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Balderston NL, Duprat RJ, Long H, Scully M, Deluisi JA, Figueroa-Gonzalez A, Teferi M, Sheline YI, Oathes DJ. Neuromodulatory transcranial magnetic stimulation (TMS) changes functional connectivity proportional to the electric-field induced by the TMS pulse. Clin Neurophysiol 2024; 165:16-25. [PMID: 38945031 DOI: 10.1016/j.clinph.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/15/2024] [Accepted: 06/09/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE Transcranial magnetic stimulation (TMS) can efficiently and robustly modulate synaptic plasticity, but little is known about how TMS affects functional connectivity (rs-fMRI). Accordingly, this project characterized TMS-induced rsFC changes in depressed patients who received 3 days of left prefrontal intermittent theta burst stimulation (iTBS). METHODS rs-fMRI was collected from 16 subjects before and after iTBS. Correlation matrices were constructed from the cleaned rs-fMRI data. Electric-field models were conducted and used to predict pre-post changes in rs-fMRI. Site by orientation heatmaps were created for vectors centered on the stimulation site and a control site (contralateral motor cortex). RESULTS For the stimulation site, there was a clear relationship between both site and coil orientation, and connectivity changes. As distance from the stimulation site increased, prediction accuracy decreased. Similarly, as eccentricity from the optimal orientation increased, prediction accuracy decreased. The systematic effects described above were not apparent in the heatmap centered on the control site. CONCLUSIONS These results suggest that rs-fMRI following iTBS changes systematically as a function of the distribution of electrical energy delivered from the TMS pulse, as represented by the e-field model. SIGNIFICANCE This finding lays the groundwork for future studies to individualize TMS targeting based on how predicted rs-fMRI changes might impact psychiatric symptoms.
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Affiliation(s)
- Nicholas L Balderston
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry University of Pennsylvania, Philadelphia, PA, USA.
| | - Romain J Duprat
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah Long
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry University of Pennsylvania, Philadelphia, PA, USA
| | - Morgan Scully
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph A Deluisi
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry University of Pennsylvania, Philadelphia, PA, USA
| | - Almaris Figueroa-Gonzalez
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry University of Pennsylvania, Philadelphia, PA, USA
| | - Marta Teferi
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry University of Pennsylvania, Philadelphia, PA, USA
| | - Yvette I Sheline
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry University of Pennsylvania, Philadelphia, PA, USA
| | - Desmond J Oathes
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry University of Pennsylvania, Philadelphia, PA, USA
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Xu G, Li G, Yang Q, Li C, Liu C. Explore the durability of repetitive transcranial magnetic stimulation in treating post-traumatic stress disorder: An updated systematic review and meta-analysis. Stress Health 2024; 40:e3292. [PMID: 37452747 DOI: 10.1002/smi.3292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/27/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
The objective was to synthesize results from studies that assessed symptom relief after repetitive transcranial magnetic stimulation (rTMS) treatment for post-traumatic stress disorder (PTSD) and investigate the long-term effectiveness of rTMS for treating PTSD. We searched multiple databases for relevant randomized controlled trials of rTMS for PTSD treatment up to 1 January 2023. Two researchers evaluated the studies and focused on the CAPS and PCL as outcome indicators. We used STATA17 SE software for the data analysis. Eight articles involving 309 PTSD patients were analysed in a meta-analysis, which found that rTMS had a significant and large effect on reducing core post-traumatic symptoms [Hedges'g = 1.75, 95% CI (1.18, 2.33)]. Both low and high-frequency rTMS also significantly reduced symptoms, with the latter having a greater effect. rTMS was shown to have a long-term effect on PTSD, with all three subgroup analyses demonstrating significant results. Interestingly, no significant difference in symptom relief was found between the follow-up and completion of treatments [Hedges'g = 0.01, 95% CI (-0.30, 0.33)], suggesting that the treatment effect of rTMS is stable. The meta-analysis provides strong evidence that rTMS is effective in reducing the severity and symptoms of PTSD in patients, and follow-up studies confirm its long-term stability.
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Affiliation(s)
- Guobin Xu
- Clinical College, Southwest Medical University, Luzhou, Sichuan, China
| | - Geng Li
- School of Physical Education, Hunan Normal University, Changsha, Hunan, China
| | - Qizhang Yang
- Clinical College, Southwest Medical University, Luzhou, Sichuan, China
| | - Chao Li
- Clinical College, Southwest Medical University, Luzhou, Sichuan, China
| | - Chengzhen Liu
- School of Humanities and Management Science, Southwest Medical University, Luzhou, Sichuan, China
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White LK, Makhoul W, Teferi M, Sheline YI, Balderston NL. The role of dlPFC laterality in the expression and regulation of anxiety. Neuropharmacology 2023; 224:109355. [PMID: 36442650 PMCID: PMC9790039 DOI: 10.1016/j.neuropharm.2022.109355] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/07/2022] [Accepted: 11/23/2022] [Indexed: 11/27/2022]
Abstract
Anxiety disorders are the most common mental health disorder. Therefore, elucidating brain mechanisms implicated in anxiety disorders is important avenue for developing novel treatments and improving care. The dorsolateral prefrontal cortex (dlPFC) is thought to be critically involved in working memory processes (i.e. maintenance, manipulation, suppression, etc.). In addition, there is evidence that this region is involved in anxiety regulation. However, it is unclear how working memory related dlPFC processes contribute to anxiety regulation. Furthermore, we know that laterality plays an important role in working memory related dlPFC processing, however there is no current model of dlPFC mediated anxiety regulation that accounts for potential laterality effects. To address this gap, we propose a potential framework where the dlPFC contributes to emotion regulation via working memory processing. According to this framework, working memory is a fundamental process executed by the dlPFC. However, the domain of content differs across the left and right dlPFC, with the left dlPFC sensitive to primarily verbal content, and the right dlPFC sensitive to primarily non-verbal (affective content). Critically, working memory processes allow for both the retention and suppression of affective information in working memory and the overall net effect of processing on mood will depend on the balance of retention and suppression, the valence of the information being processed (positive vs. negative), and the domain of the information (verbal vs. non-verbal). If accurate, the proposed framework predicts that effects of neuromodulation targeting the dlPFC may be dependent upon the context during which the stimulation is presented. This article is part of the Special Issue on 'Fear, Anxiety and PTSD'.
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Affiliation(s)
- Lauren K White
- Lifespan Brain Institute Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Walid Makhoul
- Center for Neuromodulation in Depression and Stress Department of Psychiatry University of Pennsylvania, Philadelphia, PA, USA
| | - Marta Teferi
- Center for Neuromodulation in Depression and Stress Department of Psychiatry University of Pennsylvania, Philadelphia, PA, USA
| | - Yvette I Sheline
- Center for Neuromodulation in Depression and Stress Department of Psychiatry University of Pennsylvania, Philadelphia, PA, USA
| | - Nicholas L Balderston
- Center for Neuromodulation in Depression and Stress Department of Psychiatry University of Pennsylvania, Philadelphia, PA, USA.
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Teferi M, Makhoul W, Deng ZD, Oathes DJ, Sheline Y, Balderston NL. Continuous Theta Burst Stimulation to the Right Dorsolateral Prefrontal Cortex may increase Potentiated Startle in healthy individuals. BIOLOGICAL PSYCHIATRY GLOBAL OPEN SCIENCE 2022. [PMID: 37519467 PMCID: PMC10382694 DOI: 10.1016/j.bpsgos.2022.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Convergent neuroimaging and neuromodulation studies implicate the right dorsolateral prefrontal cortex (dlPFC) as a key region involved in anxiety-cognition interactions. However, neuroimaging data are correlational, and neuromodulation studies often lack appropriate methodological controls. Accordingly, this work was designed to explore the role of right prefrontal cognitive control mechanisms in the expression/regulation of anxiety using continuous theta-burst transcranial magnetic stimulation (cTBS) and threat of unpredictable shock. Based on prior neuromodulation studies, we hypothesized that the right dlPFC contributed to anxiety expression, and that cTBS should downregulate this expression. Methods We measured potentiated startle and performance on the Sternberg working memory paradigm in 28 healthy participants before and after 4 sessions (600 pulses/session) of active or sham cTBS. Stimulation was individualized to the right dlPFC site of maximal working memory-related activity and optimized using electric-field modeling. Results Compared with sham cTBS, active cTBS, which is thought to induce long-term depression-like synaptic changes, increased startle during threat of shock, but the effect was similar for predictable and unpredictable threat. As a measure of target (dis)engagement, we also showed that active but not sham cTBS decreased accuracy on the Sternberg task. Conclusions Counter to our initial hypothesis, cTBS to the right dlPFC made individuals more anxious, rather than less anxious. Although preliminary, these results are unlikely to be due to transient effects of the stimulation, because anxiety was measured 24 hours after cTBS. In addition, these results are unlikely to be due to off-target effects, because target disengagement was evident from the Sternberg performance data.
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Chen L, Hudaib AR, Hoy KE, Fitzgerald PB. Is rTMS effective for anxiety symptoms in major depressive disorder? An efficacy analysis comparing left-sided high-frequency, right-sided low-frequency, and sequential bilateral rTMS protocols. Depress Anxiety 2019; 36:723-731. [PMID: 30958907 DOI: 10.1002/da.22894] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/22/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Anxiety symptoms are common in major depressive disorder. Whilst therapeutic efficacy of repetitive transcranial magnetic stimulation (rTMS) in depression is well-established, minimal research has investigated rTMS's efficacy in treating anxiety symptoms in depression. METHODS This study investigates the effectiveness of rTMS in treating anxiety symptoms in depression, specifically the relative efficacy of the three rTMS protocols commonly used in clinical practice: left-sided high-frequency, right-sided low-frequency and sequential bilateral rTMS. Antidepressant efficacy of each rTMS protocol is also investigated. Treatment data for 697 patients were pooled from three studies across five sites. Changes in Beck's Anxiety Inventory (BAI) and the Hamilton Depression Rating Scale over 4-week rTMS courses were analysed using latent growth curve modelling. RESULTS All rTMS protocols were effective in treating anxiety symptoms (mean BAI reduction, 8.13 points; p < 0.001) and depressive symptoms. Near therapeutic equivalence was seen across the three protocols. Improvement in depressive severity positively correlated with improvement in anxiety. Both high- and low-baseline anxiety scores showed overall symptom reduction. CONCLUSIONS This study addresses the clinical knowledge gap pertaining to rTMS's therapeutic efficacy in treating anxiety symptoms in depression and the relative efficacy of three commonly used stimulation protocols. Our findings suggest therapeutic equivalence across left-sided high-frequency, right-sided low-frequency, and sequential bilateral rTMS approaches.
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Affiliation(s)
- Leo Chen
- Monash Alfred Psychiatry Research Centre, Monash University, Melbourne, Victoria, Australia.,Epworth Centre for Innovation in Mental Health, Epworth HealthCare, Camberwell, Victoria, Australia.,Alfred Mental and Addiction Health, Alfred Health, Melbourne, Victoria, Australia
| | - Abdul-Rahman Hudaib
- Monash Alfred Psychiatry Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Kate E Hoy
- Monash Alfred Psychiatry Research Centre, Monash University, Melbourne, Victoria, Australia.,Epworth Centre for Innovation in Mental Health, Epworth HealthCare, Camberwell, Victoria, Australia
| | - Paul B Fitzgerald
- Monash Alfred Psychiatry Research Centre, Monash University, Melbourne, Victoria, Australia.,Epworth Centre for Innovation in Mental Health, Epworth HealthCare, Camberwell, Victoria, Australia
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Tan SZK, Sheng V, Chan YS, Lim LW. Eternal sunshine of the neuromodulated mind: Altering fear memories through neuromodulation. Exp Neurol 2019; 314:9-19. [PMID: 30639183 DOI: 10.1016/j.expneurol.2019.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/27/2018] [Accepted: 01/09/2019] [Indexed: 11/17/2022]
Abstract
Anxiety disorders pose one of the greatest threats to mental health. Modern treatment methods exist but are hindered by relapse, toxicity, and low efficacy. The use of neuromodulation to treat anxiety disorders has shown promising results, yet its underpinning mechanisms remain poorly understood. In this review, we make the case for further development of neuromodulation techniques to alter fear memories, with particular regard to future clinical applications in treating anxiety disorders. We start by briefly summarizing the neural circuitry of fear while identifying the pros and cons of possible neuromodulation targets. We then highlight recent advances in neuromodulation techniques that have been used to alter fear memories. Next, we apply a novel network-based approach to elucidate possible mechanisms of neuromodulation which may disrupt the consolidation of fear memory. Finally, we emphasize the need for more systematic neuromodulation studies on animal models and the developing brain. Overall, we aim to provide an integrated framework for future action, identifying key research priorities that must be addressed before effective neuromodulation-based treatments can be developed for practical use.
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Affiliation(s)
- Shawn Zheng Kai Tan
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region
| | - Victoria Sheng
- School of Biological Sciences, The University of Hong Kong, Hong Kong Special Administrative Region
| | - Ying-Shing Chan
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region
| | - Lee Wei Lim
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region.
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Dorfman J, Benson B, Farber M, Pine D, Ernst M. Altered striatal intrinsic functional connectivity in pediatric anxiety. Neuropsychologia 2016; 85:159-68. [PMID: 27004799 DOI: 10.1016/j.neuropsychologia.2016.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 02/06/2016] [Accepted: 03/18/2016] [Indexed: 01/07/2023]
Abstract
Anxiety disorders are among the most common psychiatric disorders of adolescence. Behavioral and task-based imaging studies implicate altered reward system function, including striatal dysfunction, in adolescent anxiety. However, no study has yet examined alterations of the striatal intrinsic functional connectivity in adolescent anxiety disorders. The current study examines striatal intrinsic functional connectivity (iFC), using six bilateral striatal seeds, among 35 adolescents with anxiety disorders and 36 healthy comparisons. Anxiety is associated with abnormally low iFC within the striatum (e.g., between nucleus accumbens and caudate nucleus), and between the striatum and prefrontal regions, including subgenual anterior cingulate cortex, posterior insula and supplementary motor area. The current findings extend prior behavioral and task-based imaging research, and provide novel data implicating decreased striatal iFC in adolescent anxiety. Alterations of striatal neurocircuitry identified in this study may contribute to the perturbations in the processing of motivational, emotional, interoceptive, and motor information seen in pediatric anxiety disorders. This pattern of the striatal iFC perturbations can guide future research on specific mechanisms underlying anxiety.
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Affiliation(s)
- Julia Dorfman
- All work was conducted at National Institute of Mental Health, 9000 Rockville Pike, Building 15k, Bethesda, MD 20892, USA.
| | - Brenda Benson
- All work was conducted at National Institute of Mental Health, 9000 Rockville Pike, Building 15k, Bethesda, MD 20892, USA.
| | - Madeline Farber
- All work was conducted at National Institute of Mental Health, 9000 Rockville Pike, Building 15k, Bethesda, MD 20892, USA.
| | - Daniel Pine
- All work was conducted at National Institute of Mental Health, 9000 Rockville Pike, Building 15k, Bethesda, MD 20892, USA.
| | - Monique Ernst
- All work was conducted at National Institute of Mental Health, 9000 Rockville Pike, Building 15k, Bethesda, MD 20892, USA.
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Machado S, Arias-Carrión O, Paes F, Vieira RT, Caixeta L, Novaes F, Marinho T, Almada LF, Silva AC, Nardi AE. Repetitive transcranial magnetic stimulation for clinical applications in neurological and psychiatric disorders: an overview. Eurasian J Med 2015; 45:191-206. [PMID: 25610279 DOI: 10.5152/eajm.2013.39] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 07/01/2013] [Indexed: 01/01/2023] Open
Abstract
Neurological and psychiatric disorders are characterized by several disabling symptoms for which effective, mechanism-based treatments remain elusive. Consequently, more advanced non-invasive therapeutic methods are required. A method that may modulate brain activity and be viable for use in clinical practice is repetitive transcranial magnetic stimulation (rTMS). It is a non-invasive procedure whereby a pulsed magnetic field stimulates electrical activity in the brain. Here, we focus on the basic foundation of rTMS, the main stimulation parametters, the factors that influence individual responses to rTMS and the experimental advances of rTMS that may become a viable clinical application to treat neurological and psychiatric disorders. The findings showed that rTMS can improve some symptoms associated with these conditions and might be useful for promoting cortical plasticity in patients with neurological and psychiatric disorders. However, these changes are transient and it is premature to propose these applications as realistic therapeutic options, even though the rTMS technique has been evidenced as a potential modulator of sensorimotor integration and neuroplasticity. Functional imaging of the region of interest could highlight the capacity of rTMS to bring about plastic changes of the cortical circuitry and hint at future novel clinical interventions. Thus, we recommend that further studies clearly determine the role of rTMS in the treatment of these conditions. Finally, we must remember that however exciting the neurobiological mechanisms might be, the clinical usefulness of rTMS will be determined by its ability to provide patients with neurological and psychiatric disorders with safe, long-lasting and substantial improvements in quality of life.
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Affiliation(s)
- Sergio Machado
- Panic and Respiration Laboratory, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ); National Institute for Translational Medicine (INCT-TM), Brazil ; Quiropraxia Program of Faculty of Health Sciences, Central University (UCEN), Santiago, Chile ; Institute of Phylosophy of Federal University of Uberlândia (IFILO/UFU), Brazil ; Physical Activity Neuroscience Laboratory, Physical Activity Sciences Postgraduate Program of Salgado de Oliveira University, Niterói, Brazil
| | - Oscar Arias-Carrión
- Movement Disorders and Transcranial Magnetic Stimulation Unit, Hospital General Dr. Manuel Gea González, México DF, México
| | - Flávia Paes
- Panic and Respiration Laboratory, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ); National Institute for Translational Medicine (INCT-TM), Brazil
| | | | - Leonardo Caixeta
- Faculty of Medicine of Federal University of Goiás, Goiás-GO, Brazil
| | - Felipe Novaes
- Panic and Respiration Laboratory, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ); National Institute for Translational Medicine (INCT-TM), Brazil
| | - Tamires Marinho
- Panic and Respiration Laboratory, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ); National Institute for Translational Medicine (INCT-TM), Brazil
| | | | - Adriana Cardoso Silva
- Panic and Respiration Laboratory, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ); National Institute for Translational Medicine (INCT-TM), Brazil
| | - Antonio Egidio Nardi
- Panic and Respiration Laboratory, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ); National Institute for Translational Medicine (INCT-TM), Brazil
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Li H, Wang J, Li C, Xiao Z. Repetitive transcranial magnetic stimulation (rTMS) for panic disorder in adults. Cochrane Database Syst Rev 2014; 2014:CD009083. [PMID: 25230088 PMCID: PMC6885044 DOI: 10.1002/14651858.cd009083.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Panic disorder (PD) is a common type of anxiety disorder, characterized by unexpected and repeated panic attacks or fear of future panic attacks, or both. Individuals with PD are often resistant to pharmacological or psychological treatments and this can lead to the disorder becoming a chronic and disabling illness. Repetitive transcranial magnetic stimulation (rTMS) can deliver sustained and spatially selective current to suppress or induce cortical excitability, and its therapeutic effect on pathological neuronal activity in people with PD has already been examined in case studies and clinical trials. However, a systematic review is necessary to assess the efficacy and safety of rTMS for PD. OBJECTIVES To assess the effects of repetitive transcranial magnetic stimulation (rTMS) for panic disorder (PD) in adults aged 18 to 65 years, either as a monotherapy or as an augmentation strategy. SEARCH METHODS An electronic search of the Cochrane Depression, Anxiety and Neurosis Review Group Controlled Trials Register (CCDANCTR) was conducted to 19 February 2014. The CCDANCTR includes reports of relevant randomised controlled trials (RCTs) from MEDLINE (1950 to date), EMBASE (1974 to date), PsycINFO (1967 to date) and the Cochrane Central Register of Controlled Trials (CENTRAL) (all years). Additional searches were conducted in Psyndex and the main Chinese medical databases. SELECTION CRITERIA RCTs or quasi-randomised trials evaluating rTMS for PD in people aged between 18 and 65 years, either as a monotherapy or as an augmentation strategy. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data and verified the data by cross-checking. Disagreements were resolved by discussion. For binary data, we calculated fixed-effect model risk ratio (RR) and its 95% confidence interval (CI). For continuous data, we calculated fixed-effect model standardized mean difference (SMD) and its 95% CI. MAIN RESULTS Two RCTs (n = 40) were included in this review. The included trials compared rTMS with sham rTMS; no trials comparing rTMS with active treatments (electroconvulsive therapy (ECT), pharmacotherapy, psychotherapy) met our inclusion criteria. Both included studies used 1 Hz rTMS over the right dorso-lateral prefrontal cortex (DLPFC) for two or four weeks as an augmentation treatment for PD. However, in both studies the data for the primary outcome, panic symptoms as measured by the Panic Disorder Severity Scale (PDSS), were skewed and could not be pooled for a quantitative analysis. For this primary outcome one trial with 25 participants reported a superior effect of rTMS in reducing panic symptoms compared with sham rTMS (t = 3.04, df = 16.57, P = 0.007), but this trial had a 16% dropout rate and so was deemed as having a high risk of attrition bias. The other trial found that all 15 participants exhibited a reduction in panic symptoms but there was no significant difference between rTMS and sham rTMS (Mann Whitney U test, P > 0.05). Regarding the acceptability of rTMS, no significant difference was found between rTMS and sham rTMS in dropout rates or in reports of side effects. The quality of evidence contributing to this review was assessed as very low. Assessments of the risk of bias for the two studies were hampered by the lack of information provided in the reports, especially on methods of sequence generation and whether allocation concealment had been applied. Of the remaining sources of bias, we considered one of the studies to have been at risk of attrition bias. AUTHORS' CONCLUSIONS Only two RCTs of rTMS were available and their sample sizes were small. The available data were insufficient for us to draw any conclusions about the efficacy of rTMS for PD. Further trials with large sample sizes and adequate methodology are needed to confirm the effectiveness of rTMS for PD.
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Affiliation(s)
- Hui Li
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of MedicineShanghai Key Laboratory of Psychotic Disorders600 Wanping Nan RoadShanghaiChina200030
| | - Jijun Wang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of MedicineDepartment of EEG Source ImagingShanghaiShanghaiChina200030
| | - Chunbo Li
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of MedicineShanghai Key Laboratory of Psychotic Disorders600 Wanping Nan RoadShanghaiChina200030
| | - Zeping Xiao
- Shanghai Jiao Tong University School of MedicineDepartment of Psychosomatic Medicine, Shanghai Mental Health Center600 Wan Ping Nan RoadShanghaiChina200030
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Lefaucheur JP, André-Obadia N, Antal A, Ayache SS, Baeken C, Benninger DH, Cantello RM, Cincotta M, de Carvalho M, De Ridder D, Devanne H, Di Lazzaro V, Filipović SR, Hummel FC, Jääskeläinen SK, Kimiskidis VK, Koch G, Langguth B, Nyffeler T, Oliviero A, Padberg F, Poulet E, Rossi S, Rossini PM, Rothwell JC, Schönfeldt-Lecuona C, Siebner HR, Slotema CW, Stagg CJ, Valls-Sole J, Ziemann U, Paulus W, Garcia-Larrea L. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clin Neurophysiol 2014; 125:2150-2206. [PMID: 25034472 DOI: 10.1016/j.clinph.2014.05.021] [Citation(s) in RCA: 1255] [Impact Index Per Article: 125.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/09/2014] [Accepted: 05/13/2014] [Indexed: 12/11/2022]
Abstract
A group of European experts was commissioned to establish guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS) from evidence published up until March 2014, regarding pain, movement disorders, stroke, amyotrophic lateral sclerosis, multiple sclerosis, epilepsy, consciousness disorders, tinnitus, depression, anxiety disorders, obsessive-compulsive disorder, schizophrenia, craving/addiction, and conversion. Despite unavoidable inhomogeneities, there is a sufficient body of evidence to accept with level A (definite efficacy) the analgesic effect of high-frequency (HF) rTMS of the primary motor cortex (M1) contralateral to the pain and the antidepressant effect of HF-rTMS of the left dorsolateral prefrontal cortex (DLPFC). A Level B recommendation (probable efficacy) is proposed for the antidepressant effect of low-frequency (LF) rTMS of the right DLPFC, HF-rTMS of the left DLPFC for the negative symptoms of schizophrenia, and LF-rTMS of contralesional M1 in chronic motor stroke. The effects of rTMS in a number of indications reach level C (possible efficacy), including LF-rTMS of the left temporoparietal cortex in tinnitus and auditory hallucinations. It remains to determine how to optimize rTMS protocols and techniques to give them relevance in routine clinical practice. In addition, professionals carrying out rTMS protocols should undergo rigorous training to ensure the quality of the technical realization, guarantee the proper care of patients, and maximize the chances of success. Under these conditions, the therapeutic use of rTMS should be able to develop in the coming years.
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Affiliation(s)
- Jean-Pascal Lefaucheur
- Department of Physiology, Henri Mondor Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, France; EA 4391, Nerve Excitability and Therapeutic Team, Faculty of Medicine, Paris Est Créteil University, Créteil, France.
| | - Nathalie André-Obadia
- Neurophysiology and Epilepsy Unit, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France; Inserm U 1028, NeuroPain Team, Neuroscience Research Center of Lyon (CRNL), Lyon-1 University, Bron, France
| | - Andrea Antal
- Department of Clinical Neurophysiology, Georg-August University, Göttingen, Germany
| | - Samar S Ayache
- Department of Physiology, Henri Mondor Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, France; EA 4391, Nerve Excitability and Therapeutic Team, Faculty of Medicine, Paris Est Créteil University, Créteil, France
| | - Chris Baeken
- Department of Psychiatry and Medical Psychology, Ghent Experimental Psychiatry (GHEP) Lab, Ghent University, Ghent, Belgium; Department of Psychiatry, University Hospital (UZBrussel), Brussels, Belgium
| | - David H Benninger
- Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Roberto M Cantello
- Department of Translational Medicine, Section of Neurology, University of Piemonte Orientale "A. Avogadro", Novara, Italy
| | | | - Mamede de Carvalho
- Institute of Physiology, Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, Portugal
| | - Dirk De Ridder
- Brai(2)n, Tinnitus Research Initiative Clinic Antwerp, Belgium; Department of Neurosurgery, University Hospital Antwerp, Belgium
| | - Hervé Devanne
- Department of Clinical Neurophysiology, Lille University Hospital, Lille, France; ULCO, Lille-Nord de France University, Lille, France
| | - Vincenzo Di Lazzaro
- Department of Neurosciences, Institute of Neurology, Campus Bio-Medico University, Rome, Italy
| | - Saša R Filipović
- Department of Neurophysiology, Institute for Medical Research, University of Belgrade, Beograd, Serbia
| | - Friedhelm C Hummel
- Brain Imaging and Neurostimulation (BINS) Laboratory, Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Satu K Jääskeläinen
- Department of Clinical Neurophysiology, Turku University Hospital, University of Turku, Turku, Finland
| | - Vasilios K Kimiskidis
- Laboratory of Clinical Neurophysiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Giacomo Koch
- Non-Invasive Brain Stimulation Unit, Neurologia Clinica e Comportamentale, Fondazione Santa Lucia IRCCS, Rome, Italy
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Thomas Nyffeler
- Perception and Eye Movement Laboratory, Department of Neurology, University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Antonio Oliviero
- FENNSI Group, Hospital Nacional de Parapléjicos, SESCAM, Toledo, Spain
| | - Frank Padberg
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - Emmanuel Poulet
- Department of Emergency Psychiatry, CHU Lyon, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; EAM 4615, Lyon-1 University, Bron, France
| | - Simone Rossi
- Brain Investigation & Neuromodulation Lab, Unit of Neurology and Clinical Neurophysiology, Department of Neuroscience, University of Siena, Siena, Italy
| | - Paolo Maria Rossini
- Brain Connectivity Laboratory, IRCCS San Raffaele Pisana, Rome, Italy; Institute of Neurology, Catholic University, Rome, Italy
| | - John C Rothwell
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, London, United Kingdom
| | | | - Hartwig R Siebner
- Department of Neurology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark; Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | | | - Charlotte J Stagg
- Oxford Centre for Functional MRI of the Brain (FMRIB), Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Josep Valls-Sole
- EMG Unit, Neurology Service, Hospital Clinic, Department of Medicine, University of Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Ulf Ziemann
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard Karls University, Tübingen, Germany
| | - Walter Paulus
- Department of Clinical Neurophysiology, Georg-August University, Göttingen, Germany
| | - Luis Garcia-Larrea
- Inserm U 1028, NeuroPain Team, Neuroscience Research Center of Lyon (CRNL), Lyon-1 University, Bron, France; Pain Unit, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France
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11
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Repetitive transcranial magnetic stimulation (rTMS) for obsessive-compulsive disorder (OCD): an exploratory meta-analysis of randomized and sham-controlled trials. J Psychiatr Res 2013; 47:999-1006. [PMID: 23615189 DOI: 10.1016/j.jpsychires.2013.03.022] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 03/06/2013] [Accepted: 03/28/2013] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Randomized and sham-controlled trials (RCTs) on repetitive transcranial magnetic stimulation (rTMS) for treating obsessive-compulsive disorder (OCD) have yielded conflicting results that may be due to limited statistical power among individual studies. We pursued the present systematic review and meta-analysis to assess the efficacy of rTMS for OCD and to generate hypotheses for more robustly powered RCTs. METHOD We searched the literature for RCTs on rTMS for OCD from 1995 through December 2012 using MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, and SCOPUS. We then performed an exploratory random-effects meta-analysis with the main outcome measures as pre-post changes in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores, response to treatment and overall dropout rates at study end. RESULTS Data were obtained from 10 RCTs, totaling 282 subjects with OCD. The pooled Hedges' g for pre-post Y-BOCS scores was 0.59 (z = 2.73, p = 0.006), indicating a significant and medium-sized difference in outcome favoring active rTMS. Furthermore, response rates were 35% and 13% for patients receiving active and sham rTMS, respectively (OR = 3.4, p = 0.002). Sub-group analyses indicated that LF-rTMS and rTMS protocols targeting non-DLPFC regions (i.e., orbitofrontal cortex or supplementary motor area) seem to be the most promising for reducing OCD-related symptoms. No differences on baseline depression scores or dropout rates at study end were observed between active and sham rTMS groups, although OCD severity at baseline was higher in the active group. CONCLUSIONS Our exploratory analyses show that active rTMS seems to be efficacious for treating OCD. Moreover, LF-rTMS and protocols targeting the orbitofrontal cortex or the supplementary motor area seem to be the most promising. Nevertheless, future RCTs on rTMS for OCD should include larger sample sizes and be more homogeneous in terms of demographic/clinical variables as well as stimulation parameters and brain targets.
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Hovington CL, McGirr A, Lepage M, Berlim MT. Repetitive transcranial magnetic stimulation (rTMS) for treating major depression and schizophrenia: a systematic review of recent meta-analyses. Ann Med 2013; 45:308-21. [PMID: 23687987 DOI: 10.3109/07853890.2013.783993] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In recent years, repetitive transcranial magnetic stimulation (rTMS) has been developed for the treatment of major depression (MD) and schizophrenia. Although rTMS has shown some promising findings, the lack of standardization in the methodology employed has resulted in discordant findings. OBJECTIVES The objective of this systematic review was to summarize several meta-analytical studies exploring the efficacy of rTMS in either MD or schizophrenia in order to examine the methodologies that increase the efficacy of rTMS and to provide some recommendations for future studies. METHODS We searched the MEDLINE database for potentially relevant meta-analytic studies on the use of rTMS for treating major depression and schizophrenia published from January 2000 to October 2011. RESULTS Fifteen rTMS meta-analytical studies were reviewed (11 on MD and 5 on schizophrenia). Several variables were reviewed including outcome measures, side-effects of rTMS, site of stimulation, frequency and intensity of stimulation, and number of treatment sessions. CONCLUSIONS Overall, rTMS appears to be an effective and promising therapeutic for both MD and schizophrenia.
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Affiliation(s)
- Cindy L Hovington
- Neuromodulation Program, Douglas Mental Health University Institute and McGill University, Montréal, Québec, Canada
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13
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Nauczyciel C, Drapier D. [Repetitive transcranial magnetic stimulation in the treatment of obsessive-compulsive disorder]. Rev Neurol (Paris) 2012; 168:655-61. [PMID: 22902174 DOI: 10.1016/j.neurol.2012.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 05/25/2012] [Accepted: 05/29/2012] [Indexed: 11/27/2022]
Abstract
Obsessive-compulsive disorder (OCD) is a chronic, often resistant neuropsychiatric disorder leading to severe social impairment. Neurophysiological theories suggest an imbalance between the frontal-striatal circuits involved in goal directed behavior. Repetitive transcranial magnetic stimulation (rTMS) has been suggested as a therapeutic option. Various targets of stimulation have been tested based on neurophysiological theories. The first studies, stimulating the dorsolateral prefrontal cortex, did not show an efficacy but the more recent ones, stimulating the supplementary motor area or the orbitofrontal cortex, seem to be promising. Further studies with larger sample should be conducted in order to propose rTMS as a therapeutic tool for OCD.
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Affiliation(s)
- C Nauczyciel
- Unité de recherche universitaire 425 « Comportement et noyaux gris centraux », université de Rennes 1, service hospitalo-universitaire de Rennes, centre hospitalier Guillaume-Regnier, Rennes cedex, France.
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14
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Abstract
The evidence-based pharmacotherapy of panic disorder continues to evolve. This paper reviews data on first-line pharmacotherapy, evidence for maintenance treatment, and management options for treatment-refractory patients. A Medline search of research on pharmacotherapy was undertaken, and a previous systematic review on the evidence-based pharmacotherapy of panic disorder was updated. Selective serotonin reuptake inhibitors remain a first-line pharmacotherapy of panic disorder, with the serotonin noradrenaline reuptake inhibitor venlafaxine also an acceptable early option. Temporary co-administration of benzodiazepines can be considered. Maintenance treatment reduces relapse rates, but further research to determine optimal duration is needed. For patients not responding to first-line agents several pharmacotherapy options are available, but there is a notable paucity of data on the optimal choice.
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15
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Jaafari N, Rachid F, Rotge JY, Polosan M, El-Hage W, Belin D, Vibert N, Pelissolo A. Safety and efficacy of repetitive transcranial magnetic stimulation in the treatment of obsessive-compulsive disorder: a review. World J Biol Psychiatry 2012; 13:164-77. [PMID: 21623668 DOI: 10.3109/15622975.2011.575177] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Obsessive-compulsive disorder (OCD) is a chronic, often severe, neuropsychiatric disorder leading to a dramatic impairment in interpersonal and occupational functions. rTMS has been tried out in several studies in patients with OCD with different characteristics. In this paper, we review the safety and efficacy of rTMS in the treatment of mostly severe resistant OCD. METHODS A review of the English literature from 1966 to 2010 pertaining to rTMS in the treatment of OCD was conducted using MEDLINE by selectively entering the search terms "transcranial magnetic stimulation", "repetitive transcranial magnetic stimulation", "obsessive-compulsive disorder" and "OCD". Twelve studies including open and randomized, sham-controlled trials were included in this review. RESULTS Although available data about the use of rTMS in OCD treatment are quite heterogeneous in terms of sample size, study design, stimulus parameters used and stimulation areas targeted, promising findings regarding rTMS efficacy appeared for two structures based on recent controlled studies: the supplementary motor area and the orbitofrontal cortex. On the other hand, rTMS of the dorsolateral prefrontal cortex is not significantly effective when compared to sham rTMS. CONCLUSIONS Three target areas have already been selected of which the supplementary motor area in particular and the orbitofrontal cortex seem to be the most promising in terms of potential efficacy and could more accurately be targeted with the help of neuronavigational techniques. Larger randomized controlled trials should be conducted in order to better clarify the therapeutic role of rTMS in OCD.
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Affiliation(s)
- Nematollah Jaafari
- Unité de recherche clinique intersectorielle en psychiatrie, Centre Hospitalier Henri Laborit , INSERM CIC-P 0802, CHU et faculté de médecine de Poitiers, Poitiers, France.
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16
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Lefaucheur JP, André-Obadia N, Poulet E, Devanne H, Haffen E, Londero A, Cretin B, Leroi AM, Radtchenko A, Saba G, Thai-Van H, Litré CF, Vercueil L, Bouhassira D, Ayache SS, Farhat WH, Zouari HG, Mylius V, Nicolier M, Garcia-Larrea L. [French guidelines on the use of repetitive transcranial magnetic stimulation (rTMS): safety and therapeutic indications]. Neurophysiol Clin 2011; 41:221-95. [PMID: 22153574 DOI: 10.1016/j.neucli.2011.10.062] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 10/18/2011] [Indexed: 12/31/2022] Open
Abstract
During the past decade, a large amount of work on transcranial magnetic stimulation (TMS) has been performed, including the development of new paradigms of stimulation, the integration of imaging data, and the coupling of TMS techniques with electroencephalography or neuroimaging. These accumulating data being difficult to synthesize, several French scientific societies commissioned a group of experts to conduct a comprehensive review of the literature on TMS. This text contains all the consensual findings of the expert group on the mechanisms of action, safety rules and indications of TMS, including repetitive TMS (rTMS). TMS sessions have been conducted in thousands of healthy subjects or patients with various neurological or psychiatric diseases, allowing a better assessment of risks associated with this technique. The number of reported side effects is extremely low, the most serious complication being the occurrence of seizures. In most reported seizures, the stimulation parameters did not follow the previously published recommendations (Wassermann, 1998) [430] and rTMS was associated to medication that could lower the seizure threshold. Recommendations on the safe use of TMS / rTMS were recently updated (Rossi et al., 2009) [348], establishing new limits for stimulation parameters and fixing the contraindications. The recommendations we propose regarding safety are largely based on this previous report with some modifications. By contrast, the issue of therapeutic indications of rTMS has never been addressed before, the present work being the first attempt of a synthesis and expert consensus on this topic. The use of TMS/rTMS is discussed in the context of chronic pain, movement disorders, stroke, epilepsy, tinnitus and psychiatric disorders. There is already a sufficient level of evidence of published data to retain a therapeutic indication of rTMS in clinical practice (grade A) in chronic neuropathic pain, major depressive episodes, and auditory hallucinations. The number of therapeutic indications of rTMS is expected to increase in coming years, in parallel with the optimisation of stimulation parameters.
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Affiliation(s)
- J-P Lefaucheur
- EA 4391, faculté de médecine, université Paris-Est-Créteil, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
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Machado S, Paes F, Velasques B, Teixeira S, Piedade R, Ribeiro P, Nardi AE, Arias-Carrión O. Is rTMS an effective therapeutic strategy that can be used to treat anxiety disorders? Neuropharmacology 2011; 62:125-34. [PMID: 21807002 DOI: 10.1016/j.neuropharm.2011.07.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Revised: 07/16/2011] [Accepted: 07/18/2011] [Indexed: 11/30/2022]
Abstract
Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive procedure whereby a pulsed magnetic field stimulates electrical activity in the brain. Anxiety disorders are the most common of all mental health problems for which effective, mechanism-based treatments remain elusive. Consequently, more advanced non-invasive therapeutic methods are required. A possible method to modulate brain activity and potentially viable for use in clinical practice is rTMS. Here, we focus on the main findings of rTMS from animal models of anxiety and the experimental advances of rTMS that may become a viable clinical application to treat anxiety disorders, one of the most common causes of disability in the workplace in the world. Key advances in combining rTMS with neuroimaging technology may aid such future developments. This article is part of a Special Issue entitled 'Anxiety and Depression'.
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Affiliation(s)
- Sergio Machado
- Panic & Respiration Laboratory, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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