***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Suicide attempts and completed suicides are common , yet there are no proven acute medication or device treatments for treating a suicidal crisis . Repeated daily left prefrontal repetitive transcranial magnetic stimulation ( rTMS ) for 4 - 6 weeks is a new FDA -approved treatment for acute depression . Some open-label rTMS studies have found rapid reductions in suicidality . DESIGN This study tests whether a high dose of rTMS to suicidal in patients is feasible and safe , and also whether this higher dosing might rapidly improve suicidal thinking . This prospect i ve , 2-site , r and omized , active sham-controlled ( 1:1 r and omization ) design incorporated 9 sessions of rTMS over 3 days as adjunctive to usual inpatient suicidality treatment . The setting was two inpatient military hospital wards ( one VA , the other DOD ) . PATIENTS Research staff screened approximately 377 in patients , yielding 41 adults admitted for suicidal crisis . Because of the funding source , all patients also had either post-traumatic stress disorder , mild traumatic brain injury , or both .  TMS METHODS Repetitive TMS ( rTMS ) was delivered to the left prefrontal cortex with a figure-eight solid core coil at 120 % motor threshold , 10 Hertz ( Hz ) , 5 second ( s ) train duration , 10 s intertrain interval for 30 minutes ( 6000 pulses ) 3 times daily for 3 days ( total 9 sessions ; 54,000 stimuli ) . Sham rTMS used a similar coil that contained a metal insert blocking the magnetic field and utilized electrodes on the scalp , which delivered a matched somatosensory sensation . MAIN OUTCOME MEASURE Primary outcomes were the daily change in severity of suicidal thinking as measured by the Beck Scale of Suicidal Ideation ( SSI ) administered at baseline and then daily , as well as subjective visual analog scale measures before and after each TMS session . Mixed model repeated measures ( MMRM ) analysis was performed on modified intent to treat ( mITT ) and completer population s. RESULTS This intense schedule of rTMS with suicidal in patients was feasible and safe . Minimal side effects occurred , none differing by arm , and the 3-day retention rate was 88 % . No one died of suicide within the 6 month followup . From the mITT analyses , SSI scores declined rapidly over the 3 days for both groups ( sham change -15.3 points , active change -15.4 points ) , with a trend for more rapid decline on the first day with active rTMS ( sham change -6.4 points , active -10.7 points , P = 0.12 ) . This decline was more pronounced in the completers subgroup [ sham change -5.9 ( 95 % CI : -10.1 , -1.7 ) , active -13 points ( 95 % CI : -18.7 , -7.4 ) ; P = 0.054 ] . Subjective ratings of ' being bothered by thoughts of suicide ' declined non-significantly more with active rTMS than with sham at the end of 9 sessions of treatment in the mITT analysis [ sham change -31.9 ( 95 % CI : -41.7 , -22.0 ) , active change -42.5 ( 95 % CI : -53.8 , -31.2 ) ; P = 0.17 ] . There was a significant decrease in the completers sample [ sham change -24.9 ( 95 % CI : -34.4 , -15.3 ) , active change -43.8 ( 95 % CI : -57.2 , -30.3 ) ; P = 0.028 ] . CONCLUSIONS Delivering high doses of left prefrontal rTMS over three days ( 54,000 stimuli ) to suicidal in patients is possible and safe , with few side effects and no worsening of suicidal thinking . The suggestions of a rapid anti-suicide effect ( day 1 SSI data , Visual Analogue Scale data over the 3 days ) need to be tested for replication in a larger sample . TRIAL REGISTRATION Clinical Trials.gov Identifier : NCT01212848 , TMS for suicidal ideation BACKGROUND Theta-burst transcranial magnetic stimulation ( TBS ) has been shown to induce potent and long lasting effects on cortical excitability . In a previous open study , we demonstrated safety , tolerability and antidepressant properties of continuous TBS ( cTBS ) in major depression ( MD ) . The present study was aim ed to evaluate the therapeutic efficacy of cTBS in depressed patients using a double-blind , sham-controlled design . METHODS Twenty nine patients with MD were r and omized to receive either active cTBS to the right dorsolateral prefrontal cortex ( n=15 ) or sham cTBS ( n=14 ) for 10 consecutive work days . After the 10th session , patients who received sham TBS were crossed over to active cTBS which consisted of 10 daily sessions . Patients who received active cTBS continued with the same treatment protocol for additional 10 treatments . Each treatment session consisted of 3600 stimuli at an intensity of 100 % of the active motor threshold . Severity of depression was assessed weekly . RESULTS Overall , there was no significant difference in the degree of clinical improvement between active and sham cTBS groups . However , in patients whose medication status remained unchanged before the trial ( n=8 ) and in those who were medication-free ( n=3 ) , active cTBS result ed in a significantly greater reduction of Hamilton depression scores as compared to sham cTBS . LIMITATIONS A small sample size , confounding effect of medication and short treatment period . CONCLUSIONS Our results suggest that the antidepressant effect of cTBS is modest , yet it might be beneficial to patients nonresponsive to ongoing pharmacological treatment . A direct comparison between cTBS and conventional rTMS protocol s is warranted BACKGROUND Repetitive transcranial magnetic stimulation ( rTMS ) has been shown to be an effective treatment for depression . However , there has been little research to determine optimal parameters for treatment . METHOD This study compared two rTMS treatment regimes for the treatment of major depression .  Seventy-seven participants were r and omized to either spaced or daily treatment . Spaced rTMS was given 3 days/week for 6 weeks ( 18 treatments in total ) and daily rTMS was given 5 days/week for 4 weeks ( 20 treatments in total ) . All participants were assessed at baseline and after 4 weeks of treatment . Participants in the spaced treatment group were also assessed after 6 weeks of treatment . All participants were treated at 110 % of the resting motor threshold with high-frequency rTMS ( 10 Hz ) to the left dorsolateral prefrontal cortex ( DLPFC ) followed by low-frequency rTMS to the right DLPFC . RESULTS Participants in the daily treatment group showed more improvement by week 4 than those in the spaced treatment group ; however , both groups had similar improvement by treatment completion . There was significant improvement in both groups in ratings of depression and anxiety , with no significant differences between groups . CONCLUSIONS Our study indicates that the efficacy of rTMS  is related to the number of treatments given and that spacing the treatments neither improves nor reduces efficacy BACKGROUND Major depressive disorder ( MDD ) is a significant cause of worldwide disability and treatment resistance is common . High-frequency repetitive transcranial magnetic stimulation ( HF-rTMS ) has emerged as a treatment for MDD , and while efficacious , the daily commitment for typical 4 - 6 weeks of treatment poses a significant challenge . We aim ed to determine the effectiveness and acceptability of an accelerated rTMS protocol for MDD . METHODS In this naturalistic trial , 27 patients with moderate to severe chronic and treatment-resistant MDD were treated with twice-daily HF-rTMS ( 10 Hz ) applied over the left dorsolateral prefrontal cortex for 2 consecutive weeks ( 60,000 pulses ) . The primary outcomes were rates of clinical remission and response ( 16-item Quick Inventory of Depressive Symptomatology post-treatment score ≤ 6 , and ≥ 50 % reduction , respectively ) . Secondary outcomes were self-reported anxious symptoms , depressive symptoms and quality of life , and dropout rates as a proxy for acceptability . RESULTS Ten ( 37.0 % ) patients met criteria for clinical remission and 15 ( 55.6 % ) were classified as responders , with comparable outcomes for both moderate and severe MDD . Clinician-rated improvements in depressive symptoms were paralleled in self-reported depressive and anxious symptoms , as well as quality of life . No patient discontinued treatment . LIMITATIONS This study is limited by short treatment duration that might be lengthened with corresponding improvements in effectiveness , limited duration of follow-up , small sample size , and an open-label design requiring r and omized controlled replication . CONCLUSION An accelerated protocol involving twice-daily sessions of HF-rTMS over the left DLPFC for 2 weeks was effective in treatment-resistant MDD , and had excellent acceptability . Additional research is required to optimize accelerated rTMS treatment protocol s and determine efficacy using sham-controlled trials Ultrabrief pulse width stimulation electroconvulsive therapy ( ECT ) results in less cognitive side-effects than brief pulse ECT , but recent work suggests that more treatment sessions may be required to achieve similar efficacy . In this retrospective analysis of subjects pooled from three research studies , time to improvement was analysed in 150 depressed subjects who received right unilateral ECT with a brief pulse width ( at five times seizure threshold ) or ultrabrief pulse width ( at six times seizure threshold ) . Multivariate Cox regression analyses compared the number of treatments required for 50 % reduction in depression scores ( i.e. speed of response ) in these two sample s. The analyses controlled for clinical , demographic and treatment variables that differed between the sample s or that were found to be significant predictors of speed of response in univariate analyses . In the multivariate analysis , older age predicted faster speed of response . There was a non-significant trend for faster time to 50 % improvement with brief pulse ECT  ( p = 0.067 ) . Remission rates were higher after brief pulse ECT than ultrabrief pulse ECT ( p = 0.007 ) but response rates were similar . This study , the largest of its kind reported to date , suggests that fewer treatments may be needed to attain response with brief than ultrabrief pulse ECT and that remission rates are higher with brief pulse ECT . Further research with a larger r and omized and blinded study is recommended The objective of this study was to explore the response rate to high-frequency left-sided repetitive transcranial magnetic stimulation ( rTMS ) in patients who had failed to respond to right-sided low-frequency stimulation  , and to investigate whether there was differential efficacy between stimulation at 5 or 10 Hz . Data from two r and omized controlled trials were pooled . In both studies a group of patients were r and omized to receive either 5- or 10-Hz left prefrontal rTMS after failing to respond to right-sided stimulation . These patients received blinded 5- or 10-Hz stimulation ( but without a sham control ) for a period of up to 4 weeks and outcomes were compared . There was a small but significant overall response to left-sided rTMS but no difference in response between the 5- and 10-Hz treatment conditions . There appears to be a significant but modest likelihood of response to left-sided TMS  in patients who fail right-sided stimulation , but there is no difference in efficacy between 5- and 10-Hz stimulation CONTEXT Electroconvulsive therapy ( ECT ) is highly effective for treatment of major depression , but naturalistic studies show a high rate of relapse after discontinuation of ECT . OBJECTIVE To determine the efficacy of continuation pharmacotherapy with nortriptyline hydrochloride or combination nortriptyline and lithium carbonate in preventing post-ECT relapse . DESIGN R and omized , double-blind , placebo-controlled trial conducted from 1993 to 1998 , stratified by medication resistance or presence of psychotic depression in the index episode . SETTING Two university-based hospitals and 1 private psychiatric hospital . PATIENTS Of 290 patients with unipolar major depression recruited through clinical referral who completed an open ECT treatment phase , 159 patients met remitter criteria ; 84 remitting patients were eligible and agreed to participate in the continuation study . INTERVENTIONS Patients were r and omly assigned to receive continuation treatment for 24 weeks with placebo ( n = 29 ) , nortriptyline ( target steady-state level , 75 - 125 ng/mL ) ( n = 27 ) , or combination nortriptyline and lithium ( target steady-state level , 0.5 - 0.9 mEq/L ) ( n = 28 ) . MAIN OUTCOME MEASURE Relapse of major depressive episode , compared among the 3 continuation groups . RESULTS Nortriptyline-lithium combination therapy had a marked advantage in time to relapse , superior to both placebo and nortriptyline alone . Over the 24-week trial , the relapse rate for placebo was 84 % ( 95 % confidence interval [ CI ] , 70%-99 % ) ; for nortriptyline , 60 % ( 95 % CI , 41%-79 % ) ; and for nortriptyline-lithium , 39 % ( 95 % CI , 19%-59 % ) . All but 1 instance of relapse with nortriptyline-lithium occurred within 5 weeks of 
    Output:
    
Conclusions : There is increasing evidence for efficacy , tolerability , and safety of neurostimulation treatments .
rTMS is now a first-line recommendation for patients with MDD who have failed at least 1 antidepressant .
ECT remains a second-line treatment for patients with treatment-resistant depression , although in some situations , it may be considered first line .