Repetitive Transcranial Magnetic Stimulation-Induced Neuroplasticity and the Treatment of Psychiatric Disorders: State of the Evidence and Future Opportunities

More rTMS pulses or more sessions? The impact on treatment outcome for treatment resistant depression

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is effective for treatment-resistant depression (TRD). Optimal rTMS parameters remain unclear, especially whether number of sessions or amount of pulses contribute more to treatment outcome. We hypothesize that treatment outcome depends on the number of sessions rather than on the amount of pulses.

METHODS

We searched databases for randomized clinical trials (RCTs) on high-frequent (HF) or low-frequent (LF)-rTMS targeting the left or right DLPFC for TRD. Treatment efficacy was measured using standardized mean difference (SMD), calculated from pre- and post-treatment depression scores. Meta-regressions were used to explore linear associations between SMD and rTMS pulses, pulses/session and sessions for HF and LF-rTMS, separately for active and sham-rTMS. If these variables showed no linear association with SMD, we divided the data into quartiles and explored subgroup SMDs.

RESULTS

Eighty-seven RCTs were included: 67 studied HF-rTMS, eleven studied LF-rTMS, and nine studied both. No linear association was found between SMD and amount of pulses or pulses/session for HF and LF-rTMS. Subgroup analyses showed the largest SMDs for 1200-1500 HF-pulses/session and 360-450 LF-pulses/session. The number of sessions was significantly associated with SMD for active HF (β = 0.09, p < 0.05) and LF-rTMS (β = 0.06, p < 0.01). Thirty was the maximal number of sessions, in the included RCTs.

CONCLUSION

More rTMS sessions, but not more pulses, were associated with improved treatment outcome, in both HF and LF-rTMS. Our findings suggest that 1200-1500 HF-pulses/session and 360-450 LF-pulses/session are already sufficient, and that a treatment course should consist of least 30 sessions for higher chance of response.

Neuroplasticity-based novel brain stimulation support intervention options for autistic population

Transcranial magnetic stimulation (TMS), introduced in 1985, has become a vital tool for investigating brain-behaviour relationships and therapeutic interventions. Repetitive TMS (rTMS) as a therapeutic tool has shown promise for various neuropsychiatric conditions, including autism, which affects approximately 1% of the global population. Evidence suggests that atypical neuroplasticity characterizes the neurobiology of autism. Recent studies using TMS paradigms like theta-burst stimulation (TBS) indicate an excessive neuroplasticity or hyper-plasticity in the form of an excessive long-term potentiation (LTP) in the motor cortex of autistic adults compared to neurotypical controls. Hyper-plasticity may negatively impact cognitive and behavioural outcomes. Our proposed neuroplasticity-based rTMS intervention protocols aim to address motor function, sensory sensitivities, and executive function difficulties in autistic adults. We present a testable framework to evaluate neuroplasticity in the motor, sensory, and dorsolateral prefrontal cortices, hypothesizing the presence of hyper-plasticity in autistic adults. We anticipate that this hyper-plasticity underpins motor, sensory, and executive function difficulties in autistic adults. Additionally, we propose investigating the efficacy of bilateral rTMS to reduce hyper-plasticity and improve these functions in autistic adults. This approach not only seeks to enhance therapeutic options but also provides biological insights into the brain mechanisms underlying some of the common autism-associated difficulties.

Repetitive Transcranial Magnetic Stimulation and Tai Chi Chuan for Older Adults With Sleep Disorders and Mild Cognitive Impairment: A Randomized Clinical Trial

Importance

Sleep disorders and mild cognitive impairment (MCI) commonly coexist in older adults, increasing their risk of developing dementia. Long-term tai chi chuan has been proven to improve sleep quality in older adults. However, their adherence to extended training regimens can be challenging. Repetitive transcranial magnetic stimulation (rTMS) is a neuromodulation technique that may enhance the benefits of exercise.

Objective

To investigate whether 1-Hz rTMS of the right dorsolateral prefrontal cortex could enhance the clinical benefits of tai chi chuan in improving sleep quality and cognitive function among older adults with sleep disorders and MCI.

Design, Setting, and Participants

This 2-arm, sham-controlled, assessor-masked randomized clinical trial was conducted at a university hospital in China between October 2022 and February 2024. Adults aged 60 to 75 years with sleep disorders and MCI were eligible. Data analysis was performed from February to May 2024.

Intervention

Participants were randomized in a 1:1 ratio to an experimental group (tai chi chuan and 1-Hz rTMS) or a sham group (tai chi chuan and sham rTMS). Each participant received 30 sessions of personalized rTMS targeting the right dorsolateral prefrontal cortex, and the sham group underwent the same procedure. The 2 groups received 30 sessions of 60 minutes of the 24-form simplified tai chi chuan, 5 times per week for 6 weeks.

Main Outcomes and Measures

The primary outcomes were subjective sleep quality assessed by the Pittsburgh Sleep Quality Index (PSQI), in which scores range from 0 to 21, with lower scores indicating a healthier sleep quality, and global cognitive function assessed by the Montreal Cognitive Assessment (MoCA), in which scores range from 0 to 30, with higher scores indicating less cognitive impairment. The secondary outcomes included measures of objective sleep actigraphy, anxiety and depression scales, and other cognitive subdomains. Assessments were performed at baseline, 6 weeks after the intervention, and at the 12-week follow-up.

Results

A total of 110 participants (mean [SD] age, 67.9 [4.6] years; 68 female [61.8%]) were randomized to the experimental group (n = 55) and the sham group (n = 55) and included in the intention-to-treat analysis. At 6 weeks after the intervention, compared with the sham group, the experimental group showed a lower PSQI score (between-group mean difference, -3.1 [95% CI, -4.2 to -2.1]; P < .001) and a higher MoCA score (between-group mean difference, 1.4 [95% CI, 0.7-2.1]; P < .001). The per-protocol dataset analyses and 12-week follow-up showed similar results. The generalized estimated equation model revealed an interaction effect between the PSQI score (mean difference, -2.1 [95% CI, -3.1 to -0.1]; P < .001) and the MoCA total score (mean difference, 0.9 [95% CI, 0.1-1.6]; P = .01). There were 7 nonserious, unrelated adverse events (experimental group: 2; sham group: 5) with no significant difference between the 2 groups.

Conclusions and Relevance

In this randomized clinical trial, the findings suggest that 1-Hz rTMS enhanced the clinical benefits of tai chi chuan in improving sleep quality and cognitive function among older adults with sleep disorders and MCI, which may be related to alterations in neural plasticity. These findings provide novel data on nonpharmacologic strategies for the rehabilitation of sleep disorders and may delay or even prevent MCI.

Trial Registration

Chinese Clinical Trial Registry Identifier: ChiCTR2200063274.

Engineering and Technological Advancements in Repetitive Transcranial Magnetic Stimulation (rTMS): A Five-Year Review

In the past five years, repetitive transcranial magnetic stimulation (rTMS) has evolved significantly, driven by advancements in device design, treatment protocols, software integration, and brain-computer interfaces (BCIs). This review evaluates how these innovations enhance the safety, efficacy, and accessibility of rTMS while identifying key challenges such as protocol standardization and ethical considerations. A structured review of peer-reviewed studies from 2019 to 2024 focused on technological and clinical advancements in rTMS, including AI-driven personalized treatments, portable devices, and integrated BCIs. AI algorithms have optimized patient-specific protocols, while portable devices have expanded access. Enhanced coil designs and BCI integration offer more precise and adaptive neuromodulation. However, challenges remain in standardizing protocols, addressing device complexity, and ensuring equitable access. While recent innovations improve rTMS's clinical utility, gaps in long-term efficacy and ethical concerns persist. Future research must prioritize standardization, accessibility, and robust ethical frameworks to ensure rTMS's sustainable impact.

Personalised transcranial magnetic stimulation for treatment-resistant depression, depression with comorbid anxiety and negative symptoms of schizophrenia: a narrative review

ABSTRACT

Transcranial magnetic stimulation (TMS) is a promising intervention for treatment-resistant psychiatric disorders. However, conventional TMS typically utilises a one-size-fits-all approach when determining stimulation targets. Recent retrospective brain circuit-based analyses using lesion network mapping have suggested that a left dorsal lateral prefrontal cortex target has a higher efficacy for alleviating depression symptoms, a dorsomedial prefrontal cortex target is more effective for anxiety symptoms, and a rostromedial prefrontal cortex target is effective for schizophrenia-associated psychiatric symptoms. Nonetheless, symptom-specific brain circuit targeting has not been tested prospectively. We conducted a narrative review of selected literature to investigate individualised targeting for TMS and discuss potential future directions to elucidate the efficacy of this approach.

Repetitive Transcranial Magnetic Stimulation for the Treatment of Depression in a Real-World Setting: Findings from a Cohort Study

BACKGROUND/OBJECTIVES

In the past two decades, significant advancements in neuromodulation techniques have occurred, such as transcranial magnetic stimulation (TMS) for treatment-resistant depression (TRD). According to the assumption that repeated stimulation within a condensed timeframe can yield sustained efficacy, an accelerated protocol may be more effective in reducing time to response. With those premises, this study aimed to evaluate a sample of TRD patients treated with standard repetitive TMS (rTMS) and accelerated rTMS (arTMS).

METHODS

Nine subjects were treated with standard rTMS and 19 with arTMS. Psychometric assessment was made at the baseline and one week, one month, and three months after the treatment. A linear mixed-effect regression was performed along with other appropriate statistical analyses.

RESULTS

A significant improvement over time was observed for both depressive and cognitive symptoms. Moreover, considering the reduction in the Montgomery-Asberg Depression Rating Scale scores, a better treatment response was observed in subjects treated with arTMS (p < 0.05).

CONCLUSIONS

Our findings showed a significant difference between the two protocols in terms of clinical response. Although further studies are needed to confirm the superiority of arTMS, the better cost-effectiveness of this technique should be considered.

Lack of effects of eight-week left dorsolateral prefrontal theta burst stimulation on white matter macro/microstructure and connection in autism

Whether brain stimulation could modulate brain structure in autism remains unknown. This study explored the impact of continuous theta burst stimulation (cTBS) over the left dorsolateral prefrontal cortex (DLPFC) on white matter macro/microstructure in intellectually able children and emerging adults with autism. Sixty autistic participants were randomized (30 active) and received active or sham cTBS for eight weeks twice per week, 16 total sessions using a double-blind (participant-, rater-, analyst-blinded) design. All participants received high-angular resolution diffusion MR imaging at baseline and week 8. Twenty-eight participants in the active group and twenty-seven in the sham group with good imaging quality entered the final analysis. With longitudinal fixel-based analysis and network-based statistics, we found no significant difference between the active and sham groups in changes of white matter macro/microstructure and connections following cTBS. In addition, we found no association between baseline white matter macro/microstructure and autistic symptom changes from baseline to week 8 in the active group. In conclusion, we did not find a significant impact of left DLPFC cTBS on white matter macro/microstructure and connections in children and emerging adults with autism. These findings need to be interpreted in the context that the current intellectually able cohort in a single university hospital site limits the generalizability. Future studies are required to investigate if higher stimulation intensities and/or doses, other personal factors, or rTMS parameters might confer significant brain structural changes visible on MRI in ASD.

Brain stimulation over the left DLPFC enhances motivation for effortful rewards in patients with major depressive disorder

BACKGROUND

Amotivation is a typical feature in major depressive disorder (MDD), which produces reduced willingness to exert effort. The dorsolateral prefrontal cortex (DLPFC) is a crucial structure in goal-directed actions and therefore is a potential target in modulating effortful motivation. However, it remains unclear whether the intervention is effective for patients with MDD.

METHODS

We employed transcranial magnetic stimulation (TMS), computational modelling and event-related potentials (ERPs) to reveal the causal relationship between the left DLPFC and motivation for effortful rewards in MDD. Fifty patients underwent both active and sham TMS sessions, each followed by performing an Effort-Expenditure for Rewards Task, during which participants chose and implemented between low-effort/low-reward and high-effort/high-reward options.

RESULTS

The patients showed increased willingness to exert effort for rewards during the DLPFC facilitated session, compared with the sham session. They also had a trend in larger P3 amplitude for motivated attention toward chosen options, larger CNV during preparing for effort exertion, and larger SPN during anticipating a high reward. Besides, while behavior indexes for effortful choices were negatively related to depression severity in the sham session, this correlation was weakened in the active stimulation session.

CONCLUSIONS

These findings provide behavioral, computational, and neural evidence for the left DLPFC on effortful motivation for rewards. Facilitated DLPFC improves motor preparation and value anticipation after making decisions especially for highly effortful rewards in MDD. Facilitated DLPFC also has a potential function in enhancing motivated attention during cost-benefit trade-off. This neuromodulation effect provides a potential treatment for improving motivation in clinics.