Transcranial magnetic stimulation (TMS) safety: a practical guide for psychiatrists

Evaluating repetitive transcranial magnetic stimulation for neurogenic overactive bladder management in stroke survivors: A randomized sham-controlled trial protocol

BACKGROUND

Neurogenic overactive bladder (OAB) is a distressing condition in stroke. Existing neurogenic OAB management is expensive, unstandardized regimens, or invasive. Evaluating the effectiveness of repetitive transcranial magnetic stimulation (rTMS) remains crucial. We aimed to (1) compare the effectiveness of active-rTMS with sham-rTMS on neurogenic OAB symptoms, (2) analyze whether rTMS is cost-effective, and (3) explore the rTMS's experiences on participants' symptoms.

METHODS

This is a randomized, sham-controlled, double-blinded trial with embedded qualitative and cost-effectiveness studies. A total of 110 stroke survivors with neurogenic OAB symptoms were screened for eligibility; 60 participants were eligible for inclusion and were randomly assigned to either the active (n = 30) or sham-rTMS (n = 30) groups using a computer-generated randomization schedule. The active-rTMS group received low-frequency rTMS of 1200 pulses per session lasting 20 min thrice weekly to pelvic floor muscle representation at the contralesional primary motor cortex. The sham-rTMS group received low-frequency stimulation at a 20 % resting motor threshold using the same coil as the active-rTMS but was configured to reduce the TMS-induced electrical fields significantly. The primary and secondary outcome measures were assessed at baseline, post-intervention (week 4) and follow-up (week 8). The analysis of covariance (ANCOVA) analysis compared changes in the study groups. Quality-adjusted life-years (QALY) were measured to evaluate the cost-effectiveness while EQ-5D-5L estimated QALY changes. Additionally, the focus group discussion data were thematically analyzed.

CONCLUSIONS

The findings from this rTMS intervention study will be useful in alleviating neurogenic OAB symptoms and enhancing patient satisfaction in a cost-effective way.

Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of repetitive transcranial magnetic stimulation

OBJECTIVES

To provide guidance for the optimal administration of repetitive transcranial magnetic stimulation, based on scientific evidence and supplemented by expert clinical consensus.

METHODS

Articles and information were sourced from existing guidelines and published literature. The findings were then formulated into consensus-based recommendations and guidance by the authors. The guidelines were subjected to rigorous successive consultation within the RANZCP, involving the Section of ECT and Neurostimulation (SEN) Committee, its broader membership and expert committees.

RESULTS

The RANZCP professional practice guidelines (PPG) for the administration of rTMS provide up-to-date advice regarding the use of rTMS in clinical practice. The guidelines are intended for use by psychiatrists and non-psychiatrists engaged in the administration of rTMS to facilitate best practice to optimise outcomes for patients. The guidelines strive to find the appropriate balance between promoting best evidence-based practice and acknowledging that evidence for rTMS use is a continually evolving.

CONCLUSION

The guidelines provide up-to-date advice for psychiatrists and non-psychiatrists to promote optimal standards of rTMS practice.

The effects of combining repetitive transcranial magnetic stimulation with task-specific training on gait performance in individuals with Parkinson's disease: A review article

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative disorder characterized by motor impairments, especially in the area of gait disturbances. Physiotherapy, with a focus on task-specific training, has demonstrated a level of efficacy as regards alleviating symptoms and enhancing functional capabilities in individuals with PD. Repetitive Transcranial Magnetic Stimulation (rTMS) has emerged as a potential therapeutic intervention for improving motor functions in individuals with PD.

AIMS

This review article aims to investigate the effects of combining rTMS with task-specific training on gait performance in individuals with PD.

MATERIALS AND METHODS

PubMed, Physiotherapy Evidence Database (PEDro), and Scopus were all searched for relevant studies. The focus of the search was on studies that investigated the efficacy of combining rTMS with task-specific training to improve gait performance in individuals with PD.

RESULTS

Four studies were identified as fulfilling the eligibility criteria and were included in the study. The combination of rTMS with specific treadmill training and weight-bearing exercises can significantly enhance walking efficiency, including improvements in walking speed, self-mobility, and step rate. In addition, the combination of rTMS and task-specific training, such as treadmill-based training, shows promise in enhancing gait performance in individuals with PD.

DISCUSSION AND CONCLUSION

High-frequency rTMS targeting the primary motor cortex (or M1) can result in improved walking speed, self-mobility, and step rate. However, limited research exists regarding low-frequency stimulation of the supplementary motor area (SMA) in individuals with gait issues. Further research is required to determine the optimal parameters of rTMS, such as strength, frequency, and duration of stimulation and it is worth considering the incorporation of additional training modalities, including cognitive exercises.

Sequential Multilocus Repetitive Transcranial Magnetic Stimulation for Treatment of Tinnitus With and Without Comorbid Major Depressive Disorder

OBJECTIVE

Repetitive transcranial magnetic stimulation (rTMS) is a promising treatment for tinnitus, although outcomes are highly variable. We previously described a multilocus sequential rTMS treatment protocol for tinnitus involving stimulation of both prefrontal and auditory targets. In this study, we report results using this approach in an open-label treatment study of tinnitus with and without comorbid major depressive disorder (MDD).

MATERIALS AND METHODS

Forty patients with chronic tinnitus (mean age 56 years, ten female) and with (n = 17) or without (n = 23) MDD received multilocus rTMS administered sequentially to 1) left dorsolateral prefrontal cortex, followed by 2) auditory cortex (Heschel's gyrus). Patients completed weekly self-report ratings using the Tinnitus Functional Index (TFI) and Tinnitus Handicap Inventory, and patients with MDD completed the Inventory of Depressive Symptomatology Self-Report 30-item.

RESULTS

Patients showed significant mean improvement in tinnitus at sessions 5 (mean TFI improvement 6.8 points ± 12.2, p = 0.002) and 10 (mean improvement 9.2 points ± 14.1, p = 0.002), with 48% of patients responding within ten treatment sessions. Responders were significantly older than nonresponders (61.5 ± 15 years vs 51.3 ± 16 years), and there was a trend toward decreased likelihood of response in subjects with comorbid MDD compared with subjects without comorbidity (odds ratio = 0.28, p = 0.06). Patients with comorbid MDD reported significantly less improvement after ten sessions than did those with tinnitus alone (4.3 ± 10.3 vs 14.7 ± 15.0 points, p = 0.04). Post hoc analyses suggested that the comorbid group achieved improvement comparable to that of the tinnitus-only group after 30 treatments.

CONCLUSIONS

Patients showed significant improvement in tinnitus from multilocus sequential rTMS treatment, and those with tinnitus alone improved more quickly. Those with depression who continued rTMS through a full 30-session course further improved, indicating that tinnitus with comorbid MDD may respond with extended treatment.

Pilot study with randomised control of dual site theta burst transcranial magnetic stimulation (TMS) for methamphetamine use disorder: a protocol for the TARTAN study

BACKGROUND

Transcranial magnetic stimulation (TMS) (including the theta burst stimulation (TBS) form of TMS used in this study) is a non-invasive means to stimulate nerve cells in superficial areas of the brain. In recent years, there has been a growth in the application of TMS to investigate the modulation of neural networks involved in substance use disorders. This study examines the feasibility of novel TMS protocols for the treatment of methamphetamine (MA) use disorder in an ambulatory drug and alcohol treatment setting.

METHODS

Thirty participants meeting the criteria for moderate to severe MA use disorder will be recruited in community drug and alcohol treatment settings and randomised to receive active TMS or sham (control) intervention. The treatment is intermittent TBS (iTBS) applied to the left dorsolateral prefrontal cortex (DLPFC), then continuous TBS (cTBS) to the left orbitofrontal cortex (OFC). Twelve sessions are administered over 4 weeks with opt-in weekly standardized cognitive behaviour therapy (CBT) counselling and a neuroimaging sub-study offered to participants. Primary outcomes are feasibility measures including recruitment, retention and acceptability of the intervention. Secondary outcomes include monitoring of safety and preliminary efficacy data including changes in substance use, cravings (cue reactivity) and cognition (response inhibition).

DISCUSSION

This study examines shorter TBS protocols of TMS for MA use disorder in real-world drug and alcohol outpatient settings where withdrawal and abstinence from MA, or other substances, are not eligibility requirements. TMS is a relatively affordable treatment and staff of ambulatory health settings can be trained to administer TMS. It is a potentially scalable and translatable treatment for existing drug and alcohol clinical settings. TMS has the potential to provide a much-needed adjuvant treatment to existing psychosocial interventions for MA use disorder. A limitation of this protocol is that the feasibility of follow-up is only examined at the end of treatment (4 weeks).

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry ACTRN12622000762752. Registered on May 27, 2022, and retrospectively registered (first participant enrolled) on May 23, 2022, with protocol version 7 on February 24, 2023.

A Critical Review of Noninvasive Brain Stimulation Technologies in Alzheimer's Dementia and Primary Progressive Aphasia

Multiple pharmacologic agents now have been approved in the United States and other countries as treatment to slow disease and clinical progression for Alzheimer's disease. Given these treatments have not been proven to lessen the cognitive deficits already manifested in the Alzheimer's Clinical Syndrome (ACS), and none are aimed for another debilitating dementia syndrome identified as primary progressive aphasia (PPA), there is an urgent need for new, safe, tolerable, and efficacious treatments to mitigate the cognitive deficits experienced in ACS and PPA. Noninvasive brain stimulation has shown promise for enhancing cognitive functioning, and there has been interest in its potential therapeutic value in ACS and PPA. This review critically examines the evidence of five technologies in ACS and PPA: transcranial direct current stimulation (tDCS), transcranial alternating current stimulation (tACS), transcranial random noise stimulation (tRNS), repetitive transcranial magnetic stimulation (rTMS), and noninvasive vagus nerve stimulation (nVNS). Many randomized controlled trials of tDCS and rTMS report positive treatment effects on cognition in ACS and PPA that persist out to at least 8 weeks, whereas there are few trials for tACS and none for tRNS and nVNS. However, most positive trials did not identify clinically meaningful changes, underscoring that clinical efficacy has yet to be established in ACS and PPA. Much is still to be learned about noninvasive brain stimulation in ACS and PPA, and shifting the focus to prioritize clinical significance in addition to statistical significance in trials could yield greater success in understanding its potential cognitive effects and optimal parameters.

The Effects of Transcranial Direct Current Stimulation and Exercise on Salivary S100B Protein Indicated Blood-Brain Barrier Permeability: A Pilot Study

OBJECTIVE

This study aimed to assess the effect of transcranial direct current stimulation (tDCS) and exercise on blood-brain barrier (BBB) permeability in humans as assessed through the quantification of the salivary protein biomarker S100B. It was hypothesized that active tDCS would induce a significant increase in salivary S100B concentration when compared with sham stimulation and no stimulation. It also was hypothesized that the increase in salivary S100B concentration would be greater after active tDCS and exercise than after tDCS or exercise alone.

MATERIALS AND METHODS

A total of 13 healthy adults (five male, eight female), ranging in age from 21 to 32 years, underwent three experimental conditions (active tDCS, sham tDCS, inactive control). To assess exercise- and tDCS-induced changes in BBB permeability, S100B in saliva was measured. Saliva samples were taken before tDCS, after tDCS, and immediately after a ramped cycling time-to-exhaustion (TTE) task. Active tDCS involved the application of anodal stimulation over the primary motor cortex for 20 minutes at 2 mA.

RESULTS

S100B concentrations in the control condition did not differ significantly from the active condition (estimate = 0.10, SE = 0.36, t = 0.27, p = 0.79) or the sham condition (estimate = 0.33, SE = 0.36, t = 0.89, p = 0.38). Similarly, S100B concentrations at baseline did not differ significantly from post-intervention (estimate = -0.35, SE = 0.34, t = -1.03, p = 0.31) or post-TTE (estimate = 0.66, SE = 0.34, t = 1.93, p = 0.06).

CONCLUSIONS

This research provides novel insight into the effect of tDCS and exercise on S100B-indicated BBB permeability in humans. Although the effects of tDCS were not significant, increases in salivary S100B after a fatiguing cycling task may indicate exercise-induced changes in BBB permeability.

Effects of non-invasive brain stimulation over supplementary motor area in people with Parkinson's disease: a protocol for a systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

Individuals with Parkinson's disease (PD) often experience initial hesitation, slowness of movements, decreased balance and impaired standing ability, which can significantly impact their independence. Transcranial magnetic stimulation and transcranial direct current stimulation are two widely used and promising non-invasive brain stimulation (NIBS) modalities for treating PD. The supplementary motor area (SMA), associated with motor behaviour and processing, has received increasing attention as a potential stimulation target to alleviate PD-related symptoms. However, the data on NIBS over SMA in PD individuals are inconsistent and has not been synthesised. In this article, we will review the evidence for NIBS over SMA in PD individuals and evaluate its efficacy in improving PD function.

METHOD AND ANALYSIS

Randomised controlled clinical trials comparing the effects of NIBS and sham stimulation on motor function, activities of daily living and participation for people with PD will be included. A detailed computer-aided search of the literature will be performed from inception to February 2023 in the following databases: PubMed, EMBASE, Physiotherapy Evidence Database (PEDro), Web of Science (WOS) and The Chinese National Knowledge Infrastructure (CNKI). Two independent reviewers will screen articles for relevance and methodological validity. The PEDro scale will be used to evaluate the risk of bias of selected studies. Data from included studies will be extracted by two independent reviewers through a customised, preset data extraction sheet.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review. The study's findings will be presented at scientific meetings and published in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42023399945.

Clinical application of transcranial magnetic stimulation for functional bowel disease

Functional bowel disorder (FBD) is a common gastrointestinal disease syndrome characterized by dysmotility and secretion without known organic lesions. The pathogenesis of FBD is still unclear. In recent years, with the rise of neurogastroenterology, it has initially revealed its close relationship with the "brain-gut axis." Transcranial magnetic stimulation (TMS) is a technique for detecting and treating the nervous system, that is characterized by non-invasiveness and painlessness. TMS plays an important role in the diagnosis and treatment of diseases, and provides a new method for the treatment of FBD. In this paper, we summarized and analyzed the research progress of using TMS therapy applied to patients with irritable bowel syndrome and functional constipation by domestic and foreign scholars in recent years by means of literature search, and found that TMS therapy could improve the intestinal discomfort and accompanying mental symptoms in patients with FBD.

Effectiveness of Repetitive Transcranial Magnetic Stimulation (rTMS) Add-On Therapy to a Standard Treatment in Individuals with Multiple Sclerosis and Concomitant Symptoms of Depression—Results from a Randomized Clinical Trial and Pilot Study

Background: Compared to the general population, persons with multiple sclerosis (MS) are at increased risk of suffering from major depressive disorder (MDD). Repetitive Transcranial Magnetic Stimulation (rTMS) was used successfully to treat individuals with MDD. Here, we conducted a randomized clinical trial and pilot study, and tested the effectiveness of rTMS adjuvant to a standard pharmacological treatment among persons with MS, compared to a sham condition. Materials and Methods: A total of 40 persons with MS (mean age: 32 years; 42.5% females; median EDSS score: 4) and with moderate to severe symptoms of depression were randomly assigned to the rTMS or to the rTMS sham condition, always as adjuvant intervention to the standard treatment with sertraline, a selective serotonin reuptake inhibitor (SSRI). rTMS consisted of 10 sessions each of 37.5 min; the sham condition was identical to the active condition except for the absence of rTMS stimuli. At the beginning and two weeks after the end of the study, participants reported on their fatigue, while experts rated the severity of participants’ depressive symptoms (Montgomery–Asberg Depression Rating Scale; MADRS), cognitive performance (Montreal Cognitive Assessment; MoCA), and degree of disability (Expanded Disability Status Scale; EDSS). Results: Data were analyzed per intent-to-treat. Scores for depression, fatigue, and EDSS declined significantly over time (large effect sizes), but more so in the rTMS condition than in the sham condition (large effect sizes for the time by group-interactions). Compared to the sham condition, scores for depression were significantly lower in the rTMS condition. Scores for cognition improved over time in both study conditions (large effect size). Conclusion: Compared to a sham condition, adjuvant rTMS to a standard pharmacological treatment ameliorated typical MS-related symptoms (depression; fatigue; EDSS scores). Results from this pilot study suggested that rTMS might be routinely applied in persons with MS displaying symptoms of depression and fatigue.

The effect of repetitive transcranial magnetic stimulation on electroencephalography microstates of patients with heroin-addiction

The effects of transcranial magnetic stimulation in treating substance use disorders are gaining attention; however, most existing studies used subjective measures to examine the treatment effects. Objective electroencephalography (EEG)-based microstate analysis is important for measuring the efficacy of transcranial magnetic stimulation in patients with heroin addiction. We investigated dynamic brain activity changes in individuals with heroin addiction after transcranial magnetic stimulation using microstate indicators. Thirty-two patients received intermittent theta-burst stimulation (iTBS) over the left dorsolateral prefrontal cortex. Resting-state EEG data were collected pre-intervention and 10 days post-intervention. The feature values of the significantly different microstate classes were computed using a K-means clustering algorithm. Four EEG microstate classes (A-D) were noted. There were significant increases in the duration, occurrence, and contribution of microstate class A after the iTBS intervention. K-means classification accuracy reached 81.5%. The EEG microstate is an effective improvement indicator in patients with heroin addiction treated with iTBS. Microstates were examined using machine learning; this method effectively classified the pre- and post-intervention cohorts among patients with heroin addiction and healthy individuals. Using EEG microstate to measure heroin addiction and further exploring the effect of iTBS in patients with heroin addiction merit clinical investigation.

A review of functional brain differences predicting relapse in substance use disorder: Actionable targets for new methods of noninvasive brain stimulation

Neuroimaging studies have identified a variety of brain regions whose activity predicts substance use (i.e., relapse) in patients with substance use disorder (SUD), suggesting that malfunctioning brain networks may exacerbate relapse. However, this knowledge has not yet led to a marked improvement in treatment outcomes. Noninvasive brain stimulation (NIBS) has shown some potential for treating SUDs, and a new generation of NIBS technologies offers the possibility of selectively altering activity in both superficial and deep brain structures implicated in SUDs. The goal of the current review was to identify deeper brain structures involved in relapse to SUD and give an account of innovative methods of NIBS that might be used to target them. Included studies measured fMRI in currently abstinent SUD patients and tracked treatment outcomes, and fMRI results were organized with the framework of the Addictions Neuroclinical Assessment (ANA). Four brain structures were consistently implicated: the anterior and posterior cingulate cortices, ventral striatum and insula. These four deeper brain structures may be appropriate future targets for the treatment of SUD using these innovative NIBS technologies.

Bipolar depression: a review of treatment options

Bipolar depression (BD-D) is both common and incredibly challenging to treat. Even treated individuals with BD-D experience depression approximately 19% of the time, and subsyndromal depression an additional 18%. This stands in clear contrast to the approximately 10% of time spent in hypomania and 1% of time spent in mania. Despite this high illness burden, there remain relatively few treatment options approved by the US Food and Drug Administration for BD-D. Of the approved medications, four are second-generation antipsychotics (SGAs) and one is an SGA combined with an antidepressant. However, particularly when used long-term, antipsychotics can pose a significant risk of adverse effects, raising the clinical conundrum of weighing the risks associated with long-term antipsychotic use versus the risk of relapse when patients are off medications. Here, we review commonly used treatments for BD-D, including antipsychotics, classic mood stabilisers, electroconvulsive therapy and psychotherapy. We then address the somewhat controversial topic of antidepressant use in BD-D. Finally, we summarise emerging treatment options and highlight ongoing clinical trials. We hope this review will help compare the risks and benefits of several common and novel options for the treatment of patients with BD-D. In doing so, we also hope this review will aid the individualised selection of treatments based on each patient's history and treatment goals.

Exploring Patient Perceptions of Noninvasive Brain Stimulation: A Systematic Review

OBJECTIVE

To synthesize and critically appraise literature exploring patient perceptions regarding the therapeutic use of noninvasive brain stimulation.

MATERIAL AND METHODS

A systematic search of CINHAL, PUBMED, Web of Science, and Medline was performed. Reference lists of relevant articles were also screened. Studies exploring participant perceptions regarding the therapeutic use of noninvasive brain stimulation were eligible for inclusion. Perceptions were divided into three domains: knowledge, experience, and attitudes. Noninvasive brain stimulation was defined as any neuromodulation technique that alters brain activity but does not require invasive methods such as surgery. No restrictions were placed upon study design or participant population. Two reviewers performed data extraction and risk of bias assessment. Data relating to methodological characteristics, participant demographics, type of noninvasive brain stimulation, and nature of perceptions (knowledge, experience, or attitudes) were extracted.

RESULTS

Four studies comprising data from 163 participants met the inclusion criteria. All studies investigated perceptions of repetitive transcranial magnetic stimulation (rTMS) in psychiatric populations. Most participants perceived rTMS to be safe and beneficial, demonstrated low levels of fear, and were willing to recommend the intervention to others. No studies were found investigating patient perception of transcranial direct current stimulation (tDCS).

CONCLUSION

The findings from this review suggest that rTMS is well accepted as a therapeutic treatment among psychiatric populations, providing support for its clinical utility. Future work is needed to determine if similar findings exist for other conditions (eg, chronic pain) and for other therapeutic forms of brain stimulation (eg, tDCS).

High-frequency Repetitive Transcranial Magnetic Stimulation (rTMS) Accelerates onset Time of Beneficial Treating Effects and Improves Clinical Symptoms of Depression

BACKGROUND

In recent years, more and more patients with depression demonstrate suicidal intention and suicidal behavior.

OBJECTIVE

To evaluate the effectiveness of repetitive transcranial magnetic stimulation (rTMS) in treating depression with suicidal ideation.

METHODS

Eighty-nine depression patients with suicide intention were administrated drugs combined with four weeks of Active rTMS (n=40) or sham (n=49) rTMS treatment. The 24-item Hamilton Depression Rating Scale for Depression (HAMD-24) and Self-rating Idea of Suicide Scale (SIOSS) were used to evaluate suicide risk and depression severity at baseline, weeks 2 and 4. A 25% reduction in HAMD-24 score from baseline was defined as treatment response. More than a 20% reduction in HAMD-24 score from baseline within the first 2 weeks of treatment was defined as an early improvement.

RESULTS

No statistical significance was found for baseline sociodemographic and illness characteristics between the two groups (P >0.05). There was a significant difference for HAMD-24 and SIOSS scores between the two groups at weeks 2 and 4. Active rTMS group demonstrated a more significant score reduction compared to the Sham rTMS group at weeks 2 and 4. There was a significantly greater number of patients with early improvement observed in the Active rTMS group compared to those in the Sham rTMS group at weeks 2 (P <0.05). There was a significant difference in responder rates between the two groups at weeks 4 for HAMD-24 scores (P <0.05).

CONCLUSION

rTMS could accelerate the onset time of beneficial treating effects and improve clinical symptoms of depression. During the treatment course, cognitive disorder, sleep disorder, anxiety/ somatization, retardation, and hopelessness symptoms were improved dramatically, and suicidal ideation was reduced.

Safety of transcranial magnetic stimulation in unipolar depression: A systematic review and meta-analysis of randomized-controlled trials

BACKGROUND

To study the safety and patients' tolerance of transcranial magnetic stimulation (TMS), we conducted a systematic review and meta-analysis of the major depressive disorder population.

METHODS

Our study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the literature published before April 30th, 2021 and performed a random-effects meta-analyses which included drop-out due to adverse events, serious adverse events and other non-serious adverse events as primary and secondary outcomes.

RESULTS

A total of 53 randomized sham-controlled trials with 3,273 participants were included. There was no increased risk of drop-out due to an adverse event (active TMS intervention group=3.3%, sham TMS intervention group=2.3%, odds ratio = 1.30, 95% CI= 0.78-2.16, P = 0.31) or a serious adverse event (active TMS intervention group=0.9%, sham TMS intervention group=1.5%, odds ratio = 0.67, 95% CI= 0.29-1.55, P = 0.35). Our findings suggest that TMS intervention may significantly increase the risk of non-serious adverse events including: headaches (active TMS intervention group=22.6%, sham TMS intervention group=16.2%, odds ratio = 1.48, 95% CI= 1.15-1.91, P = 0.002), discomfort (active TMS intervention group=10.9%, sham TMS intervention group=5.0%, odds ratio 1.98, 95% CI= 1.22-3.21, P = 0.006) and pain (active TMS intervention group=23.8%, sham TMS intervention group=5.2%, odds ratio= 8.09, 95% CI= 4.71-13.90, P < 0.001) at the stimulation site, but these non-serious events were mostly mild and transient after TMS treatment.

CONCLUSIONS

These findings provide evidence for the safety and patients' tolerance of transcranial magnetic stimulation technique as an alternative monotherapy or as an add-on treatment for major depressive disorder.

Treatment of Spider Phobia Using Repeated Exposures and Adjunctive Repetitive Transcranial Magnetic Stimulation: A Proof-of-Concept Study

BACKGROUND

Specific phobias represent the largest category of anxiety disorders. Previous work demonstrated that stimulating the ventromedial prefrontal cortex (vmPFC) with repetitive Transcranial Magnetic Stimulation (rTMS) may improve response to exposure therapy for acrophobia.

OBJECTIVE

To examine feasibility of accelerating extinction learning in subjects with spider phobia using intermittent Theta Burst Stimulation (iTBS) rTMS of vmPFC.

METHODS

In total, 17 subjects with spider phobia determined by spider phobia questionnaires [Spider Phobia Questionnaire (SPQ) and Fear of Spiders questionnaire (FSQ)] underwent ratings of fear of spiders as well as behavioral and skin conductance data during a behavioral avoidance test (BAT). Subjects then received a sequential protocol of in vivo spider exposure followed by iTBS for three sessions administered to either active or control treatment sites (vmPFC [n = 8] or vertex [n = 9], respectively), followed 1 week later by repetition of questionnaires and BAT.

RESULTS

All subjects improved significantly regardless of group across both questionnaires (FSQ η² = 0.43, p = 0.004; SPQ η² = 0.39, p = 0.008) and skin conductance levels during BAT (Wald χ² = 30.9, p < 0.001). Subjects in the vmPFC group tolerated lower treatment intensity than in the control group, and there was a significant correlation between treatment intensity, BAT subjective distress improvement, and physiologic measures (all ρ > 0.5).

CONCLUSION

This proof-of-concept study provides preliminary evidence that a sequential exposure and iTBS over vmPFC is feasible and may have rTMS intensity-dependent effects on treatment outcomes, providing evidence for future areas of study in the use of rTMS for phobias.

Transcranial Magnetic Stimulation for Post-traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a psychiatric disorder that causes significant functional impairment and is related to altered stress response and reinforced learned fear behavior. PTSD has been found to impact three functional networks in the brain: default mode, executive control, and salience. The executive control network includes the dorsolateral prefrontal cortex (DLPFC) and lateral PPC. The salience network involves the anterior cingulate cortex, anterior insula, and amygdala. This latter network has been found to have increased functional connectivity in PTSD. Transcranial Magnetic Stimulation (TMS) is a technique used in treating PTSD and involves stimulating specific portions of the brain through electromagnetic induction. Currently, high-frequency TMS applied to the left dorsolateral prefrontal cortex (DLPFC) is approved for use in treating major depressive disorder (MDD) in patients who have failed at least one medication trial. In current studies, high-frequency stimulation has been shown to be more effective in PTSD rating scales posttreatment than low-frequency stimulation. The most common side effect is headache and scalp pain treated by mild analgesics. Seizures are a rare side effect and are usually due to predisposing factors. Studies have been done to assess the overall efficacy of TMS. However, results have been conflicting, and sample sizes were small. More research should be done with larger sample sizes to test the efficacy of TMS in the treatment of PTSD. Overall, TMS is a relatively safe treatment. Currently, the only FDA- approved to treat refractory depression, but with the potential to treat many other conditions.

Electroacupuncture Improves Clearance of Amyloid-β through the Glymphatic System in the SAMP8 Mouse Model of Alzheimer's Disease

Background

Memory loss and cognitive impairment characterize the neurodegenerative disorder, Alzheimer's disease (AD). Amyloid-β (Aβ) is the key factor that triggers the course of AD, and reducing the deposition of Aβ in the brain has been considered as a potential target for the treatment of AD. In clinical and animal studies, electroacupuncture (EA) has been shown to be an effective treatment for AD. In recent years, substantial evidence has accumulated suggesting the important role of the glymphatic system in Aβ clearance.

Objective

The purpose of this study was to explore whether EA modifies the accumulation of Aβ through the glymphatic system and may thus be applied to alleviate cognitive impairments.

Methods

Seven-month-old SAMP8 mice were randomized into a control group (Pc) and an electroacupuncture group (Pe). Age-matched SAMR1 mice were used as normal controls (Rc). Mice in the Pe group were stimulated on Baihui (GV20) and Yintang (GV29) for 10 min and then pricked at Shuigou (GV26) for ten times. EA treatment lasted for 8 weeks. In each week, EA would be applied once a day for the first five consecutive days and ceased at the remaining two days. After EA treatment, Morris water maze (MWM) test was used to evaluate the cognitive function; HE and Nissl staining was performed to observe the brain histomorphology; ELISA, contrast-enhanced MRI, and immunofluorescence were applied to explore the mechanisms underlying EA effects from Aβ accumulation, glymphatic system function, reactivity of astrocytes, and AQP4 polarization, respectively.

Results

This EA regime could improve cognition and alleviate neuropathological damage to brain tissue. And EA treatment might reduce Aβ accumulation, enhance paravascular influx in the glymphatic system, inhibit the reactivity of astrocytes, and improve AQP4 polarity.

Conclusion

EA treatment might reduce Aβ accumulation from the brain via improving clearance performance of the glymphatic system and thereby alleviating cognitive impairment.

Repeated Sessions of Transcranial Direct Current Stimulation on Adolescents With Autism Spectrum Disorder: Study Protocol for a Randomized, Double-Blind, and Sham-Controlled Clinical Trial

Background: Social-emotional difficulties are a core symptom of autism spectrum disorder (ASD). Accordingly, individuals with ASD have problems with social cognition such as recognizing emotions from other peoples' faces. Various results from functional magnetic resonance imaging and electroencephalography studies as well as eye-tracking data reveal a neurophysiological basis of these deficits by linking them to abnormal brain activity. Thus, an intervention targeting the neural origin of ASD impairments seems warranted. A safe method able to influence neural activity is transcranial direct current stimulation (tDCS). This non-invasive brain stimulation method has already demonstrated promising results in several neuropsychiatric disorders in adults and children. The aim of this project is to investigate the effects of tDCS on ASD symptoms and their neural correlates in children and adolescents with ASD. Method: This study is designed as a double-blind, randomized, and sham-controlled trial with a target sample size of 20 male participants (aged 12-17 years) diagnosed with ASD. Before randomization, the participants will be stratified into comorbid depression, comorbid ADHS/conduct disorder, or no-comorbidity groups. The intervention phase comprises 10 sessions of anodal or sham tDCS applied over the left prefrontal cortex within 2 consecutive weeks. To engage the targeted brain regions, participants will perform a social cognition training during the stimulation. TDCS-induced effects on ASD symptoms and involved neural circuits will be investigated through psychological, neurophysiological, imaging, and behavioral data at pre- and post-measurements. Tolerability will be evaluated using a standardized questionnaire. Follow-up assessments 1 and 6 months after the intervention will examine long-lasting effects. Discussion: The results of this study will provide insights into the changeability of social impairments in ASD by investigating social and emotional abilities on different modalities following repeated sessions of anodal tDCS with an intra-simulation training. Furthermore, this trial will elucidate the tolerability and the potential of tDCS as a new treatment approach for ASD in adolescents. Clinical Trial Registration: The study is ongoing and has been registered in the German Registry of Clinical Trials (DRKS00017505) on 02/07/2019.

Hypomanic/manic switch after transcranial magnetic stimulation in mood disorders: A systematic review and meta-analysis

BACKGROUND

Nowadays there is an increasing use of transcranial magnetic stimulation (TMS) both in neurological and psychiatric fields. After Food and Drug Administration approval of TMS for the therapy of treatment-resistant depression, TMS has been widely used in the context of mood disorders (MD). However, growing reports regarding the possibility of developing hypomanic/manic switch (HMS) have generated concern regarding its use in MDs.

AIM

To investigate the actual risk of developing HMS due to TMS in the treatment of MD.

METHODS

We led our research on PubMed, Scopus and Web of Science on March 22, 2020, in accordance to the PRISMA guidelines for systematic review. Only double blind/single blind studies, written in English and focused on the TMS treatment of MD, were included. A meta-analysis of repetitive TMS protocol studies including HMS was conducted using RevMan 5.4 software. The assessment of Risk of Bias was done using Cochrane risk of bias tool. This protocol was registered on PROSPERO with the CRD42020175811 code.

RESULTS

Twenty-five studies were included in our meta-analysis: Twenty-one double blind randomized controlled trials (RCT) and four single blind-RCT (no. of subjects involved in active stimulation = 576; no. of subjects involved in sham protocol = 487). The most frequently treated pathology was major depressive episode/major depressive disorder, followed by resistant depression, bipolar depression and other MD. The majority of the studies used a repetitive TMS protocol, and the left dorsolateral prefrontal cortex was the main target area. Side effects were reported in eight studies and HMS (described as greater energy, insomnia, irritability, anxiety, suicidal attempt) in four studies. When comparing active TMS vs sham treatment, the risk of developing HMS was not significantly different between conditions.

CONCLUSION

Applying the most usual protocols and the appropriate precautionary measures, TMS seems not to be related to HMS development.

Design of a Novel Paired Associative Nerve Stimulation System and Treatment Strategy for Incomplete Spinal Cord Injury: A Preliminary Study

Paired associative nerve stimulation (PANS) was proposed as a potential nerve rehabilitation treatment strategy. However, few relevant documents are available regarding the strategy, and only a few clinical studies have involved healthy people. To determine the feasibility of the neurorehabilitation treatment and to estimate the effect of PANS on nerve plasticity for individuals with incomplete spinal cord injury (iSCI), a design combining repetitive transcranial magnetic stimulation (rTMS) with trans-spinal electrical stimulation was developed for treating individuals with iSCI in this pilot case study. First, a novel PANS system with multiple stimulation modes was designed and verified with resistors and a metal coil as load. Then, the system was applied to three individuals with iSCI, and five types of paired associative stimulation was performed to confirm the feasibility of the system and determine the most effective treatment strategy. The preliminary result showed that 20-Hz rTMS combined with cathodal trans-spinal direct current stimulation (tsDCS) had the greatest effect on corticospinal excitability. Next, stimulations of 20-Hz rTMS (brain) and sham (spine) as well as sham (brain) and cathode tsDCS (spine) were administered to individuals with iSCI, and the results revealed that paired associative stimulation of brain and spine was more effective than only 20-Hz rTMS brain stimulation or cathodal tsDCS stimulation for corticospinal plasticity.

Repetitive transcranial magnetic stimulation as a potential treatment approach for cannabis use disorder

The expanding legalization of cannabis across the United States is associated with increases in cannabis use, and accordingly, an increase in the number and severity of individuals with cannabis use disorder (CUD). The lack of FDA-approved pharmacotherapies and modest efficacy of psychotherapeutic interventions means that many of those who seek treatment for CUD relapse within the first few months. Consequently, there is a pressing need for innovative, evidence-based treatment development for CUD. Preliminary evidence suggests that repetitive transcranial magnetic stimulation (rTMS) may be a novel, non-invasive therapeutic neuromodulation tool for the treatment of a variety of substance use disorders (SUDs), including recently receiving FDA clearance (August 2020) for use as a smoking cessation aid in tobacco cigarette smokers. However, the potential of rTMS for CUD has not yet been reviewed. This paper provides a primer on therapeutic neuromodulation techniques for SUDs, with a particular focus on reviewing the current status of rTMS research in people who use cannabis. Lastly, future directions are proposed for rTMS treatment development in CUD, with suggestions for study design parameters and clinical endpoints based on current gold-standard practices for therapeutic neuromodulation research.

The Effects of Repetitive Transcranial Magnetic Stimulation in Patients with Chronic Schizophrenia: Insights from EEG Microstates

The objective of this study was to investigate the effects of 10 Hz repetitive transcranial magnetic stimulation (rTMS) in patients with schizophrenia using EEG microstates. Thirty-eight patients with chronic schizophrenia were included in a double-blind, randomized and sham-controlled trial (19 participants in the active group and 19 participants in the sham group) and received 10 Hz active or sham rTMS stimulation to the left dorsolateral prefrontal cortex (left DLPFC) 5 days per week over for 4 weeks. Four classical microstate classes (i.e., classes A, B, C and D) were identified by clustering, and the parameters (i.e., duration, occurrence and contribution) of each class were computed. Our results showed that (1) after stimulation, the positive and negative syndrome scale (PANSS) positive scores decreased significantly in the active group; (2) the duration of the microstate of class C derived from EEG data decreased significantly in the active group; and (3) the change of the duration of class D in the active group was significantly higher than that in the sham group. Our findings demonstrated that 10 Hz active rTMS stimulation was beneficial to improving the positive symptoms of patients with chronic schizophrenia, and the EEG microstate could be an effective indicator of symptom improvements.

The Safety and Efficacy of Repetitive Transcranial Magnetic Stimulation in the Treatment of Major Depression Among Children and Adolescents: A Systematic Review

Major depression is a chronic debilitating condition affecting people of all ages and is rising over the past decade. Major depression among children and adolescents is often resistant to traditional treatments, thus necessitating the exploration of novel strategies. Repetitive transcranial magnetic stimulation (rTMS) is gaining increasing attention as a useful tool in treating various conditions and has received the US Food and Drug Administration (FDA) approval to treat depression and obsessive-compulsive disorder among adults. Favorable outcomes among adults generated interest in using it among children. Until recently, the existing literature lacked randomized sham-controlled trials on this topic among children and adolescents. The newest additions in the literature necessitated another in-depth look at the data to explore the safety and efficacy of rTMS in the context of depression among children and adolescents. We searched the Medline and Cochrane databases and included 18 articles for our systematic review. Our systematic review indicates level 1 evidence that rTMS is safe but failed to show its superiority to placebo as a stand-alone treatment for resistant depression among children and adolescents. However, there is level 2 evidence favoring add-on rTMS to treat major depression among children and adolescents. The study subjects appear to tolerate the rTMS treatment well with some minor and mostly self-limited side effects. Risks of treatment-emergent hypomanic symptoms and seizure appear to be very low. There is no evidence of worsening of suicidal ideation or cognitive decline during rTMS treatment.

Using cortical non-invasive neuromodulation as a potential preventive treatment in schizophrenia - A review

BACKGROUND

Evidence suggests that schizophrenia constitutes a neurodevelopmental disorder, characterized by a gradual emergence of behavioral and neurobiological abnormalities over time. Therefore, applying early interventions to prevent later manifestation of symptoms is appealing.

OBJECTIVE

This review focuses on the use of cortical neuromodulation in schizophrenia and its potential as a preventive treatment approach. We present clinical and preclinical findings investigating the use of neuromodulation in schizophrenia, including the current research focusing on cortical non-invasive stimulation and its possibility as a future preventive treatment.

METHODS

We performed a search in Medline (PubMed) in September 2020 using a combination of relevant medical subject headings (MeSH) and text words. The search included human and preclinical trials as well as existing systematic reviews and meta-analysis. There were no restrictions on language or the date of publication.

RESULTS

Neurodevelopmental animal models may be used to investigate how the disease progresses and thus which brain areas ideally should be targeted at a given time point. Here, abnormalities of the prefrontal cortex have been often identified as an early and persistent impairment in schizophrenia. Currently there is insufficient evidence to either support or refute the use of neuromodulation to the cortex in adult patients with already manifested symptoms. However, preclinical results show that early non-invasive neuromodulation to the prefrontal cortex of adolescent animals, sufficiently prevents later psychosis-relevant abnormalities in adulthood. This points to the promising potential of cortical non-invasive neuromodulation as a preventive treatment when applied early in the course of the disease.

CONCLUSION

Preclinical translational-oriented findings indicate, that neuromodulation to cortical areas offers the possibility of targeting early neuropathology and through this diminish the progression of a later schizophrenic profile. Further studies are needed to investigate whether such early cortical stimulation may serve as a future preventive treatment in schizophrenia.

Treatment-resistant depression: An overview for psychiatric advanced practice nurses

PURPOSE

Treatment-resistant depression (TRD) can require complex management. The purpose of this paper is to provide an update on the hypothesized neurobiology of depression, and to describe treatment options for patients impacted by TRD.

CONCLUSIONS

Recent neurobiological findings support the use of augmenting pharmacological agents, neuromodulation techniques, and esketamine as effective in achieving remission for those with TRD.

PRACTICE IMPLICATIONS

First-line interventions for depression can be safely managed by primary care providers. Psychiatric advanced practice nurses must be well versed and capable of treating more complicated cases, including TRD, that may require second- or third-line approaches.

Ethical and Legal Considerations of Alternative Neurotherapies

Neurotherapies for diagnostics and treatment-such as electroencephalography (EEG) neurofeedback, single-photon emission computerized tomography (SPECT) imaging for neuropsychiatric evaluation, and off-label/experimental uses of brain stimulation-are continuously being offered to the public outside mainstream healthcare settings. Because these neurotherapies share many key features of complementary and alternative medicine (CAM) techniques-and meet the definition of CAM as set out in Kaptchuk and Eisenberg-here we refer to them as "alternative neurotherapies." By explicitly linking these alternative neurotherapy practices under a common conceptual framework, this paper draws attention to, and critically considers, the cross-cutting ethical and legal issues related to the provision of these services. The first section of this paper provides an updated empirical overview of uses of SPECT neuropsychiatric evaluations, EEG neurofeedback, and experimental/off-label forms of brain stimulation. Next, drawing on CAM bioethics scholarship, we highlight the pertinent ethical issues in the alternative neurotherapy context, including the truthful representation of evidence base, marketing to vulnerable populations, potential harms, provider competency, and conflicts of interest. Finally, we consider the principal legal issues at stake for the provision of alternative neurotherapies in the U.S., namely those related to licensing and scope-of-practice considerations. We conclude with recommendations for future research in this domain.

Efficacy of coupling intermittent theta-burst stimulation and 1 Hz repetitive transcranial magnetic stimulation to enhance upper limb motor recovery in subacute stroke patients: A randomized controlled trial

BACKGROUND

Both 1 Hz repetitive transcranial magnetic stimulation (rTMS) and intermittent theta-burst stimulation (iTBS) are reported to benefit upper limb motor function rehabilitation in patients with stroke. However, the efficacy of combining 1 Hz rTMS and iTBS has not been adequately explored.

OBJECTIVE

We aimed to compare the effects of 1 Hz rTMS and the combination of 1 Hz rTMS and iTBS on the upper limb motor function in the subacute phase post-stroke.

METHODS

Twenty-eight participants were randomly assigned to three groups: Group A (1 Hz rTMS over the contralesional primary motor cortex (M1) and iTBS over the ipsilesional M1), Group B (contralesional 1 Hz rTMS and ipsilesional sham iTBS), and Group C (contralesional sham 1 Hz rTMS and ipsilesional sham iTBS). The participants received the same conventional rehabilitation accompanied by sessions of transcranial magnetic stimulation for two weeks (5 days one week). Motor-evoked potential (MEP), upper extremity Fugl-Meyer Assessment (UE-FMA), and Barthel Index (BI) were performed before and after the sessions.

RESULTS

Group A showed greater UE-FMA, BI, and MEP amplitude improvement and more significant decrement in MEP latency compared to Group B and Group C in testable patients. Correlation analyses in Group A revealed a close relation between ipsilesional MEP amplitude increment and UE-FMA gain.

CONCLUSIONS

The combining of 1 Hz rTMS and iTBS protocol in the present study is tolerable and more beneficial for motor improvement than the single use of 1 Hz rTMS in patients with subacute stroke.

Safety and tolerability of repeated sessions of deep transcranial magnetic stimulation in obesity

PURPOSE

Repetitive Transcranial Magnetic Stimulation (rTMS) has been demonstrated to be effective in body weight control in individuals with obesity. Most clinical trials on rTMS provided a reassuring safety profile. In the present work, we present an extensive analysis on both severe and mild Adverse Events (AEs) in obese individuals treated with rTMS.

METHODS

We examined the intensity, duration, correlation with the treatment, up to 1 year after the end of rTMS treatment.

RESULTS

Descriptive analysis included a total of 63 subjects undergoing a 5-week deep rTMS experimental treatment for obesity (age 48.3 ± 10.4 years; BMI 36.3 ± 4.4 kg/m²): 31 patients were treated with high-frequency rTMS (HF), 13 with low-frequency rTMS (LF), and 19 were sham treated (Sham). Thirty-two subjects (50.8%) reported a total of 52 AEs, including mainly moderate (51.9%) events. The most frequently reported side effects were headaches of moderate intensity (40.4%) and local pain/discomfort (19.2%) and resulted significantly more frequent in HF group compared to other groups (p < 0.05). No significant differences among groups were found for the other reported AEs: drowsiness, insomnia, paresthesia, vasovagal reactions, hypertensive crisis. No AEs potentially related to the rTMS arised up to 1 year from the end of the treatment.

CONCLUSIONS

This is the first comprehensive safety analysis in obese patients treated with rTMS. The analysis did not reveal any unexpected safety concerns. Only headaches and local pain/discomfort have been significantly more frequent in the HF group, confirming the good tolerability of rTMS even in the obese population potentially more susceptible to side effects of brain stimulation.

EEG, MEG and neuromodulatory approaches to explore cognition: Current status and future directions

Neural oscillations and their association with brain states and cognitive functions have been object of extensive investigation over the last decades. Several electroencephalography (EEG) and magnetoencephalography (MEG) analysis approaches have been explored and oscillatory properties have been identified, in parallel with the technical and computational advancement. This review provides an up-to-date account of how EEG/MEG oscillations have contributed to the understanding of cognition. Methodological challenges, recent developments and translational potential, along with future research avenues, are discussed.

Repetitive Transcranial Magnetic Stimulation Modulates Frontal and Temporal Time-Varying EEG Network in Generalized Anxiety Disorder: A Pilot Study

Generalized Anxiety Disorder (GAD) is a highly prevalent yet poorly understood chronic mental disorder. Previous studies have associated GAD with excessive activation of the right dorsolateral prefrontal cortex (DLPFC). This study aimed to investigate the effect of low-frequency repetitive transcranial magnetic stimulation (repetitive TMS, rTMS) targeting the right DLPFC on clinical symptoms and TMS-evoked time-varying brain network connectivity in patients with GAD. Eleven patients with GAD received 1 Hz rTMS treatment targeting the right DLPFC for 10 days. The severity of the clinical symptoms was evaluated using the Hamilton Anxiety Scale (HAMA) and the Hamilton Depression Scale (HAMD) at baseline, right after treatment, and at the one-month follow-up. Co-registration of single-pulse TMS (targeting the right DLPFC) and electroencephalography (TMS-EEG) was performed pre- and post-treatment in these patients and 11 healthy controls. Time-varying brain network connectivity was analyzed using the adaptive directed transfer function. The scores of HAMA and HAMD significantly decreased after low-frequency rTMS treatment, and these improvements in ratings remained at the one-month follow-up. Analyses of the time-varying EEG network in the healthy controls showed a continuous weakened connection information outflow in the left frontal and mid-temporal regions. Compared with the healthy controls, the patients with GAD showed weakened connection information outflow in the left frontal pole and the posterior temporal pole at baseline. After 10-day rTMS treatment, the network patterns showed weakened connection information outflow in the left frontal and temporal regions. The time-varying EEG network changes induced by TMS perturbation targeting right DLPFC in patients with GAD were characterized by insufficient information outflow in the left frontal and temporal regions. Low-frequency rTMS targeting the right DLPFC reversed these abnormalities and improved the clinical symptoms of GAD.

Predictors of remission after repetitive transcranial magnetic stimulation for the treatment of major depressive disorder: An analysis from the randomised non-inferiority THREE-D trial

BACKGROUND

Although repetitive transcranial magnetic stimulation (rTMS) is an effective treatment for major depressive disorder (MDD), treatment selection is still mainly a process of trial-and-error. The present study aimed to identify clinical predictors of remission after a course of rTMS delivered to the left DLPFC to improve patient selection.

METHODS

Data from a large randomised non-inferiority trial comparing standard 10 Hz and intermittent theta burst stimulation (iTBS) for the treatment of MDD were used for the exploratory analyses. Individual variables were assessed for their association with remission and then included in a logistic regression model to determine odds ratios (OR) and corresponding 95% confidence intervals. Model discrimination (internal validation) was carried out to assess model optimism using the c-index. ClinicalTrials.gov identifier: NCT01887782.

FINDINGS

388 subjects were included in the analysis (199-iTBS and 189-10 Hz, respectively). Higher baseline severity of both depressive and anxiety symptoms were associated with a lower chance of achieving remission (OR=0.64, 95% CI 0.46-0.88; and 0.78, 95% CI 0·60-0.98, respectively). Current employment was a positive predictor for remission (OR=1.69, 95% CI 1.06-2.7), while greater number of treatment failures was associated with lower odds of achieving remission (OR=0.51, 95% CI 0.27-0.98). A non-linear effect of age and remission was observed. An analysis to allow an estimate of the probability of remission using all variables was assessed. The c-index for the fitted model was 0.687.

INTERPRETATION

Our results suggest that measuring depression symptom severity, employment status, and refractoriness are important in prognosticating outcome to a course of rTMS in MDD.

FUNDING

Canadian Institutes of Health Research MOP-136801.

Transcranial Magnetic Stimulation as Treatment in Multiple Neurologic Conditions

PURPOSE OF REVIEW

Transcranial magnetic stimulation (TMS) is a method of Non-Invasive Brain Stimulation that is based on electro-physical principles discovered by Michael Faraday. A TMS device is made of one or two copper coils, positioned superficially to a site of interest in the brain, to non-invasively produce a brief magnetic pulse to an estimated depth from the surface of the scalp with the following axonal depolarization. This axonal depolarization activates cortical and subcortical networks with multiple effects. There are different methods of TMS used, all with different mechanisms of action. TMS is well tolerated with very few side effects.

RECENT FINDINGS

TMS is now approved for major depression disorder and obsessive-compulsive disorder. There is significant data to consider approval of TMS for many neurological disorders. This is a review of the uses of TMS in diverse neurological conditions, including stroke and spasticity, migraine, and dementia. TMS is a device that utilizes non-invasive brain stimulation, and it has shown promising results with objective clinical and basic science data. Its ability to trigger neuronal plasticity and potentiating synaptic transmission gives it incredible therapeutic potential. There are diverse mechanisms of action, and this could be troublesome in elaborating clinical trials and standardization of therapy.

Food Addiction: Implications for the Diagnosis and Treatment of Overeating

With the obesity epidemic being largely attributed to overeating, much research has been aimed at understanding the psychological causes of overeating and using this knowledge to develop targeted interventions. Here, we review this literature under a model of food addiction and present evidence according to the fifth edition of the Diagnostic and Statistical Manual (DSM-5) criteria for substance use disorders. We review several innovative treatments related to a food addiction model ranging from cognitive intervention tasks to neuromodulation techniques. We conclude that there is evidence to suggest that, for some individuals, food can induce addictive-type behaviours similar to those seen with other addictive substances. However, with several DSM-5 criteria having limited application to overeating, the term 'food addiction' is likely to apply only in a minority of cases. Nevertheless, research investigating the underlying psychological causes of overeating within the context of food addiction has led to some novel and potentially effective interventions. Understanding the similarities and differences between the addictive characteristics of food and illicit substances should prove fruitful in further developing these interventions.

Transcranial Magnetic Stimulation for Major Depressive Disorder in Pregnancy: A Literature Review

Major depressive disorder (MDD) is a growing problem among pregnant women as current treatment with antidepressants pose significant risks to the mother and fetus. Transcranial magnetic stimulation (TMS) is a neuromodulation technique that is being increasingly utilized to treat MDD in adults. We conducted a literature search using the keyword “TMS” and cross-referencing it with MDD, depression, major depressive episode, pregnancy, efficacy, safety, and clinical trial. This review explores current studies conducted to evaluate the efficacy and safety of TMS to treat MDD in pregnant females. Low-frequency TMS over the right dorsolateral prefrontal cortex, when given to pregnant women with MDD during the second and third trimester, has shown a significant response in depressive symptom reduction. TMS offers a promising alternative to current treatment options for managing MDD during pregnancy, but with limited research available, its safety and efficacy still need to be studied by conducting multicenter trials and long-term studies. 

Low-Field Magnetic Stimulation Restores Cognitive and Motor Functions in the Mouse Model of Repeated Traumatic Brain Injury: Role of Cellular Prion Protein

Traumatic brain injury (TBI)/concussion is a growing epidemic throughout the world. Memory and neurobehavioral dysfunctions are among the sequelae of TBI. Dislodgement of cellular prion protein (PrPc) and disruption of circadian rhythm have been linked to TBI. Low-field magnetic stimulation (LFMS) is a new noninvasive repetitive transcranial magnetic stimulation (rTMS) technique that generates diffused and low-intensity magnetic stimulation to deep cortical and subcortical areas. The role of LFMS on PrPc, proteins related to the circadian rhythm, and behavior alterations in a repeated TBI mouse model were studied in the present study. TBI was induced to the mice (right hemisphere) using weight-drop method, once daily for 3 days. LFMS treatment was given for 20 min once daily for 4 days (immediately after each TBI induction). The results showed that LFMS-treated TBI mice significantly improved cognitive and motor function as evidenced by open field exploration, rotarod, and novel location recognition tasks. In addition, a significant increase in PrPc and decreased glial fibrillary acidic protein levels were observed in cortical and hippocampal regions of LFMS-treated TBI mice brain compared with sham-treated TBI mice, while neuronal nuclei level was significantly increased in cortical region. In LFMS-treated mice, a decrease in proteins related to circadian rhythm were observed, compared with sham-treated TBI mice. The results obtained from the study demonstrated the neuroprotective effect of LFMS, which may be through regulating PrPc and/or proteins related to circadian rhythm. Thus, the present study suggests that LFMS may improve the subject's neurological condition following TBI.

Repetitive transcranial magnetic stimulation (rTMS) using different TMS instruments for major depressive disorder at a suburban tertiary clinic

Repetitive transcranial magnetic stimulation (rTMS) is a neurostimulatory technique used to modulate orbital frontal corticostriatal (OFC) activity and clinical symptomatology for psychiatric disorders involving OFC dysfunction. We examined the effectiveness of rTMS in the treatment of major depressive disorder in an applied clinical setting (Awakening KC CNI) to assess efficacy and optimize rTMS parameters within clinical practice. A retrospective review of medical records was carried out on patients with major depressive disorder undergoing rTMS therapy at Awakenings KC Clinical Neuroscience Institute (CNI), a suburban tertiary psychiatric clinic. A detailed de-identified data set of clinical outcomes was compiled. Patient Health Questionnaire 9 (PHQ-9) total score, clinical remission rate and week achieved were evaluated over 6 weeks of treatment to assess clinical response referencing two different rTMS instruments (MagVenture; NeuroStar). Our survey included 247 participants from males (N=98) and females (N=149) with average baseline PHQ-9 scores of 21.7±4, classified as severe depression. Clinically rated remission rates of 72% were achieved in 3.1±1.0 weeks and associated with prior history of psychiatric hospitalization, suicide attempts and substance use disorder. Average baseline PHQ- 9 scores decreased significantly over time with proportionately greater remission rates achieved for patients treated using the MagVenture over NeuroStar instrument. rTMS in applied clinical practice is efficacious over a wide range of settings and patients. Clinical response was related to severity of depression symptoms (e.g., prior hospitalization; suicide attempts) validating efficacy in critically ill groups. Clinical response may be impacted by rTMS instrument, magnetic field parameters or individual factors.

Increased Excitability Induced in the Primary Motor Cortex by Transcranial Ultrasound Stimulation

Background: Transcranial Ultrasound Stimulation (tUS) is an emerging technique that uses ultrasonic waves to noninvasively modulate brain activity. As with other forms of non-invasive brain stimulation (NIBS), tUS may be useful for altering cortical excitability and neuroplasticity for a variety of research and clinical applications. The effects of tUS on cortical excitability are still unclear, and further complications arise from the wide parameter space offered by various types of devices, transducer arrangements, and stimulation protocols. Diagnostic ultrasound imaging devices are safe, commonly available systems that may be useful for tUS. However, the feasibility of modifying brain activity with diagnostic tUS is currently unknown. Objective: We aimed to examine the effects of a commercial diagnostic tUS device using an imaging protocol on cortical excitability. We hypothesized that imaging tUS applied to motor cortex could induce changes in cortical excitability as measured using a transcranial magnetic stimulation (TMS) motor evoked potential (MEP) paradigm. Methods: Forty-three subjects were assigned to receive either verum (n = 21) or sham (n = 22) diagnostic tUS in a single-blind design. Baseline motor cortex excitability was measured using MEPs elicited by TMS. Diagnostic tUS was subsequently administered to the same cortical area for 2 min, immediately followed by repeated post-stimulation MEPs recorded up to 16 min post-stimulation. Results: Verum tUS increased excitability in the motor cortex (from baseline) by 33.7% immediately following tUS (p = 0.009), and 32.4% (p = 0.047) 6 min later, with excitability no longer significantly different from baseline by 11 min post-stimulation. By contrast, subjects receiving sham tUS showed no significant changes in MEP amplitude. Conclusion: These findings demonstrate that tUS delivered via a commercially available diagnostic imaging ultrasound system transiently increases excitability in the motor cortex as measured by MEPs. Diagnostic tUS devices are currently used for internal imaging in many health care settings, and the present results suggest that these same devices may also offer a promising tool for noninvasively modulating activity in the central nervous system. Further studies exploring the use of diagnostic imaging devices for neuromodulation are warranted.

Effect of high-frequency repetitive transcranial magnetic stimulation (rTMS) in patients with comorbid panic disorder and major depression

OBJECTIVE

To explore the role of dorsolateral prefrontal cortex (DLPFC) stimulation in the treatment of panic disorder with comorbid depression.

METHODS

The present study reports findings from retrospective analysis of 13 treatment-resistant patients diagnosed with comorbid panic disorder and depression, given 20 sessions of high-frequency transcranial magnetic stimulation (rTMS) over left-DLPFC over a period of 1 month.

RESULTS

There was a significant reduction in both the panic and depressive symptom severity, assessed by applying Panic Disorder Severity Scale (PDSS) and Hamilton Depression Rating Scale (HDRS) at baseline and after 20 sessions of rTMS. There was a 38% and 40% reduction of PDSS and HDRS scores, respectively, in the sample. The changes in PDSS and HDRS scores were not significantly correlated (ρ = -0.103, p = 0.737).

CONCLUSIONS

High-frequency rTMS delivered at left-DLPFC may have a potential role in treatment of comorbid panic disorder and depression. Future studies done on a larger sample in a controlled environment are required to establish its role.