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Bohmeier B, Cybinski LM, Gromer D, Bellinger D, Deckert J, Erhardt-Lehmann A, Deserno L, Mühlberger A, Pauli P, Polak T, Herrmann MJ. Intermittent theta burst stimulation of the left dorsolateral prefrontal cortex has no additional effect on the efficacy of virtual reality exposure therapy for acrophobia. A randomized double-blind placebo-controlled study. Behav Brain Res 2024; 476:115232. [PMID: 39236930 DOI: 10.1016/j.bbr.2024.115232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 07/19/2024] [Accepted: 08/26/2024] [Indexed: 09/07/2024]
Abstract
Anxiety disorders are among the most common mental disorders. Treatment guidelines recommend pharmacotherapy and cognitive behavioral therapy as standard treatment. Although cognitive behavioral therapy is an effective therapeutic approach, not all patients benefit sufficiently from it. In recent years, non-invasive brain stimulation techniques, such as transcranial magnetic stimulation, have been investigated as promising adjuncts in the treatment of affective disorders. The aim of this study is to investigate whether a combination of intermittent theta burst stimulation (iTBS) and virtual reality exposure therapy leads to a significantly greater reduction in acrophobia than virtual reality exposure with sham stimulation. In this randomized double-blind placebo-controlled study, 43 participants with acrophobia received verum or sham iTBS over the left dorsolateral prefrontal cortex prior to two sessions of virtual reality exposure therapy. Stimulation of the left dorsolateral prefrontal cortex with iTBS was motivated by an experimental study showing a positive effect on extinction memory retention. Acrophobic symptoms were assessed using questionnaires and two behavioral approach tasks one week before, after treatment and six months after the second diagnostic session. The results showed that two sessions of virtual reality exposure therapy led to a significant reduction in acrophobic symptoms, with an overall remission rate of 79 %. However, there was no additional effect of iTBS of the left dorsolateral prefrontal cortex on the therapeutic effects. Further research is needed to determine how exactly a combination of transcranial magnetic stimulation and exposure therapy should be designed to enhance efficacy.
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Affiliation(s)
- Barbara Bohmeier
- Center of Mental Health, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Lisa M Cybinski
- Center of Mental Health, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Daniel Gromer
- Department of Psychology (Clinical Psychology and Psychotherapy), University of Wuerzburg, Wuerzburg, Germany
| | - Daniel Bellinger
- Center of Mental Health, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Jürgen Deckert
- Center of Mental Health, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Angelika Erhardt-Lehmann
- Center of Mental Health, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Wuerzburg, Wuerzburg, Germany; Department of Translational Research in Psychiatry, Max Planck Institute of Psychiatry, Munich, Germany
| | - Lorenz Deserno
- Center of Mental Health, Department for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Andreas Mühlberger
- Department of Psychology (Clinical Psychology and Psychotherapy), University of Regensburg, Regensburg, Germany
| | - Paul Pauli
- Department of Psychology (Clinical Psychology and Psychotherapy), University of Wuerzburg, Wuerzburg, Germany
| | - Thomas Polak
- Center of Mental Health, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Martin J Herrmann
- Center of Mental Health, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Wuerzburg, Wuerzburg, Germany.
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Widge AS. Closed-Loop Deep Brain Stimulation for Psychiatric Disorders. Harv Rev Psychiatry 2023; 31:162-171. [PMID: 37171475 PMCID: PMC10188203 DOI: 10.1097/hrp.0000000000000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
ABSTRACT Deep brain stimulation (DBS) is a well-established approach to treating medication-refractory neurological disorders and holds promise for treating psychiatric disorders. Despite strong open-label results in extremely refractory patients, DBS has struggled to meet endpoints in randomized controlled trials. A major challenge is stimulation "dosing"-DBS systems have many adjustable parameters, and clinicians receive little feedback on whether they have chosen the correct parameters for an individual patient. Multiple groups have proposed closed loop technologies as a solution. These systems sense electrical activity, identify markers of an (un)desired state, then automatically deliver or adjust stimulation to alter that electrical state. Closed loop DBS has been successfully deployed in movement disorders and epilepsy. The availability of that technology, as well as advances in opportunities for invasive research with neurosurgical patients, has yielded multiple pilot demonstrations in psychiatric illness. Those demonstrations split into two schools of thought, one rooted in well-established diagnoses and symptom scales, the other in the more experimental Research Domain Criteria (RDoC) framework. Both are promising, and both are limited by the boundaries of current stimulation technology. They are in turn driving advances in implantable recording hardware, signal processing, and stimulation paradigms. The combination of these advances is likely to change both our understanding of psychiatric neurobiology and our treatment toolbox, though the timeframe may be limited by the realities of implantable device development.
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Affiliation(s)
- Alik S Widge
- From the Department of Psychiatry & Behavioral Sciences and Medical Discovery Team on Addictions, University of Minnesota
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Sugrue LP, Desikan RS. Precision neuroradiology: mapping the nodes and networks that link genes to behaviour. Br J Radiol 2019; 92:20190093. [PMID: 31294609 PMCID: PMC6732927 DOI: 10.1259/bjr.20190093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
What is the future of neuroradiology in the era of precision medicine? As with any big change, this transformation in medicine presents both challenges and opportunities, and to flourish in this new environment we will have to adapt. It is difficult to predict exactly how neuroradiology will evolve in this shifting landscape, but there will be changes in both what we image and what we do. In terms of imaging, we will need to move beyond simply imaging brain anatomy and toward imaging function, both at the molecular and circuit level. In terms of what we do, we will need to move from the periphery of the clinical enterprise toward its center, with a new emphasis on integrating imaging with genetic and clinical data to form a comprehensive picture of the patient that can be used to direct further testing and care.The payoff is that these changes will align neuroradiology with the emerging field of precision psychiatry, which promises to replace symptom-based diagnosis and trial-and-error treatment of psychiatric disorders with diagnoses based on quantifiable genetic, imaging, physiologic, and behavioural criteria and therapies targeted to the particular pathophysiology of individual patients. Here we review some of the recent developments in behavioural genetics and neuroscience that are laying the foundation for precision psychiatry. By no means comprehensive, our goal is to introduce some of the perspectives and techniques that are likely to be relevant to the precision neuroradiologist of the future.
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Affiliation(s)
- Leo P Sugrue
- 1Departments of Radiology and Biomedical Imaging, University California, San Francisco, USA
| | - Rahul S Desikan
- 1Departments of Radiology and Biomedical Imaging, University California, San Francisco, USA.,2Department of Neurology, University California, San Francisco, USA
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Maeng LY, Murillo MF, Mu M, Lo MC, de la Rosa M, O'Brien JM, Freeman DK, Widge AS. Behavioral validation of a wireless low-power neurostimulation technology in a conditioned place preference task. J Neural Eng 2019; 16:026022. [PMID: 30620935 DOI: 10.1088/1741-2552/aafc72] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Neurostimulation technologies are important for studying neural circuits and the connections that underlie neurological and psychiatric disorders. However, current methods come with limitations such as the restraint on movement imposed by the wires delivering stimulation. The objective of this study was to assess whether the e-Particle (EP), a novel wireless neurostimulator, could sufficiently stimulate the brain to modify behavior without these limitations. APPROACH Rats were implanted with the EP and a commercially available stimulating electrode. Animals received rewarding brain stimulation, and performance in a conditioned place preference (CPP) task was measured. To ensure stimulation-induced neuronal activation, immediate early gene c-fos expression was also measured. MAIN RESULTS The EP was validated in a commonly used CPP task by demonstrating that (1) wireless stimulation via the EP induced preference behavior that was comparable to that induced by standard wired electrodes and (2) neuronal activation was observed in projection targets of the stimulation site. SIGNIFICANCE The EP may help achieve a better understanding of existing brain stimulation methods while overcoming their limitations. Validation of the EP in a behavioral model suggests that the benefits of this technology may extend to other areas of animal research and potentially to human clinical applications.
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Affiliation(s)
- Lisa Y Maeng
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02129, United States of America
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Abdelnaim MA, Langguth B, Deppe M, Mohonko A, Kreuzer PM, Poeppl TB, Hebel T, Schecklmann M. Anti-Suicidal Efficacy of Repetitive Transcranial Magnetic Stimulation in Depressive Patients: A Retrospective Analysis of a Large Sample. Front Psychiatry 2019; 10:929. [PMID: 31969842 PMCID: PMC6960193 DOI: 10.3389/fpsyt.2019.00929] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/22/2019] [Indexed: 01/08/2023] Open
Abstract
Background: Suicide is a major public health problem. About 90% of suicide victims have one or more major psychiatric disorder, with a reported 20-fold increased risk for suicide in patients with affective disorders in comparison with healthy subjects. Repetitive transcranial magnetic stimulation (rTMS) has been established as an effective alternative or adjunctive treatment option for patients with depressive disorders, but little is known about its effects on suicide risk. Objective: For the assessment of the effectiveness of rTMS on suicidal ideation and behaviors, we performed a retrospective analysis of a large sample of patients with depressive disorders, who were treated with rTMS. Methods: We analyzed the records of 711 TMS in- and out-patients with depressive affective disorders in a tertiary referral hospital between 2002 and 2017. Out of these patients we were able to collect Hamilton depression rating scale (HAMD) data of 332 patients (180 females, 152 males; age range 20 to 79 years; mean age 47.3 ± 12.3) for which we analyzed the change of suicidal ideation by using item 3 (suicidality) of HAMD. Results: Out of all 711 patients treated with rTMS for their depression, one patient (0.1%) committed suicide during the TMS treatment. In the statistical analysis of the subsample with 332 patients there was an overall amelioration of depressive symptoms accompanied by a significant decrease in the suicidality item with a medium effect size. Decrease in suicidality was not inferior to changes in other items as indicated by effect sizes. Forty-seven percent of patients showed an amelioration in suicidality, 41.3% of patients did not show a change in their suicidality's scores, and 11.7% of patients showed an increase in suicidality's scores from baseline to final rating. Correlation of item 3 (suicidality) and item 7 (drive) demonstrated a significant positive association, revealing improved drive with a parallel decreased suicidality. Conclusion: Based on the proposed data, there is no evidence that rTMS increases the risk for suicide during the course of the treatment. Conversely, rTMS tends to reduce suicidal ideation. Our findings call for further rTMS controlled studies using large sample sizes and specific suicidality assessment measures to obtain more conclusive results.
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Affiliation(s)
- Mohamed A Abdelnaim
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Markus Deppe
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Alexey Mohonko
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Peter M Kreuzer
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Timm B Poeppl
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany.,Department of Psychiatry, Psychotherapy, and Psychosomatics, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Tobias Hebel
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Martin Schecklmann
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
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Bilge MT, Gosai AK, Widge AS. Deep Brain Stimulation in Psychiatry: Mechanisms, Models, and Next-Generation Therapies. Psychiatr Clin North Am 2018; 41:373-383. [PMID: 30098651 PMCID: PMC6092041 DOI: 10.1016/j.psc.2018.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Deep brain stimulation has preliminary evidence of clinical efficacy, but has been difficult to develop into a robust therapy, in part because its mechanisms are incompletely understood. We review evidence from movement and psychiatric disorder studies, with an emphasis on how deep brain stimulation changes brain networks. From this, we argue for a network-oriented approach to future deep brain stimulation studies. That network approach requires methods for identifying patients with specific circuit/network deficits. We describe how dimensional approaches to diagnoses may aid that identification. We discuss the use of network/circuit biomarkers to develop self-adjusting "closed loop" systems.
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Affiliation(s)
- Mustafa Taha Bilge
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, Boston, MA 02129, USA
| | - Aishwarya K Gosai
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, Boston, MA 02129, USA
| | - Alik S Widge
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, Boston, MA 02129, USA; Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA, USA.
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Widge AS, Malone DA, Dougherty DD. Closing the Loop on Deep Brain Stimulation for Treatment-Resistant Depression. Front Neurosci 2018; 12:175. [PMID: 29618967 PMCID: PMC5871707 DOI: 10.3389/fnins.2018.00175] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 03/05/2018] [Indexed: 12/20/2022] Open
Abstract
Major depressive episodes are the largest cause of psychiatric disability, and can often resist treatment with medication and psychotherapy. Advances in the understanding of the neural circuit basis of depression, combined with the success of deep brain stimulation (DBS) in movement disorders, spurred several groups to test DBS for treatment-resistant depression. Multiple brain sites have now been stimulated in open-label and blinded studies. Initial open-label results were dramatic, but follow-on controlled/blinded clinical trials produced inconsistent results, with both successes and failures to meet endpoints. Data from follow-on studies suggest that this is because DBS in these trials was not targeted to achieve physiologic responses. We review these results within a technology-lifecycle framework, in which these early trial “failures” are a natural consequence of over-enthusiasm for an immature technology. That framework predicts that from this “valley of disillusionment,” DBS may be nearing a “slope of enlightenment.” Specifically, by combining recent mechanistic insights and the maturing technology of brain-computer interfaces (BCI), the next generation of trials will be better able to target pathophysiology. Key to that will be the development of closed-loop systems that semi-autonomously alter stimulation strategies based on a patient's individual phenotype. Such next-generation DBS approaches hold great promise for improving psychiatric care.
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Affiliation(s)
- Alik S Widge
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Donald A Malone
- Department of Psychiatry, Cleveland Clinic, Cleveland, OH, United States
| | - Darin D Dougherty
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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