients, with a depression; 4 (13%) patients, with a mania; 2 (7%) patients, with a postpartum psychosis; 3 (10%) patients, with a schizophrenia; and 6 (20%) patients, with a schizoaffective disorder. The total number of sessions varied from 4 to 6. The length of the clinically observed convulsions varied from 11 to 160 seconds and the dose ranged from 225 to 400 microcoulombs. The findings showed that 30 (100%) patients underwent modified ECT for various affective and psychotic disorders, with 97% of the files having ECT forms included. It was also found that 90% of the patient files had indication for ECT written down. Consent was not routinely asked from the patients, and most were given ECT without a written consent; thus, only 30% of the case files had the consent forms completed appropriately. The sample showed that 63% of the patients who underwent ECT had their physical workup, and similarly, 90% of the case files indicated that the patients had their vital signs checked and recorded before and after the ECT. Eighty-six percent of the case files recorded the ECT procedure; thus, the dose, seizure length, and anesthetic were given. Seventy-three percent of the case files indicated that the patients were reviewed for clinical condition, adverse effects, and consent status after 2 ECT sessions. In summary, the audit results revealed the gaps in the provision of ECT services in relation to the required standards. The results also indicated commitment to satisfy the introduced standards. The audit developed www.ectjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
e49
Journal of ECT • Volume 30, Number 4, December 2014
Letters to the Editor
several recommendations that, if implemented, could result in the ZMH reaching the standard set targets. Some of the strategies include review of the ECT form to cater properly for all pre-ECT vitals and postECT vitals, translation of the consent form and ECT information sheet to vernacular language, as well as placement of the ECT protocol in all wards and also in procedure manuals. Continuous and ongoing in-service education of clinicians and nurses regarding ECT provision and documentation, with reaudit, is still required for improved and sustained compliance of the standards. Michael Udedi, MPhil Non Communicable Diseases and Mental Health Unit Department of Clinical Services Ministry of Health Lilongwe, Malawi [email protected]
The author has no conflict of interest or financial disclosures to report. REFERENCE 1. Selis MA, Kauye F, Leentjens AF. The practice of electroconvulsive therapy in Malawi. J ECT. 2008;24: 137–140.
Combined Ketamine/Transcranial Magnetic Stimulation Treatment of Severe Depression in Bipolar I Disorder To the Editor: report on the first case of treatment of severe depression in a patient with bipolar I disorder using a combined ketamine/ transcranial magnetic stimulation (TMS) technique. The patient had been largely nonresponsive to electroconvulsive therapy (ECT), repetitive TMS (rTMS), or vagal nerve stimulation. Ketamine is an N-methyl D-aspartate antagonist that has been shown to provide rapid relief for depressive symptoms.1 Transcranial magnetic stimulation, a noninvasive brain stimulation technique, has been shown to possibly reduce symptoms of depression and mania.2,3 The patient, a 31-year-old white man, had presented to my clinic after a 2-month psychiatric hospitalization earlier in that year. He reported that, at the time of the hospitalization, he had been under extreme
I
e50
www.ectjournal.com
stress from working 80 to 90 hours per week. He was diagnosed with bipolar I disorder on the basis of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria by the attending psychiatrist and was administered with ECT 14 times during the course of 2 months. The patient reported that the first 4 ECT treatments had been successful in reducing his acute suicidality but that he returned to feeling suicidal after the fourth treatment and did not experience any gains from the subsequent 10 treatments. Thereafter, he consulted in my clinic and began rTMS with relief but not quiescence. After a year, vagal nerve stimulation was added to the existing rTMS strategy. This addition resulted in some improvement, but the patient still did not attain symptomatic quiescence. I therefore described to him the option of pursuing combined ketamine/ TMS. After weighing the potential risks and benefits, the patient decided to undergo the combined treatment. Institutional review board approval was obtained from an independent accredited agency. Before the onset of the combined treatment of TMS applied during infused ketamine, the patient underwent a systematic psychodiagnostic assessment conducted by an independent licensed clinical psychologist. As part of the assessment, the patient completed a valid Personality Assessment Inventory (PAI) and a Beck Depression Inventory (BDI) II. These measures revealed marked elevations in depression (PAI depression scale T score = 87, BDI-II = 24) and anxiety (PAI anxiety scale T score = 74). Furthermore, the patient showed problems with attention, concentration, and clear thinking (PAI schizophrenia scale T score = 81). Largely consistent with the results of these assessments, the patient described himself as feeling severely depressed, including having frequent thoughts of suicide. In terms of functioning, the patient was severely debilitated, being unable to read or speak in complete sentences. He was on leave from his job and had withdrawn from all of his personal and social relationships, including spending time with his wife and volunteering at his church. In preparation for the combined treatment, the patient received 2 days of rTMS consisting of 4 treatments per day, each of which lasted 30 minutes separated by a 45-minute rest period. The combined treatment then began the following day and was administered approximately once weekly for 3 years. The ketamine dosage varied from 40 to 80 mg per treatment. At each treatment, 40 minutes of 1-Hz continuous rTMS was administered at 115% of motor threshold and intravenous ketamine infusion was administered concurrent to and
bracketed within the middle 30 minutes of TMS. Preinfusion and postinfusion, there were 5 minutes of TMS. The TMS head coil, manufactured by Neotonus, was positioned at the midline of the scalp. This position was selected to maximally stimulate the medial prefrontal area that overlays the anterior cingulate region, which has been implicated in depression.4 All stimulation levels fell within published safety guidelines. A follow-up psychodiagnostic assessment, which included a valid PAI and BDI-II, was conducted a year after the beginning of the combined treatment by the same psychologist who administered the pretreatment battery. This assessment revealed a partial remission of symptoms with partial functional improvement. Specifically, the results showed improvements in depression (PAI depression scale T score = 74, BDI-II = 18) and anxiety (PAI anxiety scale T score = 61) as well as attention, concentration, and clear thinking (PAI schizophrenia scale T score = 74). Although these scores were still elevated, they nonetheless represented substantial decreases from the baseline levels. Consistent with these changes in scores, the patient reported experiencing substantially improved mood, including the absence of any suicidal ideation. He said that he had largely regained his ability to read and speak clearly. Although he remained unemployed, he had returned to spending more time with his wife as well as volunteering approximately 10 to 20 hours per week for his church. These findings are the first of which I am aware to show that a combined ketamine/TMS treatment can be used to treat severe depression in bipolar I disorder. Future research should systematically examine whether the combined treatment of bipolar I symptoms offers benefits over either ECT or ketamine administered independently of TMS. Steven Richard Devore Best, MD The Neuroscience Center Deerfield, IL [email protected]
The author has no conflict of interest or financial disclosures to report. REFERENCES 1. Zarate CA Jr, Brutsche NE, Ibrahim L, et al. Replication of ketamine’s antidepressant efficacy in bipolar depression: a randomized controlled add-on trial. Biol Psychiatry. 2012;71:939–946. 2. Dolberg OT, Dannon PN, Schreiber S, et al. Transcranial magnetic stimulation in patients with bipolar depression: a double blind, controlled study. Bipolar Disord. 2002;4:94–95.
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Lars Helgeson, MD Department of Anesthesiology Yale School of Medicine New Haven, CT
Robert B. Ostroff, MD Department of Psychiatry Yale School of Medicine New Haven, CT
The authors have no conflicts of interest or financial disclosures to report. REFERENCES 1. Drop LJ, Bouckoms AJ, Welch CA. Arterial hypertension and multiple cerebral aneurysms in a patient treated with electroconvulsive therapy. J Clin Psychiatry. 1988;49:280–282. 2. Bader GM, Silk KR, Dequardo JR, et al. Electroconvulsive therapy and intracranial aneurysm. Convuls Ther. 1995;11:139–143. 3. Hunt SA, Kaplan E. ECT in the presence of a cerebral aneurysm. J ECT. 1998;14:123–124. 4. Kolano JE, Chhibber A, Calalang CC. Use of esmolol to control bleeding and heart rate during electroconvulsive therapy in a patient with an intracranial aneurysm. J Clin Anesth. 1997;9:493–495. 5. Najjar F, Guttmacher LB. ECT in the presence of intracranial aneurysm. J ECT. 1998;14: 266–271. 6. Gardner MW, Kellner CH. Safe use of ECT with an intracranial aneurysm. J ECT. 1998;14: 290–292. 7. Viguera A, Rordorf G, Schouten R, et al. Intracranial haemodynamics during attenuated responses to electroconvulsive therapy in the presence of an intracerebral aneurysm. J Neurol Neurosurg Psychiatry. 1998;64:802–805. 8. Salaris S, Szuba MP, Traber K. ECT and intracranial vascular masses. J ECT. 2000;16: 198–203. 9. Husum B, Vester-Andersen T, Buchmann G, et al. Electroconvulsive therapy and intracranial aneurysm. Prevention of blood pressure elevation in a normotensive patient by hydralazine and propranolol. Anaesthesia. 1983;38:1205–1207. 10. Farah A, McCall WV, Amundson RH. ECT after cerebral aneurysm repair. Convuls Ther. 1996;12:165–170. 11. Power-Connon M, Pridmore S. Electroconvulsive therapy post cerebral aneurysm repair. Aust N Z J Psychiatry. 2003; 37:244. 12. Sharma A, Ramaswamy S, Bhatia SC. Electroconvulsive therapy after repair of cerebral aneurysm. J ECT. 2005;21:180–181. 13. Okamura T, Kudo K, Sata N, et al. Electroconvulsive therapy after coil embolization of cerebral aneurysm: a case report and literature review. J ECT. 2006;22: 148–149.
© 2014 Lippincott Williams & Wilkins
14. The International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. International Study of Unruptured Intracranial Aneurysms Investigators. N Engl J Med. 1998; 339:1725–1733. 15. Morita A, Kirino T, Hashi K, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med. 2012;366: 2474–2482. 16. Wiebers DO, Whisnant JP, Huston J 3rd, et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003;362: 103–110. 17. Vlak MH, Rinkel GJ, Greebe P, et al. Risk of rupture of an intracranial aneurysm based on patient characteristics: a case-control study. Stroke. 2013;44:1256–1259. 18. Tada Y, Wada K, Shimada K, et al. Roles of hypertension in the rupture of intracranial aneurysms. Stroke. 2014;45:579–586.
Electroconvulsive Therapy Service Provision at Zomba Mental Hospital, Malawi To the Editor: omba Mental Hospital (ZMH) is the only tertiary psychiatric government referral hospital and is located in the southern region of Malawi. It has a bed capacity of 333, with an average admission per year of 2000 patients. It offers the following services: long-stay care, forensic care, acute inpatient care, community care, rehabilitation services, occupation therapy, outpatient care, and electroconvulsive therapy (ECT) services. This is 1 of the 2 facilities in the country among the 3 psychiatric units that provide ECT services. The hospital acquired a donation of 2 ECT machines (Mecta SR models) from Scotland. Modified ECT was introduced at ZMH in the first week of September in 2007. Electroconvulsive therapy takes place 3 times per week, with a maximum of 5 patients per day. Patients may receive ECT up to 3 times per week. A previous study in Malawi suggests that modification of ECT approaching Western standards was possible with clear ECT guidelines, consent procedures, and adequate monitoring of adverse effects.1 It is against this background that there was a need to conduct an audit at ZMH to assess the provision of care with regard to ECT services. The main objective was to determine the quality of care in terms of ECT provision to patients at ZMH in Malawi since adaptation of the modified ECT. The specific objectives were as follows:
Z
Letters to the Editor
1. to audit deficiencies in the current ECT services against the standards, 2. to redesign the ECT ordering and administration form and increase compliance with standards, and 3. to implement the new ECT ordering and administration form.
A baseline audit was performed by reviewing the case files of all patients who received ECT between August 2008 and December 2008. The patients’ ECT records were audited against the standards set for ECT provision at ZMH. Thirty case files of the 60 patient files belonging to the patients who were previously admitted at ZMH and underwent ECT between August and December 2008 were sampled using systematic sampling, and the results were analyzed statistically using Excel. The 30 case files were reviewed, with a few having missing data on other variables. The female patients dominated the sample, thus 24 females and 6 males. Their ages ranged from 16 to 54 years. Ten (33%) patients were diagnosed with a bipolar disorder; 5 (17%) patients, with a depression; 4 (13%) patients, with a mania; 2 (7%) patients, with a postpartum psychosis; 3 (10%) patients, with a schizophrenia; and 6 (20%) patients, with a schizoaffective disorder. The total number of sessions varied from 4 to 6. The length of the clinically observed convulsions varied from 11 to 160 seconds and the dose ranged from 225 to 400 microcoulombs. The findings showed that 30 (100%) patients underwent modified ECT for various affective and psychotic disorders, with 97% of the files having ECT forms included. It was also found that 90% of the patient files had indication for ECT written down. Consent was not routinely asked from the patients, and most were given ECT without a written consent; thus, only 30% of the case files had the consent forms completed appropriately. The sample showed that 63% of the patients who underwent ECT had their physical workup, and similarly, 90% of the case files indicated that the patients had their vital signs checked and recorded before and after the ECT. Eighty-six percent of the case files recorded the ECT procedure; thus, the dose, seizure length, and anesthetic were given. Seventy-three percent of the case files indicated that the patients were reviewed for clinical condition, adverse effects, and consent status after 2 ECT sessions. In summary, the audit results revealed the gaps in the provision of ECT services in relation to the required standards. The results also indicated commitment to satisfy the introduced standards. The audit developed www.ectjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
e49
Journal of ECT • Volume 30, Number 4, December 2014
Letters to the Editor
several recommendations that, if implemented, could result in the ZMH reaching the standard set targets. Some of the strategies include review of the ECT form to cater properly for all pre-ECT vitals and postECT vitals, translation of the consent form and ECT information sheet to vernacular language, as well as placement of the ECT protocol in all wards and also in procedure manuals. Continuous and ongoing in-service education of clinicians and nurses regarding ECT provision and documentation, with reaudit, is still required for improved and sustained compliance of the standards. Michael Udedi, MPhil Non Communicable Diseases and Mental Health Unit Department of Clinical Services Ministry of Health Lilongwe, Malawi [email protected]
The author has no conflict of interest or financial disclosures to report. REFERENCE 1. Selis MA, Kauye F, Leentjens AF. The practice of electroconvulsive therapy in Malawi. J ECT. 2008;24: 137–140.
Combined Ketamine/Transcranial Magnetic Stimulation Treatment of Severe Depression in Bipolar I Disorder To the Editor: report on the first case of treatment of severe depression in a patient with bipolar I disorder using a combined ketamine/ transcranial magnetic stimulation (TMS) technique. The patient had been largely nonresponsive to electroconvulsive therapy (ECT), repetitive TMS (rTMS), or vagal nerve stimulation. Ketamine is an N-methyl D-aspartate antagonist that has been shown to provide rapid relief for depressive symptoms.1 Transcranial magnetic stimulation, a noninvasive brain stimulation technique, has been shown to possibly reduce symptoms of depression and mania.2,3 The patient, a 31-year-old white man, had presented to my clinic after a 2-month psychiatric hospitalization earlier in that year. He reported that, at the time of the hospitalization, he had been under extreme
I
e50
www.ectjournal.com
stress from working 80 to 90 hours per week. He was diagnosed with bipolar I disorder on the basis of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria by the attending psychiatrist and was administered with ECT 14 times during the course of 2 months. The patient reported that the first 4 ECT treatments had been successful in reducing his acute suicidality but that he returned to feeling suicidal after the fourth treatment and did not experience any gains from the subsequent 10 treatments. Thereafter, he consulted in my clinic and began rTMS with relief but not quiescence. After a year, vagal nerve stimulation was added to the existing rTMS strategy. This addition resulted in some improvement, but the patient still did not attain symptomatic quiescence. I therefore described to him the option of pursuing combined ketamine/ TMS. After weighing the potential risks and benefits, the patient decided to undergo the combined treatment. Institutional review board approval was obtained from an independent accredited agency. Before the onset of the combined treatment of TMS applied during infused ketamine, the patient underwent a systematic psychodiagnostic assessment conducted by an independent licensed clinical psychologist. As part of the assessment, the patient completed a valid Personality Assessment Inventory (PAI) and a Beck Depression Inventory (BDI) II. These measures revealed marked elevations in depression (PAI depression scale T score = 87, BDI-II = 24) and anxiety (PAI anxiety scale T score = 74). Furthermore, the patient showed problems with attention, concentration, and clear thinking (PAI schizophrenia scale T score = 81). Largely consistent with the results of these assessments, the patient described himself as feeling severely depressed, including having frequent thoughts of suicide. In terms of functioning, the patient was severely debilitated, being unable to read or speak in complete sentences. He was on leave from his job and had withdrawn from all of his personal and social relationships, including spending time with his wife and volunteering at his church. In preparation for the combined treatment, the patient received 2 days of rTMS consisting of 4 treatments per day, each of which lasted 30 minutes separated by a 45-minute rest period. The combined treatment then began the following day and was administered approximately once weekly for 3 years. The ketamine dosage varied from 40 to 80 mg per treatment. At each treatment, 40 minutes of 1-Hz continuous rTMS was administered at 115% of motor threshold and intravenous ketamine infusion was administered concurrent to and
bracketed within the middle 30 minutes of TMS. Preinfusion and postinfusion, there were 5 minutes of TMS. The TMS head coil, manufactured by Neotonus, was positioned at the midline of the scalp. This position was selected to maximally stimulate the medial prefrontal area that overlays the anterior cingulate region, which has been implicated in depression.4 All stimulation levels fell within published safety guidelines. A follow-up psychodiagnostic assessment, which included a valid PAI and BDI-II, was conducted a year after the beginning of the combined treatment by the same psychologist who administered the pretreatment battery. This assessment revealed a partial remission of symptoms with partial functional improvement. Specifically, the results showed improvements in depression (PAI depression scale T score = 74, BDI-II = 18) and anxiety (PAI anxiety scale T score = 61) as well as attention, concentration, and clear thinking (PAI schizophrenia scale T score = 74). Although these scores were still elevated, they nonetheless represented substantial decreases from the baseline levels. Consistent with these changes in scores, the patient reported experiencing substantially improved mood, including the absence of any suicidal ideation. He said that he had largely regained his ability to read and speak clearly. Although he remained unemployed, he had returned to spending more time with his wife as well as volunteering approximately 10 to 20 hours per week for his church. These findings are the first of which I am aware to show that a combined ketamine/TMS treatment can be used to treat severe depression in bipolar I disorder. Future research should systematically examine whether the combined treatment of bipolar I symptoms offers benefits over either ECT or ketamine administered independently of TMS. Steven Richard Devore Best, MD The Neuroscience Center Deerfield, IL [email protected]
The author has no conflict of interest or financial disclosures to report. REFERENCES 1. Zarate CA Jr, Brutsche NE, Ibrahim L, et al. Replication of ketamine’s antidepressant efficacy in bipolar depression: a randomized controlled add-on trial. Biol Psychiatry. 2012;71:939–946. 2. Dolberg OT, Dannon PN, Schreiber S, et al. Transcranial magnetic stimulation in patients with bipolar depression: a double blind, controlled study. Bipolar Disord. 2002;4:94–95.
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
