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Zuckerman H, Pan Z, Park C, Brietzke E, Musial N, Shariq AS, Iacobucci M, Yim SJ, Lui LMW, Rong C, McIntyre RS. Recognition and Treatment of Cognitive Dysfunction in Major Depressive Disorder. Front Psychiatry 2018; 9:655. [PMID: 30564155 PMCID: PMC6288549 DOI: 10.3389/fpsyt.2018.00655] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 11/16/2018] [Indexed: 12/15/2022] Open
Abstract
Major Depressive Disorder (MDD) is a prevalent, chronic, disabling, and multidimensional mental disorder. Cognitive dysfunction represents a core diagnostic and symptomatic criterion of MDD, and is a principal determinant of functional non-recovery. Cognitive impairment has been observed to persist despite remission of mood symptoms, suggesting dissociability of mood and cognitive symptoms in MDD. Recurrent impairments in several domains including, but not limited to, executive function, learning and memory, processing speed, and attention and concentration, are associated with poor psychosocial and occupational outcomes. Attempts to restore premorbid functioning in individuals with MDD requires regular screenings and assessment of objective and subjective measures of cognition by clinicians. Easily accessible and cost-effective tools such as the THINC-integrated tool (THINC-it) are suitable for use in a busy clinical environment and appear to be promising for routine usage in clinical settings. However, antidepressant treatments targeting specific cognitive domains in MDD have been insufficiently studied. While select antidepressants, e.g., vortioxetine, have been demonstrated to have direct and independent pro-cognitive effects in adults with MDD, research on additional agents remains nascent. A comprehensive clinical approach to cognitive impairments in MDD is required. The current narrative review aims to delineate the importance and relevance of cognitive dysfunction as a symptomatic target for prevention and treatment in the phenomenology of MDD.
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Affiliation(s)
- Hannah Zuckerman
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Zihang Pan
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Caroline Park
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Elisa Brietzke
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Natalie Musial
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Aisha S Shariq
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Michelle Iacobucci
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Samantha J Yim
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Leanna M W Lui
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Carola Rong
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Department of Pharmacology, University of Toronto, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain and Cognition Discovery Foundation, Toronto, ON, Canada
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52
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Fiorillo A, Carpiniello B, De Giorgi S, La Pia S, Maina G, Sampogna G, Spina E, Tortorella A, Vita A. Assessment and Management of Cognitive and Psychosocial Dysfunctions in Patients With Major Depressive Disorder: A Clinical Review. Front Psychiatry 2018; 9:493. [PMID: 30364225 PMCID: PMC6193102 DOI: 10.3389/fpsyt.2018.00493] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 09/20/2018] [Indexed: 12/20/2022] Open
Abstract
Background: Full functional recovery is defined as a state in which patients are again able to enjoy their usual activities, return to work, and take care of themselves, and it should represent the end goal of treatment in patients with major depressive disorder (MDD). Patients with MDD report many unmet needs, including residual cognitive symptoms, lack of improvement in psychosocial functioning and life satisfaction, even during mood symptom remission. In this paper, we aim to: (a) identify the available assessment tools for evaluating cognitive and psychosocial functioning in patients with MDD; (b) provide an overview of therapeutic options that can improve full functional recovery in MDD also by improving cognitive symptoms. Methods: The relevant databases MEDLINE, ISI Web of Knowledge - Web of Science Index, Cochrane Reviews Library and PsychoINFO were searched for identifying papers on validated tools for the assessment of cognitive and personal functioning in patients with MDD. Results: New assessment tools (such as the THINC-it TOOL, the COBRA, the SCIP-D, and the UPSA-D) have been developed for evaluating the cognitive dysfunction in MDD patients. Adopting these tools in the clinical routine practice is useful to evaluate the improvement in cognitive functioning and, therefore, the achievement of full functioning recovery. The optimal management of patients with MDD include the combination of pharmacological compounds and psychosocial interventions for achieving full functional recovery in patients with MDD. Conclusions: Full functional recovery must be the target of any treatment programme for patients with MDD. In order to achieve this goal, it is necessary to develop personalized treatment and integrate psychosocial and psychopharmacological interventions.
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Affiliation(s)
- Andrea Fiorillo
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Bernardo Carpiniello
- Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy
| | | | | | - Giuseppe Maina
- AOU San Luigi Gonzaga, University of Turin, Turin, Italy
| | - Gaia Sampogna
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Edoardo Spina
- Department of Clinical and Experimental Pharmacology, University of Messina, Messina, Italy
| | | | - Antonio Vita
- Neuroscience Section, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Department of Mental Health, Spedali Civili Hospital, Brescia, Italy
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53
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Zhao YJ, Tor PC, Khoo AL, Teng M, Lim BP, Mok YM. Cost-Effectiveness Modeling of Repetitive Transcranial Magnetic Stimulation Compared to Electroconvulsive Therapy for Treatment-Resistant Depression in Singapore. Neuromodulation 2017; 21:376-382. [PMID: 29143405 DOI: 10.1111/ner.12723] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/20/2017] [Accepted: 09/25/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Compared to electroconvulsive therapy (ECT), the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) in the management of treatment-resistant depression (TRD) remains unclear. OBJECTIVE/HYPOTHESIS This study evaluated the cost-effectiveness of rTMS vs. ECT for TRD from Singapore societal perspective. METHODS We constructed a Markov model to project the cost and benefit of rTMS compared with ECT over one year in patients with TRD. The relative treatment effects between rTMS and ECT were obtained from meta-analyses of published trials. The effectiveness and quality of life data for patients using ECT, resource use for TRD and their associated costs were derived from the national tertiary mental institution in Singapore. RESULTS At one year, rTMS was cost-effective relative to ECT. The incremental cost-effectiveness ratio (ICER) associated with ECT was Singapore dollars (SGD) 311,024 per quality-adjusted life-year (QALY) gained. This exceeded the willingness-to-pay threshold of SGD 70,000 per QALY gained. A similar trend was observed for ICER per remission achieved (i.e., SGD 143,811 per remission achieved with ECT). In the subgroup analysis, rTMS was found to be less costly and more effective than ECT in nonpsychotic depressive patients. In the scenario analysis, ECT employed as an ambulatory service yielded a much smaller ICER (i.e., SGD 78,819 per QALY gained) compared to the standard inpatient setting. CONCLUSIONS rTMS was a cost-effective treatment compared to ECT in TRD over one year. The cost-effectiveness of rTMS was attenuated when ECT was used in the outpatient setting.
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Affiliation(s)
- Ying Jiao Zhao
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore, Singapore
| | - Phern Chern Tor
- Department of General Psychiatry 2, Institute of Mental Health, Mood Disorder Unit, Singapore, Singapore.,Duke-NUS Graduate Medical School, Singapore, Singapore.,National University of Singapore, Singapore, Singapore
| | - Ai Leng Khoo
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore, Singapore
| | - Monica Teng
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore, Singapore
| | - Boon Peng Lim
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore, Singapore
| | - Yee Ming Mok
- Department of General Psychiatry 2, Institute of Mental Health, Mood Disorder Unit, Singapore, Singapore
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54
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Liu S, Sheng J, Li B, Zhang X. Recent Advances in Non-invasive Brain Stimulation for Major Depressive Disorder. Front Hum Neurosci 2017; 11:526. [PMID: 29163106 PMCID: PMC5681844 DOI: 10.3389/fnhum.2017.00526] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 10/18/2017] [Indexed: 12/24/2022] Open
Abstract
Non-invasive brain stimulation (NBS) is a promising treatment for major depressive disorder (MDD), which is an affective processing disorder involving abnormal emotional processing. Many studies have shown that repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) over the prefrontal cortex can play a regulatory role in affective processing. Although the clinical efficacy of NBS in MDD has been demonstrated clinically, the precise mechanism of action remains unclear. Therefore, this review article summarizes the current status of NBS methods, including rTMS and tDCS, in the treatment of MDD. The article explores possible correlations between depressive symptoms and affective processing, highlighting the relevant affective processing mechanisms. Our review provides a reference for the safety and efficacy of NBS methods in the clinical treatment of MDD.
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Affiliation(s)
- Shui Liu
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetics, The Second Hospital of Jilin University, Changchun, China
| | - Jiyao Sheng
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetics, The Second Hospital of Jilin University, Changchun, China
| | - Bingjin Li
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetics, The Second Hospital of Jilin University, Changchun, China
| | - Xuewen Zhang
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetics, The Second Hospital of Jilin University, Changchun, China
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55
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Martin DM, McClintock SM, Forster JJ, Lo TY, Loo CK. Cognitive enhancing effects of rTMS administered to the prefrontal cortex in patients with depression: A systematic review and meta-analysis of individual task effects. Depress Anxiety 2017; 34:1029-1039. [PMID: 28543994 DOI: 10.1002/da.22658] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/31/2017] [Accepted: 04/23/2017] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) is an approved therapeutic treatment of major depressive disorder and has increasing clinical use throughout the world. However, it remains unclear whether an rTMS course for depression may also produce cognitive enhancement. In a recent meta-analysis of sham-controlled randomized controlled studies (RCTs) conducted in patients with neuropsychiatric conditions, no evidence was found for generalized cognitive enhancing effects across cognitive domains with active compared to sham rTMS. Notwithstanding, there remains the possibility of cognitive effects following an rTMS course that are more highly specific, for example, in specific clinical conditions, or at the individual task level. This study aimed to determine whether a therapeutic rTMS course in patients with depression is associated with cognitive enhancing effects at the task level. METHODS A systematic review and meta-analysis of outcomes on individual neuropsychological tasks from sham-controlled RCTs where an rTMS course was administered to the dorsolateral prefrontal cortex (DLPFC) in patients with depression. RESULTS Eighteen studies met the inclusion criteria. Active rTMS treatment showed no specific enhancing effects on the majority of cognitive tasks. Modest effect size improvements with active compared to sham rTMS treatment were found for performance on the Trail Making Test Parts A (g = 0.28, 95% CI = 0.06-0.50) and B (g = 0.26, 95% CI = 0.06-0.47). CONCLUSION A therapeutic rTMS course administered to the prefrontal cortex for depression may produce modest cognitive enhancing effects specific to psychomotor speed, visual scanning, and set-shifting ability.
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Affiliation(s)
- Donel M Martin
- School of Psychiatry, Black Dog Institute, University of New South Wales, Sydney, Australia
| | - Shawn M McClintock
- Neurocognitive Research Laboratory, Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Jane J Forster
- School of Psychiatry, Black Dog Institute, University of New South Wales, Sydney, Australia
| | - Tin Yan Lo
- School of Psychiatry, Black Dog Institute, University of New South Wales, Sydney, Australia
| | - Colleen K Loo
- School of Psychiatry, Black Dog Institute, University of New South Wales, Sydney, Australia
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56
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Mi Z, Biswas K, Fairchild JK, Davis-Karim A, Phibbs CS, Forman SD, Thase M, Georgette G, Beale T, Pittman D, McNerney MW, Rosen A, Huang GD, George M, Noda A, Yesavage JA. Repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant major depression (TRMD) Veteran patients: study protocol for a randomized controlled trial. Trials 2017; 18:409. [PMID: 28865495 PMCID: PMC5581925 DOI: 10.1186/s13063-017-2125-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/02/2017] [Indexed: 01/29/2023] Open
Abstract
Background Evaluation of repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant major depression (TRMD) in Veterans offers unique clinical trial challenges. Here we describe a randomized, double-blinded, intent-to-treat, two-arm, superiority parallel design, a multicenter study funded by the Cooperative Studies Program (CSP No. 556) of the US Department of Veterans Affairs. Methods We recruited medical providers with clinical expertise in treating TRMD at nine Veterans Affairs (VA) medical centers as the trial local investigators. We plan to enroll 360 Veterans diagnosed with TRMD at the nine VA medical centers over a 3-year period. We will randomize participants into a double-blinded clinical trial to left prefrontal rTMS treatment or to sham (control) rTMS treatment (180 participants each group) for up to 30 treatment sessions. All participants will meet Diagnostic and statistical manual of mental disorders, 4thedition (DSM-IV) criteria for major depression and will have failed at least two prior pharmacological interventions. In contrast with other rTMS clinical trials, we will not exclude Veterans with posttraumatic stress disorder (PTSD) or history of substance abuse and we will obtain detailed history regarding these disorders. Furthermore, we will maintain participants on stable anti-depressant medication throughout the trial. We will evaluate all participants on a wide variety of potential predictors of treatment response including cognitive, psychological and functional parameters. Discussion The primary dependent measure will be remission rate (Hamilton Rating Scale for Depression (HRSD24) ≤ 10), and secondary analyses will be conducted on other indices. Comparisons between the rTMS and the sham groups will be made at the end of the acute treatment phase to test the primary hypothesis. The unique challenges to performing such a large technically challenging clinical trial with Veterans and potential avenues for improvement of the design in future trials will be described. Trial registration ClinicalTrials.gov, NCT01191333. Registered on 26 August 2010. This report is based on the protocol version 4.6 amended in February 2016. All items from the World Health Organization Trial Registration Data Set are listed in Appendix A. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2125-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zhibao Mi
- Department of Veterans Affairs, Cooperative Studies Program Coordinating Center, Perry Point, MD, USA
| | - Kousick Biswas
- Department of Veterans Affairs, Cooperative Studies Program Coordinating Center, Perry Point, MD, USA
| | - J Kaci Fairchild
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Anne Davis-Karim
- Department of Veterans Affairs, Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Ciaran S Phibbs
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA.,Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven D Forman
- Department of Veterans Affairs, VA Medical Center, Pittsburgh, PA, USA.,Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael Thase
- Department of Veterans Affairs, VA Medical Center, Philadelphia, PA, USA
| | - Gerald Georgette
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA
| | - Tamara Beale
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA
| | - David Pittman
- Department of Veterans Affairs, Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Margaret Windy McNerney
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Allyson Rosen
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Grant D Huang
- Department of Veterans Affairs, Cooperative Studies Program Central Office, Washington DC, USA
| | - Mark George
- Department of Veterans Affairs, Ralph H. Johnson VA Medical Center, Charleston, SC, USA.,Brain Stimulation Laboratory (BSL), Psychiatry Department, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Art Noda
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Jerome A Yesavage
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA. .,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA. .,VISN21 MIRECC, Department of Veterans Affairs, Department of Psychiatry, Stanford University School of Medicine, 3801 Miranda Avenue, Palo Alto, CA, 94304, USA.
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57
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Thomas-Ollivier V, Foyer E, Bulteau S, Pichot A, Valriviere P, Sauvaget A, Deschamps T. Cognitive component of psychomotor retardation in unipolar and bipolar depression: Is verbal fluency a relevant marker? Impact of repetitive transcranial stimulation. Psychiatry Clin Neurosci 2017; 71:612-623. [PMID: 28419623 DOI: 10.1111/pcn.12529] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 03/14/2017] [Accepted: 04/10/2017] [Indexed: 12/26/2022]
Abstract
AIMS In the literature, psychomotor retardation (PMR) is increasingly highlighted as a relevant marker for depression. Currently, we chose to focus on the fluency capacities as an evaluation of the frontal lobes functioning to reach a better understanding of cognitive and neurobiological mechanisms involved in PMR in depression. The aims of this study were: (i) to explore the cognitive component of PMR through the analysis of verbal fluency (VF) performance in unipolar and bipolar depression; and (ii) to examine whether a repetitive transcranial magnetic stimulation treatment could improve concomitantly the PMR and VF capacities, as a relevant marker characteristic of the cognitive component of PMR. METHODS Fifteen unipolar and 15 bipolar patients were compared to 15 healthy adults. Before treatment, the results showed VF deficits, particularly marked in the bipolar group. The investigation of the interplay between PMR, VF performance, Montgomery-Åsberg Depression Rating Scale scores, and Montreal Cognitive Assessment scores showed that the deficits in these various dimensions were not homogeneous. RESULTS The absence of correlation between the psychomotor retardation scale (the French Retardation Rating Scale for Depression) and VF, and the correlation with MoCA raise the hypothesis of a more global cognitive impairment associated with PMR in the BD group. The repetitive transcranial magnetic stimulation treatment had a positive impact on depression, PMR, and fluency scores. CONCLUSION Correlations between the Retardation Rating Scale for Depression and VF performances appeared after treatment, showing the cognitive role of psychomotor functioning in depression. Further analyses, including other cognitive measures in an objective evaluation of PMR, are required for a better understanding of these complex relationships.
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Affiliation(s)
- Véronique Thomas-Ollivier
- Laboratory 'Movement, Interactions, Performance' (EA 4334), Faculty of Sport Sciences, University of Nantes, Nantes, France
| | - Emmanuelle Foyer
- Laboratory 'Movement, Interactions, Performance' (EA 4334), Faculty of Sport Sciences, University of Nantes, Nantes, France.,Addictology and Liaison Psychiatry Department, University Hospital of Nantes, Nantes, France
| | - Samuel Bulteau
- Addictology and Liaison Psychiatry Department, University Hospital of Nantes, Nantes, France.,EA SPHERE 4275 MethodS for Patients-centered outcomes and Health Research, University of Nantes, Nantes, France
| | - Anne Pichot
- Addictology and Liaison Psychiatry Department, University Hospital of Nantes, Nantes, France
| | - Pierre Valriviere
- Addictology and Liaison Psychiatry Department, University Hospital of Nantes, Nantes, France
| | - Anne Sauvaget
- Addictology and Liaison Psychiatry Department, University Hospital of Nantes, Nantes, France.,EA SPHERE 4275 MethodS for Patients-centered outcomes and Health Research, University of Nantes, Nantes, France
| | - Thibault Deschamps
- Laboratory 'Movement, Interactions, Performance' (EA 4334), Faculty of Sport Sciences, University of Nantes, Nantes, France
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58
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Kedzior KK, Schuchinsky M, Gerkensmeier I, Loo C. Challenges in comparing the acute cognitive outcomes of high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) vs. electroconvulsive therapy (ECT) in major depression: A systematic review. J Psychiatr Res 2017; 91:14-17. [PMID: 28288306 DOI: 10.1016/j.jpsychires.2017.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 02/08/2017] [Accepted: 03/01/2017] [Indexed: 01/21/2023]
Abstract
The present study aimed to systematically compare the cognitive outcomes of high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) and electroconvulsive therapy (ECT) in head-to-head studies with major depression (MDD) patients. A systematic literature search identified six studies with 219 MDD patients that were too heterogeneous to reliably detect meaningful differences in acute cognitive outcomes after ECT vs. HF-rTMS. Cognitive effects of brain stimulation vary depending on the timeframe and methods of assessment, stimulation parameters, and maintenance treatment. Thus, acute and longer-term differences in cognitive outcomes both need to be investigated at precisely defined timeframes and with similar instruments assessing comparable functions.
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Affiliation(s)
| | | | | | - Colleen Loo
- University of New South Wales, Black Dog Institute, St. George Hospital, Australia
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59
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Tovar-Perdomo S, McGirr A, Van den Eynde F, Rodrigues Dos Santos N, Berlim MT. High frequency repetitive transcranial magnetic stimulation treatment for major depression: Dissociated effects on psychopathology and neurocognition. J Affect Disord 2017; 217:112-117. [PMID: 28407553 DOI: 10.1016/j.jad.2017.03.075] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 03/30/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This open-label pilot study explored the effects of a course of accelerated high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) on two neurocognitive domains (decision-making and impulse control) in patients with major depressive disorder (MDD). METHODS Participants with MDD and a treatment resistant major depressive episode (n=24) underwent twice-daily HF-rTMS targeted at the left dorsolateral prefrontal cortex (lDLPFC) over two weeks. Psychopathology was assessed by clinician-administered and self-reported measures of depression and anxiety; decision-making was assessed by the Iowa Gambling Task, the Balloon Analog Risk Task and the Game of Dice Task; impulse control was assessed by the Stroop Color-Word Task, the Continuous Performance Task and the Stop-Signal Task. RESULTS Depression and anxiety scores significantly improved from pre-post HF-rTMS treatment. However, none of the decision-making or impulse control variables of interest changed significantly from pre-post HF-rTMS. Moreover, there was no correlation between changes in psychopathological symptoms and in neurocognition. LIMITATIONS This is a moderately sized open label trial, and the confounds of ongoing psychotropics and illness chronicity can not be excluded in this treatment resistant sample. CONCLUSIONS There is dissociation between acute symptomatic benefit after a course of accelerated HF-rTMS applied to the lDLPFC in treatment resistant MDD and performance on tests of decision making and impulse control. Though rTMS appears cognitively safe, additional research is warranted to understand this potential dissociation and its putative clinical implications.
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Affiliation(s)
- Santiago Tovar-Perdomo
- Neuromodulation Research Clinic, Douglas Mental Health University Institute and McGill University, Montréal, Québec, Canada
| | - Alexander McGirr
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Frederique Van den Eynde
- Neuromodulation Research Clinic, Douglas Mental Health University Institute and McGill University, Montréal, Québec, Canada
| | - Nicole Rodrigues Dos Santos
- Neuromodulation Research Clinic, Douglas Mental Health University Institute and McGill University, Montréal, Québec, Canada
| | - Marcelo T Berlim
- Neuromodulation Research Clinic, Douglas Mental Health University Institute and McGill University, Montréal, Québec, Canada; Depressive Disorders Program, Douglas Mental Health University Institute and McGill University, Montréal, Québec, Canada.
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60
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Felipe RDM, Ferrão YA. Transcranial magnetic stimulation for treatment of major depression during pregnancy: a review. TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2017; 38:190-197. [PMID: 28076639 DOI: 10.1590/2237-6089-2015-0076] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 03/16/2016] [Indexed: 02/26/2023]
Abstract
Introduction: Pregnancy is characterized by a high prevalence of mental disorders. Depression is the most common of these disorders and it is a risk factor for negative maternal and child development outcomes. Psychotherapy and pharmacotherapy are conventional and well-established therapeutic options, but some clients fail to respond and the safety of using some pharmacological agents during pregnancy is unclear. Some neuromodulation techniques, such as repetitive transcranial magnetic stimulation (rTMS), have been studied in depressed pregnant women. Objective: To evaluate the safety and efficacy of rTMS for major depression in pregnant women. Methods: The LILACS and PubMed databases were reviewed using the search terms depression, pregnancy and magnetic stimulation. Texts including primary data, published in Portuguese, Spanish, or English, between 1995 and 2014, that evaluated depressed pregnant women and used rTMS as the intervention were selected. Papers lacking sufficient data were excluded. Twenty-two texts were initially identified; after applying the inclusion criteria, 12 were selected and analyzed. Results: The studies reviewed reported satisfactory responses to rTMS in acute depressive episodes, as measured using depressive symptom scales. Remission of symptoms was achieved in many cases. The procedure was well tolerated and there were no reports of damage/complications to unborn children. Conclusion: The data available at this time support the efficacy and tolerability of rTMS for depression in pregnant women. Controlled studies should corroborate this conclusion. This review only included studies in three languages and the resulting sample size was not large enough to conduct a meta-analysis.
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Affiliation(s)
- Renata de Melo Felipe
- Programa de Residência Médica em Psiquiatria, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Ygor Arzeno Ferrão
- Departamento de Medicina Interna - Psiquiatria, UFCSPA, Porto Alegre, RS, Brazil
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61
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Martin DM, McClintock SM, Forster J, Loo CK. Does Therapeutic Repetitive Transcranial Magnetic Stimulation Cause Cognitive Enhancing Effects in Patients with Neuropsychiatric Conditions? A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Neuropsychol Rev 2016; 26:295-309. [PMID: 27632386 DOI: 10.1007/s11065-016-9325-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 07/25/2016] [Indexed: 01/14/2023]
Abstract
Repetitive transcranial magnetic stimulation (rTMS) is increasingly used as a therapeutic intervention for neuropsychiatric illnesses and has demonstrated efficacy for treatment of major depression. However, an unresolved question is whether a course of rTMS treatment results in effects on cognitive functioning. In this systematic review and meta-analysis we aimed to quantitatively determine whether a course of rTMS has cognitive enhancing effects. We examined cognitive outcomes from randomised, sham-controlled studies conducted in patients with neuropsychiatric conditions where rTMS was administered to the dorsolateral prefrontal cortex (DLPFC) across repeated sessions, searched from PubMed/MEDLINE and other databases up until October 2015. Thirty studies met our inclusion criteria. Cognitive outcomes were pooled and examined across the following domains: Global cognitive function, executive function, attention, working memory, processing speed, visual memory, verbal memory and visuospatial ability. Active rTMS treatment was unassociated with generalised gains across the majority of domains of cognitive functioning examined. Secondary analyses revealed a moderate sized positive effect for improved working memory in a small number of studies in patients with schizophrenia (k = 3, g = 0.507, 95 % CI = [0.183-0.831], p < .01). Therapeutic rTMS when administered to the DLPFC in patients with neuropsychiatric conditions does not result in robust cognitive enhancing effects.
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Affiliation(s)
- Donel M Martin
- School of Psychiatry, University of New South Wales, Sydney, Australia. .,Black Dog Institute, Sydney, Australia.
| | - Shawn M McClintock
- Neurocognitive Research Laboratory, Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Jane Forster
- School of Psychiatry, University of New South Wales, Sydney, Australia
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Assessing the Effects of Repetitive Transcranial Magnetic Stimulation on Cognition in Major Depressive Disorder Using Computerized Cognitive Testing. J ECT 2016; 32:169-73. [PMID: 26934275 DOI: 10.1097/yct.0000000000000308] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES A range of different treatment approaches are available for depression; however, there is an ongoing concern about the cognitive impairment associated with many treatments. This study investigated the effect of treatment with repetitive transcranial magnetic stimulation (rTMS) on cognition in patients with major depressive disorder. Cognition before and after treatment was assessed using a computerized cognitive testing battery, which provided comprehensive assessment across a range of cognitive domains. This was a naturalistic study involving patients attending an outpatient clinical rTMS service. METHODS A total of 63 patients with treatment-resistant depression completed the IntegNeuro cognitive test battery, a well-validated comprehensive computerized assessment tool before and after receiving 18 or 20 treatments of sequential bilateral rTMS. Change in the various cognitive domains was assessed, and analyses were undertaken to determine whether any change in cognition was associated with a change in rating of depression severity. RESULTS There was a significant decrease in Hamilton Depression Rating Scale scores from baseline to posttreatment. There was no decline in performance on any of the cognitive tests. There were significant improvements in maze completion time and the number of errors in the maze task. However, these were accounted for by improvement in mood when change in depressive symptoms was included as a covariate. CONCLUSIONS This open-label study provides further support for the efficacy and safety of rTMS as a treatment option for people with major depressive disorder in a naturalistic clinical setting. Using a comprehensive, robust computerized battery of cognitive tests, the current study indicated that there was no significant cognitive impairment associated with rTMS and that any improvements in cognitive functioning were associated with a reduction in depressive symptoms.
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Milev RV, Giacobbe P, Kennedy SH, Blumberger DM, Daskalakis ZJ, Downar J, Modirrousta M, Patry S, Vila-Rodriguez F, Lam RW, MacQueen GM, Parikh SV, Ravindran AV. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 4. Neurostimulation Treatments. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2016; 61:561-75. [PMID: 27486154 PMCID: PMC4994792 DOI: 10.1177/0706743716660033] [Citation(s) in RCA: 353] [Impact Index Per Article: 44.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals. METHODS Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. "Neurostimulation Treatments" is the fourth of six sections of the 2016 guidelines. RESULTS Evidence-informed responses were developed for 31 questions for 6 neurostimulation modalities: 1) transcranial direct current stimulation (tDCS), 2) repetitive transcranial magnetic stimulation (rTMS), 3) electroconvulsive therapy (ECT), 4) magnetic seizure therapy (MST), 5) vagus nerve stimulation (VNS), and 6) deep brain stimulation (DBS). Most of the neurostimulation treatments have been investigated in patients with varying degrees of treatment resistance. CONCLUSIONS There is increasing evidence for efficacy, tolerability, and safety of neurostimulation treatments. rTMS is now a first-line recommendation for patients with MDD who have failed at least 1 antidepressant. ECT remains a second-line treatment for patients with treatment-resistant depression, although in some situations, it may be considered first line. Third-line recommendations include tDCS and VNS. MST and DBS are still considered investigational treatments.
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Affiliation(s)
- Roumen V Milev
- Department of Psychiatry, Queen's University, Kingston, Ontario
| | - Peter Giacobbe
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | - Sidney H Kennedy
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | | | | | - Jonathan Downar
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | | | - Simon Patry
- Department of Psychiatry, L'Université Laval, Québec City, Québec
| | - Fidel Vila-Rodriguez
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia
| | - Raymond W Lam
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia
| | | | - Sagar V Parikh
- Department of Psychiatry, University of Toronto, Toronto, Ontario Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Arun V Ravindran
- Department of Psychiatry, University of Toronto, Toronto, Ontario
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Cognitive safety of dorsomedial prefrontal repetitive transcranial magnetic stimulation in major depression. Eur Neuropsychopharmacol 2016; 26:1213-26. [PMID: 27157074 DOI: 10.1016/j.euroneuro.2016.04.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/30/2016] [Accepted: 04/14/2016] [Indexed: 01/26/2023]
Abstract
The most widely used target for repetitive transcranial magnetic stimulation (rTMS) in treatment-resistant depression (TRD) is the dorsolateral prefrontal cortex (DLPFC). Despite convergent evidence that the dorsomedial prefrontal cortex (DMPFC) may be a promising alternative target for rTMS in TRD, its cognitive safety profile has not previously been assessed. Here, we applied 20 sessions of rTMS to the DMPFC in 21 TRD patients. Before and after treatment, a battery of neuropsychological tasks was administered to evaluate changes in cognition across three general cognitive domains: learning and memory, attention and processing speed, and cognitive flexibility. Subjects also completed the 17-item Hamilton Rating Scale for Depression (HamD17) prior to and following treatment to measure changes in severity of depressive symptoms, and to assess the relationship between mood and cognitive performance over the course of treatment. No serious adverse effects or significant deterioration in cognitive performance were observed. Overall, subjects improved significantly on Stroop Inhibition/Switching and on Trails B, and this improvement was independent of the degree of improvement in depression symptoms. No domains or items significantly predicted clinical outcome, with the exception of baseline performance on Visual Elevator Accuracy. Clinical improvement correlated to improved performance in the overall domain of attention and processing speed, although this effect was not evident following covariate adjustment. DMPFC-rTMS did not produce any detectable cognitive adverse effects during treatment of TRD. Performance did not deteriorate significantly on any measures. Taken together, the present findings support the tolerability and cognitive safety of DMPFC-rTMS in refractory depression.
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Kedzior KK, Gierke L, Gellersen HM, Berlim MT. Cognitive functioning and deep transcranial magnetic stimulation (DTMS) in major psychiatric disorders: A systematic review. J Psychiatr Res 2016; 75:107-15. [PMID: 26828370 DOI: 10.1016/j.jpsychires.2015.12.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 12/18/2015] [Accepted: 12/18/2015] [Indexed: 10/22/2022]
Abstract
Deep transcranial magnetic stimulation (DTMS) is a non-invasive brain stimulation method mostly utilised in the treatment of major depression. The aim of the current study was to systematically review the literature on the cognitive effects of DTMS applied with the H-coil system in major psychiatric disorders. Following a literature search in PsycInfo and PubMed (any time to December 2015), 13 out of 32 studies on DTMS and cognitive functioning were included in the current review. Three studies included 38 healthy participants, eight studies included 158 unipolar or bipolar depression patients and two studies included 45 schizophrenia patients. Low-frequency DTMS (1-3 sessions) had little effect on cognitive functioning in healthy participants. The most consistent cognitive and clinical improvements were reported in the short-term (after 20 daily sessions of high-frequency DTMS with H1-coil) in studies with major depression patients. There was also a trend towards a short-term cognitive and clinical improvement in studies with schizophrenia patients. High-frequency DTMS might improve cognitive functioning and alleviate clinical symptoms in the short-term, particularly in major depression. However, this conclusion is based on data from mostly uncontrolled, open-label studies with patients receiving concurrent antidepressants or antipsychotics. Randomised, sham-controlled trials are needed to investigate the magnitude of the cognitive outcomes of DTMS in the short-term and beyond the daily stimulation phase in major psychiatric disorders.
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Affiliation(s)
| | - Lioba Gierke
- Institute of Psychology and Transfer, University of Bremen, Bremen, Germany
| | | | - Marcelo T Berlim
- Department of Psychiatry, McGill University, and Neuromodulation Research Clinic, Douglas Institute, Montreal, Canada
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Chakrabarty T, Hadjipavlou G, Lam RW. Cognitive Dysfunction in Major Depressive Disorder: Assessment, Impact, and Management. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2016; 14:194-206. [PMID: 31975803 PMCID: PMC6519654 DOI: 10.1176/appi.focus.20150043] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cognitive dysfunction is increasingly being recognized as an important clinical dimension in major depressive disorder. This review summarizes the existing data on the epidemiology, assessment, and treatment of cognitive dysfunction among nonelderly adults with the disorder. Overall, cognitive dysfunction is prevalent, persists through periods of symptom remission, and may be independently associated with functional outcomes. However, although the evidence increasingly suggests that clinicians should be heedful of their patients' cognitive functioning, there is as yet no consensus on how best to monitor cognition clinically. In addition, although most studies have reported improved cognition with antidepressant medications, psychotherapy, and neuromodulation, the clinical significance of these improvements is unclear, and high-level evidence to guide decision making is limited. Nonetheless, given the important functional implications, clinicians should assess and monitor cognition and optimize both medication and psychological treatments to mitigate cognitive dysfunction among patients with major depressive disorder.
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Affiliation(s)
- Trisha Chakrabarty
- The authors are with the Department of Psychiatry, University of British Columbia, and the Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Vancouver, British Columbia, Canada. Send correspondence to Dr. Lam (e-mail: )
| | - George Hadjipavlou
- The authors are with the Department of Psychiatry, University of British Columbia, and the Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Vancouver, British Columbia, Canada. Send correspondence to Dr. Lam (e-mail: )
| | - Raymond W Lam
- The authors are with the Department of Psychiatry, University of British Columbia, and the Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Vancouver, British Columbia, Canada. Send correspondence to Dr. Lam (e-mail: )
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Kerns SE, Bess J, Melman K. A Case for rTMS in Late Life Depression with Comorbid Alzheimer's Dementia. Brain Stimul 2016; 9:151-2. [DOI: 10.1016/j.brs.2015.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 11/07/2015] [Accepted: 11/07/2015] [Indexed: 10/22/2022] Open
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Ketamine, Transcranial Magnetic Stimulation, and Depression Specific Yoga and Mindfulness Based Cognitive Therapy in Management of Treatment Resistant Depression: Review and Some Data on Efficacy. DEPRESSION RESEARCH AND TREATMENT 2015; 2015:842817. [PMID: 26509083 PMCID: PMC4609854 DOI: 10.1155/2015/842817] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/29/2015] [Accepted: 09/10/2015] [Indexed: 12/13/2022]
Abstract
Depression affects about 121 million people worldwide and prevalence of major depressive disorder (MDD) in US adults is 6.4%. Treatment resistant depression (TRD) accounts for approximately 12-20% of all depression patients and costs $29-$48 billion annually. Ketamine and repetitive transcranial magnetic stimulation (rTMS) have useful roles in TRD, but their utility in long term is unknown. As per the latest literature, the interventions using Yoga and meditation including the mindfulness based cognitive therapy (MBCT) have been useful in treatment of depression and relapse prevention. We present a review of rTMS, ketamine, and MBCT and also report efficacy of a depression specific, innovative, and translational model of Yoga and mindfulness based cognitive therapy (DepS Y-MBCT), developed by the first author. DepS Y-MBCT as an adjunctive treatment successfully ameliorated TRD symptoms in 27/32 patients in an open label pilot trial in TRD patients. Considering the limitations of existing treatment options, including those of ketamine and rTMS when used as the sole modality of treatment, we suggest a "tiered approach for TRD" by combining ketamine and rTMS (alone or along with antidepressants) for rapid remission of acute depression symptoms and to use DepS Y-MBCT for maintaining remission and preventing relapse.
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