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Seewoo BJ, Rodger J, Demitrack MA, Heart KL, Port JD, Strawn JR, Croarkin PE. Neurostructural Differences in Adolescents With Treatment-Resistant Depression and Treatment Effects of Transcranial Magnetic Stimulation. Int J Neuropsychopharmacol 2022; 25:619-630. [PMID: 35089358 PMCID: PMC9380715 DOI: 10.1093/ijnp/pyac007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 01/11/2022] [Accepted: 01/26/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Despite its morbidity and mortality, the neurobiology of treatment-resistant depression (TRD) in adolescents and the impact of treatment on this neurobiology is poorly understood. METHODS Using automatic segmentation in FreeSurfer, we examined brain magnetic resonance imaging baseline volumetric differences among healthy adolescents (n = 30), adolescents with major depressive disorder (MDD) (n = 19), and adolescents with TRD (n = 34) based on objective antidepressant treatment rating criteria. A pooled subsample of adolescents with TRD were treated with 6 weeks of active (n = 18) or sham (n = 7) 10-Hz transcranial magnetic stimulation (TMS) applied to the left dorsolateral prefrontal cortex. Ten of the adolescents treated with active TMS were part of an open-label trial. The other adolescents treated with active (n = 8) or sham (n = 7) were participants from a randomized controlled trial. RESULTS Adolescents with TRD and adolescents with MDD had decreased total amygdala (TRD and MDD: -5%, P = .032) and caudal anterior cingulate cortex volumes (TRD: -3%, P = .030; MDD: -.03%, P = .041) compared with healthy adolescents. Six weeks of active TMS increased total amygdala volumes (+4%, P < .001) and the volume of the stimulated left dorsolateral prefrontal cortex (+.4%, P = .026) in adolescents with TRD. CONCLUSIONS Amygdala volumes were reduced in this sample of adolescents with MDD and TRD. TMS may normalize this volumetric finding, raising the possibility that TMS has neurostructural frontolimbic effects in adolescents with TRD. TMS also appears to have positive effects proximal to the site of stimulation.
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Affiliation(s)
- Bhedita J Seewoo
- Experimental and Regenerative Neurosciences, School of Biological Sciences, The University of Western Australia, WA, Australia
- Brain Plasticity Group, Perron Institute for Neurological and Translational Science, WA, Australia
- Centre for Microscopy, Characterisation and Analysis, Research Infrastructure Centre, The University of Western Australia, Perth, WA, Australia
| | - Jennifer Rodger
- Experimental and Regenerative Neurosciences, School of Biological Sciences, The University of Western Australia, WA, Australia
- Brain Plasticity Group, Perron Institute for Neurological and Translational Science, WA, Australia
| | - Mark A Demitrack
- Mayo Clinic, Rochester, Minnesota, USA; Trevena, Inc. Chesterbrook, Pennsylvania, USA
| | | | - John D Port
- Department of Radiology
Chesterbrook, Pennsylvania, USA
- Department of Psychiatry and Psychology
Chesterbrook, Pennsylvania, USA
| | - Jeffrey R Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA
| | - Paul E Croarkin
- Department of Psychiatry and Psychology
Chesterbrook, Pennsylvania, USA
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Zheng W, Jiang ML, He HB, Li RP, Li QL, Zhang CP, Zhou SM, Yan S, Ning YP, Huang X. A Preliminary Study of Adjunctive Nonconvulsive Electrotherapy for Treatment-Refractory Depression. Psychiatr Q 2021; 92:311-320. [PMID: 32661940 DOI: 10.1007/s11126-020-09798-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Nonconvulsive electrotherapy (NET) defined as electrical brain stimulation administered like standard electroconvulsive therapy (ECT), but below seizure threshold, could be effective for patients with treatment-refractory depression (TRD) with fewer adverse neurocognitive outcomes. However, there is a lack of studies in Chinese patients with TRD. Thus, this study was conducted to examine the efficacy and safety of adjunctive NET for Chinese patients with TRD. Twenty TRD patients were enrolled and underwent six NET treatments. Depressive symptoms, response, and remission were assessed with the 17-item Hamilton Depression Rating Scale (HAMD-17) at baseline and after 1, 3, and 6 NET treatments. Neurocognitive function was assessed by the Wisconsin Card Sorting Test (WCST) at baseline and after the completion of six NET treatments. Mean HAMD-17 scores declined significantly from 26.2 to 10.4 (p < 0.001) after post-NET. The rates of response and remission were 60.0% (95% CI: 36.5-83.5) and 10.0% (95% CI: 0-24.4), respectively. Neurocognitive performance improved following a course of NET. No significant association was found between changes in depressive symptoms and baseline neurocognitive function. Adjunctive NET appeared to be effective for patients with TRD, without adverse neurocognitive effects. Randomized controlled studies were warranted to confirm these findings.
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Affiliation(s)
- Wei Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Miao-Ling Jiang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Hong-Bo He
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Ri-Peng Li
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Qi-Long Li
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Chun-Ping Zhang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Su-Miao Zhou
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Su Yan
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Yu-Ping Ning
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China. .,The First School of Clinical Medicine, Southern Medical University, Guangzhou, China.
| | - Xiong Huang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.
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Croarkin PE, Elmaadawi AZ, Aaronson ST, Schrodt GR, Holbert RC, Verdoliva S, Heart KL, Demitrack MA, Strawn JR. Left prefrontal transcranial magnetic stimulation for treatment-resistant depression in adolescents: a double-blind, randomized, sham-controlled trial. Neuropsychopharmacology 2021; 46:462-469. [PMID: 32919400 PMCID: PMC7852515 DOI: 10.1038/s41386-020-00829-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/08/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023]
Abstract
Treatment-resistant depression (TRD) is prevalent and associated with a substantial psychosocial burden and mortality. There are few prior studies of interventions for TRD in adolescents. This was the largest study to date examining the feasibility, safety, and efficacy of 10-Hz transcranial magnetic stimulation (TMS) for adolescents with TRD. Adolescents with TRD (aged 12-21 years) were enrolled in a randomized, sham-controlled trial of TMS across 13 sites. Treatment resistance was defined as an antidepressant treatment record level of 1 to 4 in a current episode of depression. Intention-to-treat patients (n = 103) included those randomly assigned to active NeuroStar TMS monotherapy (n = 48) or sham TMS (n = 55) for 30 daily treatments over 6 weeks. The primary outcome measure was change in the Hamilton Depression Rating Scale (HAM-D-24) score. After 6 weeks of blinded treatment, improvement in the least-squares mean (SE) HAM-D-24 scores were similar between the active (-11.1 [2.03]) and sham groups (-10.6 [2.00]; P = 0.8; difference [95% CI], - 0.5 [-4.2 to 3.3]). Response rates were 41.7% in the active group and 36.4% in the sham group (P = 0.6). Remission rates were 29.2% in the active group and 29.0% in the sham group (P = 0.95). There were no new tolerability or safety signals in adolescents. Although TMS treatment produced a clinically meaningful change in depressive symptom severity, this did not differ from sham treatment. Future studies should focus on strategies to reduce the placebo response and examine the optimal dosing of TMS for adolescents with TRD.
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Affiliation(s)
- Paul E. Croarkin
- grid.66875.3a0000 0004 0459 167XDivision of Child and Adolescent Psychiatry and Psychology, Mayo Clinic Depression Center, Mayo Clinic, Rochester, Minnesota USA
| | - Ahmed Z. Elmaadawi
- grid.429317.a0000 0004 4659 5310Beacon Health System, South Bend, Indiana USA, Indiana University School of Medicine, South Bend, USA
| | - Scott T. Aaronson
- grid.415693.c0000 0004 0373 4931Sheppard Pratt Health System, Baltimore, Maryland USA
| | | | | | - Sarah Verdoliva
- North American Science Associates, Inc. (NAMSA) Minneapolis, Minnesota, USA
| | | | | | - Jeffrey R. Strawn
- grid.24827.3b0000 0001 2179 9593Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio USA
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Suresh V, Mills JA, Croarkin PE, Strawn JR. What next? A Bayesian hierarchical modeling re-examination of treatments for adolescents with selective serotonin reuptake inhibitor-resistant depression. Depress Anxiety 2020; 37:926-934. [PMID: 32579280 PMCID: PMC7595266 DOI: 10.1002/da.23064] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/21/2020] [Accepted: 06/03/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Psychiatrists frequently struggle with how to sequence treatment for depressed adolescents who do not respond to an adequate trial of a selective serotonin reuptake inhibitor (SSRI). This study leveraged recent statistical and computational advances to create Bayesian hierarchal models (BHMs) of response in the treatment of SSRI-resistant depression in adolescents study to inform treatment planning. METHODS BHMs of individual treatment trajectories were developed and estimated using Hamiltonian Monte Carlo no u-turn sampling. From the Monte Carlo pseudorandom sample, 95% credible intervals, means, posterior tail probabilities, and so forth, were determined. Then, for the random effects model, posterior tail probabilities were used to create Bayesian two-tailed p values to evaluate the null hypotheses: no difference in efficacy between SSRIs and venlafaxine. The robustness of the results was examined using the fixed effects model of treatment comparisons. RESULTS In patients not receiving cognitive behavioral therapy (CBT; n = 168), SSRIs produced greater and faster improvement in depressive symptoms compared to venlafaxine (p = .015). No differences in response or trajectory of response for symptoms of anxiety were detected between SSRIs and venlafaxine (p = .168). For patients receiving CBT (n = 162), SSRIs and venlafaxine produced similar improvements in symptoms of anxiety and depression. CONCLUSIONS Findings from this novel computational approach suggest that a second trial of an SSRI is warranted for depressed adolescents who fail to respond to initial SSRI treatment.
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Affiliation(s)
- Vikram Suresh
- Carl H. Lindner College of Business, University of Cincinnati, Cincinnati, Ohio 45221
| | - Jeffrey A. Mills
- Carl H. Lindner College of Business, University of Cincinnati, Cincinnati, Ohio 45221
| | - Paul E. Croarkin
- Mayo Clinic, Department of Psychiatry and Psychology, Rochester, MN
| | - Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH 45219,Department of Pediatrics, Division of Child and Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio 45267
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Strawn JR, Aaronson ST, Elmaadawi AZ, Schrodt GR, Holbert RC, Verdoliva S, Heart K, Demitrack MA, Croarkin PE. Treatment-Resistant Depression in Adolescents: Clinical Features and Measurement of Treatment Resistance. J Child Adolesc Psychopharmacol 2020; 30:261-266. [PMID: 32315537 PMCID: PMC7640745 DOI: 10.1089/cap.2020.0008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Objective: To describe the clinical characteristics of adolescents with antidepressant treatment-resistant major depressive disorder (MDD) and to examine the utility of the Antidepressant Treatment Record (ATR) in categorizing treatment resistance in this population. Methods: Adolescents with treatment-resistant MDD enrolled in an interventional study underwent a baseline evaluation with the ATR, Children's Depression Rating Scale-Revised (CDRS-R), and Clinical Global Impressions-Severity (CGI-S) scales. Demographic and clinical characteristics were examined with regard to ATR-defined level of resistance (level 1 to ≥3) using analysis of variance and χ2 tests. Results: In adolescents with treatment-resistant MDD (N = 97), aged 12-21 years, most were female (65%), white (89%), and had recurrent illness (78%). Patients were severely ill (median CGI-S score of 5), had a mean CDRS-R score of 63 ± 10, and 17.5% had been hospitalized for depression-related symptoms. Fifty-two patients were classified as ATR 1, whereas 32 were classified as ATR level 2 and 13 patients as ≥3, respectively. For increasing ATR-defined levels, illness duration increased from 12.0 (range: 1.5-31.9) to 14.8 (range: 1.8-31.7) to 19.5 (range: 2.5-36.2) months and the likelihood of treatment with serotonin norepinephrine reuptake inhibitors (SNRIs) and dopamine norepinephrine reuptake inhibitors (DNRIs) similarly increased (p = 0.006 for both SNRIs and DNRIs) as did the likelihood of treatment with mixed dopamine serotonin receptor antagonists (χ2 = 17, p < 0.001). Conclusions: This study underscores the morbidity and chronicity of treatment-resistant MDD in adolescents. The present characterization of related clinical features describes the use of nonselective serotonin reuptake inhibitors in adolescents with treatment-resistant depression and raises the possibility that those with the greatest medication treatment resistance are less likely to have had recurrent episodes. The study also demonstrates the utility of the ATR in categorizing treatment resistance in adolescents with MDD.
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Affiliation(s)
- Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Divisions of Child and Adolescent Psychiatry and Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Address correspondence to: Jeffrey R. Strawn, MD, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Box 670559, Cincinnati, OH 45267-0559, USA
| | | | - Ahmed Z. Elmaadawi
- Indiana University School of Medicine, Beacon Health System, South Bend, Indiana, USA
| | | | - Richard C. Holbert
- Shands Psychiatric Hospital, University of Florida Department of Psychiatry, Gainsville, Florida, USA
| | | | - Karen Heart
- Neuronetics, Inc., Malvern, Pennsylvania, USA
| | | | - Paul E. Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
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