Concomitant Transcranial Direct Current Stimulation With Ultrabrief Electroconvulsive Therapy: A 2-Week Double-Blind Randomized Sham-Controlled Trial

Effects of the combination of neurostimulation techniques in patients with mental disorders: A systematic review

BACKGROUND

despite years of development, response to neurostimulation remains partial and variable. Combining techniques could improve clinical efficacy and tolerance.

OBJECTIVE

to examine the literature on the effects of combining several neurostimulation techniques in patients with mental disorders.

METHODS

this systematic review follows the PRISMA guidelines RESULTS: 23 studies were included. The most studied combination was electroconvulsive therapy (ECT) along with another neurostimulation technique in depression. The RCTs that showed a significant effect targeted the left dorsolateral prefrontal cortex with high-frequency repetitive transcranial magnetic stimulation, before ECT. Combining neurostimulation techniques is a promising field of research.

Is transcranial direct current stimulation, alone or in combination with antidepressant medications or psychotherapies, effective in treating major depressive disorder? A systematic review and meta-analysis

BACKGROUND

Transcranial direct current stimulation (tDCS) has shown mixed results for depression treatment. The efficacies of tDCS combination therapies have not been investigated deliberately. This review aims to evaluate the clinical efficacy of tDCS as a monotherapy and in combination with medication, psychotherapy, and ECT for treating adult patients with major depressive disorder (MDD) and identified the factors influencing treatment outcome measures (i.e. depression score, dropout, response, and remission rates).

METHODS

The systematic review was performed in PubMed/Medline, EMBASE, PsycINFO, Web of Sciences, and OpenGrey. Two authors performed independent literature screening and data extraction. The primary outcomes were the standardized mean difference (SMD) for continuous depression scores after treatment and odds ratio (OR) dropout rate; secondary outcomes included ORs for response and remission rates. Random effects models with 95% confidence intervals were employed in all outcomes. The overall effect of tDCS was investigated by meta-analysis. Sources of heterogeneity were explored via subgroup analyses, meta-regression, sensitivity analyses, and assessment of publication bias.

RESULTS

Twelve randomised, sham-controlled trials (active group: N = 251, sham group: N = 204) were included. Overall, the integrated depression score of the active group after treatment was significantly lower than that of the sham group (g = - 0.442, p = 0.017), and further analysis showed that only tDCS + medication achieved a significant lower score (g = - 0.855, p < 0.001). Moreover, this combination achieved a significantly higher response rate than sham intervention (OR = 2.7, p = 0.006), while the response rate remained unchanged for the other three therapies. Dropout and remission rates were similar in the active and sham groups for each therapy and also for the overall intervention. The meta-regression results showed that current intensity is the only predictor for the response rate. None of publication bias was identified.

CONCLUSION

The effect size of tDCS treatment was obviously larger in depression score compared with sham stimulation. The tDCS combined selective serotonin re-uptake inhibitors is the optimized therapy that is effective on depression score and response rate. tDCS monotherapy and combined psychotherapy have no significant effects. The most important parameter for optimization in future trials is treatment strategy.

Determinants of sham response in tDCS depression trials: a systematic review and meta-analysis

BACKGROUND

Randomised clinical trials (RCTs) investigating transcranial direct current stimulation (tDCS) efficacy for depression show significant heterogeneity in outcomes.

OBJECTIVE

To investigate the magnitude of the sham tDCS response and its potential moderators in the treatment of depression.

METHODOLOGY

A systematic review and aggregate meta-analysis (PROSPERO ID CRD42020161254). The systematic review was conducted in the PubMed, Scopus (EMBASE) and Cochrane Library databases. Only RCTs enrolling adult subjects with an acute depressive episode with a sham tDCS group were included.

RESULTS

Twenty-three studies (twenty-five datasets, 501 participants) were included. Sham tDCS response was large (Hedges' g = 1.09; 95% CI: 0.8;1.38). Secondary and subgroup analyses showed that sham protocols employing a ramp-up/ramp-down at the beginning and end of stimulation presented a significantly lower sham response compared to other protocols. Univariate meta-regression analyses found that sham response was associated with higher risk of blinding bias, and with thetreatment effect size of the active tDCS group. Subgroup analyses also showed that placement of the cathode over the lateral right frontal area (F8) presented a significantly lower sham response. Other moderators, including treatment resistance, baseline severity of depressive symptoms, and total charge delivered were not associated with the magnitude of the sham response.

CONCLUSION

The sham tDCS response was large. Our findings demonstrate the need for standardization of sham tDCS protocols and bring attention to important considerations that can guide future RCTs employing tDCS for the treatment of MDD.

Evidence-Based Guidelines and Secondary Meta-Analysis for the Use of Transcranial Direct Current Stimulation in Neurological and Psychiatric Disorders

BACKGROUND

Transcranial direct current stimulation has shown promising clinical results, leading to increased demand for an evidence-based review on its clinical effects.

OBJECTIVE

We convened a team of transcranial direct current stimulation experts to conduct a systematic review of clinical trials with more than 1 session of stimulation testing: pain, Parkinson's disease motor function and cognition, stroke motor function and language, epilepsy, major depressive disorder, obsessive compulsive disorder, Tourette syndrome, schizophrenia, and drug addiction.

METHODS

Experts were asked to conduct this systematic review according to the search methodology from PRISMA guidelines. Recommendations on efficacy were categorized into Levels A (definitely effective), B (probably effective), C (possibly effective), or no recommendation. We assessed risk of bias for all included studies to confirm whether results were driven by potentially biased studies.

RESULTS

Although most of the clinical trials have been designed as proof-of-concept trials, some of the indications analyzed in this review can be considered as definitely effective (Level A), such as depression, and probably effective (Level B), such as neuropathic pain, fibromyalgia, migraine, post-operative patient-controlled analgesia and pain, Parkinson's disease (motor and cognition), stroke (motor), epilepsy, schizophrenia, and alcohol addiction. Assessment of bias showed that most of the studies had low risk of biases, and sensitivity analysis for bias did not change these results. Effect sizes vary from 0.01 to 0.70 and were significant in about 8 conditions, with the largest effect size being in postoperative acute pain and smaller in stroke motor recovery (nonsignificant when combined with robotic therapy).

CONCLUSION

All recommendations listed here are based on current published PubMed-indexed data. Despite high levels of evidence in some conditions, it must be underscored that effect sizes and duration of effects are often limited; thus, real clinical impact needs to be further determined with different study designs.

Efficacy and acceptability of transcranial direct current stimulation for treating depression: A meta-analysis of randomized controlled trials

BACKGROUND

Transcranial direct current stimulation (tDCS) is a promising nonpharmacological intervention for treating depression. We aimed to provide an updated meta-analysis assessing the anti-depressant efficacy of tDCS.

METHODS

We searched the literature from the first available date to 30 December 2020 to identify relevant randomized controlled trials (RCTs).

RESULTS

27 RCTs (N = 1204 patients, 653 in active tDCS and 551 in sham tDCS) were included. Active tDCS was superior to sham tDCS (g = 0.46, 95 % CI 0.15-0.76) in modulating depressive symptoms measured by depression rating scales. Active tDCS was also superior to sham tDCS in reducing response and remission rates, but these differences did not reach statistically significant levels (OR_response = 1.75, 95 % CI 0.85-3.58; OR_remission = 1.29, 95 % CI 0.59-2.83). The two groups had comparable dropout rates (OR = 1.28, 95 % CI 0.62-1.64).

CONCLUSION

For treatments of depressive episodes, tDCS may be efficacious. Specific tDCS parameters (e.g., a 2-mA stimulation current and 30-min sessions) and clinical characteristics (e.g., antidepressant-free) may augment the treatment efficacy of tDCS.

Effect of prefrontal tDCS on resting brain fMRI graph measures in Alcohol Use Disorders: A randomized, double-blind, sham-controlled study

OBJECTIVES

Transcranial Direct Current Stimulation (tDCS) is a promising new adjuvant approach in the treatment of Alcohol Use Disorders (AUDs) that has the potential to ameliorate the aberrations secondary to chronic alcohol use. In this study, using a randomized, double-blind, sham-controlled, parallel-arm design, we examined the effects of prefrontal tDCS on resting-state functional magnetic resonance imaging (rsfMRI) and its correlates with impulsivity and time to first lapse in subjects with AUDs.

METHODS

Patients with AUD as per DSM-5 criteria were randomly allocated to receive a five-day course of either verum-tDCS (n = 12) or sham-tDCS (n = 12). Of them, 21 patients (verum/sham = 11/10) participated in both baseline and post-intervention 10-min rsfMRI sessions. Outside the scanner, subjects also performed the Stop-Signal Task at two time-points (baseline and post-intervention), which provided a measure of changes in impulsivity following tDCS. After completion of the post-intervention scan, all subjects were discharged and were followed-up for 90 days post-discharge or until lapse to first alcohol use.

RESULTS

Graph theoretical analysis of rsfMRI data revealed that verum-tDCS (but not sham) resulted in a significant increase in the global efficiency of brain networks with a concurrent significant reduction in global clustering; network-based statistical analysis identified a significant increase in the functional connectivity of a specific sub-network involving prefrontal regions. Furthermore, increased global efficiency of brain networks following verum tDCS predicted a significantly reduced likelihood of relapse. In addition, a reduction in the global clustering had a significant positive correlation with a reduction in the measure of impulsivity.

CONCLUSIONS

The present study adds further support to the increasing evidence base for the clinical utility of tDCS in AUDs. Importantly, we observed improvement in both whole-brain network efficiency as well as inter-regional connectivity within a specific local prefrontal sub-network that is relevant to the neurobiology of AUDs. Replication and extension of these promising leads from the present study can facilitate clinical translation of tDCS, given its advantages (i.e. safety, cost-effectiveness, administration ease with potential for remotely-supervised / home-based application) for treating patients with AUDs.

A systematic review and meta-analysis on the effects of transcranial direct current stimulation in depressive episodes

BACKGROUND

Transcranial direct current stimulation (tDCS) has shown mixed results for depression treatment.

OBJECTIVE

To perform a systematic review and meta-analysis of trials using tDCS to improve depressive symptoms.

METHODS

A systematic review was performed from the first date available to January 06, 2020 in PubMed, EMBASE, Cochrane Library, and additional sources. We included randomized, sham-controlled clinical trials (RCTs) enrolling participants with an acute depressive episode and compared the efficacy of active versus sham tDCS, including association with other interventions. The primary outcome was the Hedges' g for continuous depression scores; secondary outcomes included odds ratios (ORs) and number needed to treat (NNT) for response, remission, and acceptability. Random effects models were employed. Sources of heterogeneity were explored via metaregression, sensitivity analyses, subgroup analyses, and bias assessment.

RESULTS

We included 23 RCTs (25 datasets, 1,092 participants), most (57%) presenting a low risk of bias. Active tDCS was superior to sham regarding endpoint depression scores (k = 25, g = 0.46, 95% confidence interval [CI]: 0.22-0.70), and also achieved superior response (k = 18, 33.3% vs. 16.56%, OR = 2.28 [1.52-3.42], NNT = 6) and remission (k = 18, 19.12% vs. 9.78%, OR = 2.12 [1.42-3.16], NNT = 10.7) rates. Moreover, active tDCS was as acceptable as sham. No risk of publication bias was identified. Cumulative meta-analysis showed that effect sizes are basically unchanged since total sample reached 439 participants.

CONCLUSIONS

TDCS is modestly effective in treating depressive episodes. Further well-designed, large-scale RCTs are warranted.

Transcranial direct current stimulation for the treatment of major depressive disorder: A meta-analysis of randomized controlled trials

Major depressive disorder (MDD) is a common and refractory mental disorder. Although antidepressant drugs may be effective for treating MDD, a number of patients do not improve with pharmacologic treatment. Novel therapeutic strategies which are safer and more effective are of great significance in the treatment of MDD. Transcranial direct cranial stimulation (tDCS) is a promising intervention for treating MDD, and it has demonstrated antidepressant effects and beneficial effects on cognitive function. The aim was to assess the efficacy of tDCS as a treatment for MDD. Four databases including PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI) and Wanfang database were searched for articles related to tDCS and major depression. The mean difference (MD) and 95% confidence interval (CI) were calculated in this study. A significant difference between tDCS compared with the control group in Montgomery-Asberg depression rating scale (MADRS) was found. There was a significant statistical difference between tDCS and the control group in Hamilton Depression Rating Scale, 17-items (HDRS-17). This study demonstrated that the intervention of active tDCS was superior to the use of sham tDCS in improving MDD. Furthermore, tDCS might be an effective treatment for MDD.

Transcranial Direct Current Stimulation (tDCS): A Promising Treatment for Major Depressive Disorder?

Background: Transcranial direct current stimulation (tDCS) opens new perspectives in the treatment of major depressive disorder (MDD), because of its ability to modulate cortical excitability and induce long-lasting effects. The aim of this review is to summarize the current status of knowledge regarding tDCS application in MDD. Methods: In this review, we searched for articles published in PubMed/MEDLINE from the earliest available date to February 2018 that explored clinical and cognitive effects of tDCS in MDD. Results: Despite differences in design and stimulation parameters, the examined studies indicated beneficial effects of tDCS for MDD. These preliminary results, the non-invasiveness of tDCS, and its good tolerability support the need for further research on this technique. Conclusions: tDCS constitutes a promising therapeutic alternative for patients with MDD, but its place in the therapeutic armamentarium remains to be determined.