Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 4. Neurostimulation Treatments

Cognitive functioning as predictor and marker of response to repetitive transcranial magnetic stimulation in depressive disorders: A systematic review

OBJECTIVE

Cognitive performance in Major Depressive Disorder (MDD) is frequently impaired and related to functional outcomes. Repetitive Transcranial Magnetic Stimulation (rTMS) may exert its effects on MDD acting both on depressive symptoms and neurocognition. Furthermore, cognitive status could predict the therapeutic response of depressive symptoms to rTMS. However, cognitive performances as a predictor of rTMS response in MDD has not been thoroughly investigated. This review aims to evaluate the role of pre-treatment cognitive performance as a predictor of clinical response to rTMS, and the effects of rTMS on neurocognition in MDD.

METHOD

A systematic review of studies evaluating neurocognition in MDD as an outcome and/or predictor of response to rTMS was conducted using PubMed/Medline and Embase.

RESULTS

Fifty-eight articles were identified: 25 studies included neurocognition as a predictor of response to rTMS; 56 used cognitive evaluation as an outcome of rTMS. Baseline cognitive performance and cognitive improvements after rTMS predicted clinical response to rTMS. Moreover, rTMS improved cognition in MDD.

CONCLUSIONS

Cognitive assessment could predict improvement of depression in MDD patients undergoing rTMS and help selecting patients that could have beneficial effects from rTMS. A routine cognitive assessment might stratify MDD patients and track rTMS related cognitive improvement.

The Rise, Fall, and Resurgence of Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is one of the most effective treatments for depression. However, significant stigma from the media and the antipsychiatry movement has biased the public toward ECT, leading to underutilization, particularly among those most in need. This report reviews some of the key historical events in the rise, fall, and resurgence of ECT and how modern ECT knowledge and practice are more refined, including an improved understanding of its mechanisms of action and optimal treatment parameters.

Recent innovations in non-invasive brain stimulation (NIBS) for the treatment of unipolar and bipolar depression: a narrative review

Depression, either bipolar or unipolar, is a highly prevalent and disabling condition. Even though several treatment options exist for depressed patients, a significant portion of individuals receiving conventional pharmacotherapy fails to achieve and sustain remission. For this reason, there is a strong need for effective alternatives to pharmacotherapy. In this respect, non-invasive brain stimulation (NIBS), including transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), have been increasingly investigated in the last two decade as promising treatment strategies for major depression and treatment-resistant depression (TRD). Indeed, due to their safety and tolerability and to the growing evidence on their efficacy, NIBS has been included in international treatment guidelines, having become part of the standard clinical practice. Even though several clinical trials involving NIBS in patients with major depression and TRD have been conducted, literature in specific areas is still marked by some inconsistencies, due to small sample-sizes, lack of multicentre-studies and to the difficulty in comparing different treatment modalities and stimulation protocols. In light of the above, we sought to provide a brief, updated compendium of the latest innovative acquisition for the use of NIBS in the treatment of depression, either unipolar or bipolar, as well as TRD with a specific focus on innovative set-up, devices, target areas, and parameters that may affect the outcome.

Peripheral proteomic changes after electroconvulsive seizures in a rodent model of non-response to chronic fluoxetine

Major depressive disorder (MDD) is the psychiatric disorder with the highest prevalence in the world. Pharmacological antidepressant treatment (AD), such as selective serotonin reuptake inhibitors [SSRI, i.e., fluoxetine (Flx)] is the first line of treatment for MDD. Despite its efficacy, lack of AD response occurs in numerous patients characterizing Difficult-to-treat Depression. ElectroConvulsive Therapy (ECT) is a highly effective treatment inducing rapid improvement in depressive symptoms and high remission rates of ∼50–63% in patients with pharmaco-resistant depression. Nevertheless, the need to develop reliable treatment response predictors to guide personalized AD strategies and supplement clinical observation is becoming a pressing clinical objective. Here, we propose to establish a proteomic peripheral biomarkers signature of ECT response in an anxio/depressive animal model of non-response to AD. Using an emotionality score based on the analysis complementary behavioral tests of anxiety/depression (Elevated Plus Maze, Novelty Suppressed Feeding, Splash Test), we showed that a 4-week corticosterone treatment (35 μg/ml, Cort model) in C57BL/6JRj male mice induced an anxiety/depressive-like behavior. A 28-day chronic fluoxetine treatment (Flx, 18 mg/kg/day) reduced corticosterone-induced increase in emotional behavior. A 50% decrease in emotionality score threshold before and after Flx, was used to separate Flx-responding mice (Flx-R, n = 18), or Flx non-responder mice (Flx-NR, n = 7). Then, Flx-NR mice received seven sessions of electroconvulsive seizure (ECS, equivalent to ECT in humans) and blood was collected before and after ECS treatment. Chronic ECS normalized the elevated emotionality observed in Flx-NR mice. Then, proteins were extracted from peripheral blood mononuclear cells (PBMCs) and isolated for proteomic analysis using a high-resolution MS Orbitrap. Data are available via ProteomeXchange with identifier PXD037392. The proteomic analysis revealed a signature of 33 peripheral proteins associated with response to ECS (7 down and 26 upregulated). These proteins were previously associated with mental disorders and involved in regulating pathways which participate to the depressive disorder etiology.

Predictors of Electroconvulsive Therapy Outcome in Major Depressive Disorder

BACKGROUND

Electroconvulsive therapy (ECT) is an effective therapy for major depressive disorder (MDD) patients. However, few clinical predictors are available to predict the treatment outcome. This study aimed to characterize the response trajectories of MDD patients undergoing ECT treatment and to identify potential clinical and demographic predictors for clinical improvement.

METHODS

We performed a secondary analysis on data from a multicenter, randomized, blinded, controlled trial with 3 ECT modalities (bifrontal, bitemporal, unilateral). The sample consisted of 239 patients whose demographic and clinical characteristics were investigated as predictors of ECT outcomes.

RESULTS

The results of growth mixture modeling suggested there were 3 groups of MDD patients: a non-remit group (n = 17, 7.11%), a slow-response group (n = 182, 76.15%), and a rapid-response group (n = 40, 16.74%). Significant differences in age, education years, treatment protocol, types of medication used, Hamilton Depression Scale, Hamilton Anxiety Scale score, Mini-Mental State Examination score, and Clinical Global Impression score at baseline were observed across the groups.

CONCLUSIONS

MDD patients exhibited distinct and clinically relevant response trajectories to ECT. The MDD patients with more severe depression at baseline are associated with a rapid response trajectory. In contrast, MDD patients with severe symptoms and older age are related to a less response trajectory. These clinical predictors may help guide treatment selection.

Therapeutic non-invasive brain treatments in Alzheimer's disease: recent advances and challenges

Alzheimer's disease (AD) is one of the major neurodegenerative diseases and the most common form of dementia. Characterized by the loss of learning, memory, problem-solving, language, and other thinking abilities, AD exerts a detrimental effect on both patients' and families' quality of life. Although there have been significant advances in understanding the mechanism underlying the pathogenesis and progression of AD, there is no cure for AD. The failure of numerous molecular targeted pharmacologic clinical trials leads to an emerging research shift toward non-invasive therapies, especially multiple targeted non-invasive treatments. In this paper, we reviewed the advances of the most widely studied non-invasive therapies, including photobiomodulation (PBM), transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and exercise therapy. Firstly, we reviewed the pathological changes of AD and the challenges for AD studies. We then introduced these non-invasive therapies and discussed the factors that may affect the effects of these therapies. Additionally, we review the effects of these therapies and the possible mechanisms underlying these effects. Finally, we summarized the challenges of the non-invasive treatments in future AD studies and clinical applications. We concluded that it would be critical to understand the exact underlying mechanisms and find the optimal treatment parameters to improve the translational value of these non-invasive therapies. Moreover, the combined use of non-invasive treatments is also a promising research direction for future studies and sheds light on the future treatment or prevention of AD.

Efficacy of repetitive transcranial magnetic stimulation in Parkinson's disease: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive form of brain stimulation that positively regulates the motor and non-motor symptoms of Parkinson's disease (PD). Although, most reviews and meta-analysis have shown that rTMS intervention is effective in treating motor symptoms and depression, very few have used randomised controlled trials (RCTs) to analyse the efficacy of this intervention in PD. We aimed to review RCTs of rTMS in patients with PD to assess the efficacy of rTMS on motor and non-motor function in patients with PD.

METHODS

In this systematic review and meta-analysis, we searched PubMed, MEDLINE and Web of Science databases for RCTs on rTMS in PD published between January 1, 1988 to January 1, 2022. Eligible studies included sham-controlled RCTs that used rTMS stimulation for motor or non-motor symptoms in PD. RCTs not focusing on the efficacy of rTMS in PD were excluded. Summary data were extracting from those RCTs by two investigators independently. We then calculated standardised mean difference with random-effect models. The main outcome included motor and non-motor examination of scales that were used in PD motor or non-motor assessment. This study was registered with PROSPERO, CRD42022329633.

FINDINGS

Fourteen studies with 469 patients met the criteria for our meta-analysis. Twelve eligible studies with 381 patients were pooled to analyse the efficacy of rTMS on motor function improvement. The effect size on motor scale scores was 0.51 (P < 0.0001) and were not distinctly heterogeneous (I² = 29%). Five eligible studies with 202 patients were collected to evaluate antidepressant-like effects. The effect size on depression scale scores was 0.42 (P = 0.004), and were not distinctly heterogeneous (I² = 25%), indicating a significant anti-depressive effect (P = 0.004). The results suggest that high-frequency of rTMS on primary motor cortex (M1) is effective in improving motor symptoms; while the dorsolateral prefrontal cortex (DLPFC) may be a potentially effective area in alleviating depressive symptom.

INTERPRETATION

The findings suggest that rTMS could be used as a possible adjuvant therapy for PD mainly to improve motor symptoms, but could have potential efficacy on depressive symptoms of PD. However, further investigation is needed.

FUNDING

The National Natural Science Foundation of China (NO: 81873777, 82071414), Initiated Foundation of Zhujiang Hospital (NO: 02020318005), Scientific Research Foundation of Guangzhou (NO: 202206010005), and Science and Technology Program of Guangdong of China (NO: 2020A0505100037).

A Different rTMS Protocol for a Different Type of Depression: 20.000 rTMS Pulses for the Treatment of Bipolar Depression Type II

In this open-label naturalistic study, we assess the feasibility, tolerability, and effectiveness of a repetitive transcranial magnetic stimulation protocol with a reduced total pulse number for treating patients suffering from bipolar disorder type II. All patients received one rTMS treatment session of 1000 pulses for 20 consecutive working days, accumulating to 20.000 rTMS pulses applied over 4 weeks. We measured the patients’ symptoms before the start, halfway through, directly after, and one month after treatment. We quantified the depression symptoms using both the Beck depression inventory scale and the symptom checklist-90 depression subscale. Patients showed a significant reduction in depression symptoms directly after treatment and an even further reduction one month after treatment. The remission rates were at 26% halfway through treatment (after the 10th session), 61% directly after treatment (after the 20th session), and increased to 78% at the 1-month follow-up. Importantly, the protocol proved to be feasible and highly tolerable in this patient population, with no adverse effects being reported. Considering these positive results, further research should focus on replicating these findings in larger clinical samples with control groups and longer follow-up periods, while potentially adding maintenance sessions to optimize the treatment effect and stability for bipolar disorder type II patients.

Neuromodulation as an Augmenting Strategy for Behavioral Therapies for Anxiety and PTSD: a Narrative Review

PURPOSE OF REVIEW

Post-traumatic stress disorder (PTSD) is a prevalent problem. Despite current treatments, symptoms may persist, and neuromodulation therapies show great potential. A growing body of research suggests that transcranial magnetic stimulation (TMS) is effective as a standalone treatment for PTSD, with recent research demonstrating promising use when combined synergistically with behavioral treatments. In this review, we survey this literature including data suggesting mechanisms involved in anxiety and PTSD that may be targeted by neurostimulation.

RECENT FINDINGS

Evidence suggests the mechanism of action for TMS that contributes to behavioral change may be enhanced neural plasticity via increased functionality of prefrontal and subcortical/limbic structures and associated networks. Some research has demonstrated a behavioral change in PTSD and anxiety due to enhanced extinction learning or improved ability to think flexibly and reduce ruminative tendencies. Growing evidence suggests TMS may be best used as a therapeutic adjunct, at least acutely, for extinction-based exposure therapies in patients by accelerating therapy response.

SUMMARY

While TMS has shown promise as a standalone intervention, augmentation with psychotherapy is one avenue of interest. Non-responders to current EBPs might particularly benefit from this sort of targeted approach, and it may shorten treatment length, which would help the successful completion of a course of therapy.

Cardiovascular Effects of High-Frequency Magnetic Seizure Therapy Compared With Electroconvulsive Therapy

BACKGROUND

Magnetic seizure therapy (MST) is a novel convulsive therapy that has been shown to have antidepressant efficacy comparable to electroconvulsive therapy (ECT) with fewer cognitive side effects. However, the cardiovascular (CVS) effects of high frequency MST in comparison to ECT have not been investigated.

MATERIALS AND METHODS

Forty-five patients with depression received 6 treatment sessions of 100 Hz MST versus 6 bifrontal ECT treatments in a nonrandomized comparative clinical design. Data on CVS function including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and rate pressure product (RPP) were collected at baseline (T0), after the induction of anesthesia but before the electrical stimulation (T1), during convulsion (T2), 2 minutes after cessation of motor seizure (T3), 5 minutes after cessation of motor seizure (T4), and 10 minutes after cessation of motor seizure (T5). Comparisons were made with baseline data and between MST and ECT groups.

RESULTS

There were statistically significant elevations in the maximum HR, SBP, DBP, and RPP in patients receiving ECT compared with MST both in the initial and sixth treatments (all P < 0.05). Particularly, at T2, the ECT group had significantly higher HR, SBP, DBP, and RPP than those in MST group both in initial and sixth treatment (all P < 0.001). At the sixth treatment, the ECT group had significantly higher SBP, DBP, and RPP during the treatment than in the MST group (all P < 0.001).

LIMITATIONS

The anesthetic choices for this study may limit the generalizability of our findings. The sample size was relatively small.

CONCLUSIONS

Compared with ECT, high-frequency MST has fewer CVS side effects and may be a safer option for depression patients with CVS disorders.

National Network of Depression Centers' Recommendations on Harmonizing Clinical Documentation of Electroconvulsive Therapy

ABSTRACT

Electroconvulsive therapy (ECT) is a highly therapeutic and cost-effective treatment for severe and/or treatment-resistant major depression. However, because of the varied clinical practices, there is a great deal of heterogeneity in how ECT is delivered and documented. This represents both an opportunity to study how differences in implementation influence clinical outcomes and a challenge for carrying out coordinated quality improvement and research efforts across multiple ECT centers. The National Network of Depression Centers, a consortium of 26+ US academic medical centers of excellence providing care for patients with mood disorders, formed a task group with the goals of promoting best clinical practices for the delivery of ECT and to facilitate large-scale, multisite quality improvement and research to advance more effective and safe use of this treatment modality. The National Network of Depression Centers Task Group on ECT set out to define best practices for harmonizing the clinical documentation of ECT across treatment centers to promote clinical interoperability and facilitate a nationwide collaboration that would enable multisite quality improvement and longitudinal research in real-world settings. This article reports on the work of this effort. It focuses on the use of ECT for major depressive disorder, which accounts for the majority of ECT referrals in most countries. However, most of the recommendations on clinical documentation proposed herein will be applicable to the use of ECT for any of its indications.

Prolonged intermittent theta burst stimulation in the treatment of major depressive disorder: a case series

Intermittent theta burst stimulation (iTBS) using 600 pulses is an effective and FDA-cleared transcranial magnetic stimulation (TMS) protocol for major depressive disorder (MDD). Prolonged iTBS (piTBS) using 1,800 pulses could increase the effectiveness of TMS for MDD, but its real-world effectiveness is still debated. We assessed the safety, tolerability, and preliminary effectiveness of a 3x daily piTBS 1,800 pulses protocol delivered over 2 weeks in 27 participants. Only four participants (18.2%) achieved response, two of them achieving remission (9.1%). Five participants (18.5%) experienced tolerability issues. Future studies should focus on the neurophysiological effects of TBS protocols to determine optimal parameters.

ECT on a world map - a narrative review of the use of electroconvulsive therapy and its frequency in the world

Introduction: Since implementation, electroconvulsive therapy has remained very effective treatment in psychiatry. The aim of this study is to present the differences in its use in medical practice around the world. The range of diseases in which ECT is most commonly used and the frequency of its use in different countries were compared with special attention to the differences between highly and poorly developed countries.

Material and method: Review of literature by searching PubMed and Google Scholar databases using the keywords: indications of ECT, frequency of ECT use for papers published from 1991 to 2021.

Results: Among the diseases for which electroconvulsive therapy is used worldwide, major depression dominates, while in Asia and Africa this therapy is used in schizophrenia. In Latin America it is used primarily for schizophrenia and bipolar disorder. In Poland, it is used for depression, bipolar disorder, and fewer for schizophrenia. The highest rate of people treated with therapy per 100,000 population is found in countries such as the USA (51), Canada (23.2-25.6), Australia (37.85), Sweden (41), Finland (23), Slovakia (29.2), Estonia (27.8) and Belgium (47).

Conclusions: There is a relationship between the range of diseases most frequently treated with ECT, the frequency of use and the level of country development. In the high developed countries, ECT is used mainly in major depression, in less developed countries more frequent treatment of schizophrenia may be determined by the high cost of medications and limited availability of hospital beds. The highest rates of use of this therapy are found in more developed countries.

Potential Targets for Noninvasive Brain Stimulation on Depersonalization-Derealization Disorder

INTRODUCTION

Non-invasive brain stimulation seems to be beneficial for DPD patients. However, the sites used in previous studies were empirical. Exploring new stimulation locations via functional magnetic resonance imaging may improve the efficacy.

OBJECTIVES

The objective was to find potential locations for non-invasive brain stimulation on the depersonalization-derealization disorder.

METHODS

We explored the potential brain surface regions from three pipelines: pipeline 1: activation likelihood estimation meta-analysis (five studies with 36 foci included); pipeline 2: functional connectivity analysis based on DPD-network (76 subjects included); and pipeline 3: functional connectivity analysis based on DPD regions of interest from the meta-analysis. Potential targets were the 10-20 system coordinates for brain surface regions.

RESULTS

We identified several potential brain surface regions, including the bilateral medial prefrontal cortex, dorsal lateral prefrontal cortex, superior parietal gyrus, superior temporal gyrus, and right ventrolateral prefrontal cortex as potential sites.

CONCLUSION

Our findings of the potential stimulation targets might help clinicians optimize the application of non-invasive brain stimulation therapy in individuals with DPD.

Assessment of Objective and Subjective Cognitive Function in Patients With Treatment-Resistant Depression Undergoing Repeated Ketamine Infusions

BACKGROUND

Subanesthetic ketamine infusions can elicit rapid and sustained antidepressant effects, yet the potential cognitive impact of ketamine has not been thoroughly examined. This study measured changes in objective and subjective cognitive function following repeated ketamine treatment.

METHODS

Thirty-eight patients with treatment-resistant depression were administered cognitive assessments before and after undergoing 7 i.v. ketamine infusions (0.5 mg/kg over 40 minutes) within a clinical trial examining the efficacy of single and repeated administrations. Depression severity and perceived concentration were evaluated with the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Quick Inventory of Depressive Symptoms Self-Report.

RESULTS

Twenty-three participants (60.5%) responded after repeated infusions (≥50% decrease in MADRS total scores). We measured significant improvements in several cognitive domains, including attention, working memory, verbal, and visuospatial memory (effect sizes ranging from Cohen d = 0.37-0.79). Cognitive changes were attributed to reduction in depressive symptoms except for improvement in verbal memory, which remained significant after adjustment for change in MADRS total score (P = .029, η p2 = 0.13). Only responders reported improvement in subjective cognitive function with repeated ketamine administration (MADRS item 6, P < .001, d = 2.00; Quick Inventory of Depressive Symptoms Self-Report item 10, P < .001, d = 1.36).

CONCLUSION

A short course of repeated ketamine infusions did not impair neurocognitive function in patients with treatment-resistant depression. Further research is required to understand the potential mediating role of response and remission on improved cognitive function accompanying ketamine treatment as well as to examine longer-term safety outcomes. ClinicalTrials.gov identifier NCT01945047.

SIRT1/FOXO1 Axis-Mediated Hippocampal Angiogenesis is Involved in the Antidepressant Effect of Chaihu Shugan San

Objective

Methods

Results

Conclusion

Assessment of Noninvasive Brain Stimulation Interventions for Negative Symptoms of Schizophrenia: A Systematic Review and Network Meta-analysis

IMPORTANCE

Negative symptoms have a detrimental impact on functional outcomes and quality of life in people with schizophrenia, and few therapeutic options are considered effective for this symptomatic dimension. Studies have suggested that noninvasive brain stimulation (NIBS) interventions may be effective in treating negative symptoms. However, the comparative efficacy of different NIBS protocols for relieving negative symptoms remains unclear.

OBJECTIVE

To compare the efficacy and acceptability of different NIBS interventions for treating negative symptoms.

DATA SOURCES

The ClinicalKey, Cochrane CENTRAL, Embase, ProQuest, PubMed, ScienceDirect, ClinicalTrials.gov, and Web of Science electronic databases were systematically searched from inception through December 7, 2021.

STUDY SELECTION

A frequentist model network meta-analysis was conducted to assess the pooled findings of trials that evaluated the efficacy of repetitive transcranial magnetic stimulation (rTMS), theta-burst stimulation, transcranial random noise stimulation, transcutaneous vagus nerve stimulation, and transcranial direct current stimulation on negative symptoms in schizophrenia. Randomized clinical trials (RCTs) examining NIBS interventions for participants with schizophrenia were included.

DATA EXTRACTION AND SYNTHESIS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed. Data were independently extracted by multiple observers. The pair-wise meta-analytic procedures were conducted using a random-effects model.

MAIN OUTCOMES AND MEASURES

The coprimary outcomes were changes in the severity of negative symptoms and acceptability (ie, dropout rates owing to any reason). Secondary outcomes were changes in positive and depressive symptoms.

RESULTS

Forty-eight RCTs involving 2211 participants (mean [range] age, 38.7 [24.0-57.0] years; mean [range] proportion of female patients, 30.6% [0%-70.0%]) were included. Compared with sham control interventions, excitatory NIBS strategies (standardized mean difference [SMD]: high-definition transcranial random noise stimulation, -2.19 [95% CI, -3.36 to -1.02]; intermittent theta-burst stimulation, -1.32 [95% CI, -1.88 to -0.76]; anodal transcranial direct current stimulation, -1.28 [95% CI, -2.55 to -0.02]; high-frequency rTMS, -0.43 [95% CI, -0.68 to -0.18]; extreme high-frequency rTMS, -0.45 [95% CI, -0.79 to -0.12]) over the left dorsolateral prefrontal cortex with or without other inhibitory stimulation protocols in the contralateral regions of the brain were associated with significantly larger reductions in negative symptoms. Acceptability did not significantly differ between the groups.

CONCLUSIONS AND RELEVANCE

In this network meta-analysis, excitatory NIBS protocols over the left dorsolateral prefrontal cortex were associated with significantly large improvements in the severity of negative symptoms. Because relatively few studies were available for inclusion, additional well-designed, large-scale RCTs are warranted.

Risk of relapse within 6 months associated with borderline personality disorder in major depressed individuals treated with electroconvulsive therapy

Given the limited data in the literature, the aim of this study was to investigate the risk of relapse within 6 months associated with borderline personality disorder (BPD) in major depressed individuals treated with electroconvulsive therapy. Demographic and clinical data from 109 major depressed individuals with partial or complete response to electroconvulsive therapy recruited from the database of the Psychiatry Department of Erasme Hospital were analysed. Cox regression analyses were used to determine the risk of relapse within 6 months associated with BPD in major depressed individuals treated with electroconvulsive therapy. Relapses within 6 months were frequent (37.6%) in our sample of major depressed individuals treated with electroconvulsive therapy. After adjusting for major confounding factors, multivariate Cox regression analyses demonstrated that BPD was a risk factor for relapse within 6 months in major depressed individuals treated with electroconvulsive therapy. In our study, we demonstrated that BPD is associated with higher risk of relapse within 6 months in major depressed individuals treated with electroconvulsive therapy, which seems to justify a more systematic screening for BPD in order to allow the implementation of more effective prevention strategies for relapse within 6 months in this particular subpopulation.

A Southeast Asian expert consensus on the management of major depressive disorder with suicidal behavior in adults under 65 years of age

BACKGROUND

The high prevalence of suicidal behavior among individuals with major depressive disorder (MDD) in Southeast Asia (SEA) underscores the need for optimized management to address depressive symptoms, reduce suicide risk and prevent suicide in these individuals. Given the lack of clear guideline recommendations for assessing and managing these patients, regional consensus-based recommendations which take into account diverse local contexts across SEA may provide useful guidance for clinical practice.

METHODS

A narrative literature review and pre-meeting survey were conducted prior to the consensus meeting of an SEA expert panel comprising 13 psychiatrists with clinical experience in managing patients with MDD with suicidal behavior. Utilizing the RAND/UCLA Appropriateness Method, the expert panel developed consensus-based recommendations on the assessment and treatment of adult patients with MDD with suicidal behavior under 65 years.

RESULTS

Screening of adult patients under 65 years with MDD for suicide risk using both a validated assessment tool and clinical interview is recommended. An improved suicide risk stratification - incorporating both severity and temporality, or using a prevention-focused risk formulation - should be considered. For a patient with an MDD episode with low risk of suicide, use of antidepressant monotherapy, and psychotherapy in combination with pharmacological treatment are both recommended approaches. For a patient with an MDD episode with high risk of suicide, or imminent risk of suicide requiring rapid clinical response, or for a patient who had received adequate AD but still reported suicidal behavior, recommended treatment strategies include antidepressant augmentation, combination use of psychotherapy or electroconvulsive therapy with pharmacological treatment, and inpatient care. Suicide-specific psychosocial interventions are important for suicide prevention and should also be part of the management of patients with MDD with suicidal behavior.

CONCLUSIONS

There are still unmet needs in the assessment of suicide risk and availability of treatment options that can deliver rapid response in patients with MDD with suicidal behavior. These consensus recommendations on the management of adult patients with MDD with suicidal behavior under 65 years may serve as a useful guidance in diverse clinical practices across the SEA region. Clinical judgment based on careful consideration of individual circumstances of each patient remains key to determining the most appropriate treatment option.

Predictive Value of Acute Neuroplastic Response to rTMS in Treatment Outcome in Depression: A Concurrent TMS-fMRI Trial

OBJECTIVE

The study objective was to investigate the predictive value of functional connectivity changes induced by acute repetitive transcranial magnetic stimulation (rTMS) for clinical response in treatment-resistant depression.

METHODS

Cross-sectional changes in functional connectivity induced by a single concurrent rTMS-fMRI session were assessed in 38 outpatients with treatment-resistant depression (26 of them female; mean age, 41.87 years) who subsequently underwent a 4-week course of rTMS. rTMS was delivered at 1 Hz over the right dorsolateral prefrontal cortex. Acute rTMS-induced functional connectivity changes were computed and subjected to connectome-based predictive modeling to test their association with changes in score on the Montgomery-Åsberg Depression Rating Scale (MADRS) after rTMS treatment.

RESULTS

TMS-fMRI induced widespread, acute, and transient alterations in functional connectivity. The rTMS-induced connectivity changes predicted about 30% of the variance of improvement in the MADRS score. The most robust predictive associations involved connections between prefrontal regions and motor, parietal, and insular cortices and between bilateral regions of the thalamus.

CONCLUSIONS

Acute rTMS-induced connectivity changes in patients with treatment-resistant depression may index macro-level neuroplasticity, relevant to interindividual variability in rTMS treatment response. Large-scale network phenomena occurring during rTMS might be used to inform prospective clinical trials.

Oral theophylline augmentation for patients with missed or inadequate seizures with electroconvulsive therapy

AIM

An inadequate seizure occasionally occurs during a course of acute electroconvulsive therapy (ECT) under the maximum approved electrical stimulation in Japan of 504 mC. This retrospective study was conducted to determine the effectiveness and adverse reactions of an oral theophylline augmentation technique.

METHODS

A retrospective review of medical records was conducted of patients admitted to the Department of Psychiatry, Hiroshima Citizens Hospital, who received acute phase ECT from October 2014 to March 2017.

RESULTS

A theophylline augmentation technique was instituted in 13 patients (7 males, 6 females; 56-79 years old). The total number of ECT sessions per patient ranged from 9 to 20 and the number of those with theophylline augmentation per patient ranged from 1 to 17. An augmentation effect was noted in all patients and each finished the scheduled ECT course, except for 1 who developed memory disturbance. The maximum dose of theophylline ranged from 200 to 700 mg/day, and the serum level at 06:00 on the day of the ECT session ranged from 5.3 to 23.6 mg/L in 12 patients, as 1 missed the examination.

CONCLUSION

Oral theophylline augmentation can be considered as an effective treatment option for patients undergoing ECT with inadequate seizures.

Repetitive transcranial magnetic stimulation may be a cost-effective alternative to antidepressant therapy after two treatment failures in patients with major depressive disorder

BACKGROUND

The cost-effectiveness of treatment strategies for patients with Major Depressive Disorder (MDD) who have not responded to two adequate treatments with antidepressants (TRD) are still unclear. The aim of this analysis was to evaluate the cost-effectiveness of add-on repetitive Transcranial Magnetic Stimulation (rTMS) compared with standard treatment.

METHODS

A Markov-model simulated clinical events over one year from the perspective of healthcare payer. Third- and fourth-line treatment pathways (augmentation, antidepressant switch or combination, and Electro-Convulsive Therapy (ECT)) were defined based on medical practice guidelines. Transition probabilities were derived from a recent meta-analysis and scientific publications. Resource utilization and cost estimates were based on the patient-level database of a large university hospital.

RESULTS

Incremental Quality-Adjusted Life Years (QALYs) and costs were 0.053 and 785 €, respectively, corresponding to an Incremental Cost-Effectiveness Ratio (ICER) of 14,670 € per QALY. The difference in cost between standard treatment and rTMS is explained by the rTMS sessions used in acute (€660) and maintenance (€57/month) treatments, partly offset by lower hospital costs due to higher remission rates in the rTMS arm. Key parameters driving the ICER were incremental utility of remission, unit cost of rTMS treatment and remission rate. At a threshold of €22,243 add-on rTMS is a cost-effective alternative to pharmacotherapy. Evidence on long-term effectiveness is not yet available, so results are estimated for a one-year period.

CONCLUSION

Not only does rTMS treatment have beneficial clinical effects compared with drug therapy in TRD, but it also appears to offer good value-for-money, especially in centres with larger numbers of patients where unit costs can be kept low.

Household food insecurity, sense of community belonging, and access to a regular medical doctor as mediators in the relationship between mood and/or anxiety disorders and self-rated general health in Canada between 2011 and 2016: a serial cross-sectional analysis

OBJECTIVE

To assess whether (household) food insecurity, access to a regular medical doctor, and sense of community belonging mediate the relationship between mood and/or anxiety disorders and self-rated general health.

METHODS

We used six annual cycles of the Canadian Community Health Survey, including Canadian adults aged 18-59 years, between 2011 and 2016. Mediation models, adjusted for key determinants of health, were based on a series of weighted logistic regression models. The Sobel products of coefficients approach was used to estimate the indirect effect, and bootstrapping to estimate uncertainty.

RESULTS

The annual (weighted) prevalence of mood and/or anxiety disorders increased from 11.3% (2011) to 13.2% (2016). Across the 6 years, 23.9-27.7% of individuals with mood and/or anxiety disorders reported fair/poor self-rated health as compared with 4.9-6.5% of those without mood and/or anxiety disorders (p<0.001). Similarly, the 7.2-8.9% of the population reporting fair/poor self-rated health were disproportionately represented among individuals reporting food insecurity (21.1-26.2%, p<0.001) and a weak sense of community belonging (10.0-12.2%, p<0.001). A significantly lower prevalence of poor self-rated health was observed among respondents reporting having access to a regular medical doctor in 2012, 2015, and 2016. In 2016, sense of community belonging and food insecurity significantly mediated the effect of mood and/or anxiety disorders on self-rated general health. Access to a regular medical doctor did not mediate this relationship.

CONCLUSION

Efficient policies that address food insecurity and sense of community belonging are needed to decrease the mental health burden and improve health satisfaction of Canadians.

Brain stimulation and other biological non-pharmacological interventions in mental disorders: An umbrella review

BACKGROUND

The degree of efficacy, safety, quality, and certainty of meta-analytic evidence of biological non-pharmacological treatments in mental disorders is unclear.

METHODS

We conducted an umbrella review (PubMed/Cochrane Library/PsycINFO-04-Jul-2021, PROSPERO/CRD42020158827) for meta-analyses of randomized controlled trials (RCTs) on deep brain stimulation (DBS), transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), electro-convulsive therapy (ECT), and others. Co-primary outcomes were standardized mean differences (SMD) of disease-specific symptoms, and acceptability (for all-cause discontinuation). Evidence was assessed with AMSTAR/AMSTAR-Content/GRADE.

RESULTS

We selected 102 meta-analyses. Effective interventions compared to sham were in depressive disorders: ECT (SMD=0.91/GRADE=moderate), TMS (SMD=0.51/GRADE=moderate), tDCS (SMD=0.46/GRADE=low), DBS (SMD=0.42/GRADE=very low), light therapy (SMD=0.41/GRADE=low); schizophrenia: ECT (SMD=0.88/GRADE=moderate), tDCS (SMD=0.45/GRADE=very low), TMS (prefrontal theta-burst, SMD=0.58/GRADE=low; left-temporoparietal, SMD=0.42/GRADE=low); substance use disorder: TMS (high frequency-dorsolateral-prefrontal-deep (SMD=1.16/GRADE=moderate), high frequency-left dorsolateral-prefrontal (SMD=0.77/GRADE=very low); OCD: DBS (SMD=0.89/GRADE=moderate), TMS (SMD=0.64/GRADE=very low); PTSD: TMS (SMD=0.46/GRADE=moderate); generalized anxiety disorder: TMS (SMD=0.68/GRADE=low); ADHD: tDCS (SMD=0.23/GRADE=moderate); autism: tDCS (SMD=0.97/GRADE=very low). No significant differences for acceptability emerged. Median AMSTAR/AMSTAR-Content was 8/2 (suggesting high-quality meta-analyses/low-quality RCTs), GRADE low.

DISCUSSION

Despite limited certainty, biological non-pharmacological interventions are effective and safe for numerous mental conditions. Results inform future research, and guidelines.

FUNDING

None.

Efficacy and tolerability of Brain Stimulation interventions in Borderline Personality Disorder: state of the art and future perspectives - A systematic review

Treating Borderline Personality Disorder (BPD) is a major challenge for psychiatrists. As Brain Stimulation represents an alternative approach to treat psychiatric disorders, our systematic review is the first to focus on both invasive and Non-Invasive Brain Stimulation (NIBS) interventions in people living with BPD, examining clinical effects over core features and comorbid conditions. Following PRISMA guidelines, out of 422 original records, 24 papers were included regarding Deep Brain Stimulation (n = 1), Electroconvulsive therapy (n = 5), Transcranial Magnetic Stimulation (n = 13) and transcranial Direct Current Stimulation (n = 5). According to impulsivity and emotional dysregulated domain improvements, NIBS in BPD appears to restore frontolimbic network deficiencies. NIBS seems also to modulate depressive features. Safety and tolerability profiles for each technique are discussed. Despite encouraging results, definitive recommendations on Brain Stimulation in BPD are mitigated by protocols heterogeneity, lack of randomized controlled trials and poor quality of included studies, including high risk of methodological biases. To serve as guide for future systematic investigations, protocols optimization proposals are provided, focusing on alternative stimulation sites and suggesting a NIBS symptom-based approach.

Effectiveness of intravenous ketamine in mood disorder patients with a history of neurostimulation

BACKGROUND

Patients unsuccessfully treated by neurostimulation may represent a highly intractable subgroup of depression. While the efficacy of intravenous (IV) ketamine has been established in patients with treatment-resistant depression (TRD), there is an interest to evaluate its effectiveness in a subpopulation with a history of neurostimulation.

METHODS

This retrospective, posthoc analysis compared the effects of four infusions of IV ketamine in 135 (x̄ = 44 ± 15.4 years of age) neurostimulation-naïve patients to 103 (x̄ = 47 ± 13.9 years of age) patients with a history of neurostimulation. The primary outcome evaluated changes in depression severity, measured by the Quick Inventory for Depression Symptomatology-Self Report 16-Item (QIDS-SR16). Secondary outcomes evaluated suicidal ideation (SI), anxiety severity, measured by the Generalized Anxiety Disorder 7-Item (GAD-7), and consummatory anhedonia, measured by the Snaith-Hamilton Pleasure Scale (SHAPS).

RESULTS

Following four infusions, both cohorts reported a significant reduction in QIDS-SR16 Total Score (F (4, 648) = 73.4, P < .001), SI (F (4, 642) = 28.6, P < .001), GAD-7 (F (2, 265) = 53.8, P < .001), and SHAPS (F (2, 302) = 45.9, P < .001). No between-group differences emerged. Overall, the neurostimulation-naïve group had a mean reduction in QIDS-SR16 Total Score of 6.4 (standard deviation [SD] = 5.3), whereas the history of neurostimulation patients reported a 4.3 (SD = 5.3) point reduction.

CONCLUSION

IV ketamine was effective in reducing symptoms of depression, SI, anxiety, and anhedonia in both cohorts in this large, well-characterized community-based sample of adults with TRD.

The anticholinergic burden is not associated with cognitive impairments in patients treated by electroconvulsive therapy for treatment-resistant depression

BACKGROUND

Electroconvulsive therapy (ECT) is the most effective non-pharmacological treatment for treatment-resistant depression (TRD) but can expose to transient cognitive impairments. Understanding factors underlying these cognitive side effects is important. This study investigated the impact of anticholinergic treatments on cognitive performances after ECT courses for TRD in naturalistic condition.

METHODS

Impact of anticholinergic burden (Anticholinergic Impregnation Scale, AIS) on cognitive changes (Montreal Cognitive Assessment, MoCA) adjusted on depression level (Montgomery and Asberg Depression Scale, MADRS) was investigated in 42 patients who received an ECT course between 2017 and 2020 for unipolar or bipolar TRD. Collection of daily treatments given during ECT was carried out via the computerized traceability of treatments validated by nurses.

RESULTS

Among the 31 treatments identified with an anticholinergic score, which represent only 38% of total treatments, the three most frequently given treatments were Lorazepam (47%), Venlafaxine (36%) and Cyamemazine (26%). Delayed recall was the most frequently impaired cognitive function after ECT courses. Using logistic regression, we found no association between the anticholinergic burden and the decrease in cognitive scores after ECT courses, adjusted on MADRS score evolution (p > 0.1). Conversely, improvement in MADRS scores were correlated with improvement in attention MoCA subscores.

LIMITATIONS

This is a retrospective monocentric study with a moderate sample size using anticholinergic scales to calculate the anticholinergic burden without plasma dosage.

CONCLUSION

Anticholinergic treatments did not seem to explain ECT-related cognitive impairments. This warrants further large prospective investigations including different measures of anticholinergic burden.

Combining Trauma Script Exposure With rTMS to Reduce Symptoms of Post-Traumatic Stress Disorder: Randomized Controlled Trial

BACKGROUND

Innovative therapeutic interventions for post-traumatic stress disorder (PTSD) are required. We opted to facilitate fear extinction by combining trauma script exposure with repetitive transcranial magnetic stimulation (rTMS) to reduce symptoms of PTSD.

OBJECTIVE

The efficacy and safety of 10 Hz rTMS of the right dorsolateral prefrontal cortex simultaneously with exposure to personal traumatic narrative were studied in patients with PTSD.

MATERIALS AND METHODS

This trial was a single-center randomized controlled trial (NCT02584894). Patients were randomly assigned 1:1 to receive eight daily sessions of 110% of motor threshold high frequency (HF) 10 Hz rTMS (110% HF rTMS) or 70% low frequency (LF) 1 Hz rTMS (70% LF rTMS) with trauma script exposure in both groups. Severity of PTSD, depression, and anxiety were assessed before and after study treatment (one month, three months) by an assessor masked to the trial group assignment. The primary outcome was the severity of PTSD assessed by the Clinician Administered PTSD Scale (CAPS). We used mixed linear regression models for statistical comparisons.

RESULTS

Thirty-eight patients (65.8% females) were randomly assigned to 110% HF rTMS (n = 18, 31.3 ± 10.0 years, 13 females) or 70% LF rTMS (n = 20, 33.5 ± 11.1 years, 12 females). From baseline to three months, mean CAPS scores decreased by 51% in the 110% HF rTMS group (from 83.7 ± 14.4 to 41.8 ± 31.9) and by 36.9% in the 70% LF rTMS group (from 81.8 ± 15.6 to 51.6 ± 23.7), but with no significant difference in improvement (time by treatment interaction -3.61 [95% confidence interval (CI), -9.70 to 2.47]; p = 0.24; effect size 0.53). One serious adverse event occurred during the study (psychogenic nonepileptic seizure).

CONCLUSION

We found no evidence of difference in clinical improvement or remission rates between the 110% HF and 70% LF stimulation. These findings may reflect the importance of exposure procedure and that larger number of participants is needed.

Risk of suicide death following electroconvulsive therapy treatment for depression: a propensity score-weighted, retrospective cohort study in Canada

BACKGROUND

Previous studies examining the risk of suicide death after treatment with electroconvulsive therapy have been confounded and the resulting uncertainty around the risk-benefit profile of electroconvulsive therapy might contribute to its underuse. We aimed to compare the risk of death by suicide after psychiatric hospitalisation among individuals with depression who had been exposed to electroconvulsive therapy with those who had not.

METHODS

This was a propensity score-weighted, retrospective cohort study using linked population-level administrative health data for adults with depression who had been admitted to a designated psychiatric bed in Ontario, Canada for more than 3 days between April 1, 2007 and Dec 31, 2017. Electroconvulsive therapy exposure was defined as one or more physician billing procedure codes during hospitalisation. The primary outcome was death by suicide identified using administrative health records within 365 days following discharge. We used cause-specific Cox proportional hazards model to estimate the cause-specific hazard ratio (csHR) for electroconvulsive therapy-exposed and electroconvulsive therapy-unexposed individuals. Secondary outcomes were non-suicide death and all-cause mortality.

FINDINGS

In the analytic cohort, there were 67 327 psychiatric hospitalisation records (27 231 men and 40 096 women; mean age 45·1 years [SD 16·8; range 18-103]), of whom 4982 were exposed to electroconvulsive therapy and 62 345 were not exposed to electroconvulsive therapy. No ethnicity data were available. In propensity-score weighted analyses, electroconvulsive therapy was associated with a significantly reduced risk of suicide death (csHR 0·53 [95% CI 0·31-0·92]). Accounting for non-suicide death as a competing risk had no effect on the findings. Electroconvulsive therapy was also associated with a significantly reduced risk of all-cause mortality (0·75 [0·58-0·97]), but not non-suicide death (0·83 [0·61-1·12]).

INTERPRETATION

Among individuals admitted to hospital with depression, electroconvulsive therapy is associated with a significantly reduced risk of death by suicide in the year after discharge. This study reinforces the importance of electroconvulsive therapy, particularly for people with severe depression.

FUNDING

Norris Scholars Award, Department of Psychiatry, University of Toronto, and the Canadian Institutes for Health Research.

A study protocol for an ongoing multi-arm, randomized, double-blind, sham-controlled clinical trial with digital features, using portable transcranial electrical stimulation and internet-based behavioral therapy for major depression disorders: The PSYLECT study

BACKGROUND

Transcranial electrical stimulation (tES) is considered effective and safe for depression, albeit modestly, and prone to logistical burdens when performed in external facilities. Investigation of portable tES (ptES), and potentiation of ptES with remote psychological interventions have shown positive, but preliminary, results.

RESEARCH DESIGN

We report the rationale and design of an ongoing multi-arm, randomized, double-blind, sham-controlled clinical trial with digital features, using ptES and internet-based behavioral therapy (iBT) for major depressive disorder (MDD) (NCT04889976).

METHODS

We will evaluate the efficacy, safety, tolerability and usability of (1) active ptES + active iBT ('double-active'), (2) active ptES + sham iBT ('ptES-only'), and (3) sham ptES + sham iBT ('double-sham'), in adults with MDD, with a Hamilton Depression Rating Scale - 17 item version (HDRS-17) score ≥ 17 at baseline, during 6 weeks. Antidepressants are allowed in stable doses during the trial.

RESULTS

We primarily co-hypothesize changes in HDRS-17 will be greater in (1) 'double-active' compared to 'ptES-only,' (2) 'double-active' compared to 'double-sham,' and (3) 'ptES-only' compared to 'double-sham.' We aim to enroll 210 patients (70 per arm).

CONCLUSIONS

Our results should offer new insights regarding the efficacy and scalability of combined ptES and iBT for MDD, in digital mental health.

Transcutaneous Electrical Cranial-Auricular Acupoint Stimulation vs. Escitalopram for Patients With Mild-to-Moderate Depression (TECAS): Study Design for a Randomized Controlled, Non-inferiority Trial

Background

Previous studies in animals and humans indicated that transcutaneous vagus nerve stimulation (tVNS) and transcutaneous electrical acupoint stimulation (TEAS) on trigeminal nerve-innervated forehead acupoints can relief the symptoms of depression. However, due to the limited investigations on these two interventions, more research are needed to confirm their efficacy in depression. To improve the efficacy of the single treatment, we combined two treatments and created a novel non-invasive stimulation, transcutaneous electrical cranial-auricular acupoint stimulation (TECAS). To assess the efficacy and safety of TECAS, we compare it with a selective serotonin reuptake inhibitor (SSRI), escitalopram, for the treatment of depression.

Methods/Design

This is a multi-center, non-inferiority, randomized controlled trial that will involve 470 patients with mild to moderate depression. Patients will be randomly assigned to either the TECAS group or the escitalopram group in a 1:1 ratio. The TEAS group will receive two sessions of treatments per day for 8 consecutive weeks, and the escitalopram group will receive 8 weeks of oral escitalopram tablets prescribed by clinical psychiatrists as appropriate for their condition. The primary outcome is the clinical response as determined by Montgomery-Åsberg Depression Rating Scale (MADRS) scores at week 8, with -10% as the non-inferior margin. The secondary outcomes include the response rate determined by 17-item Hamilton Depression Rating Scale (HAMD-17), remission rate, changes from baseline in the scores on the MADRS, the HAMD-17, the Hamilton Anxiety Rating Scale (HAMA), the Pittsburgh Sleep Quality Index (PSQI), and the Short Form 36 Health Survey (SF-36).

Discussion

This will be the first randomized controlled trial to compare the efficacy of TECAS with escitalopram for depression. If effective, this novel intervention could have significant clinical and research implications for patients with depression.

Clinical Trial Registration

[ClinicalTrials.gov], identifier [NCT03909217].

Is Repetitive Transcranial Magnetic Stimulation (rTMS) Ready for Clinical Use as a Treatment Tool for Mental Health Targets in Children and Youth?

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation tool with potential for broad application in individuals with neuropsychiatric conditions. As in adults, most rTMS research in youth has focused on treatment-resistant depression. A limited number of rTMS studies have also been conducted in children and youth with primary diagnoses of Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD) or Tourette's syndrome. Across the available rTMS literature, rTMS appears to be well tolerated with few adverse effects reported when applied to child and youth research samples. However, the potential efficacy of rTMS treatment for a variety of targets in children and youth remains unclear, due in part to limitations of the current literature, including studies using diverse protocols, potential for bias in existing clinical trial designs, variability in the research samples, and the use of heterogenous outcome measures. While rTMS is unlikely to take the place of more accessible treatments (e.g., psychopharmacological, psychosocial, psychotherapeutic), rTMS may provide a valuable alternative treatment option, particularly for those individuals where conventional treatments are inaccessible, poorly tolerated, or ineffective. A more robust body of well-designed, controlled trials, is needed in order to clarify rTMS treatment efficacy across relevant neuropsychiatric conditions, optimize treatment protocols, and meet the critical need for novel mental health interventions in children and youth.

Allostatic load as a predictor of response to repetitive transcranial magnetic stimulation in treatment resistant depression: Research protocol and hypotheses

Treatment resistant depression is challenging because patients who fail their initial treatments often do not respond to subsequent trials and their course of illness is frequently marked by chronic depression. Repetitive transcranial magnetic stimulation (rTMS) is a well-established treatment alternative, but there are several limitations that decreases accessibility. Identifying biomarkers that can help clinicians to reliably predict response to rTMS is therefore necessary. Allostatic load (AL), which represents the 'wear and tear' on the body and brain which accumulates as an individual is exposed to chronic stress could be an interesting staging model for TRD and help predict rTMS treatment response. We propose an open study which aims to test whether patients with a lower pre-treatment AL will have a stronger antidepressant response to 4 week-rTMS treatment. We will also assess the relation between healthy lifestyle behaviors, AL, and rTMS treatment response. Blood samples for AL parameters will be collected before the treatment. The AL indices will summarize neuroendocrine (cortisol, Dehydroepiandrosterone), immune (CRP, fibrinogen, ferritin), metabolic (glycosylated hemoglobin, total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, uric acid, body mass index, waist circumference), and cardiovascular (heart rate, systolic and diastolic blood pressure) functioning. Mood assessment (Montgomery-Åsberg Depression Rating Scale and Inventory of Depressive symptomatology) will be measured before the treatment and at two-week intervals up to 4 weeks. With the help of different lifestyle questionnaires, a healthy lifestyle index (i.e., a single score based on lifestyle factors) will be created. We will use linear and logistic regressions to assess AL in relation to changes in mood score. Hierarchical regression will be done in order to assess the association between AL, healthy lifestyle index and mood score. Long-lasting and unsuccessful antidepressant trials may increase the chance of not responding to future trials of antidepressants and it can therefore increase treatment resistance. It is essential to identify reliable biomarkers that can predict treatment responses.

Anesthetic care for electroconvulsive therapy

Counselling and medication are often thought of as the only interventions for psychiatric disorders, but electroconvulsive therapy (ECT) has also been applied in clinical practice for over 80 years. ECT refers to the application of an electric stimulus through the patient’s scalp to treat psychiatric disorders such as treatment-resistant depression, catatonia, and schizophrenia. It is a safe, effective, and evidence-based therapy performed under general anesthesia with muscle relaxation. An appropriate level of anesthesia is essential for safe and successful ECT; however, little is known about this because of the limited interest from anesthesiologists. As the incidence of ECT increases, more anesthesiologists will be required to better understand the physiological changes, complications, and pharmacological actions of anesthetics and adjuvant drugs. Therefore, this review focuses on the fundamental physiological changes, management, and pharmacological actions associated with various drugs, such as anesthetics and neuromuscular blocking agents, as well as the comorbidities, indications, contraindications, and complications of using these agents as part of an ECT procedure through a literature review and our own experiences.

Vagusnervstimulation bei schwer zu behandelnden Depressionen

Einführung

Seit 20 Jahren ist die Vagusnervstimulation (VNS) eine europaweit zugelassene invasive Therapieoption für therapieresistente Depressionen (TRD). Im Gegensatz zu geläufigeren Behandlungen wie EKT sind Kenntnisse über VNS sowohl in der Allgemeinbevölkerung als auch in Fachkreisen gering.

Methoden

In diesem narrativen Review geben wir eine klinisch und wissenschaftlich fundierte Übersicht über die VNS. Hypothesen zum Wirkmechanismus sowie die aktuelle Evidenzlage zur Wirksamkeit werden dargestellt. Das perioperative Management, das Nebenwirkungsprofil und die Nachbetreuung einschließlich Dosistitration werden beschrieben. Ein Vergleich über internationale Leitlinienempfehlungen zur VNS findet sich ebenfalls. Ferner formulieren wir Kriterien, die bei der Auswahl geeigneter Patienten hilfreich sind.

Ergebnisse

Die elektrischen Impulse werden über den N. vagus afferent weitergeleitet und stimulieren über verschiedene Wege ein neuromodulatorisches zerebrales Netzwerk. Viele Studien und Fallserien zeigten die Wirksamkeit von VNS als adjuvantes Verfahren bei TRD. Der Effekt tritt mit einer Latenz von 3 bis 12 Monaten ein und steigt möglicherweise mit der Dauer der VNS. Unter der Beachtung der Stimulationsempfehlungen sind die Nebenwirkungen für die meisten Patienten tolerabel.

Fazit

Die VNS ist eine zugelassene, wirksame und gut verträgliche Langzeittherapie für chronische und therapieresistente Depressionen. Weitere Sham-kontrollierte Studien über einen längeren Beobachtungszeitraum sind zur Verbesserung der Evidenz wünschenswert.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00115-022-01282-6) enthält eine weitere Infobox. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

Dosing methods in electroconvulsive therapy: should the Scandinavian time-titration method be resumed?

AIM

To describe and evaluate the different dosing methods in ECT, and bringing back into focus the Scandinavian time-titration method.

METHOD

A narrative, unsystematic, and selective review and discussion.

RESULTS

There are five dosing methods: 1) The Scandinavian time-titration to tonic convulsion, using low-frequency pulses and a long maximal pulse train duration, was highly efficacious with right unilateral (RUL) ECT, comparable to bitemporal (BT) ECT. However, the device used went out of production in the 1990s. Because US devices until 1990 had a short maximal pulse train duration, time-titration went out of use. 2) Fixed high dosing at 50-100% of the device's maximal output, and 3) Formula-based dosing, initially the Age method, long prevailed in USA. Later, the Half-Age method was introduced for BT ECT. 4) Charge-dosing as a multiple of titrated seizure threshold (ST) demonstrated RUL and BT ECT to have comparable outcomes when dosed about six and two times the ST, respectively. 5) Dosing from benchmark is based on a high dose at the first session, to ensure a high peak heart rate and tonic-clonic convulsions. In later sessions the lowest dose producing similar outcomes is chosen.

CONCLUSIONS

No dosing method is documented superior to the others. Seizure threshold-based and benchmark dosing seems to be more accurate than fixed high and formula-based dosing. However, time-titration dosing makes it possible to adjust the dose at every session, and may be the most efficient method.

Large-scale structural network change correlates with clinical response to rTMS in depression

Response to repetitive transcranial magnetic stimulation (rTMS) among individuals with major depressive disorder (MDD) varies widely. The neural mechanisms underlying rTMS are thought to involve changes in large-scale networks. Whether structural network integrity and plasticity are associated with response to rTMS therapy is unclear. Structural MRIs were acquired from a series of 70 adult healthy controls and 268 persons with MDD who participated in two arms of a large randomized, non-inferiority trial, THREE-D, comparing intermittent theta-burst stimulation to high-frequency rTMS of the left dorsolateral prefrontal cortex (DLPFC). Patients were grouped according to percentage improvement on the 17-item Hamilton Depression Rating Score at treatment completion. For the entire sample and then for each treatment arm, multivariate analyses were used to characterize structural covariance networks (SCN) from cortical gray matter thickness, volume, and surface area maps from T1-weighted MRI. The association between SCNs and clinical improvement was assessed. For both study arms, cortical thickness and volume SCNs distinguished healthy controls from MDD (p = 0.005); however, post-hoc analyses did not reveal a significant association between pre-treatment SCN expression and clinical improvement. We also isolated an anticorrelated SCN between the left DLPFC rTMS target site and the subgenual anterior cingulate cortex across cortical measures (p = 0.0004). Post-treatment change in cortical thickness SCN architecture was associated with clinical improvement in treatment responders (p = 0.001), but not in non-responders. Structural network changes may underpin clinical response to rTMS, and SCNs are useful for understanding the pathophysiology of depression and neural mechanisms of plasticity and response to circuit-based treatments.

Clinicians’ Approach to Cognitive Impairment After Electroconvulsive Therapy: Current Situations and Challenges

Background: Electroconvulsive therapy (ECT) is one of the most effective treatments for severe refractory mental diseases. Widespread cognitive complications have affected the acceptance of this treatment. Despite current evidence of short-term cognitive impairment, long-term cognition consequences are less determined. Objectives: This study aimed to evaluate the clinical approach of psychiatrists, psychiatry residents, and nurses in psychiatric hospitals to the necessity, method, and frequency of cognitive assessment in candidate patients for ECT. Methods: In this descriptive study, 89 professional members of Roozbeh and Razi hospitals, Tehran, Iran, including nurses, residents, and faculty members of psychiatry, were selected using the purposive sampling method. The research questionnaires were sent, and 58 fulfilled questionnaires were sent back. The data were analyzed using central indicators and statistical dispersion. The designed questionnaire included the items related to the specialists’ views on the necessity of post-ECT cognitive evaluations, best batteries, frequency of performing the tests, and other related domains. Results: After close follow-up, 58 out of 89 participants completed the questionnaires, including 17 psychiatrists (29.3%), 20 nurses (34.5%), and 21 psychiatry residents (36.2%). The results were analyzed and interpreted in detail. The average work experience of respondents in the psychiatry field was 6.89 years (range: 1 - 25 years). Additionally, 97% of the specialists did not have any project in the ECT field and cognitive disorders. More than 80% of the participants believed that cognition evaluation is necessary for ECT-candidate patients; however, only 15% of the specialists referred patients for the assessment. Moreover, 43% of the experts recommended the Wechsler Memory Scale-Revised; nevertheless, nearly 26% of the experts recommended the Delis-Kaplan Executive Function System for the cognitive assessment of these patients. The Rey Auditory Verbal Learning Test was recommended by 20% of the experts. Nearly two-thirds of the respondents believed that a proper assessment should be carried out in about 30 minutes. More than 60% of the experts believed that patients should be evaluated before receiving the first session of ECT, and nearly one-third of the experts recommended only a post-ECT evaluation. More than half of the experts believed that ECT should be discontinued in case of severe cognitive impairment after ECT. Alternatively, less than 30% of the experts believed that it is necessary to make changes in the treatment dose and the interval between sessions. Furthermore, 80% of the experts recommended cognitive rehabilitation for patients with significant cognitive impairment after ECT; nonetheless, less than 20% of the experts recommended treatment with a cholinesterase inhibitor. Conclusions: A large percentage of patients do not undergo a comprehensive cognitive assessment after ECT, which is an important challenge in the estimation of post-ECT cognitive decline. There is a need to design inexpensive and sensitive tests for cognitive assessment. The test could measure different cognitive domains and be acceptable in terms of time. Due to the limited number of specialists working in this field, the frequency of assessment and treatment methods after the identification of cognitive disorders are heterogeneous. Therefore, it is required to design a native and practical guideline. These results could help the researchers design future studies to determine the best method of cognitive evaluation after ECT, appropriate batteries, recommended intervals, and treatment decisions after cognitive decline detection.

The Korean Medication Algorithm Project for Depressive Disorder 2021: Comparisons with Other Treatment Guidelines

The Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) first was published in 2002, and has been revised four times, in 2006, 2012, 2017, and 2021. In this review, we compared recommendations from the recently revised KMAP-DD 2021 to four global clinical practice guidelines (CPGs) for depression published after 2010. The recommendations from the KMAP-DD 2021 were similar to those from other CPGs, although there were some differences. The KMAP-DD 2021 reflected social culture and the healthcare system in Korea and recent evidence about pharmacotherapy for depression, as did other recently published evidence-based guidelines. Despite some intrinsic limitations as an expert consensus-based guideline, the KMAP-DD 2021 can be helpful for Korean psychiatrists making decisions in clinical settings by complementing previously published evidence-based guidelines, especially for some clinical situations lacking evidence from rigorously designed clinical trials.

Translational Informatics for Natural Products as Antidepressant Agents

Depression, a neurological disorder, is a universally common and debilitating illness where social and economic issues could also become one of its etiologic factors. From a global perspective, it is the fourth leading cause of long-term disability in human beings. For centuries, natural products have proven their true potential to combat various diseases and disorders, including depression and its associated ailments. Translational informatics applies informatics models at molecular, imaging, individual, and population levels to promote the translation of basic research to clinical applications. The present review summarizes natural-antidepressant-based translational informatics studies and addresses challenges and opportunities for future research in the field.

The CanPain SCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord injury: 2021 update

STUDY DESIGN

Clinical practice guidelines.

OBJECTIVES

The objective was to update the 2016 version of the Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI).

SETTING

The guidelines are relevant for inpatient, outpatient and community SCI rehabilitation settings in Canada.

METHODS

The guidelines were updated in accordance with the Appraisal of Guidelines for Research and Evaluation II tool. A Steering Committee and Working Group reviewed the relevant evidence on neuropathic pain management (encompassing screening and diagnosis, treatment and models of care) after SCI. The quality of evidence was scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A consensus process was followed to achieve agreement on recommendations and clinical considerations.

RESULTS

The working group identified and reviewed 46 additional relevant articles published since the last version of the guidelines. The panel agreed on 3 new screening and diagnosis recommendations and 8 new treatment recommendations. Two key changes to these treatment recommendations included the introduction of general treatment principles and a new treatment recommendation classification system. No new recommendations to model of care were made.

CONCLUSIONS

The CanPainSCI recommendations for the management of neuropathic pain after SCI should be used to inform practice.

Non-parenteral Ketamine for Depression: A Practical Discussion on Addiction Potential and Recommendations for Judicious Prescribing

Intravenous (IV) ketamine is increasingly used off-label at subanesthetic doses for its rapid antidepressant effect, and intranasal (IN) esketamine has been recently approved in several countries for treating depression. The clinical utility of these treatments is limited by a paucity of publicly funded IV ketamine and IN esketamine programs and cost barriers to private treatment programs, as well as the drug cost for IN esketamine itself, which makes generic ketamine alternatives an attractive option. Though evidence is limited, use of non-parenteral racemic ketamine formulations (oral, sublingual, and IN) may offer more realistic access in less rigidly supervised settings, both for acute and maintenance treatment in select cases. However, the psychiatric literature has repeatedly cautioned on the addictive potential of ketamine and raised caution for both less supervised and longer-term use of ketamine. To date, these concerns have not been discussed in view of available evidence, nor have they been discussed within a broader clinical context. This paper examines the available relevant literature and suggests that ketamine misuse risks appear not dissimilar to those of other well-established and commonly prescribed agents with abuse potential, such as stimulants or benzodiazepines. As such, ketamine prescribing should be considered in a similar risk/benefit context to balance patient access and need for treatment with concern for potential substance misuse. Our consortium of mood disorder specialists with significant ketamine prescribing experience considers prescribing of non-parenteral ketamine a reasonable clinical treatment option in select cases of treatment-resistant depression. This paper outlines where this may be appropriate and makes practical recommendations for clinicians in judicious prescribing of non-parenteral ketamine.

rTMS Therapy Reduces Hypofrontality in Patients With Depression as Measured by fNIRS

Multichannel functional near-infrared spectroscopy (fNIRS) is a tool used to capture changes in cerebral blood flow. A consistent result for depression is a decrease in blood flow in the frontal cortex leading to hypofrontality, which indicates multidomain functional impairment. Repetitive transcranial magnetic stimulation (rTMS) and elective convulsive therapy (ECT) are alternatives to antidepressant drugs for the treatment of depression but the underlying mechanism is yet to be elucidated. The aim of the current study was to evaluate cerebral blood flow using fNIRS following rTMS treatment in patients with depression. The cerebral blood flow of 15 patients with moderate depression after rTMS treatment was measured using fNIRS. While there was clear hypofrontality during pre-treatment (5 ± 2.5), a notable increase in oxygenated hemoglobin was observed after 30 sessions with rTMS (50 ± 15). This increased blood flow was observed in a wide range of channels in the frontal cortex; however, the centroid values were similar between the treatments. Increased blood flow leads to the activation of neuronal synapses, as noted with other neuromodulation treatments such as electroconvulsive therapy. This study describes the rTMS-induced modulation of blood oxygenation response over the prefrontal cortex in patients with depression, as captured by fNIRS. Future longitudinal studies are needed to assess cerebral blood flow dynamics during rTMS treatment for depression.