Repetitive transcranial magnetic stimulation appears to be an effective and safe treatment for depression and psychosis. It should be more widely available to patients who do not respond to pharmacotherapy. Background: Repetitive transcranial magnetic stimulation (rTMS) is a stimulation therapy approved by the Food and Drug Administration in 2008 for the treatment of depression. However, its use remains obscure. Objective: To determine whether rTMS should be brought out of obscurity for the treatment of depression, schizophrenia, and obsessive-compulsive disorder (OCD). Design: A meta-analysis of rTMS for the management of mood and anxiety disorders, psychosis, attentiondeficit/hyperactivity disorder (ADHD), Tourette syndrome, bulimia nervosa, and addiction. Participants/Methods: A literature search was conducted to identify parallel, double-blind, randomized, controlled studies investigating rTMS published between 1966 and 2008. Only those psychiatric disorders investigated in at least 3 studies were included in the meta-analysis. Effect sizes were calculated for mean differences in pretreatment versus posttreatment rating scales with rTMS compared to sham treatment. Results: The only psychiatric conditions for which rTMS had been studied sufficiently for meta-analysis were depression, psychosis with auditory verbal hallucinations (AVH), psychosis with negative symptoms, and OCD. Studies investigating rTMS for depression had varied methodologies, and they tested rTMS monotherapy, adjunctive therapy with medication, and cotherapy with medication. rTMS was also compared to electroconvulsive treatment (ECT) in 6 studies of major depression. For depression, rTMS monotherapy performed best (effect size, 0.96) followed by adjunctive treatment (effect size, 0.51) and simultaneous cotherapy with an antidepressant (effect size, 0.37). rTMS for depression was applied over the right or left dorsolateral prefrontal cortex (DLPF), although the location of stimulation did not significantly affect performance of rTMS. rTMS was less effective than ECT for severe major depression, with a weighted effect size of-0.47. In 7 randomized controlled trials, rTMS applied to the left temporoparietal cortex was moderately effective for the treatment of AVH (effect size, 0.54). rTMS was also mildly effective for the treatment of negative symptoms of psychosis in 7 studies (effect size, 0.39). Most of these studies applied rTMS over the left DLPF. In contrast, rTMS was not effective for the treatment of OCD in 3 studies (effect size, 0.15; n=38). Conclusions: Based on these meta-analyses, rTMS should be considered standard treatment for major depression and for both positive and negative symptoms of psychosis that are refractory to pharmacotherapy. rTMS appears to be more effective as monotherapy instead of as adjunctive therapy for major depression. The authors do not recommend the use of rTMS for OCD. Reviewer's Comments: Most participants in these studies were resistant to pharmacotherapy, but it was prudent and cost-effective to try an...

Much of the research on visual hallucinations (VHs) has been conducted in the context of eye disease and neurodegenerative conditions, but little is known about these phenomena in psychiatric and nonclinical populations. The purpose of this article is to bring together current knowledge regarding VHs in the psychosis phenotype and contrast this data with the literature drawn from neurodegenerative disorders and eye disease. The evidence challenges the traditional views that VHs are atypical or uncommon in psychosis. The weighted mean for VHs is 27% in schizophrenia, 15% in affective psychosis, and 7.3% in the general community. VHs are linked to a more severe psychopathological profile and less favorable outcome in psychosis and neurodegenerative conditions. VHs typically co-occur with auditory hallucinations, suggesting a common etiological cause. VHs in psychosis are also remarkably complex, negative in content, and are interpreted to have personal relevance. The cognitive mechanisms of VHs in psychosis have rarely been investigated, but existing studies point to source-monitoring deficits and distortions in top-down mechanisms, although evidence for visual processing deficits, which feature strongly in the organic literature, is lacking. Brain imaging studies point to the activation of visual cortex during hallucinations on a background of structural and connectivity changes within wider brain networks. The relationship between VHs in psychosis, eye disease, and neurodegeneration remains unclear, although the pattern of similarities and differences described in this review suggests that comparative studies may have potentially important clinical and theoretical implications.

Despite a growing interest in auditory verbal hallucinations (AVHs) in different clinical and nonclinical groups, the phenomenological characteristics of such experiences have not yet been reviewed and contrasted, limiting our understanding of these phenomena on multiple empirical, theoretical, and clinical levels. We look at some of the most prominent descriptive features of AVHs in schizophrenia (SZ). These are then examined in clinical conditions including substance abuse, Parkinson's disease, epilepsy, dementia, late-onset SZ, mood disorders, borderline personality disorder, hearing impairment, and dissociative disorders. The phenomenological changes linked to AVHs in prepsychotic stages are also outlined, together with a review of AVHs in healthy persons. A discussion of key issues and future research directions concludes the review.

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This study indicates that the incidence of schizophrenia is increased in several, but not all, immigrant groups to The Netherlands. It is possible that factors associated with a process of rapid westernisation precipitate schizophrenia in people who are genetically at risk.

AVH in BPD patients are phenomenologically similar to those in schizophrenia, and different from those in healthy individuals. As AVH in patients with BPD fulfil the criteria of hallucinations proper, we prefer the term AVH over 'pseudohallucinations', so as to prevent trivialization and to promote adequate diagnosis and treatment.

Auditory verbal hallucinations in patients with a psychotic disorder are consistently preceded by deactivation of the parahippocampal gyrus. The parahippocampus has been hypothesized to play a central role in memory recollection, sending information from the hippocampus to the association areas. Dysfunction of this region could trigger inadequate activation of right language areas during auditory hallucinations.

This article reviews the treatment of hallucinations in schizophrenia. The first treatment option for hallucinations in schizophrenia is antipsychotic medication, which can induce a rapid decrease in severity. Only 8% of first-episode patients still experience mild to moderate hallucinations after continuing medication for 1 year. Olanzapine, amisulpride, ziprasidone, and quetiapine are equally effective against hallucinations, but haloperidol may be slightly inferior. If the drug of first choice provides inadequate improvement, it is probably best to switch medication after 2-4 weeks of treatment. Clozapine is the drug of choice for patients who are resistant to 2 antipsychotic agents. Blood levels should be above 350-450 μg/ml for maximal effect. For relapse prevention, medication should be continued in the same dose. Depot medication should be considered for all patients because nonadherence is high. Cognitive-behavioral therapy (CBT) can be applied as an augmentation to antipsychotic medication. The success of CBT depends on the reduction of catastrophic appraisals, thereby reducing the concurrent anxiety and distress. CBT aims at reducing the emotional distress associated with auditory hallucinations and develops new coping strategies. Transcranial magnetic stimulation (TMS) is capable of reducing the frequency and severity of auditory hallucinations. Several meta-analyses found significantly better symptom reduction for low-frequency repetitive TMS as compared with placebo. Consequently, TMS currently has the status of a potentially useful treatment method for auditory hallucinations, but only in combination with state of the art antipsychotic treatment. Electroconvulsive therapy (ECT) is considered a last resort for treatment-resistant psychosis. Although several studies showed clinical improvement, a specific reduction in hallucination severity has never been demonstrated.