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反覆經顱磁刺激有助於巴金森氏症憂鬱
作者：Laurie Barclay, MD 出處：WebMD醫學新聞 審閱：Gary D. Vogin, MD
Aug. 13, 2004 - 根據一項發表於8月號神經學、神經外科學與精神醫學期刊（the Journal
of Neurology, Neurosurgery and
Psychiatry）的安慰劑控制臨床試驗結果顯示，反覆的經顱磁刺激（rTMS）在治療巴金森氏症的憂鬱病患與fluoxetine一樣有效。
麻州波士頓貝絲以色列女執事醫院與哈佛醫學院的F.
Fregni與其同事指出，rTMS是一種非侵入性、耐受性良好的刺激腦部技術；rTMS透過增強血清素激性系統與增加單胺類濃度，可能具有治療憂鬱症的作用；此外，之前試驗顯示，rTMS應用於前額區域，可以改善巴金森氏症患者的運動功能。
在這項雙盲試驗中，42位巴金森氏症與憂鬱患者接受活性rTMS（15赫茲，共10天）或口服安慰劑治療；或是使用特殊設計偽裝線圈組成的偽裝rTMS及每天20毫克fluoxetine。
治療2週後，以漢米爾敦憂鬱評分量表及貝克憂鬱評量表評估，結果發現2組的改善幅度相似（接受活性rTMS的分別為38%與32%；服用fluoxetine的分別為41%與33%）；經過8週治療後，只有接受rTMS組日常生活活獲得改善，而且利用統一巴金森氏症評分量表評估發現，服用fluoxetine組在運動功能上有不顯著的惡化趨勢。
雖然這2組迷你精神狀態檢查的分數都有改善，但是在接受rTMS這組進步較快，且接受rTMS的相較於使用fluoxetine的副作用較少。
該項試驗的限制包括因為道德限制所以沒有安慰劑組，以及牽涉到偽裝線圈可能的試驗方法上的問題。
研究人員指出，rTMS具有與fluoxetine相同的抗憂鬱效果、有某些改善運動及認知功能上的優點，而且副作用比較少；雖然這些仍是有爭議的，但是每種治療的缺點都必須考慮到，比如說rTMS的價格昂貴（TMS儀器、訓練人員經費）及不方便性（與治療中心位置不同），而且fluoxetine有某些與惡化巴金森氏症運動症狀相關的副作用。
研究人員進一步表示，需要更多有關最佳刺激參數的資訊，包括每位病患接受的刺激數目、每週接受刺激的次數，及一個療程中刺激的最佳長度；他們建議於同一個族群中進行更長時間的rTMS測試治療。
Repetitive Transcranial Magnetic Stimulation Helpful for
Depression in Parkinson's Disease
By Laurie Barclay, MD Medscape Medical News
Aug. 13, 2004 — Repetitive transcranial magnetic
stimulation (rTMS) is as effective as fluoxetine for the
treatment of depression in patients with Parkinson's
disease, according to the results of a
placebo-controlled trial published in the August issue
of the Journal of Neurology, Neurosurgery and
Psychiatry.
"[rTMS] is a non-invasive, well tolerated technique for
stimulating the brain," write F. Fregni, from Beth
Israel Deaconess Medical Center and Harvard Medical
School in Boston, Massachusetts, and colleagues. "rTMS
may have an antidepressant effect by the enhancing the
serotoninergic system and increasing monoamine levels.
Furthermore, previous studies showed that rTMS applied
to the prefrontal area led to an improvement in motor
function in patients with Parkinson's disease."
In this double-blind study, 42 patients with Parkinson's
disease and depression received active rTMS (15 Hz for
10 days) and oral placebo; or sham rTMS using a
specially designed sham coil and 20 mg of fluoxetine per
day.
After two weeks of treatment, the Hamilton Rating Scale
for Depression and Beck Depression Inventory were
similarly improved in both groups (38% and 32% for
active rTMS; 41% and 33% for fluoxetine, respectively).
At week 8, activities of daily living were improved only
in the active rTMS group, and there was a nonsignificant
trend for worse scores in the motor function section of
the Unified Parkinson's Disease Rating Scale in the
fluoxetine group. Although scores on the Mini-Mental
State Examination improved with both treatments, it
improved faster in the active rTMS group. There were
fewer adverse effects with active rTMS than with
fluoxetine.
Study limitations include lack of a placebo group due to
ethical constraints and possible methodological problems
involving the sham coil.
"rTMS has the same antidepressant efficacy as fluoxetine
and may have the additional advantage of some motor
improvement and earlier cognitive improvement, with
fewer adverse effects," the authors write. "The
drawbacks of each treatment have to be considered, as
rTMS involves higher costs (TMS equipment, trained
people to apply) and inconveniences (dislocation to
treatment centre), and fluoxetine has some adverse
effects, being associated with worsening of the motor
symptoms of Parkinson's disease, although this is still
controversial."
The authors note that more information is needed
concerning optimal stimulation parameters, including
number of stimuli per session, number of sessions per
week, and optimum length of a course of stimulation.
They recommend testing a longer period of rTMS treatment
in a similar population.
The authors report no potential financial conflicts of
interest.
J Neurol Neurosurg Psychiatry. 2004;75:1171-1174
Reviewed by Gary D. Vogin, MD
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反覆經顱磁刺激有助於巴金森氏症憂鬱
