Self-directedness: An indicator for clinical response to the HF-rTMS treatment in refractory melancholic depression Chris Baeken a,b,c,n , Stefanie Desmyter a,c , Romain Duprat a,c , Rudi De Raedt d , Dirk Van denabbeele a , Hannelore Tandt a , Gilbert M.D. Lemmens a , Myriam Vervaet a , Kees van Heeringen a a Department of Psychiatry and Medical Psychology, Ghent University Hospital, Ghent University, Ghent, Belgium b Department of Psychiatry University Hospital (UZBrussel), Brussels, Belgium c Ghent Experimental Psychiatry (GHEP) Lab, Ghent, Belgium d Department of Experimental Clinical and Health Psychology, Ghent University, Ghent, Belgium article info Article history: Received 30 January 2014 Received in revised form 27 July 2014 Accepted 31 July 2014 Available online 8 August 2014 Keywords: Self-directedness HF-rTMS Unipolar depression Melancholia Treatment resistance abstract Although well-defined predictors of response are still unclear, clinicians refer a variety of depressed patients for a repetitive Transcranial Magnetic Stimulation (rTMS) treatment. It has been suggested that personality features such as Harm Avoidance (HA) and self-directedness (SD) might provide some guidance for a classical antidepressant treatment outcome. However, to date no such research has been performed in rTMS treatment paradigms. In this open study, we wanted to examine whether these temperament and character scores in particular would predict clinical outcome in refractory unipolar depressed patients when a typical high-frequency (HF)-rTMS treatment protocol is applied. Thirty six unipolar right-handed antidepressant-free treatment resistant depressed (TRD) patients, all of the melancholic subtype, received 10 HF-rTMS sessions applied to the left dorsolateral prefrontal cortex (DLPFC). All patients were classified as at least stage III TRD and were assessed with the Temperament and Character Inventory (TCI) before a HF-rTMS treatment. Only the individual scores on SD predicted clinical outcome. No other personality scales were found to be a predictor of this kind of application. Our results suggest that refractory MDD patients who score higher on the character scale SD may be more responsive to the HF-rTMS treatment. & 2014 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Major depressive disorder (MDD) is a severe mental health problem affecting millions worldwide. In spite of a variety of treatment modalities, not all patients respond to current pharma- cotherapy or psychotherapy interventions (Papakostas, 2009). Furthermore, when challenged by antidepressant (AD) non- response, treatment options are limited (Shelton et al., 2010; Ward and Irazoqui, 2010; Kupfer et al., 2012). Repetitive Transcra- nial Magnetic Stimulation (rTMS) has become an established non- invasive treatment for patients suffering from MDD (Lefaucheur et al., 2011, in press; Berlim et al., 2014). Although most of the former rTMS trials have been carried-out in MDD patients with some level of treatment-resistance, 20 years of clinical experience indicates that beneficial predictors are a limited history of treatment resistance, younger age ( o65 years), and a relatively short period of clinical depression ( o1 year) (Brakemeier et al., 2007; George and Post, 2011). In daily clinical practice however, when confronted with partial or non-response, instead of a quick referral to such non-invasive approaches, clinicians tend to hold on changing or combining AD. However, this approach does not dramatically increase response and remis- sion rates (von Wolff et al., 2012; Turner et al., 2014). As a consequence, a large number of MDD patients referred to the rTMS treatment settings range from some history of treatment resistance to chronic treatment resistant depression (TRD) or refractory MDD, including patients with unsuccessful electrocon- vulsive therapy (ECT) in the past (Baeken et al., 2009a, 2010, 2013; Zeeuws et al., 2011). Typical rTMS treatment protocols follow daily sessions, spread over 2 weeks or more, applying high frequency (HF)-rTMS on the left dorsolateral prefrontal cortex (DLPFC) or low frequency (LF) rTMS to its right counterpart (George and Post, 2011; Fitzgerald Contents lists available at ScienceDirect journal homepage: www.elsevier.com/locate/psychres Psychiatry Research http://dx.doi.org/10.1016/j.psychres.2014.07.084 0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved. n Corresponding author at: Department of Psychiatry and Medical Psychology, UGent, De Pintelaan 185-9000 Ghent, Belgium. Tel.: þ32 9 332 4330: fax: þ32 9 332 4989. E-mail address: chris.baeken@ugent.be (C. Baeken). Psychiatry Research 220 (2014) 269–274