title: Decreasing procedural pain over time of left prefrontal rTMS for depression: initial results from the open-label phase of a multi-site trial (OPT-TMS).
abstract: BACKGROUND
  There is much interest in whether daily left prefrontal repetitive transcranial magnetic stimulation (rTMS) over several weeks may become a clinically useful antidepressant treatment. Although rTMS appears largely safe, many patients report that this procedure is somewhat painful, which may restrict its ultimate appeal and utility. We analyzed interim results from the open-label phase of a multi-site randomized trial of rTMS as a treatment for depression to investigate whether the procedural pain of left prefrontal rTMS changes over time.
  
  
  METHODS
  Patients with unipolar depression who had failed to respond during at least three weeks of the sham-controlled double-masked rTMS were then offered three more weeks (15 sessions) of open-label rTMS. Retrospective pain ratings and state emotional factors from 20 subjects were assessed using visual analog scales (VAS) recorded on computers before and after each treatment (289 sessions).
  
  
  RESULTS
  Over the 15 treatment sessions, subjective reports of the painfulness of rTMS decreased 48% from baseline. This reduction, although greatest in the first few days, continued steadily (average 2.11 points per session) over the 3 weeks of treatment. The analysis found a significant effect for rTMS-session (p<0.0001) on rTMS-procedural pain over and above changes in subjective emotional states.
  
  
  CONCLUSIONS
  The procedural pain of left, prefrontal rTMS decreases over time, apparently independently of other emotional changes. Since rTMS scalp pain may decline over time, physicians and patients may decide to continue treatment despite initial discomfort. These observational data can be better tested once the data from the blinded phase of the trial becomes available.
authors.affiliation: Brain Stimulation Laboratory, Psychiatry Department, Medical University of South Carolina, Charleston, SC 29425, USA. andersob@musc.edu
authors.forename: Berry S
authors.initials: BS
authors.lastname: Anderson
authors.forename: Katie
authors.initials: K
authors.lastname: Kavanagh
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Borckardt
authors.forename: Ziad H
authors.initials: ZH
authors.lastname: Nahas
authors.forename: Samet
authors.initials: S
authors.lastname: Kose
authors.forename: Sarah H
authors.initials: SH
authors.lastname: Lisanby
authors.forename: William M
authors.initials: WM
authors.lastname: McDonald
authors.forename: David
authors.initials: D
authors.lastname: Avery
authors.forename: Harold A
authors.initials: HA
authors.lastname: Sackeim
authors.forename: Mark S
authors.initials: MS
authors.lastname: George
mesh_terms: D000339:Affect / Q000502:physiology; D003866:Depressive Disorder / Q000628:therapy*; D004311:Double-Blind Method; D006801:Humans; D010146:Pain / Q000209:etiology / Q000503:physiopathology; D010147:Pain Measurement; D017397:Prefrontal Cortex / Q000502:physiology*; D011569:Psychiatric Status Rating Scales; D011795:Surveys and Questionnaires; D013997:Time Factors; D050781:Transcranial Magnetic Stimulation / Q000009:adverse effects / Q000379:methods; D016896:Treatment Outcome