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Cheng CM, Li CT, Jeng JS, Chang WH, Lin WC, Chen MH, Bai YM, Tsai SJ, Su TP. Antidepressant effects of prolonged intermittent theta-burst stimulation monotherapy at the bilateral dorsomedial prefrontal cortex for medication and standard transcranial magnetic stimulation-resistant major depression: a three arm, randomized, double blind, sham-controlled pilot study. Eur Arch Psychiatry Clin Neurosci 2023; 273:1433-1442. [PMID: 36484844 PMCID: PMC9735131 DOI: 10.1007/s00406-022-01523-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022]
Abstract
The dorsomedial prefrontal cortex (DMPFC) plays a pivotal role in depression and anxiosomatic symptom modulation. However, DMPFC stimulation using a double-cone coil has demonstrated inconsistent results for antidepressant efficacy. No study thus far has investigated the antidepressant and anti-anxiosomatic effects of prolonged intermittent theta-burst stimulation (piTBS) bilaterally over DMPFC. Furthermore, head-to-head comparisons of antidepressant effects between standard iTBS and piTBS warrant investigation. This double-blind, randomized, sham-controlled trial recruited 34 patients with highly treatment-resistant depression (TRD) unresponsive to antidepressants and standard repetitive transcranial magnetic stimulation (rTMS)/piTBS. These patients were randomly assigned to one of three monotherapy groups (standard iTBS, piTBS, or sham), with treatment administered bilaterally over the DMPFC twice per day for 3 weeks. The primary outcome was the overall changes of 17-item Hamilton Depression Rating Scale (HDRS-17) over 3-weeks intervention. The changes in Depression and Somatic Symptoms Scale (DSSS) as the secondary outcome and the anxiosomatic cluster symptoms as rated by HDRS-17 as the post-hoc outcome were measured. Multivariable generalized estimating equation analysis was performed. Although no differences in overall HDRS-17 changes between three groups were found, the antidepressant efficacy based on DSSS was higher in piTBS than in iTBS and sham at week 3 (group effect,p = 0.003, post-hoc: piTBS > iTBS, p = 0.002; piTBS > sham, p = 0.038). In post-hoc analyses, piTBS had more alleviation in anxiosomatic symptoms than iTBS (group effect, p = 0.002; post-hoc, p = 0.001). This first randomized sham-controlled study directly compared piTBS and iTBS targeting the DMPFC using a figure-of-8 coil and found piTBS may fail to demonstrate a significant antidepressant effect on overall depressive symptoms, but piTBS seems superior in alleviating anxiosomatic symptoms, even in depressed patients with high treatment resistance. This Trial registration (Registration number: NCT04037592). URL: https://clinicaltrials.gov/ct2/show/NCT04037592 .
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Affiliation(s)
- Chih-Ming Cheng
- Institute of Brain Science, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Psychiatry, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Department of Psychiatry, Taipei Veterans General Hospital, Beitou District, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan
| | - Cheng-Ta Li
- Institute of Brain Science, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan.
- Division of Psychiatry, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan.
- Department of Psychiatry, Taipei Veterans General Hospital, Beitou District, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan.
- Institute of Cognitive Neuroscience, National Central University, Jhongli, Taiwan.
| | - Jia-Shyun Jeng
- Department of Psychiatry, Taipei Veterans General Hospital, Beitou District, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Pingtung Branch, Pingtung, Taiwan
| | - Wen-Han Chang
- Department of Psychiatry, Taipei Veterans General Hospital, Beitou District, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan
- Graduate Institute of Statistics National Central University, Taoyuan, Taiwan
| | - Wei-Chen Lin
- Institute of Brain Science, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Psychiatry, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Department of Psychiatry, Taipei Veterans General Hospital, Beitou District, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan
| | - Mu-Hong Chen
- Institute of Brain Science, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Psychiatry, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Department of Psychiatry, Taipei Veterans General Hospital, Beitou District, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan
| | - Ya-Mei Bai
- Institute of Brain Science, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Psychiatry, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Department of Psychiatry, Taipei Veterans General Hospital, Beitou District, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan
| | - Shih-Jen Tsai
- Institute of Brain Science, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Psychiatry, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Department of Psychiatry, Taipei Veterans General Hospital, Beitou District, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan
| | - Tung-Ping Su
- Institute of Brain Science, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Psychiatry, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Department of Psychiatry, Taipei Veterans General Hospital, Beitou District, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan
- Department of Psychiatry, Cheng Hsin General Hospital, Taipei, Taiwan
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Chen MH, Cheng CM, Li CT, Tsai SJ, Lin WC, Bai YM, Su TP. Comparative study of low-dose ketamine infusion and repetitive transcranial magnetic stimulation in treatment-resistant depression: A posthoc pooled analysis of two randomized, double-blind, placebo-controlled studies. Psychiatry Res 2022; 316:114749. [PMID: 35940087 DOI: 10.1016/j.psychres.2022.114749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND This posthoc analysis compared the antidepressant and antisuicidal effects of low-dose ketamine infusion with those of repetitive transcranial magnetic stimulation (rTMS) on treatment-resistant depression (TRD). METHODS In the ketamine infusion trial, 48 patients with TRD were randomized to receive a single infusion of 0.5 mg/kg ketamine or normal saline. In the rTMS trial, 105 patients were randomly assigned to intermittent theta-burst stimulation (iTBS), 10-Hz rTMS, or sham stimulation. The 17-item Hamilton Rating Scale for Depression (HDRS) was administered. RESULTS The antidepressant effect was prominent at Day 7 postinfusion in the ketamine group but steadily accumulated with the treatment duration from Day 7 to 14 in the iTBS and 10-Hz rTMS groups, regardless of the level of treatment resistance (all p < .01). Low-dose ketamine infusion and iTBS exerted superior effects on suicidal symptoms (HDRS item 3) than the other three groups (p < .001). The antidepressant effect of iTBS/10-Hz rTMS may persist for up to 3 months; however, the antidepressant effect of a single low-dose ketamine infusion did not persist over a month. DISCUSSION Both low-dose ketamine infusion and rTMS/TBS must be included in TRD treatment but may be applied in different clinical situations.
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Affiliation(s)
- Mu-Hong Chen
- Department of Psychiatry, Taipei Veterans General Hospital, No. 201, Sec.2, Shih-Pai Road, Beitou district, Taipei, 112, Taiwan; Division of Psychiatry, Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Chih-Ming Cheng
- Department of Psychiatry, Taipei Veterans General Hospital, No. 201, Sec.2, Shih-Pai Road, Beitou district, Taipei, 112, Taiwan; Division of Psychiatry, Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Ta Li
- Department of Psychiatry, Taipei Veterans General Hospital, No. 201, Sec.2, Shih-Pai Road, Beitou district, Taipei, 112, Taiwan; Division of Psychiatry, Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Shih-Jen Tsai
- Department of Psychiatry, Taipei Veterans General Hospital, No. 201, Sec.2, Shih-Pai Road, Beitou district, Taipei, 112, Taiwan; Division of Psychiatry, Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Chen Lin
- Department of Psychiatry, Taipei Veterans General Hospital, No. 201, Sec.2, Shih-Pai Road, Beitou district, Taipei, 112, Taiwan; Division of Psychiatry, Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ya-Mei Bai
- Department of Psychiatry, Taipei Veterans General Hospital, No. 201, Sec.2, Shih-Pai Road, Beitou district, Taipei, 112, Taiwan; Division of Psychiatry, Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tung-Ping Su
- Department of Psychiatry, Taipei Veterans General Hospital, No. 201, Sec.2, Shih-Pai Road, Beitou district, Taipei, 112, Taiwan; Division of Psychiatry, Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Psychiatry, Cheng Hsin General Hospital, Taipei, Taiwan.
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Lantrip C, Szabo YZ, Kozel FA, Holtzheimer P. Neuromodulation as an Augmenting Strategy for Behavioral Therapies for Anxiety and PTSD: a Narrative Review. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2022; 9:406-418. [PMID: 36714210 PMCID: PMC9881183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
PURPOSE OF REVIEW Post-traumatic stress disorder (PTSD) is a prevalent problem. Despite current treatments, symptoms may persist, and neuromodulation therapies show great potential. A growing body of research suggests that transcranial magnetic stimulation (TMS) is effective as a standalone treatment for PTSD, with recent research demonstrating promising use when combined synergistically with behavioral treatments. In this review, we survey this literature including data suggesting mechanisms involved in anxiety and PTSD that may be targeted by neurostimulation. RECENT FINDINGS Evidence suggests the mechanism of action for TMS that contributes to behavioral change may be enhanced neural plasticity via increased functionality of prefrontal and subcortical/limbic structures and associated networks. Some research has demonstrated a behavioral change in PTSD and anxiety due to enhanced extinction learning or improved ability to think flexibly and reduce ruminative tendencies. Growing evidence suggests TMS may be best used as a therapeutic adjunct, at least acutely, for extinction-based exposure therapies in patients by accelerating therapy response. SUMMARY While TMS has shown promise as a standalone intervention, augmentation with psychotherapy is one avenue of interest. Non-responders to current EBPs might particularly benefit from this sort of targeted approach, and it may shorten treatment length, which would help the successful completion of a course of therapy.
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Affiliation(s)
- Crystal Lantrip
- Department of Veterans Affairs, VISN 17 Center of Excellence for Research On Returning War Veterans, Waco, TX 76711, USA
- Department of Psychology and Neuroscience, Baylor University, Waco, TX, USA
| | - Yvette Z. Szabo
- Department of Veterans Affairs, VISN 17 Center of Excellence for Research On Returning War Veterans, Waco, TX 76711, USA
- Department of Health, Human Performance and Recreation, Baylor University, Waco, TX, USA
| | - F. Andrew Kozel
- Department of Behavioral Sciences and Social Medicine, Florida State University, Tallahassee, FL, USA
| | - Paul Holtzheimer
- Department of Veterans Affairs, National Center for PTSD, White River Junction, VT, USA
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Mi Y, Ji Y, Lou Z, Hou Y, Ruan L. Left intermittent theta burst stimulation combined with right low-frequency rTMS as an additional treatment for major depression: A retrospective study. Indian J Psychiatry 2022; 64:364-369. [PMID: 36060727 PMCID: PMC9435624 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_905_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 04/16/2022] [Accepted: 05/09/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) is an effective treatment for major depression (MD). We retrospectively analyzed the efficacy of intermittent theta burst stimulation (iTBS) on the left dorsolateral prefrontal cortex (DLPFC) combined with low-frequency rTMS (LF-rTMS) on the right DLPFC as an additional therapy to standard medication treatment. MATERIALS AND METHODS The study included 54 patients with MD who completed 10 courses (5 days per week) of rTMS as an add-on therapy. Thirty patients were treated in the combination group (120% resting motor threshold; left DLPFC, iTBS, 600 stimuli + right DLPFC, 1-Hz rTMS, 600 stimuli), while 24 patients were in the high-frequency rTMS (HF-rTMS) group (120% resting motor threshold; left DLPFC, 10-Hz rTMS, 3000 stimuli). The outcome was assessed based on the changes in scores of 24-item Hamilton Depression Scale (HAMD-24) and 14-item Hamilton Anxiety Scale (HAMA-14). RESULTS Both depression and anxiety were significantly improved after 2 weeks of treatment by rTMS combined with medication. The combination of iTBS and LF-rTMS was significantly superior to HF-rTMS in improving the scores of HAMD-24 (P = 0.041) and HAMA-14 (P = 0.0095), and the response rate (P = 0.027). CONCLUSION The pilot study showed that the combination of iTBS and LF-rTMS may hold promise as a potentially effective alternative therapy for MD due to its efficacy and time-saving benefit. The preliminary results shed light on the study of the efficacy and acceptability of the combination of iTBS and LF-rTMS for MD.
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Affiliation(s)
- Yuwei Mi
- School of Medicine, Ningbo University, Ningbo, Zhejiang, P.R. China.,Department of Psychosomatic Medicine, Ningbo First Hospital, Ningbo, Zhejiang, P.R. China
| | - Yunxin Ji
- Department of Psychosomatic Medicine, Ningbo First Hospital, Ningbo, Zhejiang, P.R. China
| | - Zhongze Lou
- Department of Psychosomatic Medicine, Ningbo First Hospital, Ningbo, Zhejiang, P.R. China.,Medical Research Center, Ningbo First Hospital, Ningbo, Zhejiang, P.R. China
| | - Yanbin Hou
- Department of Psychosomatic Medicine, Ningbo First Hospital, Ningbo, Zhejiang, P.R. China
| | - Liemin Ruan
- Department of Psychosomatic Medicine, Ningbo First Hospital, Ningbo, Zhejiang, P.R. China
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Chen L, Thomas EHX, Kaewpijit P, Miljevic A, Hughes R, Hahn L, Kato Y, Gill S, Clarke P, Ng F, Paterson T, Giam A, Sarma S, Hoy KE, Galletly C, Fitzgerald PB. Accelerated theta burst stimulation for the treatment of depression: A randomised controlled trial. Brain Stimul 2021; 14:1095-1105. [PMID: 34332155 DOI: 10.1016/j.brs.2021.07.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/24/2021] [Accepted: 07/26/2021] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Theta burst pattern repetitive transcranial magnetic stimulation (TBS) is increasingly applied to treat depression. TBS's brevity is well-suited to application in accelerated schedules. Sizeable trials of accelerated TBS are lacking; and optimal TBS parameters such as stimulation intensity are not established. METHODS We conducted a three arm, single blind, randomised, controlled, multi-site trial comparing accelerated bilateral TBS applied at 80 % or 120 % of the resting motor threshold and left unilateral 10 Hz rTMS. 300 patients with treatment-resistant depression (TRD) were recruited. TBS arms applied 20 bilateral prefrontal TBS sessions over 10 days, while the rTMS arm applied 20 daily sessions of 10 Hz rTMS to the left prefrontal cortex over 4 weeks. Primary outcome was depression treatment response at week 4. RESULTS The overall treatment response rate was 43.7 % and the remission rate was 28.2 %. There were no significant differences for response (p = 0.180) or remission (p = 0.316) across the three groups. Response rates between accelerated bilateral TBS applied at sub- and supra-threshold intensities were not significantly different (p = 0.319). Linear mixed model analysis showed a significant effect of time (p < 0.01), but not rTMS type (p = 0.680). CONCLUSION This is the largest accelerated bilateral TBS study to date and provides evidence that it is effective and safe in treating TRD. The accelerated application of TBS was not associated with more rapid antidepressant effects. Bilateral sequential TBS did not have superior antidepressant effect to unilateral 10 Hz rTMS. There was no significant difference in antidepressant efficacy between sub- and supra-threshold accelerated bilateral TBS.
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Affiliation(s)
- Leo Chen
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia; Monash Alfred Psychiatry Research Centre, Department of Psychiatry, Monash University, Melbourne, Victoria, Australia; Alfred Mental and Addiction Health, Alfred Health, Melbourne, Victoria, Australia.
| | - Elizabeth H X Thomas
- Monash Alfred Psychiatry Research Centre, Department of Psychiatry, Monash University, Melbourne, Victoria, Australia
| | - Pakin Kaewpijit
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia; Monash Alfred Psychiatry Research Centre, Department of Psychiatry, Monash University, Melbourne, Victoria, Australia; Bangkok Hospital, Bang Kapi, Bangkok, Thailand
| | - Aleksandra Miljevic
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia
| | - Rachel Hughes
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia
| | - Lisa Hahn
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia
| | - Yuko Kato
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia
| | - Shane Gill
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia
| | - Patrick Clarke
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia
| | - Felicity Ng
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia; Discipline of Psychiatry, The University of Adelaide, South Australia, Australia
| | - Tom Paterson
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia; Discipline of Psychiatry, The University of Adelaide, South Australia, Australia
| | - Andrew Giam
- Central Adelaide Local Health Network, South Australia, Australia
| | - Shanthi Sarma
- Department of Mental Health, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Kate E Hoy
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia
| | - Cherrie Galletly
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia; Discipline of Psychiatry, The University of Adelaide, South Australia, Australia; Northern Adelaide Local Health Network, South Australia, Australia
| | - Paul B Fitzgerald
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia
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Miron JP, Jodoin VD, Lespérance P, Blumberger DM. Repetitive transcranial magnetic stimulation for major depressive disorder: basic principles and future directions. Ther Adv Psychopharmacol 2021; 11:20451253211042696. [PMID: 34589203 PMCID: PMC8474312 DOI: 10.1177/20451253211042696] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/11/2021] [Indexed: 12/14/2022] Open
Abstract
Repetitive transcranial magnetic stimulation (rTMS) is a safe and well-tolerated intervention for major depressive disorder (MDD). Over 150 randomized controlled trials (RCTs) have been carried out, and its efficacy has been confirmed in dozens of meta-analyses. Real world data has also confirmed the effectiveness of rTMS for MDD in clinical practice, with the most recent literature indicating response rates of 40-50% and remission rates of 25-30%. In this review, we first offer an historical perspective, followed by a review of basic principles, such as putative mechanisms, procedures and protocols, stimulation targets, efficacy and durability of response, side effects, and the placebo controversy. In the second part of this review, we first discuss solutions to increase accessibility to rTMS, such as modifications to treatment equipment, protocols and setting. We continue with possible means to further increase effectiveness, such as treatment personalization and extension. We conclude by addressing the scheduling issue, with accelerated rTMS (arTMS) as a possible solution.
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Affiliation(s)
- Jean-Philippe Miron
- Centre de Recherche du CHUM (CRCHUM), Centre Hospitalier de l'Université de Montréal (CHUM) and Département de Psychiatrie, Faculté de Médecine, Université́ de Montréal, Montréal, QC, Canada Institute of Medical Science and Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada CHUM, 1051 Sanguinet, Montréal, QC, H2X 3E4, Canada
| | - Véronique Desbeaumes Jodoin
- CRCHUM, CHUM and Département de Psychiatrie, Faculté de Médecine, Université́ de Montréal, Montréal, QC, Canada
| | - Paul Lespérance
- CRCHUM, CHUM and Département de Psychiatrie, Faculté de Médecine, Université́ de Montréal, Montréal, QC, Canada
| | - Daniel M Blumberger
- Institute of Medical Science and Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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