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S everal controlled studies suggest that highfrequency repetitive transcranial magnetic stimulation is associated with antidepressant effects. Interestingly enough, the 2 studies investigating relatively older depressed patients demonstrated a lesser effect than did the studies performed in a younger population. This is in stark contrast to the finding that another method of brain stimulation, electroconvulsive therapy, is somewhat more effective in older patients. Figiel et al assumed that this finding could be associated with the structural brain changes that are often found in older depressed patients. Lai and colleagues were recently able to demonstrate an orbitofrontal cortex volume reduction in geriatric depressed patients. Kozel et al investigated the relationship of the distance between the stimulating coil and the cortex to age and antidepressant response and were not able to find a significant correlation in 12 patients with a mean age of 42 years; however, they demonstrated that treatment responders were younger and had a shorter prefrontal coil-cortex distance. To investigate the hypothesis that a relative prefrontal atrophy could be related to the antidepressant response, we assessed the correlation between an index of the distance between the stimulating coil and the cerebral cortex (coil-cortex distance index [CCDI]) and the rate of change in Hamilton Depression Scale (HAMD) rating in 13 relatively older outpatients (mean±SD age, 56.4±12.7 years; range, 40-74 years) with treatment-resistant major depression. This index was the difference of the coilcortex distance at the prefrontal stimulation site minus the coil-cortex distance at the site where motor threshold was assessed, the result representing relative prefrontal atrophy. The patients underwent a standard repetitive transcranial magnetic stimulation treatment protocol. Stimulationswereperformedwithahigh-speedstimulator (Magstim Company Ltd, Whitland, Wales) with a figure 8–shaped air-cooled coil applied to the left dorsolateral prefrontal cortex (DLPFC), as described in other studies. Stimulus intensity was 100% of individual motor threshold at a frequency of 20 Hz. The duration of the stimulus train was 2 seconds and the intertrain interval was 28 seconds. Forty trains were applied in 20 minutes (1600 pulses) during each session, and sessions were repeated every day for 2 weeks. Brain measurements to obtain the CCDI were performed using computed tomography with a multislice spiral computed tomographic scanner (Somatom +4 Volume Zoom; Siemens AG, Munich, Germany). The stimulation sites for motor cortex and DLPFC were marked with lead balls fixed to a swim cap that was individually fitted for each patient. The position of the cervical spine in the scanner was the same as in the stimulation chair (reclined 15°). Overlapping 5-mm axial slices (increment, 1 mm) were reconstructed in the axial planes. Distances for motor cortex and left DLPFC stimulation

Antidepressant effects of repetitive transcranial magnetic stimulation in the elderly: correlation between effect size and coil-cortex distance