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Etkin A, Mathalon DH. Bringing Imaging Biomarkers Into Clinical Reality in Psychiatry. JAMA Psychiatry 2024:2822966. [PMID: 39230917 DOI: 10.1001/jamapsychiatry.2024.2553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
Importance Advancing precision psychiatry, where treatments are based on an individual's biology rather than solely their clinical presentation, requires attention to several key attributes for any candidate biomarker. These include test-retest reliability, sensitivity to relevant neurophysiology, cost-effectiveness, and scalability. Unfortunately, these issues have not been systematically addressed by biomarker development efforts that use common neuroimaging tools like magnetic resonance imaging (MRI) and electroencephalography (EEG). Here, the critical barriers that neuroimaging methods will need to overcome to achieve clinical relevance in the near to intermediate term are examined. Observations Reliability is often overlooked, which together with sensitivity to key aspects of neurophysiology and replicated predictive utility, favors EEG-based methods. The principal barrier for EEG has been the lack of large-scale data collection among multisite psychiatric consortia. By contrast, despite its high reliability, structural MRI has not demonstrated clinical utility in psychiatry, which may be due to its limited sensitivity to psychiatry-relevant neurophysiology. Given the prevalence of structural MRIs, establishment of a compelling clinical use case remains its principal barrier. By contrast, low reliability and difficulty in standardizing collection are the principal barriers for functional MRI, along with the need for demonstration that its superior spatial resolution over EEG and ability to directly image subcortical regions in fact provide unique clinical value. Often missing, moreover, is consideration of how these various scientific issues can be balanced against practical economic realities of psychiatric health care delivery today, for which embedding economic modeling into biomarker development efforts may help direct research efforts. Conclusions and Relevance EEG seems most ripe for near- to intermediate-term clinical impact, especially considering its scalability and cost-effectiveness. Recent efforts to broaden its collection, as well as development of low-cost turnkey systems, suggest a promising pathway by which neuroimaging can impact clinical care. Continued MRI research focused on its key barriers may hold promise for longer-horizon utility.
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Affiliation(s)
- Amit Etkin
- Alto Neuroscience Inc, Los Altos, California
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Daniel H Mathalon
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Veterans Affairs San Francisco Health Care System, San Francisco, California
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2
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Etkin A, Powell J, Savitz AJ. Opportunities for use of neuroimaging in de-risking drug development and improving clinical outcomes in psychiatry: an industry perspective. Neuropsychopharmacology 2024:10.1038/s41386-024-01970-8. [PMID: 39169213 DOI: 10.1038/s41386-024-01970-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/30/2024] [Accepted: 08/14/2024] [Indexed: 08/23/2024]
Abstract
Neuroimaging, across positron emission tomography (PET), electroencephalography (EEG), and magnetic resonance imaging (MRI), has been a mainstay of clinical neuroscience research for decades, yet has penetrated little into psychiatric drug development beyond often underpowered phase 1 studies, or into clinical care. Simultaneously, there is a pressing need to improve the probability of success in drug development, increase mechanistic diversity, and enhance clinical efficacy. These goals can be achieved by leveraging neuroimaging in a precision psychiatry framework, wherein effects of drugs on the brain are measured early in clinical development to understand dosing and indication, and then in later-stage trials to identify likely drug responders and enrich clinical trials, ultimately improving clinical outcomes. Here we examine the key variables important for success in using neuroimaging for precision psychiatry from the lens of biotechnology and pharmaceutical companies developing and deploying new drugs in psychiatry. We argue that there are clear paths for incorporating different neuroimaging modalities to de-risk subsequent development phases in the near to intermediate term, culminating in use of select neuroimaging modalities in clinical care for prescription of new precision drugs. Better outcomes through neuroimaging biomarkers, however, require a wholesale commitment to a precision psychiatry approach and will necessitate a cultural shift to align biopharma and clinical care in psychiatry to a precision orientation already routine in other areas of medicine.
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Affiliation(s)
- Amit Etkin
- Alto Neuroscience Inc., Los Altos, CA, 94022, USA.
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, 94304, USA.
| | | | - Adam J Savitz
- Alto Neuroscience Inc., Los Altos, CA, 94022, USA
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, 10021, USA
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3
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Morriss R, Briley PM, Webster L, Abdelghani M, Barber S, Bates P, Brookes C, Hall B, Ingram L, Kurkar M, Lankappa S, Liddle PF, McAllister-Williams RH, O'Neil-Kerr A, Pszczolkowski S, Suazo Di Paola A, Walters Y, Auer DP. Connectivity-guided intermittent theta burst versus repetitive transcranial magnetic stimulation for treatment-resistant depression: a randomized controlled trial. Nat Med 2024; 30:403-413. [PMID: 38228914 PMCID: PMC10878976 DOI: 10.1038/s41591-023-02764-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 12/12/2023] [Indexed: 01/18/2024]
Abstract
Disruption in reciprocal connectivity between the right anterior insula and the left dorsolateral prefrontal cortex is associated with depression and may be a target for neuromodulation. In a five-center, parallel, double-blind, randomized controlled trial we personalized resting-state functional magnetic resonance imaging neuronavigated connectivity-guided intermittent theta burst stimulation (cgiTBS) at a site based on effective connectivity from the right anterior insula to the left dorsolateral prefrontal cortex. We tested its efficacy in reducing the primary outcome depression symptoms measured by the GRID Hamilton Depression Rating Scale 17-item over 8, 16 and 26 weeks, compared with structural magnetic resonance imaging (MRI) neuronavigated repetitive transcranial magnetic stimulation (rTMS) delivered at the standard stimulation site (F3) in patients with 'treatment-resistant depression'. Participants were randomly assigned to 20 sessions over 4-6 weeks of either cgiTBS (n = 128) or rTMS (n = 127) with resting-state functional MRI at baseline and 16 weeks. Persistent decreases in depressive symptoms were seen over 26 weeks, with no differences between arms on the primary outcome GRID Hamilton Depression Rating Scale 17-item score (intention-to-treat adjusted mean, -0.31, 95% confidence interval (CI) -1.87, 1.24, P = 0.689). Two serious adverse events were possibly related to TMS (mania and psychosis). MRI-neuronavigated cgiTBS and rTMS were equally effective in patients with treatment-resistant depression over 26 weeks (trial registration no. ISRCTN19674644).
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Affiliation(s)
- Richard Morriss
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Paul M Briley
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lucy Webster
- Institute of Mental Health, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - Mohamed Abdelghani
- Clinical Neuromodulation Service, Camden and Islington NHS Foundation Trust, London, UK
| | - Shaun Barber
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Peter Bates
- Institute of Mental Health, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - Cassandra Brookes
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Beth Hall
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Luke Ingram
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Micheal Kurkar
- Pennine Care TMS Service, Pennine Care NHS Foundation Trust, Oldham, UK
| | - Sudheer Lankappa
- Institute of Mental Health, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - Peter F Liddle
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - R Hamish McAllister-Williams
- Northern Centre for Mood Disorders, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alexander O'Neil-Kerr
- Centre for Neuromodulation, Northamptonshire Healthcare NHS Foundation Trust, Northampton, UK
| | - Stefan Pszczolkowski
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Yvette Walters
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Dorothee P Auer
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
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4
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Drabek M, Hodkinson D, Horvath S, Millar B, Pszczolkowski Parraguez S, Tench CR, Tanasescu R, Lankappa S, Morriss R, Walsh D, Auer DP. Brain connectivity-guided, Optimised theta burst transcranial magnetic stimulation to improve Central Pain Modulation in knee Osteoarthritis Pain (BoostCPM): protocol of a pilot randomised clinical trial in a secondary care setting in the UK. BMJ Open 2023; 13:e073378. [PMID: 37844981 PMCID: PMC10582853 DOI: 10.1136/bmjopen-2023-073378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 09/14/2023] [Indexed: 10/18/2023] Open
Abstract
INTRODUCTION Chronic pain is a common health problem that is not efficiently managed by standard analgesic treatments. There is evidence that treatment resistance may result from maladaptive brain changes in areas that are fundamental to the perception of pain. Knee osteoarthritis is one of the most prevalent causes of chronic pain and commonly associated with negative affect. Chronic knee osteoarthritis pain is also associated with altered right anterior insula functional connectivity. We posit that reversal of these brain circuit alterations may be critical to alleviate chronic pain and associated negative affect, and that this can be achieved through non-invasive neuromodulation techniques. Despite growing interest in non-invasive neuromodulation for pain relief and proven efficacy in depression, results in chronic pain are mixed with limited high-quality evidence for clinical and mechanistic efficacy. Limitations include patient heterogeneity, imprecision of target selection, uncertain blinding and protocols that may deliver pulses at subclinical efficacy. METHODS AND ANALYSIS We hence developed an optimised treatment protocol of connectivity-guided intermittent theta-burst stimulation (iTBS) targeting the left dorsolateral prefrontal cortex with accelerated delivery on four consecutive days (allowing 4 days within the same week as protocol variation) with five daily treatment sessions that will be piloted in a sham-controlled design in 45 participants with chronic knee pain. This pilot study protocol will assess feasibility, tolerability and explore mechanistic efficacy through serial functional/structural magnetic resonance imaging (MRI) and quantitative sensory testing. ETHICS AND DISSEMINATION This pilot trial has been approved by the Ethics Committee Cornwall and Plymouth.Results of the pilot trial will be submitted to peer-reviewed journals, presented at research conferences and may be shared with participants and PPI/E advisors. TRIAL REGISTRATION NUMBER ISRCTN15404076.
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Affiliation(s)
- Marianne Drabek
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Duncan Hodkinson
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Suzanne Horvath
- Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Bonnie Millar
- Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Stefan Pszczolkowski Parraguez
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Christopher R Tench
- Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Radu Tanasescu
- Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
- Clinical Neurology, Nottingham University Hospital Trusts, Nottingham, UK
| | - Sudheer Lankappa
- Adult Mental Health, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - Richard Morriss
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - David Walsh
- Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Dorothee P Auer
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
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5
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Zhang ZQ, Guo ZP, Lv XY, Sörös P, Wang XX, Wang L, Liu CH. Effect and neural mechanisms of the transcutaneous vagus nerve stimulation for relapse prevention in patients with remitted major depressive disorder: protocol for a longitudinal study. BMJ Open 2022; 12:e050446. [PMID: 35193903 PMCID: PMC8867334 DOI: 10.1136/bmjopen-2021-050446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION After the first episode, patients with remitted major depressive disorder (MDD) have a 60% chance of experiencing a second episode. There are currently no accepted, effective methods to prevent the recurrence of MDD in remission. Transcutaneous vagus nerve stimulation (taVNS) is a non-invasive, safe and economical approach based on the efficacy of VNS in improving clinical depression symptoms. This clinical trial will study the efficacy of taVNS in preventing MDD relapse and investigate the underlying mechanisms of this. METHODS AND ANALYSIS We will conduct a multicentre, randomised, patient-blinded and evaluators double-blinded trial. We will randomise 90 eligible participants with recurrent MDD in remission in a 1:1 ratio into a real or sham taVNS group. All participants will be given six biopsychosocial assessments: proinflammatory cytokines, serum monoamine neurotransmitters, cognition, affective neuropsychology, multimodal neuroimaging and endocrinology. After the baseline measurements, all participants will be given corresponding interference for 6 months and then complete a 1-year follow-up. The assessments will be performed three times: at baseline, post-treatment and at the end of 1-year follow-up (except for multimodal MRI scanning, which will be conducted at the first two assessments only). Change in 17-item Hamilton Depression Rating Scale scores for MDD is the primary outcome parameter. ETHICS AND DISSEMINATION The study protocol was approved by the Medical Ethical Committee of Beijing Hospital of Traditional Chinese Medicine on 18 January 2019 (2018BL-076). The trial results will be published in peer-reviewed journals and at conferences. TRIAL REGISTRATION NUMBER ChiCTR1900022618.
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Affiliation(s)
- Zhu-Qing Zhang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Zhi-Peng Guo
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Xue-Yu Lv
- Guang'an men Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Peter Sörös
- Research Center Neurosensory Science, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Xiao-Xu Wang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Lihong Wang
- Department of Psychiatry, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Chun-Hong Liu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
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6
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Pszczolkowski S, Cottam WJ, Briley PM, Iwabuchi SJ, Kaylor-Hughes C, Shalabi A, Babourina-Brooks B, Berrington A, Barber S, Suazo Di Paola A, Blamire A, McAllister-Williams RH, Parikh J, Abdelghani M, Matthäus L, Hauffe R, Liddle P, Auer DP, Morriss R. Connectivity-Guided Theta Burst Transcranial Magnetic Stimulation Versus Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Moderate to Severe Depression: Magnetic Resonance Imaging Protocol and SARS-CoV-2-Induced Changes for a Randomized Double-blind Controlled Trial. JMIR Res Protoc 2022; 11:e31925. [PMID: 35049517 PMCID: PMC8814922 DOI: 10.2196/31925] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/16/2021] [Indexed: 11/13/2022] Open
Abstract
Background Depression is a substantial health and economic burden. In approximately one-third of patients, depression is resistant to first-line treatment; therefore, it is essential to find alternative treatments. Transcranial magnetic stimulation (TMS) is a neuromodulatory treatment involving the application of magnetic pulses to the brain that is approved in the United Kingdom and the United States in treatment-resistant depression. This trial aims to compare the clinical effectiveness, cost-effectiveness, and mechanism of action of standard treatment repetitive TMS (rTMS) targeted at the F3 electroencephalogram site with a newer treatment—a type of TMS called theta burst stimulation (TBS) targeted based on measures of functional brain connectivity. This protocol outlines brain imaging acquisition and analysis for the Brain Imaging Guided Transcranial Magnetic Stimulation in Depression (BRIGhTMIND) study trial that is used to create personalized TMS targets and answer the proposed mechanistic hypotheses. Objective The aims of the imaging arm of the BRIGhTMIND study are to identify functional and neurochemical brain signatures indexing the treatment mechanisms of rTMS and connectivity-guided intermittent theta burst TMS and to identify imaging-based markers predicting response to treatment. Methods The study is a randomized double-blind controlled trial with 1:1 allocation to either 20 sessions of TBS or standard rTMS. Multimodal magnetic resonance imaging (MRI) is acquired for each participant at baseline (before TMS treatment) with T1-weighted and task-free functional MRI during rest used to estimate TMS targets. For participants enrolled in the mechanistic substudy, additional diffusion-weighted sequences are acquired at baseline and at posttreatment follow-up 16 weeks after treatment randomization. Core data sets of T1-weighted and task-free functional MRI during rest are acquired for all participants and are used to estimate TMS targets. Additional sequences of arterial spin labeling, magnetic resonance spectroscopy, and diffusion-weighted images are acquired depending on the recruitment site for mechanistic evaluation. Standard rTMS treatment is targeted at the F3 electrode site over the left dorsolateral prefrontal cortex, whereas TBS treatment is guided using the coordinate of peak effective connectivity from the right anterior insula to the left dorsolateral prefrontal cortex. Both treatment targets benefit from the level of MRI guidance, but only TBS is provided with precision targeting based on functional brain connectivity. Results Recruitment began in January 2019 and is ongoing. Data collection is expected to continue until January 2023. Conclusions This trial will determine the impact of precision MRI guidance on rTMS treatment and assess the neural mechanisms underlying this treatment in treatment-resistant depressed patients. Trial Registration ISRCTN Registry ISRCTN19674644; https://www.isrctn.com/ISRCTN19674644 International Registered Report Identifier (IRRID) DERR1-10.2196/31925
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Affiliation(s)
- Stefan Pszczolkowski
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, United Kingdom.,Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - William J Cottam
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, United Kingdom.,Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Paul M Briley
- Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, United Kingdom
| | - Sarina J Iwabuchi
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Catherine Kaylor-Hughes
- Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Abdulrhman Shalabi
- Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Ben Babourina-Brooks
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, United Kingdom.,Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Adam Berrington
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Shaun Barber
- Leicester Clinical Trials Unit, University of Leicester, Leicester, United Kingdom
| | - Ana Suazo Di Paola
- Leicester Clinical Trials Unit, University of Leicester, Leicester, United Kingdom
| | - Andrew Blamire
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - R Hamish McAllister-Williams
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Jehill Parikh
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Lars Matthäus
- eemagine Medical Imaging Solutions GmbH, Berlin, Germany
| | - Ralf Hauffe
- eemagine Medical Imaging Solutions GmbH, Berlin, Germany
| | - Peter Liddle
- Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Dorothee P Auer
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, United Kingdom.,Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Richard Morriss
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, United Kingdom.,Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,NIHR MindTech MedTech and in Vitro Centre, Nottingham, United Kingdom.,NIHR Applied Research Collaboration East Midlands, Nottingham, United Kingdom
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