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Dellink A, Hebbrecht K, Zeeuws D, Baeken C, De Fré G, Bervoets C, De Witte S, Sabbe B, Morrens M, Coppens V. Continuous theta burst stimulation for bipolar depression: A multicenter, double-blind randomized controlled study exploring treatment efficacy and predictive potential of kynurenine metabolites. J Affect Disord 2024; 361:693-701. [PMID: 38936704 DOI: 10.1016/j.jad.2024.06.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/14/2024] [Accepted: 06/22/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND While theta burst stimulation (TBS) shows promise in Major Depressive Disorder (MDD), its effectiveness in bipolar depression (BD-D) remains uncertain. Optimizing treatment parameters is crucial in the pursuit of rapid symptom relief. Moreover, aligning with personalized treatment strategies and increased interest in immunopsychiatry, biomarker-based stratification of patients most likely to benefit from TBS might improve remission rates. We investigated treatment effectiveness of continuous TBS (cTBS) compared to sham in BD-D, and assessed the capacity of plasma kynurenine pathway metabolites to predict treatment outcome. METHODS Thirty-seven patients with BD-D underwent accelerated active or sham cTBS treatment in a multicenter, double-blind, randomized controlled trial. Depressive symptoms were measured with the 17-item Hamilton Depression Rating Scale (HDRS-17) before treatment (T0), 3-4 days posttreatment (T1) and 10-11 days posttreatment (T2). Plasma tryptophan, kynurenine, kynurenic acid and quinolinic acid concentrations were quantified with ELISA. Linear mixed models were used for statistical analyses. RESULTS Although the total sample showed depressive symptom improvement, active cTBS did not demonstrate greater symptom alleviation compared to sham. However, higher baseline quinolinic acid significantly predicted symptom improvement in the active treatment group, not in sham-stimulated patients. LIMITATIONS The modest sample size limited the power to detect significant differences with regard to treatment effect. Also, the follow-up period was 10-11 days, whereas similar studies usually follow up for at least one month. CONCLUSION More research is required to optimize cTBS for BD-D and explore the involvement of quinolinic acid in treatment outcome.
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Affiliation(s)
- Annelies Dellink
- Scientific Initiative of Neuropsychiatric and Psychopharmacological Studies (SINAPS), University Psychiatric Centre Duffel, Duffel, Belgium; Collaborative Antwerp Psychiatric Research Institute (CAPRI), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Kaat Hebbrecht
- Scientific Initiative of Neuropsychiatric and Psychopharmacological Studies (SINAPS), University Psychiatric Centre Duffel, Duffel, Belgium; Collaborative Antwerp Psychiatric Research Institute (CAPRI), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Department of Psychiatry, University Psychiatric Center KU Leuven, Leuven, Belgium
| | - Dieter Zeeuws
- Department of Psychiatry, Universitair Ziekenhuis Brussel, Brussels, Belgium; Neuroprotection and Neuromodulation Research Group (NEUR), Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Chris Baeken
- Department of Psychiatry, Universitair Ziekenhuis Brussel, Brussels, Belgium; Neuroprotection and Neuromodulation Research Group (NEUR), Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium; Ghent Experimental Psychiatry (GHEP) Lab, Ghent University, Ghent, Belgium
| | | | - Chris Bervoets
- Department of Psychiatry, University Psychiatric Center KU Leuven, Leuven, Belgium
| | - Sara De Witte
- Neuroprotection and Neuromodulation Research Group (NEUR), Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium; Ghent Experimental Psychiatry (GHEP) Lab, Ghent University, Ghent, Belgium
| | - Bernard Sabbe
- Scientific Initiative of Neuropsychiatric and Psychopharmacological Studies (SINAPS), University Psychiatric Centre Duffel, Duffel, Belgium; Collaborative Antwerp Psychiatric Research Institute (CAPRI), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Manuel Morrens
- Scientific Initiative of Neuropsychiatric and Psychopharmacological Studies (SINAPS), University Psychiatric Centre Duffel, Duffel, Belgium; Collaborative Antwerp Psychiatric Research Institute (CAPRI), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Violette Coppens
- Scientific Initiative of Neuropsychiatric and Psychopharmacological Studies (SINAPS), University Psychiatric Centre Duffel, Duffel, Belgium; Collaborative Antwerp Psychiatric Research Institute (CAPRI), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Trapp NT, Barbour T, Kritzer MD, Pottanat R, Carreon D, Chen L, Brown J, Siddiqi S. Defining a Neurostimulation-Focused Subspecialty: Perspectives Inspired by a Debate at the 2023 Clinical TMS Society Annual Meeting. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2024:10.1007/s40596-024-02025-2. [PMID: 39148002 DOI: 10.1007/s40596-024-02025-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 08/04/2024] [Indexed: 08/17/2024]
Affiliation(s)
| | | | | | | | | | - Leo Chen
- Monash University, Melbourne, Victoria, Australia
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Kim H, Kornman PT, Kweon J, Wassermann EM, Wright DL, Li J, Brown JC. Combined effects of pharmacological interventions and intermittent theta-burst stimulation on motor sequence learning. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.07.24.604878. [PMID: 39211172 PMCID: PMC11361068 DOI: 10.1101/2024.07.24.604878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Drugs that modulate N-methyl-D-aspartate (NMDA) or γ-Aminobutyric acid type A (GABA A ) receptors can shed light on their role in synaptic plasticity mechanisms underlying the effects of non-invasive brain stimulation. However, research on the combined effects of these drugs and exogenous stimulation on motor learning is limited. This study aimed to investigate the effects of pharmacological interventions combined with intermittent theta-burst stimulation (iTBS) on human motor learning. Nine right-handed healthy subjects (mean age ± SD: 31.56 ± 12.96 years; 6 females) participated in this double-blind crossover study. All participants were assigned to four drug conditions in a randomized order: (1) D-cycloserine (partial NMDA receptor agonist), (2) D-cycloserine + dextromethorphan (NMDA receptor agonist + antagonist), (3) lorazepam (GABA A receptor agonist), and (4) placebo (identical microcrystalline cellulose capsule). After drug intake, participants practiced the 12-item keyboard sequential task as a baseline measure. Two hours after drug intake, iTBS was administered at the primary motor cortex. Following iTBS, the retention test was performed in the same manner as the baseline measure. Our findings revealed that lorazepam combined with iTBS impaired motor learning during the retention test. Future studies are still needed for a better understanding of the mechanisms through which TMS may influence human motor learning.
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Kweon J, Vigne M, Fukuda AM, Ren B, Carpenter LL, Brown JC. NMDA and GABA Receptor-Mediated Plasticity Induced by 10-Hz Repetitive Transcranial Magnetic Stimulation. RESEARCH SQUARE 2024:rs.3.rs-4630964. [PMID: 38978559 PMCID: PMC11230474 DOI: 10.21203/rs.3.rs-4630964/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Although 10-Hz repetitive transcranial magnetic stimulation (rTMS) is an FDA-approved treatment for depression, we have yet to fully understand the mechanism through which rTMS induces therapeutic and durable changes in the brain. Two competing theories have emerged suggesting that 10-Hz rTMS induces N-methyl-D-aspartate receptor (NMDAR)-dependent long-term potentiation (LTP), or alternatively, removal of inhibitory gamma-aminobutyric acid receptors (GABARs). We examined these two proposed mechanisms of action in the human motor cortex in a double-blind, randomized, four-arm crossover study in healthy subjects. We tested motor-evoked potentials (MEPs) before and after 10-Hz rTMS in the presence of four drugs separated by 1-week each: placebo, NMDAR partial agonist d-cycloserine (DCS 100mg), DCS 100mg + NMDAR partial antagonist dextromethorphan (DMO 150mg; designed to "knock down" DCS-mediated facilitation), and GABAR agonist lorazepam (LZP 2.5mg). NMDAR agonism by DCS enhanced rTMS-induced cortical excitability more than placebo. This enhancement was blocked by combining DCS with NMDAR antagonist, DMO. If GABARs are removed by rTMS, GABAR agonism via LZP should lack its inhibitory effect yielding higher post/pre MEPs. However, MEPs were reduced after rTMS indicating stability of GABAR numbers. These data suggest that 10-Hz rTMS facilitation in the healthy motor cortex may enact change in the brain through NMDAR-mediated LTP-like mechanisms rather than through GABAergic reduction.
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Affiliation(s)
- Jamie Kweon
- Brain Stimulation Mechanisms Laboratory, Neurotherapeutics, Division of Depression and Anxiety, McLean Hospital
| | - Megan Vigne
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Butler Hospital
| | - Andrew M Fukuda
- Brain Stimulation Mechanisms Laboratory, Neurotherapeutics, Division of Depression and Anxiety, McLean Hospital
| | - Boyu Ren
- Department of Psychiatry, Harvard Medical School
| | - Linda L Carpenter
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Butler Hospital
| | - Joshua C Brown
- Brain Stimulation Mechanisms Laboratory, Neurotherapeutics, Division of Depression and Anxiety, McLean Hospital
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Brown JC, Kweon J, Sharma P, Siddiqi SH, Isserles M, Ressler KJ. Critically Assessing the Unanswered Questions of How, Where, and When to Induce Plasticity in the Posttraumatic Stress Disorder Network With Transcranial Magnetic Stimulation. Biol Psychiatry 2024:S0006-3223(24)01390-8. [PMID: 38909668 DOI: 10.1016/j.biopsych.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 06/02/2024] [Accepted: 06/10/2024] [Indexed: 06/25/2024]
Abstract
Extinction of traumatic memory, a primary treatment approach (termed exposure therapy) in posttraumatic stress disorder (PTSD), occurs through relearning and may be subserved at the molecular level by long-term potentiation of relevant circuits. In parallel, repetitive transcranial magnetic stimulation (TMS) is thought to work through long-term potentiation-like mechanisms and may provide a novel, safe, and effective treatment for PTSD. In a recent failed randomized controlled trial we emphasized the necessity of correctly identifying cortical targets, the directionality of TMS protocols, and the role of memory activation. Here, we provide a systematic review of TMS for PTSD to further identify how, where, and when TMS treatment should be delivered to alleviate PTSD symptoms. We conducted a systematic review of the literature by searching for repetitive TMS clinical trials involving patients with PTSD and outcomes. We searched MEDLINE through October 25, 2023, for "TMS and PTSD" and "transcranial magnetic stimulation and posttraumatic stress disorder." Thirty-one publications met our inclusion criteria (k = 17 randomized controlled trials, k = 14 open label). Randomized controlled trial protocols were varied in terms of TMS protocols, cortical TMS targets, and memory activation protocols. There was no clear superiority of low-frequency (k = 5) versus high-frequency (k = 6) protocols or by stimulation location. Memory provocation or exposure protocols (k = 7) appear to enhance response. Overall, TMS appears to be effective in treating PTSD symptoms across a variety of TMS frequencies, hemispheric target differences, and exposure protocols. Disparate protocols may be conceptually harmonized when viewed as potentiating proposed anxiolytic networks or suppressing anxiogenic networks.
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Affiliation(s)
- Joshua C Brown
- Division of Depression and Anxiety Disorders, McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.
| | - Jamie Kweon
- Division of Depression and Anxiety Disorders, McLean Hospital, Belmont, Massachusetts
| | - Prayushi Sharma
- Division of Depression and Anxiety Disorders, McLean Hospital, Belmont, Massachusetts
| | - Shan H Siddiqi
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts; Center for Brain Circuit Therapeutics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Moshe Isserles
- Department of Psychiatry, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Kerry J Ressler
- Division of Depression and Anxiety Disorders, McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.
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Li X, Liu J, Wei S, Yu C, Wang D, Li Y, Li J, Zhuang W, Luo RCX, Li Y, Liu Z, Su Y, Liu J, Xu Y, Fan J, Zhu G, Xu W, Tang Y, Yan H, Cho RY, Kosten TR, Zhou D, Zhang X. Cognitive enhancing effect of rTMS combined with tDCS in patients with major depressive disorder: a double-blind, randomized, sham-controlled study. BMC Med 2024; 22:253. [PMID: 38902735 PMCID: PMC11188255 DOI: 10.1186/s12916-024-03443-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 05/24/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Cognitive dysfunction is one of the common symptoms in patients with major depressive disorder (MDD). Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) have been studied separately in the treatment of cognitive dysfunction in MDD patients. We aimed to investigate the effectiveness and safety of rTMS combined with tDCS as a new therapy to improve neurocognitive impairment in MDD patients. METHODS In this brief 2-week, double-blind, randomized, and sham-controlled trial, a total of 550 patients were screened, and 240 MDD inpatients were randomized into four groups (active rTMS + active tDCS, active rTMS + sham tDCS, sham rTMS + active tDCS, sham rTMS + sham tDCS). Finally, 203 patients completed the study and received 10 treatment sessions over a 2-week period. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was performed to assess patients' cognitive function at baseline and week 2. Also, we applied the 24-item Hamilton Depression Rating Scale (HDRS-24) to assess patients' depressive symptoms at baseline and week 2. RESULTS After 10 sessions of treatment, the rTMS combined with the tDCS group showed more significant improvements in the RBANS total score, immediate memory, and visuospatial/constructional index score (all p < 0.05). Moreover, post hoc tests revealed a significant increase in the RBANS total score and Visuospatial/Constructional in the combined treatment group compared to the other three groups but in the immediate memory, the combined treatment group only showed a better improvement than the sham group. The results also showed the RBANS total score increased significantly higher in the active rTMS group compared with the sham group. However, rTMS or tDCS alone was not superior to the sham group in terms of other cognitive performance. In addition, the rTMS combined with the tDCS group showed a greater reduction in HDRS-24 total score and a better depression response rate than the other three groups. CONCLUSIONS rTMS combined with tDCS treatment is more effective than any single intervention in treating cognitive dysfunction and depressive symptoms in MDD patients. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR2100052122).
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Affiliation(s)
- Xingxing Li
- Ningbo Key Laboratory for Physical Diagnosis and Treatment of Mental and Psychological Disorders, Affiliated Kangning Hospital of Ningbo University (Ningbo Kangning Hospital), Ningbo, Zhejiang, China
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Junyao Liu
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Shuochi Wei
- Ningbo Key Laboratory for Physical Diagnosis and Treatment of Mental and Psychological Disorders, Affiliated Kangning Hospital of Ningbo University (Ningbo Kangning Hospital), Ningbo, Zhejiang, China
| | - Chang Yu
- Ningbo Key Laboratory for Physical Diagnosis and Treatment of Mental and Psychological Disorders, Affiliated Kangning Hospital of Ningbo University (Ningbo Kangning Hospital), Ningbo, Zhejiang, China
| | - Dongmei Wang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Yuchen Li
- Ningbo Key Laboratory for Physical Diagnosis and Treatment of Mental and Psychological Disorders, Affiliated Kangning Hospital of Ningbo University (Ningbo Kangning Hospital), Ningbo, Zhejiang, China
| | - Jiaxin Li
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Wenhao Zhuang
- Ningbo Key Laboratory for Physical Diagnosis and Treatment of Mental and Psychological Disorders, Affiliated Kangning Hospital of Ningbo University (Ningbo Kangning Hospital), Ningbo, Zhejiang, China
| | - Rui-Chen-Xi Luo
- Ningbo Key Laboratory for Physical Diagnosis and Treatment of Mental and Psychological Disorders, Affiliated Kangning Hospital of Ningbo University (Ningbo Kangning Hospital), Ningbo, Zhejiang, China
| | - Yanli Li
- Ningbo Key Laboratory for Physical Diagnosis and Treatment of Mental and Psychological Disorders, Affiliated Kangning Hospital of Ningbo University (Ningbo Kangning Hospital), Ningbo, Zhejiang, China
| | - Zhiwang Liu
- Ningbo Key Laboratory for Physical Diagnosis and Treatment of Mental and Psychological Disorders, Affiliated Kangning Hospital of Ningbo University (Ningbo Kangning Hospital), Ningbo, Zhejiang, China
| | - Yuqiu Su
- Ningbo Key Laboratory for Physical Diagnosis and Treatment of Mental and Psychological Disorders, Affiliated Kangning Hospital of Ningbo University (Ningbo Kangning Hospital), Ningbo, Zhejiang, China
| | - Jimeng Liu
- Ningbo Key Laboratory for Physical Diagnosis and Treatment of Mental and Psychological Disorders, Affiliated Kangning Hospital of Ningbo University (Ningbo Kangning Hospital), Ningbo, Zhejiang, China
| | - Yongming Xu
- Ningbo Key Laboratory for Physical Diagnosis and Treatment of Mental and Psychological Disorders, Affiliated Kangning Hospital of Ningbo University (Ningbo Kangning Hospital), Ningbo, Zhejiang, China
| | - Jialin Fan
- The Second People's Hospital of Lishui, Lishui, Zhejiang, China
| | - Guidong Zhu
- The Second People's Hospital of Lishui, Lishui, Zhejiang, China
| | - Weiqian Xu
- Taizhou Second People's Hospital, Taizhou, Zhejiang, China
| | - Yiping Tang
- Taizhou Second People's Hospital, Taizhou, Zhejiang, China
| | - Hui Yan
- Taizhou Second People's Hospital, Taizhou, Zhejiang, China
| | - Raymond Y Cho
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Thomas R Kosten
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Dongsheng Zhou
- Ningbo Key Laboratory for Physical Diagnosis and Treatment of Mental and Psychological Disorders, Affiliated Kangning Hospital of Ningbo University (Ningbo Kangning Hospital), Ningbo, Zhejiang, China.
| | - Xiangyang Zhang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China.
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China.
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Kochanowski B, Kageki-Bonnert K, Pinkerton EA, Dougherty DD, Chou T. A Review of Transcranial Magnetic Stimulation and Transcranial Direct Current Stimulation Combined with Medication and Psychotherapy for Depression. Harv Rev Psychiatry 2024; 32:77-95. [PMID: 38728568 DOI: 10.1097/hrp.0000000000000396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
LEARNING OBJECTIVES After participating in this CME activity, the psychiatrist should be better able to:• Compare and contrast therapies used in combination with transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) for treating MDD. BACKGROUND Noninvasive neuromodulation, such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), has emerged as a major area for treating major depressive disorder (MDD). This review has two primary aims: (1) to review the current literature on combining TMS and tDCS with other therapies, such as psychotherapy and psychopharmacological interventions, and (2) to discuss the efficacy, feasibility, limitations, and future directions of these combined treatments for MDD. METHOD This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched three databases: PubMed, PsycInfo, and Cochrane Library. The last search date was December 5, 2023. RESULTS The initial search revealed 2,519 records. After screening and full-text review, 58 studies (7 TMS plus psychotherapy, 32 TMS plus medication, 7 tDCS plus psychotherapy, 12 tDCS plus medication) were included. CONCLUSIONS The current literature on tDCS and TMS paired with psychotherapy provides initial support for integrating mindfulness interventions with both TMS and tDCS. Adding TMS or tDCS to stable doses of ongoing medications can decrease MDD symptoms; however, benzodiazepines may interfere with TMS and tDCS response, and antipsychotics can interfere with TMS response. Pairing citalopram with TMS and sertraline with tDCS can lead to greater MDD symptom reduction compared to using these medications alone. Future studies need to enroll larger samples, include randomized controlled study designs, create more uniform protocols for combined treatment delivery, and explore mechanisms and predictors of change.
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Affiliation(s)
- Brian Kochanowski
- From Harvard Medical School, Division of Neurotherapeutics, Department of Psychiatry, Massachusetts General Hospital, Charlestown, MA
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Tsai HA, Shih TM, Tsai T, Hu JW, Lai YA, Hsiao JF, Tsai GE. Fabrication of nanocrystal forms of ᴅ-cycloserine and their application for transdermal and enteric drug delivery systems. BEILSTEIN JOURNAL OF NANOTECHNOLOGY 2024; 15:465-474. [PMID: 38711579 PMCID: PMC11070952 DOI: 10.3762/bjnano.15.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 02/27/2024] [Indexed: 05/08/2024]
Abstract
ᴅ-cycloserine (DCS), an FDA-approved medicine for the treatment of tuberculosis, is also a partial agonist at the glycine recognition site of N-methyl-ᴅ-aspartate (NMDA) receptor and has shown significant treatment efficacy for central nervous system (CNS) disorders including depression, schizophrenia, Alzheimer's disease, and post-traumatic stress disorder. The physicochemical properties of DCS, however, limit the options of formulation and medicinal applications of DCS, and warrants further investigation for the development of CNS therapeutics. Nanocrystals play an important role in pharmaceutic design and development. The properties of nanocrystals are remarkably different from their bulk material counterpart, attributed to the large surface-area-to-volume ratio which can improve the bioavailability. In this study, for the first time, DCS, a highly water-soluble compound, has formed nanocrystals and this was confirmed by scanning electronic microscopy and X-ray powder diffraction. Furthermore, DCS nanocrystals were applied to several formulations to test their stability and then to the in vitro Franz diffusion test with reservoir patch formulation as well as in vivo pharmacokinetics study with enteric capsules. We tested these formulations regarding their nanocrystal physical properties, size effect, and dissolution rate, respectively. We found that DCS nanocrystals showed good performance in the Franz diffusion test and rodent pharmacokinetic studies due to the nanoparticle size and faster dissolution as compared with the commercial DCS powder. These DCS nanocrystal formulations could offer a new approach for the development of an advanced drug delivery system for the treatment of CNS disorders.
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Affiliation(s)
- Hsuan-Ang Tsai
- Department of Research and Development, SyneuRx International (Taiwan) Corp., 20F-8, No. 99, Sec. 1, Xintai 5th Rd., Xizhi District, New Taipei City 221, Taiwan
| | - Tsai-Miao Shih
- Department of Research and Development, SyneuRx International (Taiwan) Corp., 20F-8, No. 99, Sec. 1, Xintai 5th Rd., Xizhi District, New Taipei City 221, Taiwan
| | - Theodore Tsai
- Department of Research and Development, SyneuRx International (Taiwan) Corp., 20F-8, No. 99, Sec. 1, Xintai 5th Rd., Xizhi District, New Taipei City 221, Taiwan
| | - Jhe-Wei Hu
- Department of Research and Development, SyneuRx International (Taiwan) Corp., 20F-8, No. 99, Sec. 1, Xintai 5th Rd., Xizhi District, New Taipei City 221, Taiwan
| | - Yi-An Lai
- Department of Research and Development, SyneuRx International (Taiwan) Corp., 20F-8, No. 99, Sec. 1, Xintai 5th Rd., Xizhi District, New Taipei City 221, Taiwan
| | - Jui-Fu Hsiao
- Department of Research and Development, SyneuRx International (Taiwan) Corp., 20F-8, No. 99, Sec. 1, Xintai 5th Rd., Xizhi District, New Taipei City 221, Taiwan
| | - Guochuan Emil Tsai
- Department of Research and Development, SyneuRx International (Taiwan) Corp., 20F-8, No. 99, Sec. 1, Xintai 5th Rd., Xizhi District, New Taipei City 221, Taiwan
- Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
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Brown KA, Gould TD. Targeting metaplasticity mechanisms to promote sustained antidepressant actions. Mol Psychiatry 2024; 29:1114-1127. [PMID: 38177353 PMCID: PMC11176041 DOI: 10.1038/s41380-023-02397-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 01/06/2024]
Abstract
The discovery that subanesthetic doses of (R, S)-ketamine (ketamine) and (S)-ketamine (esketamine) rapidly induce antidepressant effects and promote sustained actions following drug clearance in depressed patients who are treatment-resistant to other therapies has resulted in a paradigm shift in the conceptualization of how rapidly and effectively depression can be treated. Consequently, the mechanism(s) that next generation antidepressants may engage to improve pathophysiology and resultant symptomology are being reconceptualized. Impaired excitatory glutamatergic synapses in mood-regulating circuits are likely a substantial contributor to the pathophysiology of depression. Metaplasticity is the process of regulating future capacity for plasticity by priming neurons with a stimulation that alters later neuronal plasticity responses. Accordingly, the development of treatment modalities that specifically modulate the duration, direction, or magnitude of glutamatergic synaptic plasticity events such as long-term potentiation (LTP), defined here as metaplastogens, may be an effective approach to reverse the pathophysiology underlying depression and improve depression symptoms. We review evidence that the initiating mechanisms of pharmacologically diverse rapid-acting antidepressants (i.e., ketamine mimetics) converge on consistent downstream molecular mediators that facilitate the expression/maintenance of increased synaptic strength and resultant persisting antidepressant effects. Specifically, while the initiating mechanisms of these therapies may differ (e.g., cell type-specificity, N-methyl-D-aspartate receptor (NMDAR) subtype-selective inhibition vs activation, metabotropic glutamate receptor 2/3 antagonism, AMPA receptor potentiation, 5-HT receptor-activating psychedelics, etc.), the sustained therapeutic mechanisms of putative rapid-acting antidepressants will be mediated, in part, by metaplastic effects that converge on consistent molecular mediators to enhance excitatory neurotransmission and altered capacity for synaptic plasticity. We conclude that the convergence of these therapeutic mechanisms provides the opportunity for metaplasticity processes to be harnessed as a druggable plasticity mechanism by next-generation therapeutics. Further, targeting metaplastic mechanisms presents therapeutic advantages including decreased dosing frequency and associated diminished adverse responses by eliminating the requirement for the drug to be continuously present.
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Affiliation(s)
- Kyle A Brown
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Todd D Gould
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Department of Neurobiology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Veterans Affairs Maryland Health Care System, Baltimore, MD, 21201, USA.
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Martin DM, Su Y, Chan HF, Dielenberg V, Chow E, Xu M, Wang A, Nikolin S, Moffa AH, Loo CK. Individualised Transcranial Magnetic Stimulation Targeting of the Left Dorsolateral Prefrontal Cortex for Enhancing Cognition: A Randomised Controlled Trial. Brain Sci 2024; 14:299. [PMID: 38671951 PMCID: PMC11048387 DOI: 10.3390/brainsci14040299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024] Open
Abstract
Repetitive transcranial magnetic stimulation (rTMS) has been demonstrated to produce cognitive enhancing effects across different neuropsychiatric disorders; however, so far, these effects have been limited. This trial investigated the efficacy of using a novel individualised approach to target the left dorsolateral prefrontal cortex (L-DLPFC) for enhancing cognitive flexibility based on performance on a cognitive task. First, forty healthy participants had their single target site at the L-DLPFC determined based on each individual's performance on a random letter generation task. Participants then received, in a cross-over single-blinded experimental design, a single session of intermittent theta burst stimulation (iTBS) to their individualised DLPFC target site, an active control site and sham iTBS. Following each treatment condition, participants completed the Task Switching task and Colour-Word Stroop test. There was no significant main effect of treatment condition on the primary outcome measure of switch reaction times from the Task Switching task [F = 1.16 (2, 21.6), p = 0.33] or for any of the secondary cognitive outcome measures. The current results do not support the use of our novel individualised targeting methodology for enhancing cognitive flexibility in healthy participants. Research into alternative methodological targeting approaches is required to further improve rTMS's cognitive enhancing effects.
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Affiliation(s)
- Donel M. Martin
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
- Black Dog Institute, Sydney, NSW 2031, Australia
| | - Yon Su
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
| | - Ho Fung Chan
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
| | - Victoria Dielenberg
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
| | - Esther Chow
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
| | - Mei Xu
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
- Black Dog Institute, Sydney, NSW 2031, Australia
| | - Ashley Wang
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
| | - Stevan Nikolin
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
- Black Dog Institute, Sydney, NSW 2031, Australia
| | - Adriano H. Moffa
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
- Black Dog Institute, Sydney, NSW 2031, Australia
| | - Colleen K. Loo
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
- Black Dog Institute, Sydney, NSW 2031, Australia
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11
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Siddiqi SH, Fox MD. Targeting Symptom-Specific Networks With Transcranial Magnetic Stimulation. Biol Psychiatry 2024; 95:502-509. [PMID: 37979642 DOI: 10.1016/j.biopsych.2023.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 10/31/2023] [Accepted: 11/14/2023] [Indexed: 11/20/2023]
Abstract
Increasing evidence suggests that the clinical effects of transcranial magnetic stimulation are target dependent. Within any given symptom, precise targeting of specific brain circuits may improve clinical outcomes. This principle can also be extended across symptoms-stimulation of different circuits may lead to different symptom-level outcomes. This may include targeting different symptoms within the same disorder (such as dysphoria vs. anxiety in patients with major depression) or targeting the same symptom across different disorders (such as primary major depression and depression secondary to stroke, traumatic brain injury, epilepsy, multiple sclerosis, or Parkinson's disease). Some of these symptom-specific changes may be desirable, while others may be undesirable. This review focuses on the conceptual framework through which symptom-specific target circuits may be identified, tested, and implemented.
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Affiliation(s)
- Shan H Siddiqi
- Center for Brain Circuit Therapeutics, Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.
| | - Michael D Fox
- Center for Brain Circuit Therapeutics, Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts; Department of Neurology, Harvard Medical School, Boston, Massachusetts
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12
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Cole E, O'Sullivan SJ, Tik M, Williams NR. Accelerated Theta Burst Stimulation: Safety, Efficacy, and Future Advancements. Biol Psychiatry 2024; 95:523-535. [PMID: 38383091 PMCID: PMC10952126 DOI: 10.1016/j.biopsych.2023.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 12/05/2023] [Accepted: 12/08/2023] [Indexed: 02/23/2024]
Abstract
Theta burst stimulation (TBS) is a noninvasive brain stimulation technique that can be used to modulate neural networks underlying psychiatric and neurological disorders. TBS can be delivered intermittently or continuously. The conventional intermittent TBS protocol is approved by the U.S. Food and Drug Administration to treat otherwise treatment-resistant depression, but the 6-week duration limits the applicability of this therapy. Accelerated TBS protocols present an opportunity to deliver higher pulse doses in shorter periods of time, thus resulting in faster and potentially more clinically effective treatment. However, the acceleration of TBS delivery raises questions regarding the relative safety, efficacy, and durability compared with conventional TBS protocols. In this review paper, we present the data from accelerated TBS trials to date that support the safety and effectiveness of accelerated protocols while acknowledging the need for more durability data. We discuss the stimulation parameters that seem to be important for the efficacy of accelerated TBS protocols and possible avenues for further optimization.
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Affiliation(s)
- Eleanor Cole
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Sean J O'Sullivan
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California; Department of Psychiatry and Behavioral Sciences, Dell School of Medicine, Austin, Texas
| | - Martin Tik
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California; Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Nolan R Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California.
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13
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Farzan F. Transcranial Magnetic Stimulation-Electroencephalography for Biomarker Discovery in Psychiatry. Biol Psychiatry 2024; 95:564-580. [PMID: 38142721 DOI: 10.1016/j.biopsych.2023.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 12/08/2023] [Accepted: 12/15/2023] [Indexed: 12/26/2023]
Abstract
Current diagnosis and treatment of psychiatric illnesses are still based on behavioral observations and self-reports, commonly leading to prolonged untreated illness. Biological markers (biomarkers) may offer an opportunity to revolutionize clinical psychiatry practice by helping provide faster and potentially more effective therapies. Transcranial magnetic stimulation concurrent with electroencephalography (TMS-EEG) is a noninvasive brain mapping methodology that can assess the functions and dynamics of specific brain circuitries in awake humans and aid in biomarker discovery. This article provides an overview of TMS-EEG-based biomarkers that may hold potential in psychiatry. The methodological readiness of the TMS-EEG approach and steps in the validation of TMS-EEG biomarkers for clinical utility are discussed. Biomarker discovery with TMS-EEG is in the early stages, and several validation steps are still required before clinical implementations are realized. Thus far, TMS-EEG predictors of response to magnetic brain stimulation treatments in particular have shown promise for translation to clinical practice. Larger-scale studies can confirm validation followed by biomarker-informed trials to assess added value compared to existing practice.
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Affiliation(s)
- Faranak Farzan
- eBrain Lab, School of Mechatronic Systems Engineering, Simon Fraser University, Surrey, British Columbia, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
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14
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Cunningham JE, Bluhm R, Achtyes ED, McCright AM, Cabrera LY. Guideline-based care for psychiatric electroceuticals: Results from a National Survey of Board-Certified Psychiatrists. J Eval Clin Pract 2024; 30:290-295. [PMID: 38050435 PMCID: PMC11096671 DOI: 10.1111/jep.13948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/09/2023] [Accepted: 10/19/2023] [Indexed: 12/06/2023]
Affiliation(s)
- Joshua E. Cunningham
- College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Robyn Bluhm
- Department of Philosophy, Lyman Briggs College, Michigan State University, East Lansing, Michigan, USA
| | - Eric D. Achtyes
- Department of Psychiatry, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Aaron M. McCright
- Department of Sociology, Michigan State University, East Lansing, Michigan, USA
| | - Laura Y. Cabrera
- Department of Engineering Science and Mechanics, Center for Neural Engineering, Pennsylvania State University, University Park, Pennsylvania, USA
- Rock Ethics Institute, Pennsylvania State University, University Park, Pennsylvania, USA
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15
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White TL, Gonsalves MA, Harris AD, Walsh EG, Joyce HE. Brain Glutamate Dynamics Predict Positive Agency in Healthy Women: Insights from Combined Application of Pharmacological Challenge, Comprehensive Affective Assessment, and Magnetic Resonance Spectroscopy. ACS Chem Neurosci 2024; 15:491-502. [PMID: 38237555 DOI: 10.1021/acschemneuro.3c00521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
Contributions of brain glutamate (Glu) to conscious emotion are not well understood. Here, we evaluate the relationship of experimentally induced change in neocortical Glu (ΔGlu) and subjective states in well individuals, using combined application of pharmacological challenge, magnetic resonance spectroscopy (MRS), and comprehensive affective assessment. Drug challenge with d-amphetamine (AMP) (20 mg oral), methamphetamine (MA) (Desoxyn, 20 mg oral), and placebo (PBO) was conducted on three separate test days in a within-subjects double blind design. Proton MRS quantified neurometabolites in the right dorsal anterior cingulate cortex 140-150 min post-drug and PBO. Subjective states were assessed at half hour intervals over 5.5 h on each session, yielding 3792 responses per participant (91,008 responses overall, N = 24 participants), with self-reports reduced by principal components analysis (PCA). PCA produced a primary factor score of AMP- and MA-induced positive agency (ΔPA). MRS indicated drug-induced ΔGlu related positively to ΔPA (ΔGluMA r = +0.44, p < 0.05, N = 21), with large effects in females (ΔGluMA r = +0.52, p < 0.05; ΔGluAMP r = +0.61, p < 0.05, N = 11). Subjective states related to ΔGlu included rise in subjective stimulation, vigor, friendliness, elation, positive mood, positive affect (r's = +0.51 to +0.74, p < 0.05), and alleviation of anxiety in females (r = -0.61, p < 0.05, N = 11). These self-reports correlated with ΔGlu to the extent they loaded on ΔPA (r = 0.95 AMP, p = 5 × 10-10; r = 0.63 MA, p = 0.0015, N = 11), indicating the coherence of ΔGlu effects on emotional states. Timing data indicated Glu shaped positive emotion both concurrently and prospectively, with no relationship with pre-MRS emotion (ΔGluAMP r = +0.59 to +0.65, p's < 0.05; ΔGluMA r = +0.53, p < 0.05, N = 11). Together these findings indicate substantive, mechanistic contributions of neocortical Glu to positive agentic states in healthy individuals, which are most readily observed in women. The findings illustrate the promise of combined application of pharmacological challenge, comprehensive affective assessment, and MRS neuroimaging techniques in basic and clinical studies.
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Affiliation(s)
- Tara L White
- Carney Institute for Brain Science, Brown University, Providence, Rhode Island 02912. United States
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island 02912. United States
- Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island 02912. United States
- Center for Human Rights and Humanitarian Studies, Watson Institute, Brown University, Providence, Rhode Island 02912. United States
- University of Cambridge, Clare Hall, Cambridge CB3 9AL England. U.K
| | - Meghan A Gonsalves
- Neuroscience Graduate Program, Brown University, Providence, Rhode Island 02912. United States
| | - Ashley D Harris
- Department of Radiology, CAIR Program, Alberta Children's Hospital Research Institute, and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta T2N 1N4, Canada
| | - Edward G Walsh
- Carney Institute for Brain Science, Brown University, Providence, Rhode Island 02912. United States
| | - Hannah E Joyce
- Undergraduate Program in Cognitive Neuroscience, Brown University, Providence, Rhode Island 02912. United States
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16
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Siddiqi SH, Khosravani S, Rolston JD, Fox MD. The future of brain circuit-targeted therapeutics. Neuropsychopharmacology 2024; 49:179-188. [PMID: 37524752 PMCID: PMC10700386 DOI: 10.1038/s41386-023-01670-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 08/02/2023]
Abstract
The principle of targeting brain circuits has drawn increasing attention with the growth of brain stimulation treatments such as transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and focused ultrasound (FUS). Each of these techniques can effectively treat different neuropsychiatric disorders, but treating any given disorder depends on choosing the right treatment target. Here, we propose a three-phase framework for identifying and modulating these targets. There are multiple approaches to identifying a target, including correlative neuroimaging, retrospective optimization based on existing stimulation sites, and lesion localization. These techniques can then be optimized using personalized neuroimaging, physiological monitoring, and engagement of a specific brain state using pharmacological or psychological interventions. Finally, a specific stimulation modality or combination of modalities can be chosen after considering the advantages and tradeoffs of each. While there is preliminary literature to support different components of this framework, there are still many unanswered questions. This presents an opportunity for the future growth of research and clinical care in brain circuit therapeutics.
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Affiliation(s)
- Shan H Siddiqi
- Center for Brain Circuit Therapeutics, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Sanaz Khosravani
- Center for Brain Circuit Therapeutics, Brigham and Women's Hospital, Boston, MA, USA
- Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - John D Rolston
- Center for Brain Circuit Therapeutics, Brigham and Women's Hospital, Boston, MA, USA
- Department of Neurosurgery, Harvard Medical School, Boston, MA, USA
| | - Michael D Fox
- Center for Brain Circuit Therapeutics, Brigham and Women's Hospital, Boston, MA, USA
- Department of Neurology, Harvard Medical School, Boston, MA, USA
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17
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Johnston JN, Kadriu B, Kraus C, Henter ID, Zarate CA. Ketamine in neuropsychiatric disorders: an update. Neuropsychopharmacology 2024; 49:23-40. [PMID: 37340091 PMCID: PMC10700638 DOI: 10.1038/s41386-023-01632-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/08/2023] [Accepted: 06/01/2023] [Indexed: 06/22/2023]
Abstract
The discovery of ketamine as a rapid-acting antidepressant led to a new era in the development of neuropsychiatric therapeutics, one characterized by an antidepressant response that occurred within hours or days rather than weeks or months. Considerable clinical research supports the use of-or further research with-subanesthetic-dose ketamine and its (S)-enantiomer esketamine in multiple neuropsychiatric disorders including depression, bipolar disorder, anxiety spectrum disorders, substance use disorders, and eating disorders, as well as for the management of chronic pain. In addition, ketamine often effectively targets symptom domains associated with multiple disorders, such as anxiety, anhedonia, and suicidal ideation. This manuscript: 1) reviews the literature on the pharmacology and hypothesized mechanisms of subanesthetic-dose ketamine in clinical research; 2) describes similarities and differences in the mechanism of action and antidepressant efficacy between racemic ketamine, its (S) and (R) enantiomers, and its hydroxynorketamine (HNK) metabolite; 3) discusses the day-to-day use of ketamine in the clinical setting; 4) provides an overview of ketamine use in other psychiatric disorders and depression-related comorbidities (e.g., suicidal ideation); and 5) provides insights into the mechanisms of ketamine and therapeutic response gleaned from the study of other novel therapeutics and neuroimaging modalities.
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Affiliation(s)
- Jenessa N Johnston
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Bashkim Kadriu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
- Translational and Experimental Medicine, Neuroscience at Jazz Pharmaceuticals, San Diego, CA, USA
| | - Christoph Kraus
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Ioline D Henter
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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18
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Heresco-Levy U, Lerer B. Synergistic psychedelic - NMDAR modulator treatment for neuropsychiatric disorders. Mol Psychiatry 2024; 29:146-152. [PMID: 37945694 DOI: 10.1038/s41380-023-02312-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 10/17/2023] [Accepted: 10/23/2023] [Indexed: 11/12/2023]
Abstract
Modern research data suggest a therapeutic role for serotonergic psychedelics in depression and other neuropsychiatric disorders, although psychotomimetic effects may limit their widespread utilization. Serotonergic psychedelics enhance neuroplasticity via serotonin 2 A receptors (5HT2AR) activation and complex serotonergic-glutamatergic interactions involving the ionotropic glutamate receptors, tropomyosin receptor kinase B (TrkB) and the mammalian target of rapamycin (mTOR). N-methyl-d-aspartate receptors (NMDAR) channel antagonists, i.e. ketamine, and glycine modulatory site full and partial agonists, i.e., D-serine (DSR) and D-cycloserine (DCS), share some of these mechanisms of action and have neuroplastic and antidepressant effects. Moreover, procognitive effects have been reported for DSR and DCS and 5HT2AR-NMDAR interactions modulate neuronal excitability in prefrontal cortex and represent a target for new antipsychotics. We hypothesize that the synchronous administration of a psychedelic and a NMDAR modulator may increase the therapeutic impact of each of the treatment components and allow for dose adjustments and improved safety. We propose to initially focus research on the acute concurrent administration of psilocybin and DSR or DCS in depression.
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Affiliation(s)
- Uriel Heresco-Levy
- Department of Psychiatry, Herzog Medical Center; Hebrew University Faculty of Medicine, Jerusalem, Israel.
| | - Bernard Lerer
- Hadassah BrainLabs, Center for Psychedelic Research, Hadassah Medical Center, Hebrew University, Jerusalem, Israel.
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19
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van Rooij SJH, Arulpragasam AR, McDonald WM, Philip NS. Accelerated TMS - moving quickly into the future of depression treatment. Neuropsychopharmacology 2024; 49:128-137. [PMID: 37217771 PMCID: PMC10700378 DOI: 10.1038/s41386-023-01599-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/20/2023] [Accepted: 04/22/2023] [Indexed: 05/24/2023]
Abstract
Accelerated TMS is an emerging application of Transcranial Magnetic Stimulation (TMS) aimed to reduce treatment length and improve response time. Extant literature generally shows similar efficacy and safety profiles compared to the FDA-cleared protocols for TMS to treat major depressive disorder (MDD), yet accelerated TMS research remains at a very early stage in development. The few applied protocols have not been standardized and vary significantly across a set of core elements. In this review, we consider nine elements that include treatment parameters (i.e., frequency and inter-stimulation interval), cumulative exposure (i.e., number of treatment days, sessions per day, and pulses per session), individualized parameters (i.e., treatment target and dose), and brain state (i.e., context and concurrent treatments). Precisely which of these elements is critical and what parameters are most optimal for the treatment of MDD remains unclear. Other important considerations for accelerated TMS include durability of effect, safety profiles as doses increase over time, the possibility and advantage of individualized functional neuronavigation, use of biological readouts, and accessibility for patients most in need of the treatment. Overall, accelerated TMS appears to hold promise to reduce treatment time and achieve rapid reduction in depressive symptoms, but at this time significant work remains to be done. Rigorous clinical trials combining clinical outcomes and neuroscientific measures such as electroencephalogram, magnetic resonance imaging and e-field modeling are needed to define the future of accelerated TMS for MDD.
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Affiliation(s)
- Sanne J H van Rooij
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA
| | - Amanda R Arulpragasam
- Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Providence, RI, USA
- VA RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, USA
| | - William M McDonald
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA
| | - Noah S Philip
- Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Providence, RI, USA.
- VA RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, USA.
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20
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Downar J, Siddiqi SH, Mitra A, Williams N, Liston C. Mechanisms of Action of TMS in the Treatment of Depression. Curr Top Behav Neurosci 2024; 66:233-277. [PMID: 38844713 DOI: 10.1007/7854_2024_483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2024]
Abstract
Transcranial magnetic stimulation (TMS) is entering increasingly widespread use in treating depression. The most common stimulation target, in the dorsolateral prefrontal cortex (DLPFC), emerged from early neuroimaging studies in depression. Recently, more rigorous casual methods have revealed whole-brain target networks and anti-networks based on the effects of focal brain lesions and focal brain stimulation on depression symptoms. Symptom improvement during therapeutic DLPFC-TMS appears to involve directional changes in signaling between the DLPFC, subgenual and dorsal anterior cingulate cortex, and salience-network regions. However, different networks may be involved in the therapeutic mechanisms for other TMS targets in depression, such as dorsomedial prefrontal cortex or orbitofrontal cortex. The durability of therapeutic effects for TMS involves synaptic neuroplasticity, and specifically may depend upon dopamine acting at the D1 receptor family, as well as NMDA-receptor-dependent synaptic plasticity mechanisms. Although TMS protocols are classically considered 'excitatory' or 'inhibitory', the actual effects in individuals appear quite variable, and might be better understood at the level of populations of synapses rather than individual synapses. Synaptic meta-plasticity may provide a built-in protective mechanism to avoid runaway facilitation or inhibition during treatment, and may account for the relatively small number of patients who worsen rather than improve with TMS. From an ethological perspective, the antidepressant effects of TMS may involve promoting a whole-brain attractor state associated with foraging/hunting behaviors, centered on the rostrolateral periaqueductal gray and salience network, and suppressing an attractor state associated with passive threat defense, centered on the ventrolateral periaqueductal gray and default-mode network.
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Affiliation(s)
- Jonathan Downar
- Department of Psychiatry, Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada.
| | - Shan H Siddiqi
- Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA
- Department of Psychiatry, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anish Mitra
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Nolan Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Conor Liston
- Department of Psychiatry, Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
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21
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Sohn MN, Brown JC, Sharma P, Ziemann U, McGirr A. Pharmacological adjuncts and transcranial magnetic stimulation-induced synaptic plasticity: a systematic review. J Psychiatry Neurosci 2024; 49:E59-E76. [PMID: 38359933 PMCID: PMC10890793 DOI: 10.1503/jpn.230090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 10/23/2023] [Accepted: 11/08/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Transcranial magnetic stimulation (TMS) is a noninvasive neurostimulation modality that has been used to study human synaptic plasticity. Leveraging work in ex vivo preparations, mechanistically informed pharmacological adjuncts to TMS have been used to improve our fundamental understanding of TMS-induced synaptic plasticity. METHODS We systematically reviewed the literature pairing pharmacological adjuncts with TMS plasticity-induction protocols in humans. We searched MEDLINE, PsycINFO, and Embase from 2013 to Mar. 10, 2023. Studies published before 2013 were extracted from a previous systematic review. We included studies using repetitive TMS, theta-burst stimulation, paired associative stimulation, and quadripulse stimulation paradigms in healthy and clinical populations. RESULTS Thirty-six studies met our inclusion criteria (28 in healthy and 8 in clinical populations). Most pharmacological agents have targeted the glutamatergic N-methyl-d-aspartate (NMDA; 15 studies) or dopamine receptors (13 studies). The NMDA receptor is necessary for TMS-induced plasticity; however, sufficiency has not been shown across protocols. Dopaminergic modulation of TMS-induced plasticity appears to be dose-dependent. The GABAergic, cholinergic, noradrenergic, and serotonergic neurotransmitter systems have small evidence bases supporting modulation of TMS-induced plasticity, as do voltage-gated calcium and sodium channels. Studies in clinical populations suggest that pharmacological adjuncts to TMS may rescue motor cortex plasticity, with implications for therapeutic applications of TMS and a promising clinical trial in depression. LIMITATIONS This review is limited by the predominance in the literature of studies with small sample sizes and crossover designs. CONCLUSION Pharmacologically enhanced TMS largely parallels findings from ex vivo preparations. As this area expands and novel targets are tested, adequately powered samples in healthy and clinical populations will inform the mechanisms of TMS-induced plasticity in health and disease.
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Affiliation(s)
- Myren N Sohn
- From the Hotchkiss Brain Institute, University of Calgary, Calgary, Alta., Canada (Sohn, McGirr); the Department of Psychiatry, University of Calgary, Alta., Canada (Sohn, McGirr); the Mathison Centre for Mental Health Research and Education, Calgary, Alta., Canada (Sohn, McGirr); the McLean Hospital, Division of Neurotherapeutics, Belmont, Mass., USA (Brown, Sharma); the Department of Psychiatry, Harvard Medical School, Boston, Mass., USA (Brown); the Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany (Ziemann); and the Hertie-Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany (Ziemann)
| | - Joshua C Brown
- From the Hotchkiss Brain Institute, University of Calgary, Calgary, Alta., Canada (Sohn, McGirr); the Department of Psychiatry, University of Calgary, Alta., Canada (Sohn, McGirr); the Mathison Centre for Mental Health Research and Education, Calgary, Alta., Canada (Sohn, McGirr); the McLean Hospital, Division of Neurotherapeutics, Belmont, Mass., USA (Brown, Sharma); the Department of Psychiatry, Harvard Medical School, Boston, Mass., USA (Brown); the Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany (Ziemann); and the Hertie-Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany (Ziemann)
| | - Prayushi Sharma
- From the Hotchkiss Brain Institute, University of Calgary, Calgary, Alta., Canada (Sohn, McGirr); the Department of Psychiatry, University of Calgary, Alta., Canada (Sohn, McGirr); the Mathison Centre for Mental Health Research and Education, Calgary, Alta., Canada (Sohn, McGirr); the McLean Hospital, Division of Neurotherapeutics, Belmont, Mass., USA (Brown, Sharma); the Department of Psychiatry, Harvard Medical School, Boston, Mass., USA (Brown); the Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany (Ziemann); and the Hertie-Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany (Ziemann)
| | - Ulf Ziemann
- From the Hotchkiss Brain Institute, University of Calgary, Calgary, Alta., Canada (Sohn, McGirr); the Department of Psychiatry, University of Calgary, Alta., Canada (Sohn, McGirr); the Mathison Centre for Mental Health Research and Education, Calgary, Alta., Canada (Sohn, McGirr); the McLean Hospital, Division of Neurotherapeutics, Belmont, Mass., USA (Brown, Sharma); the Department of Psychiatry, Harvard Medical School, Boston, Mass., USA (Brown); the Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany (Ziemann); and the Hertie-Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany (Ziemann)
| | - Alexander McGirr
- From the Hotchkiss Brain Institute, University of Calgary, Calgary, Alta., Canada (Sohn, McGirr); the Department of Psychiatry, University of Calgary, Alta., Canada (Sohn, McGirr); the Mathison Centre for Mental Health Research and Education, Calgary, Alta., Canada (Sohn, McGirr); the McLean Hospital, Division of Neurotherapeutics, Belmont, Mass., USA (Brown, Sharma); the Department of Psychiatry, Harvard Medical School, Boston, Mass., USA (Brown); the Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany (Ziemann); and the Hertie-Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany (Ziemann)
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22
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Leuchter MK, Citrenbaum C, Wilson AC, Tibbe TD, Jackson NJ, Krantz DE, Wilke SA, Corlier J, Strouse TB, Hoftman GD, Tadayonnejad R, Koek RJ, Slan AR, Ginder ND, Distler MG, Artin H, Lee JH, Adelekun AE, Leuchter AF. A comparison of self- and observer-rated scales for detecting clinical improvement during repetitive transcranial stimulation (rTMS) treatment of depression. Psychiatry Res 2023; 330:115608. [PMID: 37984281 DOI: 10.1016/j.psychres.2023.115608] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/06/2023] [Accepted: 11/11/2023] [Indexed: 11/22/2023]
Abstract
Clinical outcomes of repetitive Transcranial Magnetic Stimulation (rTMS) for treatment of Major Depressive Disorder (MDD) vary widely, and no single mood rating scale is standard for assessing rTMS outcomes. This study of 708 subjects undergoing clinical rTMS compared the performance of four scales in measuring symptom change during rTMS treatment. Self-report and observer ratings were examined weekly with the Inventory of Depressive Symptomatology 30-item (IDS), Patient Health Questionnaire 9-item (PHQ), Profile of Mood States 30-item (POMS), and Hamilton Depression Rating Scale 17-item (HDRS). While all scales were correlated and detected significant improvement, the degree of improvement over time as well as response (33-50%) and remission (20-24%) rates varied significantly. Higher baseline severity was associated with lower likelihood of remission, and greater improvement by sessions 5 and 10 predicted response across all scales. Use of only a single scale to assess outcome conferred 14-36% risk of failing to detect response/remission indicated by another scale. The PHQ was most likely to indicate improvement and least likely to miss response or remission. These findings indicate that assessment of symptom burden during rTMS treatment may be most accurately assessed through use of multiple instruments.
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Affiliation(s)
- Michael K Leuchter
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA.
| | - Cole Citrenbaum
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
| | | | - Tristan D Tibbe
- Department of Psychology, University of California, Los Angeles, CA 90024, USA; Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA 90024, USA
| | - Nicholas J Jackson
- Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA 90024, USA
| | - David E Krantz
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
| | - Scott A Wilke
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
| | - Juliana Corlier
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
| | - Thomas B Strouse
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
| | - Gil D Hoftman
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
| | - Reza Tadayonnejad
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA; Division of Humanities and Social Sciences, California Institute of Technology, Pasadena, CA, USA
| | - Ralph J Koek
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
| | - Aaron R Slan
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
| | - Nathaniel D Ginder
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
| | - Margaret G Distler
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
| | - Hewa Artin
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
| | - John H Lee
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
| | - Adesewa E Adelekun
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
| | - Andrew F Leuchter
- TMS Clinical and Research Program, Neuromodulation Division, Semel Institute for Neuroscience and Human Behavior at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA 90024, USA
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23
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Qiu Y, Li L, Duan A, Wang M, Xie M, Chen Z, Wang Z. The efficacy and tolerability of inhaled nitrous oxide in major depressive disorder: a systematic review and meta-analysis. Psychopharmacology (Berl) 2023; 240:2033-2043. [PMID: 37608194 DOI: 10.1007/s00213-023-06449-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 08/04/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Nitrous oxide (N2O) has been initially confirmed by clinical trials to benefit to patients with major depressive disorder (MDD). However, there needs to be a meta-analysis to compare the efficacy and tolerability of N2O in MDD. METHODS PubMed, EMBASE, and Cochrane Library were searched for relevant studies up to Jan 1st, 2023. The meta-analysis mainly compared the outcome of the change in depression severity scores, response, remission, and adverse events in patients with MDD receiving 50% N2O and placebo. RESULTS Four studies with 133 patients were eventually identified. We found that the N2O group and control group showed an overall significant difference in the change in depression severity score for patients at 2 h, 24 h, and 2 weeks or more (2 h, SMD = - 0.64, 95% CI - 0.01 to - 0.28, p < 0.0001) (24 h, SMD = - 0.65, 95% CI - 1.01 to - 0.29, p < 0.0001) (2 weeks, SMD = - 0.76, 95% CI - 1.16 to - 0.36, p < 0.0001). For the response and remission rate, the long-term effect of N2O was also statistically significant (for the response, RR = 2.33, 95% CI 1.23 to 4.44, p = 0.01) (for the remission, RR = 4.68, 95% CI 1.49 to 14.68, p = 0.008). For safety outcomes, patients treated with N2O had higher odds of nausea or vomiting (RR = 10.15, 95% CI 1.96 to 52.59, p = 0.009). CONCLUSION Our study suggested that N2O has a rapid and long-lasting antidepressant effect in patients with MDD. However, the efficacy of lower or titrated concentration of N2O should be further investigated.
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Affiliation(s)
- Youjia Qiu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Longyuan Li
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Aojie Duan
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Menghan Wang
- Suzhou Medical College of Soochow USniversity, Suzhou, 215002, Jiangsu Province, China
| | - Minjia Xie
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China.
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China.
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Nemani K, Goff DC. Dose Finding for d-Serine Enhancement of Plasticity in Schizophrenia. Biol Psychiatry 2023; 94:106-107. [PMID: 37380254 DOI: 10.1016/j.biopsych.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/25/2023] [Indexed: 06/30/2023]
Affiliation(s)
- Katlyn Nemani
- Nathan Kline Institute for Psychiatric Research and the New York University Grossman School of Medicine, New York, New York
| | - Donald C Goff
- Nathan Kline Institute for Psychiatric Research and the New York University Grossman School of Medicine, New York, New York.
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Wrightson JG, Cole J, Sohn MN, McGirr A. The effects of D-Cycloserine on corticospinal excitability after repeated spaced intermittent theta-burst transcranial magnetic stimulation: A randomized controlled trial in healthy individuals. Neuropsychopharmacology 2023; 48:1217-1224. [PMID: 37041205 PMCID: PMC10267195 DOI: 10.1038/s41386-023-01575-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/13/2023]
Abstract
Repeated spaced TMS protocols, also termed accelerated TMS protocols, are of increasing therapeutic interest. The long-term potentiation (LTP)-like effects of repeated spaced intermittent theta-burst transcranial magnetic stimulation (iTBS) are presumed to be N-Methyl-D-Aspartate receptor (NMDA-R) dependent; however, this has not been tested. We tested whether the LTP-like effects of repeated spaced iTBS are influenced by low-dose D-Cycloserine (100 mg), an NMDA-R partial-agonist. We conducted a randomized, double-blind, placebo-controlled crossover trial in 20 healthy adults from August 2021-Feb 2022. Participants received repeated spaced iTBS, consisting of two iTBS sessions 60 minutes apart, to the primary motor cortex. The peak-to-peak amplitude of the motor evoked potentials (MEP) at 120% resting motor threshold (RMT) was measured after each iTBS. The TMS stimulus-response (TMS-SR; 100-150% RMT) was measured at baseline, +30 min, and +60 min after each iTBS. We found evidence for a significant Drug*iTBS effect in MEP amplitude, revealing that D-Cycloserine enhanced MEP amplitudes relative to the placebo. When examining TMS-SR, pairing iTBS with D-Cycloserine increased the TMS-SR slope relative to placebo after both iTBS tetani, and this was due to an increase in the upper bound of the TMS-SR. This indicates that LTP-like and metaplastic effects of repeated-spaced iTBS involve NMDA-R, as revealed by two measures of corticospinal excitability, and that low-dose D-Cycloserine facilitates the physiological effects of repeated spaced iTBS. However, extension of these findings to clinical populations and therapeutic protocols targeting non-motor regions of cortex requires empirical validation.
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Affiliation(s)
- James G Wrightson
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Jaeden Cole
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Mathison Centre for Mental Health Research and Education, Calgary, AB, Canada
| | - Maya N Sohn
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Mathison Centre for Mental Health Research and Education, Calgary, AB, Canada
| | - Alexander McGirr
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Mathison Centre for Mental Health Research and Education, Calgary, AB, Canada.
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26
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White TL, Gonsalves MA, Harris AD, Walsh EG, Joyce HE. Brain Glutamate Dynamics Predict Positive Agency in Healthy Women. RESEARCH SQUARE 2023:rs.3.rs-3021527. [PMID: 37398402 PMCID: PMC10312947 DOI: 10.21203/rs.3.rs-3021527/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Contributions of brain glutamate to conscious emotion are not well understood. Here we evaluate the relationship of experimentally-induced change in neocortical glutamate (ΔGlu) and subjective states in well individuals. Drug challenge with d-amphetamine (AMP; 20 mg oral), methamphetamine (MA; Desoxyn®, 20 mg oral), and placebo (PBO) was conducted on three separate test days in a within-subjects double blind design. Proton magnetic resonance spectroscopy (MRS) quantified neurometabolites in the right dorsal anterior cingulate cortex (dACC) 140-150 m post-drug and PBO. Subjective states were assessed at half hour intervals over 5.5-hours on each session, yielding 3,792 responses per participant (91,008 responses overall, N=24 participants). Self-reports were reduced by principal components analysis to a single factor score of AMP- and MA-induced Positive Agency (ΔPA) in each participant. We found drug-induced ΔGlu related positively with ΔPA (ΔGluMA r=+.44, p<.05, N=21), with large effects in females (ΔGluMA r=+.52, p<.05; ΔGluAMP r=+.61, p<.05, N=11). States related to ΔGlu in females included rise in subjective stimulation, vigor, friendliness, elation, positive mood, positive affect (r's=+.51 to +.74, p<.05), and alleviation of anxiety (r=-.61, p<.05, N=11). Self-reports correlated with DGlu to the extent they loaded on ΔPA (r=.95 AMP, p=5×10-10; r=.63 MA, p=.0015, N=11), indicating coherence of ΔGlu effects. Timing data indicated Glu shaped emotion both concurrently and prospectively, with no relationship to pre-MRS emotion (ΔGluAMP r=+.59 to +.65, p's<.05; ΔGluMA r=+.53, p<.05, N=11). Together these findings indicate substantive, mechanistic contributions of neocortical Glu to positive agentic states in healthy individuals, most readily observed in women.
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Lipsman N, McDonald PJ, Illes J. Perceptions of Invasiveness: A Moving Target for Neuromodulation. AJOB Neurosci 2023; 14:15-17. [PMID: 36524950 DOI: 10.1080/21507740.2022.2150709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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28
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Sherif MA, Khalil MZ, Shukla R, Brown JC, Carpenter LL. Synapses, predictions, and prediction errors: A neocortical computational study of MDD using the temporal memory algorithm of HTM. Front Psychiatry 2023; 14:976921. [PMID: 36911109 PMCID: PMC9995817 DOI: 10.3389/fpsyt.2023.976921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 01/16/2023] [Indexed: 02/25/2023] Open
Abstract
INTRODUCTION Synapses and spines play a significant role in major depressive disorder (MDD) pathophysiology, recently highlighted by the rapid antidepressant effect of ketamine and psilocybin. According to the Bayesian brain and interoception perspectives, MDD is formalized as being stuck in affective states constantly predicting negative energy balance. To understand how spines and synapses relate to the predictive function of the neocortex and thus to symptoms, we used the temporal memory (TM), an unsupervised machine-learning algorithm. TM models a single neocortical layer, learns in real-time, and extracts and predicts temporal sequences. TM exhibits neocortical biological features such as sparse firing and continuous online learning using local Hebbian-learning rules. METHODS We trained a TM model on random sequences of upper-case alphabetical letters, representing sequences of affective states. To model depression, we progressively destroyed synapses in the TM model and examined how that affected the predictive capacity of the network. We found that the number of predictions decreased non-linearly. RESULTS Destroying 50% of the synapses slightly reduced the number of predictions, followed by a marked drop with further destruction. However, reducing the synapses by 25% distinctly dropped the confidence in the predictions. Therefore, even though the network was making accurate predictions, the network was no longer confident about these predictions. DISCUSSION These findings explain how interoceptive cortices could be stuck in limited affective states with high prediction error. Connecting ketamine and psilocybin's proposed mechanism of action to depression pathophysiology, the growth of new synapses would allow representing more futuristic predictions with higher confidence. To our knowledge, this is the first study to use the TM model to connect changes happening at synaptic levels to the Bayesian formulation of psychiatric symptomatology. Linking neurobiological abnormalities to symptoms will allow us to understand the mechanisms of treatments and possibly, develop new ones.
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Affiliation(s)
- Mohamed A Sherif
- Lifespan Physician Group, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Carney Institute for Brain Science, Norman Prince Neurosciences Institute, Providence, RI, United States
| | - Mostafa Z Khalil
- Department of Psychiatry and Behavioral Health, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, United States
| | - Rammohan Shukla
- Department of Neurosciences, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
| | - Joshua C Brown
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Butler Hospital, Providence, RI, United States
| | - Linda L Carpenter
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Butler Hospital, Providence, RI, United States
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Kweon J, Vigne MM, Jones RN, Carpenter LL, Brown JC. Practice makes plasticity: 10-Hz rTMS enhances LTP-like plasticity in musicians and athletes. Front Neural Circuits 2023; 17:1124221. [PMID: 37025991 PMCID: PMC10070804 DOI: 10.3389/fncir.2023.1124221] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/24/2023] [Indexed: 04/08/2023] Open
Abstract
Motor skill learning has been linked to functional and structural changes in the brain. Musicians and athletes undergo intensive motor training through the practice of an instrument or sport and have demonstrated use-dependent plasticity that may be subserved by long-term potentiation (LTP) processes. We know less, however, about whether the brains of musicians and athletes respond to plasticity-inducing interventions, such as repetitive transcranial magnetic stimulation (rTMS), differently than those without extensive motor training. In a pharmaco-rTMS study, we evaluated motor cortex excitability before and after an rTMS protocol in combination with oral administration of D-cycloserine (DCS) or placebo. In a secondary covariate analysis, we compared results between self-identified musicians and athletes (M&As) and non-musicians and athletes (non-M&As). Three TMS measures of cortical physiology were used to evaluate plasticity. We found that M&As did not have higher baseline corticomotor excitability. However, a plasticity-inducing protocol (10-Hz rTMS in combination with DCS) strongly facilitated motor-evoked potentials (MEPs) in M&As, but only weakly in non-M&As. Placebo and rTMS produced modest facilitation in both groups. Our findings suggest that motor practice and learning create a neuronal environment more responsive to plasticity-inducing events, including rTMS. These findings may explain one factor contributing to the high inter-individual variability found with MEP data. Greater capacity for plasticity holds implications for learning paradigms, such as psychotherapy and rehabilitation, by facilitating LTP-like activation of key networks, including recovery from neurological/mental disorders.
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Affiliation(s)
- Jamie Kweon
- Neuromodulation Research Facility, TMS Clinic, Butler Hospital, Providence, RI, United States
| | - Megan M. Vigne
- Neuromodulation Research Facility, TMS Clinic, Butler Hospital, Providence, RI, United States
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, United States
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Linda L. Carpenter
- Neuromodulation Research Facility, TMS Clinic, Butler Hospital, Providence, RI, United States
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Joshua C. Brown
- Neuromodulation Research Facility, TMS Clinic, Butler Hospital, Providence, RI, United States
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, United States
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, United States
- *Correspondence: Joshua C. Brown
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30
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Error in Figure 2. JAMA Psychiatry 2022; 79:1241. [PMID: 36477142 PMCID: PMC9856341 DOI: 10.1001/jamapsychiatry.2022.4059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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