***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 Multiple groups have reported on the use of repetitive transcranial magnetic stimulation ( rTMS ) in treatment-resistant major depression . The purpose of this study is to assess the efficacy of rTMS in unmedicated , treatment-resistant patients who meet criteria for major depression . METHODS Depressed subjects , who had failed to respond to a median of four treatment trials , were assigned in a r and omized double-blind manner to receive either active ( n = 10 ; 20 2-sec trains of 20 Hz stimulation with 58-sec intervals ; delivered at 80 % motor threshold with the figure-of-eight coil positioned over the left dorsolateral prefrontal cortex ) or sham ( n = 10 ; similar conditions with the coil elevated and angled 45 degrees tangentially to the scalp ) rTMS . These sequences were applied during 10 consecutive weekdays . Continuous electroencephalogram sampling and daily motor threshold determinations were also obtained . RESULTS The group mean 25-item Hamilton Depression Rating Scale ( HDRS ) score was 37.2 ( + /- 2.0 SEM ) points . Adjusted mean decreases in HDRS scores were 14.0 ( + /- 3.7 ) and 0.2 ( + /- 4.1 ) points for the active and control groups , respectively ( p < .05 ) . One of 10 subjects receiving active treatment demonstrated a robust response ( i.e. , HDRS decreased from 47 to 7 points ) ; three other patients demonstrated 40 - 45 % decreases in HDRS scores . No patients receiving sham treatment demonstrated partial or full responses . CONCLUSIONS A 2-week course of active rTMS result ed in statistically significant but clinical ly modest reductions of depressive symptoms , as compared to sham rTMS in a population characterized by treatment resistance BACKGROUND The role of high-frequency rTMS over the left cortex as an add-on strategy in the treatment of major depression is still uncertain even in patients resistant to pharmacotherapy . We had planned a large sham TMS controlled study in the acute phase with a placebo-controlled relapse-prevention phase with escitalopram . However , because a recent meta- analysis showed only a small effect size of rTMS over sham TMS in the acute treatment phase of depressed patients , we decided to make an interim analysis . METHOD In patients with medication-resistant major depression we administered in a r and omised trial 15 sessions of sham-controlled rTMS over three weeks in combination with 20 mg escitalopram daily . After the last rTMS , the patients were followed for another 9 weeks on 20 mg escitalopram daily . The antidepressant effect was measured by the HAM-D(6 ) as primary outcome scale . RESULTS A total of 45 patients with complete data were r and omised so that 23 patients received sham TMS and 22 patients received active , high-frequency rTMS over the left cortex . Over the 3 weeks , the active rTMS treatment was superior to sham TMS with effect sizes on the HAM-D(6 ) above 0.70 , which indicates not only a statistically but also a clinical ly significant effect . The patients had typically been through two failed antidepressant treatment attempts with non-tricyclics before inclusion in the study . Both the rTMS and escitalopram were well-tolerated . CONCLUSION High-frequency rTMS over the left cortex is an add-on strategy of clinical significance in combination with escitalopram in patients with major depression resistant to non-tricyclic antidepressants Rapid transcranial magnetic stimulation ( rTMS ) applied to the left dorsal lateral frontal cortex has been shown to produce antidepressant effects . Older depressed patients , however , in one study showed a lower response rate than younger patients . The current study examined treatment response in 20 depressed , treatment-refractory patients ( mean age 60.7 + /- 9.8 years ) given five sessions of rTMS at 20 Hz for 2 seconds over 20 trains at 80 % of motor threshold or identical placebo stimulation , after patients had been withdrawn from their antidepressants . There were no significant differences in Hamilton Depression Scale scores either before or after treatment at 7 days ' follow-up . There were three responders to active treatment and three to sham treatment and responders had significantly greater frontal lobe volume than nonresponders ( p = .03 ) . These findings suggest that the stimulation parameters used in this study were probably insufficient to produce treatment response and that frontal atrophy may interfere with the effectiveness of rTMS We conducted a prospect i ve , r and omized , sham-controlled , double blind , parallel group study of right or left pre-frontal rTMS in 48 subjects with medication-resistant depression .  Two thous and ( 50x8-s trains of 5Hz ) stimuli at MEP threshold were delivered each weekday for 2weeks . We employed a sham coil and simultaneous electrical stimulation of the scalp to simulate rTMS . Mean ( + /-S.D. ) reductions in the HAMD-24 from baseline to 3-months were not significantly different between rTMS and sham treatment groups . However , right cranial stimulation ( sham or rTMS ) was significantly more effective than left cranial stimulation ( sham or rTMS ) ( P=0.012 ) . Mean ( + /-S.D. ) reductions in the HAMD from baseline to 3 months were : left : 28.1 ( + /-5.36 ) to 19.2 ( + /-11.2 ) ; and right 27.2 ( + /-4.2 ) to 11.5 ( + /-9.4 ) . Left rTMS achieved a reduction in HAMD 9.5 points greater than that achieved by left sham , a benefit greater than that reported in a recent multi-center Phase III trial of rTMS ( O'Reardon et al. , 2007 ) , albeit not statistically significant . These results suggest that somatosensory stimuli that repeatedly engage the left hemisphere may be important to the achievement of therapeutic effect OBJECTIVE A substantive body of research has demonstrated the efficacy of repetitive transcranial magnetic stimulation treatment ( rTMS ) in patients with depression . However , the parameters needed to optimize therapeutic efficacy remain unclear . The aim of this study was to investigate whether there is an advantage in efficacy of sequential bilateral rTMS compared to st and ard high-frequency left sided rTMS . METHOD Sixty seven patients with treatment resistant depression were included in a r and omised double-blind sham controlled trial of sequential bilateral rTMS compared to st and ard high-frequency left sided rTMS and sham rTMS over a three-week period . The study also included a further three week comparison of the two active treatment conditions . The primary outcome variable was scores on the 17-item Hamilton Depression Rating Scale ( HAMD ) . RESULTS In the three-week double-blind phase of the trial there was a greater antidepressant response to unilateral left sided rTMS compared with sham or bilateral rTMS . Across the full six weeks of active rTMS , there was also a consistent pattern of improved response in unilateral left compared to bilateral treatment . Response rates were low in both active groups . CONCLUSIONS This study does not support the hypothesis that sequential bilateral rTMS is more effective than unilateral high-frequency left-sided rTMS Studies of repetitive transcranial magnetic stimulation ( rTMS ) in depression have found antidepressant effects when high frequency stimulation ( HF-rTMS ; > 1 Hz ) is applied over the left prefrontal cortex ( LPF ) . A few studies have also reported success with low frequency stimulation ( LF-rTMS ) to the right prefrontal cortex ( RPF ) . Both HF-rTMS and LF-rTMS have been reported to work better in areas with cerebral hypometabolism or hypermetabolism , respectively . Thirty medication-resistant patients with major depression were r and omized into three groups . The first group received sham rTMS and the second group received active rTMS ( 20-Hz rTMS to the LPF and 1-Hz rTMS to the RPF ) . The third group , however , received active rTMS that was focused on different regions of the brain after examination with single photon emission computed tomography ( 20-Hz rTMS to an area of relatively low activity and 1-Hz rTMS to an area showing relatively high activation ) . Patients and raters were blind to the treatment condition . Comparison of the sham rTMS group with the overall group that received active rTMS revealed statistically significant changes on the Hamilton Rating Scale for Depression after 10 sessions . This study demonstrated that combined 20 + 1-Hz rTMS was effective , but no additional advantages were obtained by focusing rTMS on areas identified by single photon emission tomography as showing high versus low levels of functional activity BACKGROUND We tested whether transcranial magnetic stimulation ( TMS ) over the left dorsolateral prefrontal cortex ( DLPFC ) is effective and safe in the acute treatment of major depression . METHODS In a double-blind , multisite study , 301 medication-free patients with major depression who had not benefited from prior treatment were r and omized to active  ( n = 155 ) or  sham TMS  ( n = 146 ) conditions . Sessions were conducted five times per week with TMS at 10 pulses/sec , 120 % of motor threshold , 3000 pulses/session , for 4 - 6 weeks . Primary outcome was the symptom score change as assessed at week 4 with the Montgomery-Asberg Depression Rating Scale ( MADRS ) . Secondary outcomes included changes on the 17- and 24-item Hamilton Depression Rating Scale ( HAMD ) and response and remission rates with the MADRS and HAMD . RESULTS Active TMS was significantly superior to sham TMS on the MADRS at week 4 ( with a post hoc correction for ine quality in symptom severity between groups at baseline ) , as well as on the HAMD17 and HAMD24 scales at weeks 4 and 6 . Response rates were significantly higher with active TMS on all three scales at weeks 4 and 6 . Remission rates were approximately twofold higher with active TMS at week 6 and significant on the MADRS and HAMD24 scales ( but not the HAMD17 scale ) . Active TMS was well tolerated with a low dropout rate for adverse events ( 4.5 % ) that were generally mild and limited to transient scalp discomfort or pain . CONCLUSIONS Transcranial magnetic stimulation was effective in treating major depression with minimal side effects reported . It offers clinicians a novel alternative for the treatment of this disorder OBJECTIVE Preliminary studies have indicated that daily left prefrontal repetitive transcranial magnetic stimulation might have antidepressant activity . The authors sought to confirm this finding by using a double-blind crossover design . METHOD Twelve depressed adults received in r and om order 2 weeks of  active treatment ( repetitive transcranial magnetic stimulation , 20 Hz at 80 % motor threshold ) and 2 weeks of sham treatment . RESULTS Changes from the relevant phase baseline in scores on the 21-item Hamilton depression scale showed that repetitive transcranial magnetic stimulation significantly improved mood over sham treatment . During the active-treatment phase , Hamilton depression scale scores decreased 5 points , while during sham treatment the scores increased or worsened by 3 points . No adverse effects were noted . CONCLUSIONS These placebo-controlled results suggest that daily left prefrontal repetitive transcranial magnetic stimulation has antidepressant activity when administered at these parameters . Further controlled studies are indicated to explore optimal stimulation characteristics and location , potential clinical applications , and possible mechanisms of action In previous studies , fast repetitive transcranial magnetic stimulation ( rTMS ) with a frequency > 1 Hz demonstrated substantial antidepressant effects compared to sham rTMS . However , it is not clear whether fast rTMS is superior to slow rTMS ( frequency < or = 1 Hz ) which is safe at therapeutically promising higher intensities . The aim of this double-blind study was to compare the action of fast , slow and sham rTMS .  Eighteen patients with pharmacotherapy-resistant major depression were r and omized to receive fast ( 10 Hz ) , slow ( 0.3 Hz ) or sham rTMS with 250 stimuli/day for 5 successive days . rTMS was applied at 90 % motor threshold intensity to the left dorsolateral prefrontal cortex . Scores on the Hamilton Depression Rating Scale ( HDRS ) , but not on the Montgomery-Asberg Depression Rating Scale ( MADRS ) , showed a statistically significant time x group interaction with a reduction of 19 % after slow rTMS . However , the effect was clinical ly marginal and not reflected by self-rating scores . Verbal memory and reaction performance were not impaired after rTMS , and there was even a statistically significant time x group interaction with improvement of verbal memory performance after fast rTMS . In conclusion , this study further supported the safety of rTMS but does not show any clinical ly meaningful antidepressant efficacy of rTMS at 250 daily stimuli over 5 days in pharmacotherapy-refractory major depression OBJECTIVE Selective serotonin reuptake inhibitors ( SSRIs ) are widely used to treat depression , but the rates , timing , and baseline predictors of remission in " real world " patients are not established . The authors ' primary objectives in this study were to evaluate the effectiveness of citalopram , an SSRI , using measurement-based care in actual practice , and to identify predictors of symptom remission in out patients with major depressive disorder . METHOD This clinical study included out patients with major depressive disorder who were treated in 23 psychiatric and 18 primary care " real world " setting s. The patients received flexible doses of citalop 
    Output:
    
RESULTS rTMS was beneficial compared with sham for all outcomes .
Limited evidence and variable treatment parameters prevented conclusions about which specific treatment options are more effective than others .
For MDD patients with 2 or more antidepressant treatment failures , rTMS is a reasonable , effective consideration