Transcranial magnetic stimulation, transcranial direct current stimulation and electroconvulsive therapy for medication-resistant psychosis of schizophrenia

Therapeutic efficacy of transcranial direct current stimulation in treating auditory hallucinations in schizophrenia: A meta-analysis

BACKGROUND

Schizophrenia is a chronic psychiatric condition with complex symptomatology, including debilitating auditory hallucinations. Transcranial direct current stimulation (tDCS) has been explored as an adjunctive treatment to alleviate such symptoms.

AIM

To evaluate the therapeutic efficacy of tDCS in schizophrenia.

METHODS

Adhering to PRISMA guidelines, we systematically searched PubMed, Embase, Web of Science, and the Cochrane Library on September 19, 2023, for randomized controlled trials examining the efficacy of tDCS in schizophrenia, with no language or time restrictions. We included studies that compared tDCS with a control condition and reported clinically relevant outcomes. Data extraction and quality assessments were performed by independent evaluators using the Cochrane Collaboration's risk of bias tool. Statistical heterogeneity was evaluated, and a random-effects model was applied due to moderate heterogeneity (I² = 41.3%).

RESULTS

Nine studies comprising 425 participants (tDCS group: 219, control group: 206) were included. The meta-analysis demonstrated a significant reduction in auditory hallucination scores following tDCS treatment (weighted mean difference: -2.18, 95% confidence interval: -4.0 to -0.29, P < 0.01). Sensitivity analysis confirmed the robustness of the results, with no significant influence from individual studies. Additionally, publication bias was not detected, supporting the reliability and generalizability of the findings. These results underscore the efficacy of tDCS as a therapeutic intervention for auditory hallucinations in schizophrenia.

CONCLUSION

tDCS significantly reduces auditory hallucinations in schizophrenia, suggesting its potential as an effective adjunctive treatment for managing this disabling symptom. The findings highlight the practical significance of tDCS in clinical settings, particularly for patients with treatment-resistant auditory hallucinations.

Antidepressive Effectiveness of Amisulpride, Aripiprazole, and Olanzapine in Patients With Schizophrenia Spectrum Disorders: A Secondary Outcome Analysis of a Pragmatic, Randomized Trial (BeSt InTro)

BACKGROUND

Depressive symptoms are frequent in schizophrenia and associated with a poorer outcome. Currently, the optimal treatment for depressive symptoms in schizophrenia remains undetermined. Amisulpride, aripiprazole, and olanzapine all have antidepressive pharmacodynamic properties, ranging from serotonergic affinities to limbic dopaminergic selectivity. Consequently, in a 12-month pragmatic, randomized clinical trial, we aimed to investigate differences in antidepressive effectiveness among amisulpride, aripiprazole, and olanzapine as a secondary outcome, measured by change in the Calgary Depression Scale for Schizophrenia sum score in patients within the schizophrenia spectrum.

METHODS

Psychotic patients within the schizophrenia spectrum were included, and effectiveness was analyzed with latent growth curve modeling.

RESULTS

Of the 144 patients, 51 (35%) were women, the mean age was 31.7 (SD 12.7), and 39% were antipsychotic naive. At inclusion, 68 (47%) participants had a Calgary Depression Scale for Schizophrenia sum score >6, indicating severe depressive symptoms. Across the 12-month follow-up, there was a depressive symptom reduction in all medication groups, but no statistically significant differences between the study drugs. Separate analyses of the subcohort with elevated depressive symptoms at inclusion also failed to find differences in depressive symptom reduction between study drugs. The reduction in depressive symptoms mainly occurred within 6 weeks after randomization.

CONCLUSIONS

There was a reduction in depressive symptoms under treatment with amisulpride, aripiprazole, and olanzapine in acutely psychotic patients with schizophrenia spectrum disorder, but no differences between the drugs.

Changes in Quality of Life in Treatment-Resistant Schizophrenia Patients Undergoing Avatar Therapy: A Content Analysis

Avatar Therapy has a significant impact on symptoms, beliefs, and quality of life of patients with treatment-resistant schizophrenia. However, little is known about how these changes are implemented into their lives and to which aspects of their lives these improvements relate. Ten consecutive patients enrolled in an ongoing clinical trial were assessed using semi-guided interviews before as well as three months after Avatar Therapy. These encounters have been recorded and transcribed so that the discourse could be thoroughly analyzed, leading to the generation of an extensive theme grid. As the cases were analyzed, the grid was adapted in a back-and-forth manner until data saturation occurred. The content analysis allowed the identification of nine main themes representing different aspects of the patients’ lives, each of which was subdivided into more specific codes. By analyzing the evolution of their frequency, it was observed that, following therapy, patients presented with fewer psychotic symptoms, better self-esteem, more hobbies and projects, and an overall improved lifestyle and mood. Finally, investigating the impact of Avatar Therapy on quality of life allows for a deeper understanding of how people with treatment-resistant schizophrenia can achieve meaningful changes and move towards a certain recovery process.

Developments in Biological Mechanisms and Treatments for Negative Symptoms and Cognitive Dysfunction of Schizophrenia

The causal mechanisms and treatment for the negative symptoms and cognitive dysfunction in schizophrenia are the main issues attracting the attention of psychiatrists over the last decade. The first part of this review summarizes the pathogenesis of schizophrenia, especially the negative symptoms and cognitive dysfunction from the perspectives of genetics and epigenetics. The second part describes the novel medications and several advanced physical therapies (e.g., transcranial magnetic stimulation and transcranial direct current stimulation) for the negative symptoms and cognitive dysfunction that will optimize the therapeutic strategy for patients with schizophrenia in future.

Depressive symptoms combined with auditory hallucinations are accompanied with severe gray matter brain impairments in patients with first-episode untreated schizophrenia - A pilot study in China

BACKGROUND

Depressive symptoms and auditory hallucinations (AHs) are often accompanied by gray matter volume (GMV) alterations in schizophrenia. However, little is known about the effects of concurrent depressive symptoms and AHs on the GMV of patients with schizophrenia.

AIM

To investigate the pathological features of gray brain matter in patients with first-episode untreated schizophrenia (FUSCH) who have concurrent moderate-to-severe depressive symptoms and AHs (FUSCH-DAH).

METHODS

The Calgary Depression Scale for Schizophrenia (CDSS) and Auditory Hallucinations Rating Scale (AHRS) were adopted. Voxel-based morphometry (VBM)-based GMV analyses were used to measure cortical alterations. FUSCH-DAH patients were compared to FUSCH patients with depressive symptoms but without AHs, denoted as FUSCH-D, along with healthy controls.

RESULTS

GMV reductions were more substantial in the FUSCH-DAH patients than FUSCH-D patients or healthy controls. Both FUSCH-DAH and FUSCH-D groups showed GMV reductions of the parietal, frontal, and temporal lobes, which were not apparent in the healthy controls. Compared to FUSCH-D patients, FUSCH-DAH patients demonstrated more substantial GMV reductions in the Broca area, Wernicke region, insular lobe, and prefrontal lobe. The GMV reductions were 1.06% and 0.58% in FUSCH-DAH and FUSCH-D patients, respectively, as compared with the healthy controls.

CONCLUSIONS

This is the first report showing that concurrent depressive symptoms and AHs leads to severe GMV deterioration in FUSCH-DAH patients. Hence, there is a reciprocal relationship between AHs and depressive symptoms in FUSCH-DAH patients. However, the potential additive effects of concurrent AHs and depressive symptoms require further investigation in order to identify future targeted therapies for schizophrenia.

Transcranial Magnetic Stimulation in Conditions Other than Major Depressive Disorder

Transcranial magnetic stimulation (TMS) is a treatment approved by the Food and Drug Administration for major depressive disorder (MDD). TMS is a neuromodulation technique that works by creating a focal magnetic field that induces a small electric current. Compared with other neuromodulation techniques, TMS is a noninvasive treatment modality that is generally well-tolerated. Because of the success of TMS in treating depression, there has been interest in applications for other neuropsychiatric diseases. The purpose of this article was to review potential uses for TMS for children and adolescents in conditions other than MDD.

Electroconvulsive Therapy and Other Neuromodulation Techniques for the Treatment of Psychosis

Electroconvulsive therapy is an established treatment for symptoms of psychosis and is currently recommended for use in patients who are experiencing an acute exacerbation of positive symptoms or who have had catatonia. There is also evidence to suggest that electroconvulsive therapy can be a safe, effective treatment in first episode psychosis, such as schizophrenia spectrum disorders, particularly in treatment-resistant patients. Other forms of neuromodulation (transcranial magnetic stimulation, transcranial direct current stimulation, vagus nerve stimulation, deep brain stimulation) have less of an evidence base to support their use and are not formally indicated for the treatment of psychosis.

ECT-induced brain plasticity correlates with positive symptom improvement in schizophrenia by voxel-based morphometry analysis of grey matter

BACKGROUND

Electroconvulsive therapy (ECT) is often considered as an augmentation of antipsychotic treatment for schizophrenia in drug-refractory cases. However, the mechanisms underlying the observed therapeutic effects are still not understood.

OBJECTIVE

We aimed to investigate changes in whole brain grey matter volume (GMV) before and after modified ECT. GMV was determined using voxel-based morphometry (VBM) whole brain analysis. Correlations of brain structural changes with clinical improvement were also investigated.

METHODS

Twenty-one schizophrenia patients treated with a full course of ECT combined with antipsychotics (ECT group) and 21 schizophrenia patients treated only with antipsychotics (Drug group) were observed in parallel. Magnetic resonance imaging scans were performed at baseline (T1) and follow-up (T2) for each patient. Data were compared to a healthy control group (HC group) of 23 persons who were only scanned at baseline. Demographic data were matched between the three groups.

RESULTS

Significant interactions of group by time were found within four brain regions: the left parahippocampal gyrus/hippocampus, right parahippocampal gyrus/hippocampus, right temporal_pole_mid/superior temporal gyrus, and right insula. Post-hoc analysis revealed an increase of GMV across all four regions amongst ECT group, but a decrease of GMV within the Drug group. Furthermore, the ECT group showed a significant positive correlation of GMV change in the right parahippocampal gyrus/hippocampus with a reduction of positive subscore in the positive and negative syndrome scale. Both treatment groups did not differ significantly in terms of GMV from the HC group in these regions either at T1 or at T2.

CONCLUSION

Our findings indicate that ECT may induce brain plasticity as indexed by grey matter volume change during the treatment of schizophrenia via distinct mechanics from those by antipsychotic medications. ECT may ameliorate the positive psychotic symptoms of patients suffering from schizophrenia by preferentially targeting limbic brain areas such as the parahippocampal gyrus/hippocampus.

Transcranial Direct Current Stimulation Use in the Treatment of Neuropsychiatric Disorders: A Brief Review

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that has grown in popularity over the past two decades as an alternative treatment option for various neuropsychiatric disorders. tDCS modulates cortical excitability through the application of a weak direct current to the scalp via electrodes placed over cortical regions of interest. It has been shown to be a promising and relatively safe treatment tool with few adverse events. In this article, we will briefly review the efficacy of tDCS in depression, bipolar disorder, schizophrenia, and obsessive-compulsive disorder. We will also discuss biomarkers of tDCS efficacy in depression, as it is the most studied neuropsychiatric disorder using tDCS application. We will then offer suggestions for future directions. Although efficacy results show promise, more studies with larger samples and longer treatment periods are needed to better understand the benefits of using tDCS as an alternative treatment option for neuropsychiatric disorders.

Noninvasive brain stimulation for the treatment of auditory verbal hallucinations in schizophrenia: methods, effects and challenges

This mini-review focuses on noninvasive brain stimulation techniques as an augmentation method for the treatment of persistent auditory verbal hallucinations (AVH) in patients with schizophrenia. Paradigmatically, we place emphasis on transcranial magnetic stimulation (TMS). We specifically discuss rationales of stimulation and consider methodological questions together with issues of phenotypic diversity in individuals with drug-refractory and persistent AVH. Eventually, we provide a brief outlook for future investigations and treatment directions. Taken together, current evidence suggests TMS as a promising method in the treatment of AVH. Low-frequency stimulation of the superior temporal cortex (STC) may reduce symptom severity and frequency. Yet clinical effects are of relatively short duration and effect sizes appear to decrease over time along with publication of larger trials. Apart from considering other innovative stimulation techniques, such as transcranial Direct Current Stimulation (tDCS), and optimizing stimulation protocols, treatment of AVH using noninvasive brain stimulation will essentially rely on accurate identification of potential responders and non-responders for these treatment modalities. In this regard, future studies will need to consider distinct phenotypic presentations of AVH in patients with schizophrenia, together with the putative functional neurocircuitry underlying these phenotypes.

An integrated network model of psychotic symptoms

The full body of research on the nature of psychosis and its determinants indicates that a considerable number of factors are relevant to the development of hallucinations, delusions, and other positive symptoms, ranging from neurodevelopmental parameters and altered connectivity of brain regions to impaired cognitive functioning and social factors. We aimed to integrate these factors in a single mathematical model based on network theory. At the microscopic level this model explains positive symptoms of psychosis in terms of experiential equivalents of robust, high-frequency attractor states of neural networks. At the mesoscopic level it explains them in relation to global brain states, and at the macroscopic level in relation to social-network structures and dynamics. Due to the scale-free nature of biological networks, all three levels are governed by the same general laws, thereby allowing for an integrated model of biological, psychological, and social phenomena involved in the mediation of positive symptoms of psychosis. This integrated network model of psychotic symptoms (INMOPS) is described together with various possibilities for application in clinical practice.