Acute reduction in anxiety after deep transcranial magnetic stimulation (DTMS) in unipolar major depression- a systematic review and meta-analysis

Brain activation alterations with adjunctive deep transcranial magnetic stimulation in obsessive-compulsive disorder: an fMRI study

BACKGROUND

Obsessive-compulsive disorder (OCD) is one of the most common neuropsychiatric disorders with lifetime prevalence higher than that of schizophrenia and bipolar disorders. Inadequate response to available pharmacological and psychotherapeutic interventions is common in OCD. Adjunctive brain stimulation methods to address the inadequate treatment response in OCD have found a special interest in research. This study aimed to examine the efficacy of adjunctive deep transcranial magnetic stimulation (dTMS) in ameliorating the symptoms of OCD and the effect of dTMS on activation of brain regions while performing the Stroop task using functional magnetic resonance imaging (fMRI).

METHODS

A total of 41 patients were assessed for the study out of which 15 OCD patients received 10 sessions of high-frequency dTMS using the H7 coil to target the anterior cingulate cortex and the medial prefrontal cortex over a period of 2 weeks. The Yale-Brown Obsessive-Compulsive Scale, the Hamilton Anxiety Rating Scale, and the Hamilton Depression Rating Scale were used for the pre- and post-stimulation clinical assessment. fMRI was used to measure the activation of brain regions while performing the Stroop task.

RESULTS

There was a significant improvement in the obsessive-compulsive, anxiety, and depressive symptoms after the 2 weeks of the dTMS treatment. A significant decrease in the activation of left caudate nucleus and adjacent white matter was noted while performing the Stroop task after the dTMS treatment.

CONCLUSION

The study provides preliminary evidence for functional correlates of effectiveness of dTMS as an adjunctive treatment modality for OCD.

Efficacy of Deep TMS with the H1 Coil for Anxious Depression

(1) Background: While the therapeutic efficacy of Transcranial Magnetic Stimulation (TMS) for major depressive disorder (MDD) is well established, less is known about the technique's efficacy for treating comorbid anxiety. (2) Methods: Data were retrospectively analyzed from randomized controlled trials (RCTs) that used Deep TMS with the H1 Coil for MDD treatment. The primary endpoint was the difference relative to sham treatment following 4 weeks of stimulation. The effect size was compared to literature values for superficial TMS and medication treatments. (3) Results: In the pivotal RCT, active Deep TMS compared with sham treatment showed significantly larger improvements in anxiety score (effect size = 0.34, p = 0.03 (FDR)) which were sustained until 16 weeks (effect size = 0.35, p = 0.04). The pooled effect size between all the RCTs was 0.55, which compares favorably to alternative treatments. A direct comparison to Figure-8 Coil treatment indicated that treatment with the H1 Coil was significantly more effective (p = 0.042). In contrast to previously reported studies using superficial TMS and medication for which anxiety has been shown to be a negative predictor of effectiveness, higher baseline anxiety was found to be predictive of successful outcome for the H1-Coil treatment. (4) Conclusions: Deep TMS is effective in treating comorbid anxiety in MDD and, unlike alternative treatments, the outcome does not appear to be adversely affected by high baseline anxiety levels.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility.

METHODS

Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg²⁰²⁰) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care.

CONCLUSION

The MDcpg²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

Guidelines for TMS/tES clinical services and research through the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has broadly disrupted biomedical treatment and research including non-invasive brain stimulation (NIBS). Moreover, the rapid onset of societal disruption and evolving regulatory restrictions may not have allowed for systematic planning of how clinical and research work may continue throughout the pandemic or be restarted as restrictions are abated. The urgency to provide and develop NIBS as an intervention for diverse neurological and mental health indications, and as a catalyst of fundamental brain research, is not dampened by the parallel efforts to address the most life-threatening aspects of COVID-19; rather in many cases the need for NIBS is heightened including the potential to mitigate mental health consequences related to COVID-19.

OBJECTIVE

To facilitate the re-establishment of access to NIBS clinical services and research operations during the current COVID-19 pandemic and possible future outbreaks, we develop and discuss a framework for balancing the importance of NIBS operations with safety considerations, while addressing the needs of all stakeholders. We focus on Transcranial Magnetic Stimulation (TMS) and low intensity transcranial Electrical Stimulation (tES) - including transcranial Direct Current Stimulation (tDCS) and transcranial Alternating Current Stimulation (tACS).

METHODS

The present consensus paper provides guidelines and good practices for managing and reopening NIBS clinics and laboratories through the immediate and ongoing stages of COVID-19. The document reflects the analysis of experts with domain-relevant expertise spanning NIBS technology, clinical services, and basic and clinical research - with an international perspective. We outline regulatory aspects, human resources, NIBS optimization, as well as accommodations for specific demographics.

RESULTS

A model based on three phases (early COVID-19 impact, current practices, and future preparation) with an 11-step checklist (spanning removing or streamlining in-person protocols, incorporating telemedicine, and addressing COVID-19-associated adverse events) is proposed. Recommendations on implementing social distancing and sterilization of NIBS related equipment, specific considerations of COVID-19 positive populations including mental health comorbidities, as well as considerations regarding regulatory and human resource in the era of COVID-19 are outlined. We discuss COVID-19 considerations specifically for clinical (sub-)populations including pediatric, stroke, addiction, and the elderly. Numerous case-examples across the world are described.

CONCLUSION

There is an evident, and in cases urgent, need to maintain NIBS operations through the COVID-19 pandemic, including anticipating future pandemic waves and addressing effects of COVID-19 on brain and mind. The proposed robust and structured strategy aims to address the current and anticipated future challenges while maintaining scientific rigor and managing risk.

Factors associated with response after deep transcranial magnetic stimulation in a real-world clinical setting: Results from the first 40 cases of treatment-resistant depression

Background:

Deep transcranial magnetic stimulation (dTMS) has been sanctioned by the United States Food and Drug Administration for treatment-resistant depression. In a retrospective cohort study, we evaluated response and effectiveness of dTMS in real-world practice, as an add-on treatment for resistant depression.

Methods:

Forty adult outpatients suffering from depression, all taking psychiatric medications, underwent 20 dTMS treatments over a 4–6 week period. At baseline (T0), visit 10 (T1), and visit 20 (T2), the Clinical Global Impression-Severity (CGI-S) scale was administered, and the Clinical Global Impression Improvement (CGI-I) scale was completed at T1 and T2; the Hamilton Depression Rating Scale (HDRS-21) was administrated at T0 and T2 only. The patients also completed the Quick Inventory of Depressive Symptoms–Self-Report (QIDS-SR) at T0, T1, and T2.

Results:

Depressive symptoms (HDRS-21 total score) decreased significantly following treatment. The HDRS total score decreased from an average of 21.22 (± 6.09) at T0, to 13.95 (± 7.24) at T2. Correspondingly, at T2, 32.5% were responders to the treatment and 20% were in remission, based on the HDRS-21. Treatment was well tolerated, with a discontinuation rate of 7.5%. While depressive symptoms at baseline did not predict remission/response at T2, higher HDRS scores at T0 were associated with a larger decrease in depressive symptoms during the study.

Conclusions:

Significant antidepressant effects were seen following 20 dTMS treatments, given as augmentation to ongoing medications in treatment-resistant depression. The findings suggest that among patients with TRD, the severity of the depressive episode (and not necessarily the number of failed antidepressant medication trials) is associated with a positive therapeutic effect of dTMS. Hence, the initial severity of the depressive episode may guide clinicians in referring patients for dTMS.

Potential predictors of depressive relapse following repetitive Transcranial Magnetic Stimulation: A systematic review

BACKGROUND

Repetitive Transcranial Magnetic Stimulation (rTMS) is widely approved treatment for major depressive disorder (MDD). However, around 50% of individuals who recover from depression following rTMS interventions experience a relapse of depressive symptomatology by 12 months. The short-term durability of the rTMS treatment effect has been systematically investigated. However, variables relating to the long-term durability of the antidepressant effect produced by rTMS are less understood. Therefore, the current review systematically assessed the research on variables relating to relapse following rTMS.

METHOD

This systematic review was performed according to PRISMA guidelines. A comprehensive electronic literature search for terms related to relapse following rTMS treatment for MDD was performed on studies published before the end of October 2018.

RESULTS

A total of 18 studies assessing relapse related variables were identified. While there is some indication that comorbid anxiety, acute response, and residual symptomatology may hold predictive potential for depressive relapse following rTMS treatment, findings were not sufficient to draw reliable conclusions.

DISCUSSION

Identified studies assessed three main categories of variables including demographic information, clinical characteristics and rating scale scores, and rTMS treatment specific factors. Only a small number of studies were available, and considerable inconsistency exists between studies, only limited conclusions were able to be drawn.

CONCLUSION

More studies assessing a wider range of predictor variables such as cognitive or neuroimaging markers are needed.

Findings From a Trial of the Smartphone and OnLine Usage-based eValuation for Depression (SOLVD) Application: What Do Apps Really Tell Us About Patients with Depression? Concordance Between App-Generated Data and Standard Psychiatric Questionnaires for Depression and Anxiety

OBJECTIVE

Depression imposes a notable societal burden, with limited treatment success despite multiple available psychotherapy and medications choices. Potential reasons may include the heterogeneity of depression diagnoses and the presence of comorbid anxiety symptoms. Despite technological advances and the introduction of many mobile phone applications (apps) claiming to relieve depression, major gaps in knowledge still exist regarding what apps truly measure and how they correlate with psychometric questionnaires. The goal of this study was to evaluate whether mobile daily mood self-ratings may be useful in monitoring and classifying depression symptoms in a clinically depressed population compared with standard psychometric instruments including the Patient Health Questionaire-9 (PHQ-9), the Hamilton Rating Scale for Depression (HAM-D), and the Hamilton Anxiety Rating Scale (HAM-A).

METHOD

For this study, 22 patients with major depressive disorder with or without comorbid anxiety disorder were recruited. The diagnosis of depression was confirmed through the Mini International Neuropsychiatric Interview (MINI). Over an 8-week period, daily moods were self-reported through the Smartphone and OnLine Usage-based eValuation for Depression (SOLVD) application, a custom-designed application that was downloaded onto patients' mobile devices. Depression and anxiety symptoms were also measured biweekly using the HAM-D, HAM-A, and PHQ-9.

RESULTS

Significant correlations were observed among self-evaluated mood, daily steps taken, SMS (text) frequency, average call duration, and biweekly psychometric scores (|r|>0.5, P<0.05). The correlation coefficients were higher in individuals with more severe depressive symptoms.

CONCLUSIONS

Although this study, given its limited sample size, was exploratory in nature, it helps fill a significant gap in our knowledge of the concordance between ratings obtained on the Ham-D, Ham-A, and the PHQ-9 psychometric instruments and data obtained via a smartphone app. These questionnaires represent gold-standard, commonly used psychiatric research/clinical instruments, and, thus, this information can serve as a foundation for digital phenotyping for depression and pave the way for interventional studies using smartphone applications.

Is rTMS effective for anxiety symptoms in major depressive disorder? An efficacy analysis comparing left-sided high-frequency, right-sided low-frequency, and sequential bilateral rTMS protocols

BACKGROUND

Anxiety symptoms are common in major depressive disorder. Whilst therapeutic efficacy of repetitive transcranial magnetic stimulation (rTMS) in depression is well-established, minimal research has investigated rTMS's efficacy in treating anxiety symptoms in depression.

METHODS

This study investigates the effectiveness of rTMS in treating anxiety symptoms in depression, specifically the relative efficacy of the three rTMS protocols commonly used in clinical practice: left-sided high-frequency, right-sided low-frequency and sequential bilateral rTMS. Antidepressant efficacy of each rTMS protocol is also investigated. Treatment data for 697 patients were pooled from three studies across five sites. Changes in Beck's Anxiety Inventory (BAI) and the Hamilton Depression Rating Scale over 4-week rTMS courses were analysed using latent growth curve modelling.

RESULTS

All rTMS protocols were effective in treating anxiety symptoms (mean BAI reduction, 8.13 points; p < 0.001) and depressive symptoms. Near therapeutic equivalence was seen across the three protocols. Improvement in depressive severity positively correlated with improvement in anxiety. Both high- and low-baseline anxiety scores showed overall symptom reduction.

CONCLUSIONS

This study addresses the clinical knowledge gap pertaining to rTMS's therapeutic efficacy in treating anxiety symptoms in depression and the relative efficacy of three commonly used stimulation protocols. Our findings suggest therapeutic equivalence across left-sided high-frequency, right-sided low-frequency, and sequential bilateral rTMS approaches.

Anxiety symptoms across twenty-years in schizoaffective disorder, bipolar disorder, and major depressive disorder

Anxiety symptoms and anxiety disorders are common in both mood and psychotic disorders. However, limited comparative information exists regarding the long-term course of anxiety in schizoaffective disorder, bipolar disorder, and major depressive disorder. Prospective evaluation of the 20-year trajectory of self-reported anxiety and somatic-related anxiety in three major diagnostic groups, 43 schizoaffective patients, 47 bipolar patients, and 109 major depression patients was conducted. The patients were recruited at an index phase of hospitalization, and then reassessed longitudinally at six subsequent follow-ups over 20-years. The sample was well characterized with symptom, recovery and functioning data being available. This study found that in the earlier years of illness, self-reported anxiety was greater in schizoaffective and major depression patients than bipolar patients. The three groups were similar for anxiety symptoms during the 20-year course of their illness. Last, we found in all patients, self-reported anxiety in the early years predicted having a period of recovery and lower global functioning in the future. Our data provides unique information regarding the comparative course of anxiety in related mood and psychotic disorders. Both clinicians and researchers should focus on assessing, diagnosing, and treating anxiety in mood and psychotic disorders, as a means to improve outcomes and quality of life in these individuals.

The effect of bilateral low-frequency rTMS over dorsolateral prefrontal cortex on serum brain-derived neurotropic factor and serotonin in patients with generalized anxiety disorder

To investigate the effect of bilateral low-frequency repetitive transcranial magnetic stimulation (rTMS) over dorsolateral prefrontal cortex on serum brain-derived neurotropic factor (BDNF) and serotonin (5-HT) in patients with generalized anxiety disorders (GAD). As compared with before treatment, the HARS score in patients markedly decreased after treatment, and the levels of serum BDNF and 5-HT were significantly higher. Pearson correlation analysis revealed that the increase in the level of serum 5-HT was positively associated with the increase of the level of serum BDNF, and the change of anxiety score was negatively associated with the change of the level of serum BDNF and 5-HT. The results suggested that alleviation of GAD by bilateral low-frequency rTMS may be involved in the increase of the level of BDNF and the release of 5-HT in the brain.

Can deep transcranial magnetic stimulation (DTMS) be used to treat substance use disorders (SUD)? A systematic review

BACKGROUND

Deep transcranial magnetic stimulation (DTMS) is a non-invasive method of stimulating widespread cortical areas and, presumably, deeper neural networks. The current study assessed the effects of DTMS in the treatment of substance use disorders (SUD) using a systematic review.

METHODS

Electronic literature search (PsycInfo, Medline until April 2017) identified k = 9 studies (k = 4 randomized-controlled trials, RCTs, with inactive sham and k = 5 open-label studies). DTMS was most commonly applied using high frequency/intensity (10-20 Hz/100-120% of the resting motor threshold, MT) protocols for 10-20 daily sessions in cases with alcohol, nicotine or cocaine use disorders. The outcome measures were craving and dependence (according to standardized scales) or consumption (frequency, abstinence or results of biological assays) at the end of the daily treatment phases and at the last follow-up.

RESULTS

Acute and longer-term (6-12 months) reductions in alcohol craving were observed after 20 sessions (20 Hz, 120% MT) relative to baseline in k = 4 open-label studies with comorbid SUD and major depressive disorder (MDD). In k = 2 RCTs without MDD, alcohol consumption acutely decreased after 10-12 sessions (10-20 Hz, 100-120% MT) relative to baseline or to sham. Alcohol craving was reduced only after higher frequency/intensity DTMS (20 Hz, 120% MT) relative to sham in k = 1 RCT. Nicotine consumption was reduced and abstinence was increased after 13 sessions (10 Hz, 120% MT) and at the 6-month follow-up relative to sham in k = 1 RCT. Cocaine craving was reduced after 12 sessions (15 Hz, 100% MT) and at the 2-month follow-up relative to baseline in k = 1 open-label study while consumption was reduced after 12 sessions (10 Hz, 100% MT) relative to baseline but not to sham in k = 1 RCT.

CONCLUSIONS

High-frequency DTMS may be effective at treating some SUD both acutely and in the longer-term. Large RCTs with inactive sham are required to determine the efficacy and the optimal stimulation parameters of DTMS for the treatment of SUD.

An Update of a Meta-Analysis on the Clinical Outcomes of Deep Transcranial Magnetic Stimulation (DTMS) in Major Depressive Disorder (MDD)

Abstract. Deep transcranial magnetic stimulation (DTMS) is a noninvasive therapy for treatment-resistant major depressive disorder (MDD). The current study aimed to update a previous meta-analysis by investigating the acute and longer-term clinical outcomes of DTMS and their possible predictors (patient characteristics and stimulation parameters) in unipolar MDD. A systematic literature search identified 11 studies with 282 treatment-resistant, unipolar MDD patients. The clinical outcomes (depression severity, response and remission rates) were evaluated using random-effects meta-analyses. High frequency and intensity DTMS protocol with H1-coil had significant acute antidepressant outcomes and improved some cognitive functions after 20 daily sessions in unipolar MDD. Response rates tended to increase with lower severity of illness. Antidepressant effects were prolonged if maintenance DTMS was used after daily stimulation phases. DTMS consistently improves various symptom domains (antidepressant, cognitive) in treatment-resistant unipolar MDD.

Emerging areas of transcranial magnetic stimulation use in psychiatry

Transcranial magnetic stimulation (TMS) is most widely known clinically as a treatment for medication-refractory major depressive disorder, but it holds promise in a number of other areas. In addition to emerging neurologic areas of investigation such as in mild cognitive impairment, dementia, Parkinson's disease and stroke rehab, novel approaches to psychiatric conditions are also being explored. This review provides a critical condensation of the available data assessing the efficacy of TMS in the treatment of other psychiatric conditions, namely bipolar disorder, substance use, post-traumatic stress disorder and other anxiety disorders. Each section details the field's current accumulation of evidence of the respective condition's pathophysiology in the context of a discussion of the relevant therapeutic target(s) of TMS. Each section then reviews both positive and negative studies evaluating TMS in clinical practice. Given the relative tolerability and proven efficacy of TMS in treatment-resistant depression (TRD), further study to determine its therapeutic effect in other psychiatric entities is warranted.

Efficacy of ketamine in the rapid treatment of major depressive disorder: a meta-analysis of randomized, double-blind, placebo-controlled studies

BACKGROUND

An increasing number of studies are reporting that ketamine could be treated as a novel antidepressant for major depressive disorder (MDD). Therefore, we performed this meta-analysis to comprehensively and systematically assess the efficacy of ketamine for treating patients with MDD.

METHOD

Randomized, double-blind, placebo-controlled studies on ketamine versus placebo for treating MDD were searched up to April 2016 in medical databases (PubMed, CCTR, Web of Science, Embase, CBM-disc, and CNKI). Three treatment time points (24 and 72 h, and day 7) were chosen. Response and remission rates were the main outcomes. The random effects model was used. An intention-to-treat analysis was conducted.

RESULTS

Nine high-quality studies that included 368 patients were selected to compare the efficacy of ketamine to placebo. The therapeutic effects of ketamine at 24 and 72 h, and day 7 were found to be significantly better than placebo. Response and remission rates in the ketamine group at 24 and 72 h, and day 7 were 52.2% and 20.6%; 47.9% and 23.8%; and 39.8% and 26.2%, respectively. No significant heterogeneity existed, and the Egger's test showed no publication bias.

CONCLUSION

These results indicated that ketamine could yield a good efficacy in the rapid treatment of MDD. Future large-scale clinical studies are needed to confirm our results and investigate the mid- and long-term efficacy of ketamine in treating MDD.

Improvements in emotion regulation following repetitive transcranial magnetic stimulation for generalized anxiety disorder

Generalized anxiety disorder (GAD) is characterized by emotion regulation difficulties, which are associated with abnormalities in neural circuits encompassing fronto-limbic regions including the dorsolateral prefrontal cortex (DLPFC). The aim of this study was to determine whether DLPFC neuromodulation improves emotion regulation in patients with GAD. This is a secondary analysis from a randomized-controlled trial comparing 30 sessions of low-frequency right-sided active (n=13) versus sham (n=12, sham coil) repetitive transcranial magnetic stimulation (rTMS) at the right DLPFC in patients with GAD. Results indicated statistically significant improvements in self-reported emotion regulation difficulties at posttreatment and 3-month follow-up in the active group only. Improvements were found primarily in the domains of goal-directed behaviors and impulse control and were significantly associated with a global clinician rating of improvement. These preliminary results support rTMS as a treatment for GAD and suggest improved emotion regulation as a possible mechanism of change.

Cognitive functioning and deep transcranial magnetic stimulation (DTMS) in major psychiatric disorders: A systematic review

Deep transcranial magnetic stimulation (DTMS) is a non-invasive brain stimulation method mostly utilised in the treatment of major depression. The aim of the current study was to systematically review the literature on the cognitive effects of DTMS applied with the H-coil system in major psychiatric disorders. Following a literature search in PsycInfo and PubMed (any time to December 2015), 13 out of 32 studies on DTMS and cognitive functioning were included in the current review. Three studies included 38 healthy participants, eight studies included 158 unipolar or bipolar depression patients and two studies included 45 schizophrenia patients. Low-frequency DTMS (1-3 sessions) had little effect on cognitive functioning in healthy participants. The most consistent cognitive and clinical improvements were reported in the short-term (after 20 daily sessions of high-frequency DTMS with H1-coil) in studies with major depression patients. There was also a trend towards a short-term cognitive and clinical improvement in studies with schizophrenia patients. High-frequency DTMS might improve cognitive functioning and alleviate clinical symptoms in the short-term, particularly in major depression. However, this conclusion is based on data from mostly uncontrolled, open-label studies with patients receiving concurrent antidepressants or antipsychotics. Randomised, sham-controlled trials are needed to investigate the magnitude of the cognitive outcomes of DTMS in the short-term and beyond the daily stimulation phase in major psychiatric disorders.