Repetitive transcranial magnetic stimulation induces active coping strategies and attenuates the neuroendocrine stress response in rats

Repetitive transcranial magnetic stimulation (rTMS) for depressive-like symptoms in rodent animal models

Repetitive transcranial magnetic stimulation (rTMS) emerged as a non-invasive brain stimulation technique in the treatment of psychiatric disorders. Both preclinical and clinical studies as well as systematic reviews provide a heterogeneous picture, particularly concerning the stimulation protocols used in rTMS. Here, we present a review of rTMS effects in rodent models of depressive-like symptoms with the aim to identify the most relevant factors that lead to an increased therapeutic success. The influence of different factors, such as the stimulation parameters (stimulus frequency and intensity, duration of stimulation, shape and positioning of the coil), symptom severity and individual characteristics (age, species and genetic background of the rodents), on the therapeutic success are discussed. Accumulating evidence indicates that rTMS ameliorates a multitude of depressive-like symptoms in rodent models, most effectively at high stimulation frequencies (≥5 Hz) especially in adult rodents with a pronounced pathological phenotype. The therapeutic success of rTMS might be increased in the future by considering these factors and using more standardized stimulation protocols.

Impact of one HF-rTMS session over the DLPFC and motor cortex on acute hormone dynamics and emotional state in healthy adults: a sham-controlled pilot study

Studies indicate that high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) can lower cortisol concentration or output, with some evidence suggesting a link to testosterone. Together, these stress and social hormones might help regulate the emotional response to HF-rTMS. This pilot study evaluated the effect of HF-rTMS on acute testosterone and cortisol dynamics and emotional state in eleven healthy adults. Using a sham-controlled, single-blind, crossover design, participants completed a HF-rTMS session targeting the dorsolateral prefrontal cortex (DLPFC) and motor cortex on separate days. Stimulation (250 total pulses) was applied at 90% of the resting motor threshold. Salivary testosterone and cortisol, mood, motivation, anxiety, and heart rate (HR) were assessed before (T₁) and 1 (T₂), 15 (T₃), and 30 min (T₄) after each session. There were no significant session differences in testosterone and cortisol concentration, mood, motivation, and HR. Although DLPFC stimulation produced less anxiety (vs. motor cortex), and testosterone output was stable across both treatments (vs. sham-related decline in testosterone), neither differed from the sham. Within-person fluctuations in testosterone, mood, motivation, and/or anxiety were significantly related across the DLPFC and motor cortex trials only. In conclusion, a single sub-maximal session of HF-rTMS did not affect the hormonal, emotional, or physiological state of healthy adults, relative to a sham. However, the emergence of stimulation-specific testosterone and/or emotional linkages suggests that the repeated effects of HF-rTMS may also manifest at the individual level. This offers another pathway to explain the therapeutic efficacy of rTMS and a model to explore interindividual variability in health-related outcomes.

The role of transcranial magnetic stimulation in understanding attention-related networks in single subjects

Attention is a cognitive mechanism that has been studied through several methodological viewpoints, including animal models, MRI in stroke patients, and fMRI in healthy subjects. Activation-based fMRI research has also pointed to specific networks that activate during attention tasks. Most recently, network neuroscience has been used to study the functional connectivity of large-scale networks for attention to reveal how strongly correlated networks are to each other when engaged in specific behaviors. While neuroimaging has revealed important information about the neural correlates of attention, it is crucial to better understand how these processes are organized and executed in the brain in single subjects to guide theories and treatments for attention. Noninvasive brain stimulation is an effective tool to causally manipulate neural activity to detect the causal roles of circuits in behavior. We describe how combining transcranial magnetic stimulation (TMS) with modern precision network analysis in single-subject neuroimaging could test the roles of regions, circuits, and networks in regulating attention as a pathway to improve treatment effect magnitudes and specificity.

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Though studied for over 100 years, the brain basis of attention is still queried.

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Complexity in frameworks for attention makes brain mapping difficult.

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Relevant brain networks vary significantly across subjects, challenging progress.

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Single-subject neuroimaging with TMS can improve our understanding of attention.

Recovering from depression with repetitive transcranial magnetic stimulation (rTMS): a systematic review and meta-analysis of preclinical studies

Repetitive transcranial magnetic stimulation (rTMS) has gained growing interest for the treatment of major depression (MDD) and treatment-resistant depression (TRD). Most knowledge on rTMS comes from human studies as preclinical application has been problematic. However, recent optimization of rTMS in animal models has laid the foundations for improved translational studies. Preclinical studies have the potential to help identify optimal stimulation protocols and shed light on new neurobiological-based rationales for rTMS use. To assess existing evidence regarding rTMS effects on depressive-like symptoms in rodent models, we conducted a comprehensive literature search in accordance with PRISMA guidelines (PROSPERO registration number: CRD42019157549). In addition, we conducted a meta-analysis to determine rTMS efficacy, performing subgroup analyses to examine the impact of different experimental models and neuromodulation parameters. Assessment of the depressive-like phenotype was quite homogeneous whilst rTMS parameters among the 23 included studies varied considerably. Most studies used a stress-induced model. Overall, results show a largely beneficial effect of active rTMS compared to sham stimulation, as reflected in the statistically significant recovery of both helplessness (SDM 1.34 [1.02;1.66]) and anhedonic (SDM 1.87 [1.02;2.72]) profiles. Improvement of the depressive-like phenotype was obtained in all included models and independently of rTMS frequency. Nonetheless, these results have limited predictive value for TRD patients as only antidepressant-sensitive models were used. Extending rTMS studies to other MDD models, corresponding to distinct endophenotypes, and to TRD models is therefore crucial to test rTMS efficacy and to develop cost-effective protocols, with the potential of yielding faster clinical responses in MDD and TRD.

Anaesthesia, not number of sessions, influences the magnitude and duration of an aHF-rTMS in dogs

BACKGROUND

Currently, the rat has been a useful animal model in brain stimulation research. Nevertheless, extrapolating results from rodent repetitive Transcranial Magnetic Stimulation (rTMS) research to humans contains several hurdles. This suggests the desperate need for a large animal model in translational rTMS research. The dog would be a valid choice, not only due to the fact that humans and dogs share a neurophysiological background, but a similar neuropathological background as well.

HYPOTHESIS

In order to evaluate the feasibility of the canine rTMS animal model, this study aimed to evaluate the neurophysiological response in dogs on a, clinically used, accelerated high frequency (aHF) rTMS protocol. This aHF-rTMS (20 Hz) protocol was performed under anaesthesia or sedation and either 20 sessions or 5 sessions were given to each dog.

METHODS

21 healthy dogs were randomly subjected to one of the four aHF-rTMS protocols (1 sham and 3 active protocols). For each dog, the perfusion indices (PI), of a [99mTc]HMPAO scan at 4 time points, for the left frontal cortex (stimulation target) were calculated for each protocol.

RESULTS

Concerning sham stimulation, the average PI remained at the baseline level. The main result was the presence of a direct transitory increase in rCBF at the stimulation site, both under anaesthesia and sedation. Nevertheless the measured increase in rCBF was higher but shorter duration under sedation. The magnitude of this increase was not influenced by number of sessions. No changes in rCBF were found in remote brain regions.

CONCLUSION

This study shows that, despite the influence of anaesthesia and sedation, comparable and clinically relevant effects on the rCBF can be obtained in dogs. Since less methodological hurdles have to be overcome and comparable results can be obtained, it would be acceptable to put the dog forward as an alternative translational rTMS animal model.

Heart Rate Variability and Skin Conductance During Repetitive TMS Course in Children with Autism

Autism spectrum disorder (ASD) is a developmental disorder marked by difficulty in social interactions and communication. ASD also often present symptoms of autonomic nervous system (ANS) functioning abnormalities. In individuals with autism the sympathetic branch of the ANS presents an over-activation on a background of the parasympathetic activity deficits, creating an autonomic imbalance, evidenced by a faster heart rate with little variation and increased tonic electrodermal activity. The objective of this study was to explore the effect of 12 sessions of 0.5 Hz repetitive transcranial magnetic stimulation (rTMS) over dorsolateral prefrontal cortex (DLPFC) on autonomic activity in children with ASD. Electrocardiogram and skin conductance level (SCL) were recorded and analyzed during each session of rTMS. The measures of interest were time domain (i.e., R-R intervals, standard deviation of cardiac intervals, NN50-cardio-intervals >50 ms different from preceding interval) and frequency domain heart rate variability (HRV) indices [i.e., power of high frequency (HF) and low frequency (LF) components of HRV spectrum, LF/HF ratio]. Based on our prior pilot studies it was proposed that the course of 12 weekly inhibitory low-frequency rTMS bilaterally applied to the DLPFC will improve autonomic balance probably through improved frontal inhibition of the ANS activity, and will be manifested in an increased length of cardiointervals and their variability, and in higher frequency-domain HRV in a form of increased HF power, decreased LF power, resulting in decreased LF/HF ratio, and in decreased SCL. Our post-12 TMS results showed significant increases in cardiac intervals variability measures and decrease of tonic SCL indicative of increased cardiac vagal control and reduced sympathetic arousal. Behavioral evaluations showed decreased irritability, hyperactivity, stereotype behavior and compulsive behavior ratings that correlated with several autonomic variables.

Repetitive Transcranial Magnetic Stimulation as a Novel Therapy in Animal Models of Traumatic Brain Injury

Traumatic brain injury (TBI) in humans causes a broad range of structural damage and functional deficits due to both primary and secondary injury mechanisms. Over the past three decades, animal models have been established to replicate the diverse changes of human TBI, to study the underlying pathophysiology and to develop new therapeutic strategies. However, drugs that were identified as neuroprotective in animal brain injury models were not successful in clinical trials phase II or phase III. Repetitive transcranial magnetic stimulation (rTMS) is a powerful noninvasive approach to excite cortical neurons in humans and animals, widely applied for therapeutic purpose in patients with brain diseases. In addition, recent animal studies showed rTMS as a strong neuroprotective tool. In this chapter, we discuss the rationale and mechanisms related to rTMS as well as therapeutic applications and putative molecular mechanisms. Furthermore, relevant biochemical studies and neuroprotective effect in animal models and possible application of rTMS as a novel treatment for rodent brain injury models are discussed.

Effects of weekly low-frequency rTMS on autonomic measures in children with autism spectrum disorder

The term autism spectrum disorder (ASD) describes a range of conditions characterized by impairments in social interactions, communication, and by restricted and repetitive behaviors. Autism spectrum disorder may also present with symptoms suggestive of autonomic nervous system (ANS) dysfunction. The objective of this study was to determine the effect of 18 sessions of low frequency (LF) repetitive transcranial magnetic stimulation (rTMS) on autonomic function in children with ASD by recording electrocardiogram (ECG) and electrodermal activity (EDA) pre- post- and during each rTMS session. The autonomic measures of interest in this study were R-R cardiointervals in EKG (R-R), time and frequency domain measures of heart rate variability (HRV) and skin conductance level (SCL). Heart rate variability measures such as R-R intervals, standard deviation of cardiac intervals, pNN50 (percentage of cardiointervals >50 ms different from preceding interval), power of high frequency (HF) and LF components of HRV spectrum, LF/HF ratio, were then derived from the recorded EKG. We expected that the course of 18 weekly inhibitory LF rTMS applied to the dorsolateral prefrontal cortex (DLPFC) would enhance autonomic balance by facilitating frontal inhibition of limbic activity thus resulting in decreased overall heart rate (HR), increased HRV (in a form of increased HF power), decreased LF power (resulting in decreased LF/HF ratio), and decreased SCL. Behavioral evaluations post-18 TMS showed decreased irritability, hyperactivity, stereotype behavior and compulsive behavior ratings while autonomic measures indicated a significant increase in cardiac interval variability and a decrease of tonic SCL. The results suggest that 18 sessions of LF rTMS in ASD results in increased cardiac vagal control and reduced sympathetic arousal.

Whole body exposure to 2.4 GHz WIFI signals: effects on cognitive impairment in adult triple transgenic mouse models of Alzheimer's disease (3xTg-AD)

The present investigation aimed at evaluating the effects of long-term exposure to WIFI type radiofrequency (RF) signals (2.40 GHz), two hours per day during one month at a Specific Absorption Rate (SAR) of 1.60 W/kg. The effects of RF exposure were studied on wildtype mice and triple transgenic mice (3xTg-AD) destined to develop Alzheimer's-like cognitive impairment. Mice were divided into four groups: two sham groups (WT, TG; n=7) and two exposed groups (WTS, TGS; n=7). The cognitive interference task used in this study was designed from an analogous human cognitive interference task including the Flex field activity system test, the two-compartment box test and the Barnes maze test. Our data demonstrate for the first time that RF improves cognitive behavior of 3xTg-AD mice. We conclude that RF exposure may represent an effective memory-enhancing approach in Alzheimer's disease.

Translational neuromodulation: approximating human transcranial magnetic stimulation protocols in rats

OBJECTIVE

Transcranial magnetic stimulation (TMS) is a well-established clinical protocol with numerous potential therapeutic and diagnostic applications. Yet, much work remains in the elucidation of TMS mechanisms, optimization of protocols, and in development of novel therapeutic applications. As with many technologies, the key to these issues lies in the proper experimentation and translation of TMS methods to animal models, among which rat models have proven popular. A significant increase in the number of rat TMS publications has necessitated analysis of their relevance to human work. We therefore review the essential principles for the approximation of human TMS protocols in rats as well as specific methods that addressed these issues in published studies.

MATERIALS AND METHODS

We performed an English language literature search combined with our own experience and data. We address issues that we see as important in the translation of human TMS methods to rat models and provide a summary of key accomplishments in these areas.

RESULTS

  An extensive literature review illustrated the growth of rodent TMS studies in recent years. Current advances in the translation of single, paired-pulse, and repetitive stimulation paradigms to rodent models are presented. The importance of TMS in the generation of data for preclinical trials is also highlighted.

CONCLUSIONS

Rat TMS has several limitations when considering parallels between animal and human stimulation. However, it has proven to be a useful tool in the field of translational brain stimulation and will likely continue to aid in the design and implementation of stimulation protocols for therapeutic and diagnostic applications.

Long-lasting effects of chronic rTMS to treat chronic rodent model of depression

Repetitive transcranial magnetic stimulation (rTMS) has been demonstrated in the pre-clinical and clinical settings to have an antidepressant effect. However, studies on the long-lasting effect of rTMS, especially when the effect is measured after treatment has ceased for a few weeks is lacking. We examined this question in a chronic unpredicted mild stress (CUMS) rat model of depression. We gave 3 weeks of high frequency (15 Hz) rTMS, venlafaxine, or these two treatments combined to a modified CUMS paradigm, and then investigated the prolonged effect of treatments. Behavioral testing (sucrose preference test, open field test, forced swimming test, novelty suppressed feeding test), plasma hormone level, hippocampal BrdU labeling, and amount of related neurotropic factors were used to assess the effects of stress and treatments. Long-term chronic rTMS significantly reversed andehonic-like behavior, increased hippocampus cell proliferation, BDNF protein level, phosphorylation of ERK1/2 compared with CUMS rats two weeks after the cessation of rTMS treatment. However, the changes in plasma hormone level were not sustained for that amount of time. Venlafaxine had no interaction with the physical stimulation. Our results suggest that high frequency rTMS has long-lasting effects, which may have some relationship with neuroplasticity.

The effects of single and repeated exposure to 2.45 GHz radiofrequency fields on c-Fos protein expression in the paraventricular nucleus of rat hypothalamus

This study investigated the effects of microwave radiation on the PVN of the hypothalamus, extracted from rat brains. Expression of c-Fos was used to study the pattern of cellular activation in rats exposed once or repeatedly (ten times in 2 weeks) to 2.45 GHz radiation in a GTEM cell. The power intensities used were 3 and 12 W and the Finite Difference Time Domain calculation was used to determine the specific absorption rate (SAR). High SAR triggered an increase of the c-Fos marker 90 min or 24 h after radiation, and low SAR resulted in c-Fos counts higher than in control rats after 24 h. Repeated irradiation at 3 W increased cellular activation of PVN by more than 100% compared to animals subjected to acute irradiation and to repeated non-radiated repeated session control animals. The results suggest that PVN is sensitive to 2.45 GHz microwave radiation at non-thermal SAR levels.

Is rTMS an effective therapeutic strategy that can be used to treat anxiety disorders?

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive procedure whereby a pulsed magnetic field stimulates electrical activity in the brain. Anxiety disorders are the most common of all mental health problems for which effective, mechanism-based treatments remain elusive. Consequently, more advanced non-invasive therapeutic methods are required. A possible method to modulate brain activity and potentially viable for use in clinical practice is rTMS. Here, we focus on the main findings of rTMS from animal models of anxiety and the experimental advances of rTMS that may become a viable clinical application to treat anxiety disorders, one of the most common causes of disability in the workplace in the world. Key advances in combining rTMS with neuroimaging technology may aid such future developments. This article is part of a Special Issue entitled 'Anxiety and Depression'.

Neurostimulatory and ablative treatment options in major depressive disorder: a systematic review

INTRODUCTION

Major depressive disorder is one of the most disabling and common diagnoses amongst psychiatric disorders, with a current worldwide prevalence of 5-10% of the general population and up to 20-25% for the lifetime period.

HISTORICAL PERSPECTIVE

Nowadays, conventional treatment includes psychotherapy and pharmacotherapy; however, more than 60% of the treated patients respond unsatisfactorily, and almost one fifth becomes refractory to these therapies at long-term follow-up.

NONPHARMACOLOGICAL TECHNIQUES

Growing social incapacity and economic burdens make the medical community strive for better therapies, with fewer complications. Various nonpharmacological techniques like electroconvulsive therapy, vagus nerve stimulation, transcranial magnetic stimulation, lesion surgery, and deep brain stimulation have been developed for this purpose.

DISCUSSION

We reviewed the literature from the beginning of the twentieth century until July 2009 and described the early clinical effects and main reported complications of these methods.

An endocrine perspective on the role of steroid hormones in the antidepressant treatment efficacy of transcranial magnetic stimulation

Evidence from recent meta-analyses indicates that transcranial magnetic stimulation (TMS) is moderately effective in the treatment of major depressive disorder (MDD). Individual differences in the susceptibility to TMS are suggested to underlie a significant portion of the variability in antidepressant efficacy observed in TMS trials. Interestingly, recent findings suggest a moderating role for steroid hormones in the antidepressant efficacy of TMS in women. Steroid hormones are known to have strong activational and organizational influences on the brain and may upregulate the efficacy of TMS by way of modulating cortical excitability in a sex-dependent manner. Here we propose that the measurement and manipulation of steroid hormones could be crucial steps in the development of successful individually based TMS protocols for the treatment of MDD.

Sex differences in antidepressant-like effect of chronic repetitive transcranial magnetic stimulation in rats

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neurophysiological technique. Pre-clinical and clinical studies supported that rTMS might have antidepressant effects. However, whether antidepressant effect of chronic rTMS is gender-dependent is still unknown. In this study, male and female Wistar rats received 10-day rTMS (4 trains of 15 Hz; 200 stimuli/day; 1.0 T) or control condition, and then were subjected to the forced-swim test (FST). We found that female rats consistently showed higher activity levels than males in FST and revealed the significant effects of gender and rTMS as well as the interaction of gender and rTMS. The result suggested the antidepressant-like effects of chronic rTMS on behavioral components in FST are gender-dependent. The gender discrepancy related to rTMS should not be neglected in antidepressant treatment of rTMS.

Repetitive transcranial magnetic stimulation protects hippocampal plasticity in an animal model of depression

Despite its therapeutic success in treating mood-related disorders, little is known about the mechanism by which repetitive transcranial magnetic stimulation (rTMS) alters physiological responses of neurons. Using the forced swim test (FST) in rats as a model of depression, we tested the protective effect of rTMS on synaptic plasticity, specifically, on the induction of hippocampal long-term potentiation (LTP). Male Sprague-Dawley rats were subjected to FST to induce immobility, a behavioral symptom of depression. They were subsequently treated with one of the three conditions: rTMS (rTMS: 1000 stimuli at 10Hz), sham rTMS (SHAM: acoustic stimulation only), or an antidepressant drug, fluoxetine (FLX: 10mg/kg, i.p.) for 7 days. There was a significant difference in immobility time between rTMS and SHAM groups after 7 days of treatment, but not after a single day. Following the second swim test on day 7, they were anesthetized and LTP was induced in vivo in the perforant path-dentate gyrus synapses. Another group (NAIVE) that had received no prior treatment was used as a control for LTP. The SHAM or FLX group exhibited little signs of LTP induction. On the contrary, the rTMS and NAIVE group showed a significant increase in field excitatory postsynaptic potentials after LTP induction. These results show that rTMS has an antidepressant-like effect after a relatively short period of treatment, and this effect might be mediated by a cellular process that can potentially reverse the impaired synaptic efficacy caused by the forced swim procedure.

Chronic repetitive transcranial magnetic stimulation is antidepressant but not anxiolytic in rat models of anxiety and depression

Transcranial magnetic stimulation (TMS) has been proposed as a treatment for depression and anxiety disorders. While the antidepressant effect has been modelled in animals, there have been few attempts to examine a possible anxiolytic effect of repetitive TMS (rTMS) in animal models. We administered 18 days of rTMS to male Sprague-Dawley rats. On days 10 through 18, rats were tested in several anxiety models (social interaction, emergence, elevated plus-maze, and predator odor avoidance) and in the forced swim test. No group differences were apparent on any of the anxiety models, while TMS produced an antidepressant effect in the forced swim test. Interestingly, on day 1 of the forced swim test, the home cage control group displayed increased swimming behaviour compared with sham-treated animals, suggesting an observable level of stress may have accompanied sham treatment. The results from the forced swim test suggested that TMS had modest antidepressant properties, but it did not show anxiolytic properties in the models examined. The study also suggested that stress associated with handling should be taken into account in the interpretation of TMS studies in animals.

Anxiolytic suppression of repetitive transcranial magnetic stimulation-induced anxiety in the rats

Repetitive transcranial magnetic stimulation (rTMS) is effective for treatment of several psychiatric disorders such as depression and anxiety disorder. However, some reports suggest that rTMS induced anxiety in normal volunteers. Consistent with this observation, we have reported that chronic rTMS induces anxiety in normal rats which was suppressed by chronic treatment, but not acute paroxetine treatment. The current study evaluates rTMS as animal model of anxiety by investigating the effect of rTMS on anxiety behaviors and the ability of standard anxiolytics to block expression of these behaviors. We found that 10-day rTMS induced anxiety in normal rats, as evidenced by expression of anxiety behaviors in the elevated plus-maze. This anxiety was suppressed by acute treatment with diazepam, alprazolam, or buspirone suggesting that chronic rTMS treatment provides a good animal model for anxiety.

Transcranial magnetic stimulation effects on one-trial learning and response to anxiogenic stimuli in adult male rats

Transcranial magnetic stimulation (TMS) is a relatively new technique for inducing small, localized, and reversible changes in living brain tissue and has been suggested to have antidepressant properties in humans and animal models of depression. Memory function generally has been found to be unaffected by TMS, although some studies have raised the possibility of memory interference from TMS. Additionally, there have been indirect indications that TMS may possess anxiolytic features. This study examines the effects of TMS in animal models of one-trial learning and anxiety. In this study, short-term treatment with TMS compared with identically handled animals not given TMS in adult rats resulted in no significant differences in memory as assessed both by a one-time learning paradigm and by components of an elevated-plus maze task, that TMS does not impair memory as assessed by these tasks. In addition, no changes were found in anxiety-like behavior on the elevated plus maze task. In summary, these findings support previous reports that TMS does not interfere with memory function. There was no evidence of an anxiolytic response from TMS in rats as assessed by the elevated plus maze test.

Repetitive transcranial magnetic stimulation increases the release of dopamine in the nucleus accumbens shell of morphine-sensitized rats during abstinence

Recent studies in rodents have shown that withdrawal from chronic drug abuse is associated with a significant decrease in dopamine (DA) release in mesolimbic structures, especially in the shell region of the nucleus accumbens. Since the DA system is known to play an important role in reward processes, a withdrawal-associated impairment in mesolimbic DA-mediated transmission could possibly implicate reward deficit and thus enhance vulnerability to drug craving and relapse. We have previously demonstrated that acute repetitive transcranial magnetic stimulation (rTMS) has a modulatory effect on DA release in several areas of the rat brain, including dorsal striatum, hippocampus, and nucleus accumbens shell. In the present study, we investigated the possible use of rTMS as a tool in re-establishing the dysregulated DA secretion observed during withdrawal in morphine-sensitized male Sprague-Dawley rats. Using intracerebral microdialysis, we monitored the effects of acute rTMS (20 Hz) on the intra-accumbal release-patterns of DA in freely moving animals that were subjected to a morphine sensitization scheme for a period of 8 days. We provide first evidence that acute rTMS (20 Hz) is able to increase DA concentration in the shell region of the nucleus accumbens in both control animals and morphine-sensitized rats during abstinence. The DA release in morphine-sensitized rats was significantly higher than in controls. rTMS, therefore, might gain a potential therapeutic role in the treatment of dysphoric and anhedonic states during drug withdrawal in humans.

Endogenous dopamine release induced by repetitive transcranial magnetic stimulation over the primary motor cortex: an [11C]raclopride positron emission tomography study in anesthetized macaque monkeys

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) has been used as a treatment for neuropsychiatric disorders such as depression and Parkinson's disease (PD). Despite the growing interest in therapeutic application of rTMS, precise mechanisms of its action remain unknown. With respect to PD, activation of the mesostriatal dopaminergic pathway is likely to be a candidate mechanism underlying the therapeutic effects; however, modulating effects of rTMS over the primary motor cortex (M1) on the dopaminergic system have not been studied.

METHODS

We used [11C]raclopride positron emission tomography to measure changes of extracellular dopamine concentration after 5Hz rTMS over the M1 in eight anesthetized monkeys.

RESULTS

rTMS over the right M1 induced a reduction of [11C]raclopride binding potential (BP) in the bilateral ventral striatum, including the nucleus accumbens, and a significant increase of BP in the right putamen; no significant BP reduction was found in the dorsal striatum. These data indicate that rTMS over the motor cortex induces a release of endogenous dopamine in the ventral striatum.

CONCLUSIONS

Our results suggest that therapeutic mechanisms of rTMS may be explained in part by an activation of the mesolimbic dopaminergic pathway, which plays critical roles in rewards, reinforcement, and incentive motivation.

Effects of repetitive transcranial magnetic stimulation on behavioral and neurochemical changes in rats during an elevated plus-maze test

In transcranial magnetic stimulation (TMS) the regional electrical activity in the brain is influenced by a pulsed magnetic field. The rapidly changed magnetic field produces electrical currents that activate neurons. Repetitive TMS (rTMS) treatment can cause functional changes in the cortex. The present study clarified the effects of rTMS treatment on behavioral changes in rats, focusing on anxiety by using an elevated plus-maze (plus-maze) test. The effects of rTMS treatment on neurochemical changes during the plus-maze test were investigated by determining the extracellular levels of serotonin (5-HT) and dopamine (DA) in the prefrontal cortex by using in vivo microdialysis. Each rat received rTMS of the frontal brain for 3 days, during which 125 stimuli from five trains in a day were applied at 25 Hz for 1 s with 2-min intervals between trains. Three-day series of (chronic) rTMS treatment caused significant increases in the time spent in open arms and the number of entries into open arms of the plus-maze compared with non-treated and sham-treated rats, which were not observed in 1-day series of (acute) rTMS treatment. Chronic rTMS treatment suppressed the increases in 5-HT levels induced by the plus-maze test, but did not influence the elicited DA levels. These data suggest that chronic rTMS treatment of the frontal brain has anxiolytic effects in rats, which are related to the 5-HTergic neuronal system.

Repetitive transcranial magnetic stimulation : does it have potential in the treatment of depression?

Transcranial magnetic stimulation (TMS) has become a major research tool in experimental clinical neurophysiology as a result of its potential to noninvasively and focally stimulate cortical brain regions. Currently, studies are being conducted to investigate whether repetitive TMS (rTMS)-mediated modulation of cortical function may also provide a therapeutic approach in neurological and psychiatric disorders. Preclinical findings have shown that prefrontal rTMS can modulate the function of fronto-limbic circuits, which is reversibly altered in major depression. rTMS has also been found to exert effects on neurotransmitter systems involved in the pathophysiology of major depression (e.g. stimulates subcortical dopamine release and acts on the hypothalamic pituitary adrenal axis, which is dysregulated in depression). To date, numerous open and controlled clinical trials with widely differing stimulation parameters have explored the antidepressant potential of rTMS. Though conducted with small sample sizes, the majority of the controlled trials demonstrated significant antidepressant effects of active rTMS compared with a sham condition. Effect sizes, however, varied from modest to substantial, and the patient selection focused on therapy-resistant cases. Moreover, the average treatment duration was approximately 2 weeks, which is short compared with other antidepressant interventions. Larger multicentre trials, which would be mandatory to demonstrate the antidepressant effectiveness of rTMS, have not been conducted to date.A putative future application of rTMS may be the treatment of patients who did not tolerate or did not respond to antidepressant pharmacotherapy before trying more invasive strategies such as electroconvulsive therapy and vagus nerve stimulation. Theoretically, rTMS may be also applied early in the course of disease in order to speed up and increase the effects of antidepressant pharmacotherapy. However, this application has not been a focus of clinical trials to date. Research efforts should be intensified to further investigate the effectiveness of rTMS as an antidepressant intervention and to test specific applications of the technique in the treatment of depressive episodes.

Add-on rTMS for treatment of depression: a pilot study using stereotaxic coil-navigation according to PET data

OBJECTIVE

Repetitive transcranial magnetic stimulation (rTMS) is regarded as a potentially new tool to treat depression. In a double-blind, randomized, sham-controlled pilot study we investigated the efficacy of neuronavigated rTMS, guided according to the prefrontal metabolic state determined by positron emission tomography (PET).

METHODS

25 patients with major depression were included. Prior to rTMS, PET scans were obtained. For the real stimulation condition, the dorsolateral prefrontal cortex (DLPFC) with lower metabolic activity compared to the contralateral hemisphere was selected, if detected by prior PET. Stimulation parameters were 15 Hz, 110% motor threshold (MT), 3000 stimuli/day, for 10 days. A neuronavigational system was used to place the magnetic coil above each individuals' selected cortical region (real condition: DLPFC, sham: midline parieto-occipital, intensity 90% of MT). RTMS was administered add-on to medication. Depression-related symptoms were rated with Beck's, Hamilton's (HAM-D), and Montgomery-Asberg's (MADRS) depression rating scales.

RESULTS

Real stimulation improved depression according to HAM-D and MADRS moderately but significantly better compared to sham at the end of the stimulation sessions. In the real condition, four out of 13 patients responded with a mean improvement in HAM-D and/or MADRS of at least 50%, whereas none responded to sham. Antidepressant effects of stimulation of the relatively hypometabolic DLPFC were comparable to stimulation in absence of metabolic differences.

CONCLUSIONS

A moderate improvement of depressive symptoms after rTMS was observed. Our preliminary data show that stimulation of prefrontal hypometabolism may not be advantageous to stimulation irrespective of the metabolic state.

Prefrontal cortex transcranial magnetic stimulation does not change local diffusion: a magnetic resonance imaging study in patients with depression

OBJECTIVE

To determine whether transcranial magnetic stimulation over the left dorsolateral prefrontal cortex produces pathologic changes or leakage of the blood-brain barrier in patients with depression by using apparent diffusion coefficient magnetic resonance imaging.

BACKGROUND

Transcranial magnetic stimulation is a new technology for noninvasively stimulating the brain. It appears to be a relatively safe technique, with some important exceptions. Its neurobiologic mechanisms of action are poorly understood. One theory to explain its apparent antidepressant effects involves a potential change in local blood-brain barrier settings, allowing passage of peripheral substances directly into brain parenchyma. Knowing whether transcranial magnetic stimulation changes local brain diffusion is important as well from a safety perspective. To test whether transcranial magnetic stimulation changes local brain diffusion, we used apparent diffusion coefficient magnetic resonance imaging in depressed patients undergoing interleaved transcranial magnetic stimulation/functional magnetic resonance imaging over the left prefrontal cortex.

METHODS

Within a 1.5 Tesla magnetic resonance imaging scanner, 14 depressed patients were stimulated with a figure-eight transcranial magnetic stimulation coil over the left prefrontal cortex. Apparent diffusion coefficient magnetic resonance imaging was acquired before, and immediately after, 1 Hertz transcranial magnetic stimulation (147 stimuli) intermittently delivered at a motor threshold of more than 7.35 minutes. Phase maps of the transcranial magnetic stimulation magnetic fields were used to guide region-of-interest placement.

RESULTS

No significant qualitative apparent diffusion coefficient differences were observed before and after 1 Hertz transcranial magnetic stimulation underneath the coil.

CONCLUSIONS

One Hertz transcranial magnetic stimulation over the left dorsolateral prefrontal cortex as applied in this study did not result in pathologic changes or leakage of the blood-brain barrier in patients with depression. If prefrontal transcranial magnetic stimulation at these usage parameters changes local diffusion, it is not an obvious or large effect.

Duration of transcranial magnetic stimulation effects on the neuroendocrine stress response and coping behavior of adult male rats

BACKGROUND

Transcranial magnetic stimulation (TMS) is a relatively novel, noninvasive method of altering cerebral electrophysiological activity that produces localized and reversible changes in brain tissue. TMS has been shown to have antidepressant properties in both human trials and animal models. Additionally, TMS may alter hypothalamic-pituitary-adrenal (HPA) function resulting in a normalized dexamethasone suppression test in some depressed subjects and an attenuated stress-induced increase in adrenocorticotropic hormone (ACTH) and a possibly lowered basal corticosterone (CORT) concentration in rats. This research was undertaken to investigate the duration of these behavioral and neuroendocrine effects of TMS in rats.

METHODS

In this study, serum ACTH, CORT, testosterone, and luteinizing hormone (LH) concentrations following and immobility parameters during a forced-swim test in adult male rats were evaluated immediately and 1, 3, 5, 7, and 14 days subsequent to a 10-day course of once-daily TMS or sham application.

RESULTS

TMS animals had significantly higher ACTH and CORT concentrations immediately following the 10-day course of TMS compared to sham controls. Higher CORT concentrations (numerically but not statistically) were displayed by TMS-treated animals 1 and 3 days after the 10-day application course, although there were no significant differences between TMS and sham groups for ACTH or CORT levels 1, 3, 5, 7, and 14 days following application of sham or TMS. No significant differences were found between groups for serum testosterone and LH levels at any given collection time point. Immobility time, a measure of coping ability that is predictive of human antidepressant response, was significantly decreased (i.e., time spent actively swimming was significantly increased) immediately after the 10-day course of TMS. Thereafter, a nonsignificant numerical trend at 1 and 3 days after TMS application for immobility times between the TMS and control groups was observed (TMS<control values). No significant differences in immobility between TMS and control animals were found at subsequent time points.

CONCLUSIONS

The present findings suggest that the HPA stress axis is significantly altered immediately following a 10-day course of TMS in that a significant increase in ACTH and CORT levels in TMS-treated animals corresponded to a significant decrease in immobility times in the forced-swim test compared to control values. Finally, based upon the obtained results, the TMS effects in rats appear to be of relatively short duration.

The combined dexamethasone-CRH test before and after repetitive transcranial magnetic stimulation (rTMS) in major depression

BACKGROUND

Hypothalamic-pituitary-adrenocortical (HPA) dysregulation assessed by the combined dexamethasone corticotropin releasing hormone test (DEX/CRH test) has been demonstrated to normalize after successful antidepressant pharmacotherapy. Here, we investigated whether repetitive transcranial magnetic stimulation (rTMS) also leads to a normalization of HPA system activity in depressed patients.

METHODS

Thirty-seven medication free patients suffering from a major depressive episode (DSM-IV) underwent a DEX/CRH test before and after 13 daily sessions of left prefrontal rTMS in an open trial.

RESULTS

There was an overshoot of CRH-induced cortisol release that was not affected by rTMS treatment. Postdexamethasone cortisol levels prior to CRH challenge decreased in responders after rTMS treatment, whereas no change of CRH-induced adrenocorticotropic hormone (ACTH) and cortisol release in responders or nonresponders was observed.

CONCLUSIONS

The persisting HPA system hyperactivity after rTMS suggests a high risk for relapse and therefore argues for an immediate maintenance therapy in patients responding to this treatment.

Depressive-like behavior and stress reactivity are independent traits in a Wistar Kyoto x Fisher 344 cross

Depression is a heritable disorder that is often precipitated by stress. Abnormalities of the stress-reactive hypothalamic-pituitary-adrenal (HPA) axis are also common in depressed patients. In animal models, the forced swim test (FST) is the most frequently used test of depressive-like behavior. We have used a proposed animal model of depression, the Wistar Kyoto (WKY) rat, to investigate the relationship as well as the mode of inheritance of FST behaviors and HPA measures. Through reciprocal breeding of WKY and F344 parent strains and brother-sister breeding of the F1 generation, we obtained 486 F2 animals. Parent, F1 and F2 animals were tested in the FST. Blood samples were collected for determination of basal and stress (10-min restraint) plasma corticosterone (CORT) levels, and adrenal weights were measured. We found that all measures were heritable to some extent and that this heritability was highly sex dependent. Both correlation and factor analyses of the F2 generation data demonstrate that FST behavior and HPA axis measures are not directly related. Thus, the underlying genetic components of depressive-like behavior and HPA axis abnormalities are likely to be disparate in the segregating F2 generation of a WKY x F344 cross.

Effects of antidepressant pharmacotherapy after repetitive transcranial magnetic stimulation in major depression: an open follow-up study

An increasing number of clinical studies demonstrates antidepressant effects of repetitive transcranial magnetic stimulation (rTMS). However, limited data are available so far concerning the stability of these effects and the efficacy of subsequent maintenance therapy. Therefore, we examined whether antidepressant pharmacotherapy can stabilize clinical improvement after rTMS monotherapy. Twenty-six drug-free patients suffering from a major depressive episode (DSM-IV criteria) participated in an open rTMS trial over two weeks (10-13 sessions, 10 Hz, left prefrontal stimulation at 100% motor threshold intensity). Subsequently, the patients were followed up during standardized antidepressant pharmacotherapy with mirtazapine for a further 4 weeks. The interval between the last rTMS and the first day of pharmacotherapy varied between one and five days. After two weeks of rTMS monotherapy 39% of the patients responded to rTMS by at least 50% reduction in their Hamilton Rating Scale for Depression (HRSD) scores. Treatment interruption after rTMS resulted in a significant increase in the HRSD score of rTMS responders. The degree of the deterioration was dependent on the length of interval without treatment. However, this deterioration was reverted and the further clinical course stabilized by subsequent mirtazapine treatment. The overall response rate after rTMS and mirtazapine treatment (alone or in combination) was 77%. Our results suggest that (1) antidepressant pharmacotherapy is able to further improve the clinical response to rTMS and (2) that responders to rTMS monotherapy should receive subsequent psychopharmalogical treatment without interruption in order to avoid a deterioration of symptoms.

Chronic psychosocial stress and concomitant repetitive transcranial magnetic stimulation: effects on stress hormone levels and adult hippocampal neurogenesis

BACKGROUND

Repetitive transcranial magnetic stimulation is increasingly used as a therapeutic tool in psychiatry and has been demonstrated to attenuate the activity of the stress hormone system. Stress-induced structural remodeling in the adult hippocampus may provide a cellular basis for understanding the impairment of neural plasticity in depressive illness. Accordingly, reversal of structural remodeling might be a desirable goal for antidepressant therapy. The present study investigated the effect of chronic psychosocial stress and concomitant repetitive transcranial magnetic stimulation treatment on stress hormone regulation and hippocampal neurogenesis.

METHODS

Adult male rats were submitted to daily psychosocial stress and repetitive transcranial magnetic stimulation (20 Hz) for 18 days. Cell proliferation in the dentate gyrus was quantified by using BrdU immunohistochemistry, and both the proliferation rate of progenitors and the survival rate of BrdU-labeled cells were evaluated. To characterize the activity of the hypothalamic-pituitary-adrenocortical system, plasma corticotropin and corticosterone concentrations were measured.

RESULTS

Chronic psychosocial stress resulted in a significant increase of stress hormone levels and potently suppressed the proliferation rate and survival of the newly generated hippocampal granule cells. Concomitant repetitive transcranial magnetic stimulation treatment normalized the stress-induced elevation of stress hormones; however, despite the normalized activity of the hypothalamic-pituitary-adrenocortical system, the decrement of hippocampal cell proliferation was only mildly attenuated by repetitive transcranial magnetic stimulation, while the survival rate of BrdU-labeled cells was further suppressed by the treatment.

CONCLUSIONS

These results support the notion that attenuation of the hypothalamic-pituitary-adrenocortical system is an important mechanism underlying the clinically observed antidepressant effect of repetitive transcranial magnetic stimulation, whereas this experimental design did not reveal beneficial effects of repetitive transcranial magnetic stimulation on adult hippocampal neurogenesis.

Repetitive transcranial magnetic stimulation increases the release of dopamine in the mesolimbic and mesostriatal system

Repetitive transcranial magnetic stimulation (rTMS) is suggested to be a potentially useful treatment in major depression. In order to optimize rTMS for therapeutic use, it is necessary to understand the neurobiological mechanisms involved, particularly the nature of the neurochemical changes induced. Using intracerebral microdialysis in urethane-anesthetized and conscious adult male Wistar rats, we monitored the effects of acute rTMS (20 Hz) on the intrahippocampal, intraaccumbal and intrastriatal release patterns of dopamine and its metabolites (homovanillic acid, 3,4-dihydroxyphenylacetic acid). The stimulation parameters were adjusted according to the results of accurate MRI-based computer-assisted reconstructions of the current density distributions induced by rTMS in the rat brain, ensuring stimulation of frontal brain regions. In the dorsal hippocampus, the shell of the nucleus accumbens and the dorsal striatum the extracellular concentration of dopamine was significantly elevated in response to rTMS. Taken together, these data provide the first in vivo evidence that acute rTMS of frontal brain regions has a modulatory effect on both the mesolimbic and the mesostriatal dopaminergic systems. This increase in dopaminergic neurotransmission may contribute to the beneficial effects of rTMS in the treatment of affective disorders and Parkinson's disease.

The application of transcranial magnetic stimulation in psychiatry and neurosciences research

OBJECTIVE

Over recent years transcranial magnetic stimulation (TMS) has become widely applied in the study of neuropsychiatric disorders. The aim of this article is to review the application of TMS as an investigative tool and as a potential therapeutic modality in psychiatric disorders.

METHOD

A comprehensive literature review.

RESULTS

When applied as an investigative tool, TMS provides innovative ways to directly study the excitability of the cortex, cortical regional connectivity, the plasticity of brain responses and cognitive functioning in illness and disease states. A number of studies suggest the potential of treatment with TMS in disease states, especially in patients with depression, although difficulties exist with the interpretation of the published literature.

CONCLUSION

TMS has a considerable role in neuropsychiatric research. It appears to have considerable potential as a therapeutic tool in depression, and perhaps a role in several other disorders, although widespread application requires larger trials and establishment of sustained response.

Transcranial magnetic stimulation (TMS) effects on testosterone, prolactin, and corticosterone in adult male rats

BACKGROUND

Transcranial magnetic stimulation is a relatively new technique for inducing small, localized, and reversible changes in living brain tissue. Although transcranial magnetic stimulation generally results in no immediate changes in plasma corticosterone, prolactin, and testosterone, it normalizes the dexamethasone suppression test in some depressed subjects and has been shown to attenuate stress-induced increases in adrenocorticotropic hormone in rats.

METHODS

In this study, serum corticosterone and testosterone concentrations were assayed in male rats immediately and 3, 6, 9, 12, 24, and 48 hours following a single transcranial magnetic stimulation or sham application. Serum prolactin concentrations were determined immediately and 2 hours following a one-time application of either transcranial magnetic stimulation or sham.

RESULTS

Transcranial magnetic stimulation animals displayed significantly lower corticosterone concentrations at 6 and 24 hours following a single application compared with sham-control values. Transcranial magnetic stimulation also resulted in lower corticosterone concentrations numerically but not statistically in transcranial magnetic stimulation animals immediately after application (p =.089). No significant differences were found between groups for serum prolactin or testosterone levels at any given collection time point.

CONCLUSIONS

These findings 1) suggest that transcranial magnetic stimulation alters the hypothalamic-pituitary-adrenal stress axis and 2) provide time-course data for the implications of the hormonal mechanism that may be involved in the actions of transcranial magnetic stimulation.

Transcranial magnetic stimulation as a therapeutic tool in psychiatry: what do we know about the neurobiological mechanisms?

Potential therapeutic properties of repetitive transcranial magnetic stimulation (rTMS) have been suggested in several psychiatric disorders such as depression, mania, obsessive-compulsive disorder, posttraumatic stress disorder and schizophrenia. By inducing electric currents in brain tissue via a time-varying strong magnetic field, rTMS has the potential to either directly or trans-synaptically modulate neuronal circuits thought to be dysfunctional in these psychiatric disorders. However, in order to optimize rTMS for therapeutic use, it is necessary to understand the neurobiological mechanisms involved, particularly the nature of the changes induced and the brain regions affected. Compared to the growing number of clinical studies on its putative therapeutic properties, the studies on the basic mechanisms of rTMS are surprisingly scarce. rTMS currently still awaits clinical routine administration although,there is compelling evidence that it causes changes in neuronal circuits as reflected by behavioural changes and decreases in the activity of the hypothalamic-pituitary-adrenocortical system. Both alterations suggest regional changes in neurotransmitter/neuromodulator release, transsynaptic efficiency, signaling pathways and in gene transcription. Together, these changes are, in part, reminiscent of those accompanying antidepressant drugs.

Hyperactivity of CRH neuronal circuits as a target for therapeutic interventions in affective disorders

Increasing evidence suggests that the neuroendocrine changes seen in psychiatric patients, especially in those suffering from affective disorders, may be causally related to the psychopathology and course of these clinical conditions. The most robustly confirmed neuroendocrine finding among psychiatric patients with affective disorders is hyperactivity of the hypothalamic-pituitary-adrenocortical (HPA) system, resulting from hyperactive hypothalamic corticotropin-releasing hormone (CRH) neurons. A large body of preclinical and clinical evidence suggests that both genetic and environmental factors contribute to the development of these HPA system abnormalities. Further, normalization of HPA system regulation was shown to be a prerequisite for favorable treatment response and stable remission among depressives. Preclinical data based on animal models including selectively bred rat lines and mouse mutants support the notion that CRH neurons are hyperactive also in neuroanatomical regions that are involved in behavioral regulation but are located outside the neuroendocrine system. This raises the question of whether more direct interventions such as CRH receptor antagonists would open a new lead in the treatment of stress-related disorders such as depression, anxiety and sleep disorders. Recent clinical observations support this possibility.

Acute transcranial magnetic stimulation of frontal brain regions selectively modulates the release of vasopressin, biogenic amines and amino acids in the rat brain

Using intracerebral microdialysis in urethane-anaesthetized adult male Wistar rats, we monitored the effects of acute repetitive transcranial magnetic stimulation (rTMS; 20 trains of 20 Hz, 2.5 s) on the intrahypothalamic release of arginine vasopressin (AVP) and selected amino acids (glutamate, glutamine, aspartate, serine, arginine, taurine, gamma-aminobutyric acid) and the intrahippocampal release of monoamines (dopamine, noradrenaline, serotonin) and their metabolites (homovanillic acid, 3,4-dihydroxyphenylacetic acid, 5-hydroxyindoleacetic acid). The stimulation parameters were adjusted according to the results of accurate computer reconstructions of the current density distributions induced by rTMS in the rat and human brains, ensuring similar stimulation patterns in both cases. There was a continuous reduction in AVP release of up to 50% within the hypothalamic paraventricular nucleus in response to rTMS. In contrast, the release of taurine, aspartate and serine was selectively stimulated within this nucleus by rTMS. Furthermore, in the dorsal hippocampus the extracellular concentration of dopamine was elevated in response to rTMS. Taken together, these data provide the first in vivo evidence that acute rTMS of frontal brain regions has a differentiated modulatory effect on selected neurotransmitter/neuromodulator systems in distinct brain areas.