Response and Remission Rates Following High-Frequency vs. Low-Frequency Repetitive Transcranial Magnetic Stimulation (rTMS) Over Right DLPFC for Treating Major Depressive Disorder (MDD): A Meta-Analysis of Randomized, Double-Blind Trials

Neural correlates of approach-avoidance behavior in healthy subjects: Effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) over the right dorsolateral prefrontal cortex

The dorsolateral prefrontal cortex (dlPFC) is implicated in top-down regulation of emotion, but the detailed network mechanisms require further elucidation. To investigate network-level functions of the dlPFC in emotion regulation, this study measured changes in task-based activation, resting-state and task-based functional connectivity (FC) patterns following suppression of dlPFC excitability by 1-Hz repetitive transcranial magnetic stimulation (rTMS). In a sham-controlled within-subject design, 1-Hz active or sham rTMS was applied to the right dlPFC of 19 healthy volunteers during two separate counterbalanced sessions. Following active and sham rTMS, functional magnetic resonance imaging (fMRI) was conducted in the resting state (rs-fMRI) and during approach-avoidance task responses to pictures with positive and negative emotional content (task-based fMRI). Activation and generalized psychophysiological interaction analyses were performed on task-based fMRI, and seed-based FC analysis was applied to rs-fMRI data. Task-based fMRI revealed greater and more lateralized activation in the right hemisphere during negative picture responses compared to positive picture responses. After active rTMS, greater activation was observed in the left middle prefrontal cortex compared to sham rTMS. Further, rTMS reduced response times and error rates in approach to positive pictures compared to negative pictures. Significant FC changes due to rTMS were observed predominantly in the frontoparietal network (FPN) and visual network (VN) during the task, and in the default mode network (DMN) and VN at rest. Suppression of right dlPFC activity by 1-Hz rTMS alters large-scale neural networks and modulates emotion, supporting potential applications for the treatment of mood disorders.

Modulation of Alcohol Use Disorder by Brain Stimulation

Currently available therapeutic modalities for alcohol use disorder (AUD) produce limited effect sizes or long-term compliance. Recent methods that were developed to modulate brain activity represent potential novel treatment options. Various methods of brain stimulation, when applied repeatedly, can induce long-term neurobiological, behavioral, and cognitive modifications. Recent studies in alcoholic subjects indicate the potential of brain stimulation methods to reduce alcohol craving, consumption, and relapse. Specifically, deep brain stimulation (DBS) of the nucleus accumbens or non-surgical stimulation of the dorsolateral prefrontal cortex (PFC) or medial PFC and anterior cingulate cortex using transcranial magnetic stimulation (TMS) has shown clinical benefit. However, further preclinical and clinical research is needed to establish understanding of mechanisms and the treatment protocols of brain stimulation for AUD. While efforts to design comparable apparatus in rodents continue, preclinical studies can be used to examine targets for DBS protocols, or to administer temporal patterns of pulsus similar to those used for TMS, to more superficial targets through implanted electrodes. The clinical field will benefit from studies with larger sample sizes, higher numbers of stimulation sessions, maintenance sessions, and long follow-up periods. The effect of symptoms provocation before and during stimulation should be further studied. Larger studies may have the power to explore predictive factors for the clinical outcome and thereby to optimize patient selection and eventually even develop personalization of the stimulation parameters.

Breakthroughs and challenges for generating brain network-based biomarkers of treatment response in depression

Treatment outcomes widely vary for individuals diagnosed with major depressive disorder, implicating a need for deeper understanding of the biological mechanisms conferring a greater likelihood of response to a particular treatment. Our improved understanding of intrinsic brain networks underlying depression psychopathology via magnetic resonance imaging and other neuroimaging modalities has helped reveal novel and potentially clinically meaningful biological markers of response. And while we have made considerable progress in identifying such biomarkers over the last decade, particularly with larger, multisite trials, there are significant methodological and practical obstacles that need to be overcome to translate these markers into the clinic. The aim of this review is to review current literature on brain network structural and functional biomarkers of treatment response or selection in depression, with a specific focus on recent large, multisite trials reporting predictive accuracy of candidate biomarkers. Regarding pharmaco- and psychotherapy, we discuss candidate biomarkers, reporting that while we have identified candidate biomarkers of response to a single intervention, we need more trials that distinguish biomarkers between first-line treatments. Further, we discuss the ways prognostic neuroimaging may help to improve treatment outcomes to neuromodulation-based therapies, such as transcranial magnetic stimulation and deep brain stimulation. Lastly, we highlight obstacles and technical developments that may help to address the knowledge gaps in this area of research. Ultimately, integrating neuroimaging-derived biomarkers into clinical practice holds promise for enhancing treatment outcomes and advancing precision psychiatry strategies for depression management. By elucidating the neural predictors of treatment response and selection, we can move towards more individualized and effective depression interventions, ultimately improving patient outcomes and quality of life.

Effect of neuronavigated repetitive Transcranial Magnetic Stimulation on pain, cognition and cortical excitability in fibromyalgia syndrome

BACKGROUND

Fibromyalgia syndrome is a widespread chronic pain condition identified by body-wide pain, fatigue, cognitive fogginess, and sleep issues. In the past decade, repetitive transcranial magnetic stimulation has emerged as a potential management tool.. In the present study, we enquired whether repetitive transcranial magnetic stimulation could modify pain, corticomotor excitability, cognition, and sleep.

METHODS

Study is a randomized, sham-controlled, double-blind, clinical trial; wherein after randomizing thirty-four fibromyalgia patients into active or sham therapy (n = 17 each), each participant received repetitive transcranial magnetic stimulation therapy. In active therapy was given at 1 Hz for 20 sessions were delivered on dorsolateral prefrontal cortex (1200 pulses, 150 pulses per train for 8 trains); while in sham therapy coil was placed at right angle to the scalp with same frequency. Functional magnetic resonance imaging was used to identify the therapeutic site. Pain intensity, corticomotor excitability, cognition, and sleep were examined before and after therapy.

RESULTS

Baseline demographic and clinical parameters for both active and sham groups were comparable. In comparison to sham, active repetitive transcranial magnetic stimulation showed significant difference in pain intensity (P < 0.001, effect size = 0.29, large effect) after intervention. Other parameters of pain perception, cognition, and sleep quality also showed a significant improvement after the therapy in active therapy group only, as compared to sham.

CONCLUSIONS

Findings suggest that repetitive transcranial magnetic stimulation intervention is effective in managing pain alongside cognition and sleep disturbances in patients of fibromyalgia. It may prove to be an important tool in relieving fibromyalgia-associated morbidity.

Neurotransmitter system gene variants as biomarkers for the therapeutic efficacy of rTMS and SSRIs in obsessive-compulsive disorder

Purpose

This study aims to examine the potential influence of RS4680 (COMT), RS16965628 (SLC6A4), and RS1019385 (GRIN2B) polymorphisms on the therapeutic response to repetitive transcranial magnetic stimulation (rTMS) and selective serotonin reuptake inhibitors (SSRIs) in individuals with obsessive-compulsive disorder (OCD).

Patients and methods

Thirty-six untreated outpatients diagnosed with OCD were recruited and allocated to active or sham rTMS groups for two weeks. The mean age of the participants was 31.61, with 17 males (47.22%) and 19 females (52.78%). Peripheral blood samples (5 mL) were collected from each participant using ethylenediaminetetraacetic acid (EDTA) vacuum tubes for genotyping purposes, clinical evaluation was taken place at baseline and second week.

Results

The A allele of RS4680, C allele of RS16965628, and GG allele of RS1019385 were identified as potential bio-markers for predicting treatment response to OCD treatments (rTMS & SSRIs).

Conclusion

Those genes may serve as bio-markers for the combined treatment of rTMS and SSRIs in OCD. The finding hold promise for further research and the potential implementation of precision treatment of OCD.

Clinical trial registration

https://www.chictr.org.cn, identifier ChiCTR1900023641.

Resting-state EEG connectivity recorded before and after rTMS treatment in patients with treatment-resistant depression

Repetitive transcranial magnetic stimulation (rTMS) has shown efficacy and tolerability in Major Depressive Disorder (MDD). However, the underlying mechanisms of its antidepressant effects remain unclear. This open-label study investigated electroencephalography (EEG) functional connectivity markers associated with response and the antidepressant effects of rTMS. Resting-state EEG data were collected from 28 participants with MDD before and after a four-week rTMS course. Source-space functional connectivity between 38 cortical regions was compared using an orthogonalised amplitude approach. Depressive symptoms significantly improved following rTMS, with 43 % of participants classified as responders. While the study's functional connectivity findings did not withstand multiple comparison corrections, exploratory analyses suggest an association between theta band connectivity and rTMS treatment mechanisms. Fronto-parietal theta connectivity increased after treatment but did not correlate with antidepressant response. Notably, low baseline theta connectivity was associated with greater response. However, due to the exploratory nature and small sample size, further replication is needed. The findings provide preliminary evidence that EEG functional connectivity, particularly within the theta band, may reflect the mechanisms by which rTMS exerts its therapeutic effects.

Abnormal stability of spontaneous neuronal activity as a predictor of diagnosis conversion from major depressive disorder to bipolar disorder

OBJECTIVE

Bipolar disorder (BD) is often misdiagnosed as major depressive disorder (MDD) in the early stage, which may lead to inappropriate treatment. This study aimed to characterize the alterations of spontaneous neuronal activity in patients with depressive episodes whose diagnosis transferred from MDD to BD.

METHODS

532 patients with MDD and 132 healthy controls (HCs) were recruited over 10 years. During the follow-up period, 75 participants with MDD transferred to BD (tBD), and 157 participants remained with the diagnosis of unipolar depression (UD). After excluding participants with poor image quality and excessive head movement, 68 participants with the diagnosis of tBD, 150 participants with the diagnosis of UD, and 130 HCs were finally included in the analysis. The dynamic amplitude of low-frequency fluctuations (dALFF) of spontaneous neuronal activity was evaluated in tBD, UD and HC using functional magnetic resonance imaging at study inclusion. Receiver operating characteristic (ROC) analysis was performed to evaluate sensitivity and specificity of the conversion prediction from MDD to BD based on dALFF.

RESULTS

Compared to HC, tBD exhibited elevated dALFF at left premotor cortex (PMC_L), right lateral temporal cortex (LTC_R) and right early auditory cortex (EAC_R), and UD showed reduced dALFF at PMC_L, left paracentral lobule (PCL_L), bilateral medial prefrontal cortex (mPFC), right orbital frontal cortex (OFC_R), right dorsolateral prefrontal cortex (DLPFC_R), right posterior cingulate cortex (PCC_R) and elevated dALFF at LTC_R. Furthermore, tBD exhibited elevated dALFF at PMC_L, PCL_L, bilateral mPFC, bilateral OFC, DLPFC_R, PCC_R and LTC_R than UD. In addition, ROC analysis based on dALFF in differential areas obtained an area under the curve (AUC) of 72.7%.

CONCLUSIONS

The study demonstrated the temporal dynamic abnormalities of tBD and UD in the critical regions of the somatomotor network (SMN), default mode network (DMN), and central executive network (CEN). The differential abnormal patterns of temporal dynamics between the two diseases have the potential to predict the diagnosis transition from MDD to BD.

Theta burst stimulation add on to dialectical behavioral therapy in borderline-personality-disorder: methods and design of a randomized, single-blind, placebo-controlled pilot trial

Specialized psychotherapeutic treatments like dialectical behavioral therapy (DBT) are recommended as first treatment for borderline personality disorder (BPD). In recent years, studies have emerged that focus on repetitive transcranial magnetic stimulation (rTMS) in BPD. Both have independently demonstrated efficacy in the treatment of BPD. Intermitted theta burst stimulation (iTBS), a modified design of rTMS, is thought to increase the excitability of neurons and could be a supplement to psychotherapy in addition to being a standalone treatment. However, no studies to date have investigated the combination of DBT and rTMS/iTBS. This study protocol describes the methods and design of a randomized, single-blinded, sham-controlled clinical pilot study in which BPD patients will be randomly assigned to either iTBS or sham during four consecutive weeks (20 sessions in total) in addition to standardized DBT treatment. The stimulation will focus on the unilateral stimulation of the left dorsolateral prefrontal cortex (DLPFC), which plays an important role in the control of impulsivity and risk-taking. Primary outcome is the difference in borderline symptomatology, while secondary target criteria are depressive symptoms, general functional level, impulsivity and self-compassion. Statistical analysis of therapy response will be conducted by Mixed Model Repeated Measurement using a 2 × 2-factorial between-subjects design with the between-subject factor stimulation (TMS vs. Sham) and the within-subject factor time (T0 vs. T1). Furthermore, structural magnetic resonance imaging (MRI) will be conducted and analyzed. The study will provide evidence and insight on whether iTBS has an enhancing effect as add-on to DBT in BPD.Trial registration: drks.de (DRKS00020413) registered 13/01/2020.

Non-linear processing and reinforcement learning to predict rTMS treatment response in depression

BACKGROUND

Forecasting the efficacy of repetitive transcranial magnetic stimulation (rTMS) therapy can lead to substantial time and cost savings by preventing futile treatments. To achieve this objective, we've formulated a machine learning approach aimed at categorizing patients with major depressive disorder (MDD) into two groups: individuals who respond (R) positively to rTMS treatment and those who do not respond (NR).

METHODS

Preceding the commencement of treatment, we obtained resting-state EEG data from 106 patients diagnosed with MDD, employing 32 electrodes for data collection. These patients then underwent a 7-week course of rTMS therapy, and 54 of them exhibited positive responses to the treatment. Employing Independent Component Analysis (ICA) on the EEG data, we successfully pinpointed relevant brain sources that could potentially serve as markers of neural activity within the dorsolateral prefrontal cortex (DLPFC). These identified sources were further scrutinized to estimate the sources of activity within the sensor domain. Then, we integrated supplementary physiological data and implemented specific criteria to yield more realistic estimations when compared to conventional EEG analysis. In the end, we selected components corresponding to the DLPFC region within the sensor domain. Features were derived from the time-series data of these relevant independent components. To identify the most significant features, we used Reinforcement Learning (RL). In categorizing patients into two groups - R and NR to rTMS treatment - we utilized three distinct classification algorithms including K-Nearest Neighbor (KNN), Support Vector Machine (SVM), and Multilayer Perceptron (MLP). We assessed the performance of these classifiers through a ten-fold cross-validation method. Additionally, we conducted a statistical test to evaluate the discriminative capacity of these features between responders and non-responders, opening the door for further exploration in this field.

RESULTS

We identified EEG features that can anticipate the response to rTMS treatment. The most robust discriminators included EEG beta power, the sum of bispectrum diagonal elements in the delta and beta frequency bands. When these features were combined into a single vector, the classification of responders and non-responders achieved impressive performance, with an accuracy of 95.28 %, specificity at 94.23 %, sensitivity reaching 96.29 %, and precision standing at 94.54 %, all achieved using SVM.

CONCLUSIONS

The results of this study suggest that the proposed approach, utilizing power, non-linear, and bispectral features extracted from relevant independent component time-series, has the capability to forecast the treatment outcome of rTMS for MDD patients based solely on a single pre-treatment EEG recording session. The achieved findings demonstrate the superior performance of our method compared to previous techniques.

Repetitive Transcranial Magnetic Stimulation With and Without Text4Support for the Treatment of Resistant Depression: Protocol for a Patient-Centered Multicenter Randomized Controlled Pilot Trial

BACKGROUND

Treatment-resistant depression (TRD) is the inability of a patient with major depressive disorder (MDD) to accomplish or achieve remission after an adequate trial of antidepressant treatments. Several combinations and augmentation treatment strategies for TRD exist, including the use of repetitive transcranial magnetic stimulation (rTMS), and new therapeutic options are being introduced. Text4Support, a text message-based form of cognitive behavioral therapy that allows patients with MDD to receive daily supportive text messages for correcting or altering negative thought patterns through positive reinforcement, may be a useful augmentation treatment strategy for patients with TRD. It is however currently unknown if adding the Text4Support intervention will enhance the response of patients with TRD to rTMS treatment.

OBJECTIVE

This study aims to assess the initial comparative clinical effectiveness of rTMS with and without the Text4Support program as an innovative patient-centered intervention for the management of patients diagnosed with TRD.

METHODS

This study is a multicenter, prospective, parallel-design, 2-arm, rater-blinded randomized controlled pilot trial. The recruitment process is scheduled to last 12 months. It will involve active treatment for 6 weeks, observation, and a follow-up period of 6 months for participants in the study arms. In total, 200 participants diagnosed with TRD at rTMS care clinics in Edmonton, Alberta, and rTMS clinics in Halifax, Nova Scotia will be randomized to 1 of 2 treatment arms (rTMS sessions alone or rTMS sessions plus Text4Support intervention). Participants in each group will be made to complete evaluation measures at baseline, and 1, 3, and 6 months. The primary outcome measure will be the mean change in the scores of the Patient Health Questionnaire-9 (PHQ-9). The secondary outcome measures will involve the scores of the 7-item Generalized Anxiety Disorders Scale (GAD-7), Columbia-Suicide Severity Rating Scale (CSSRS), and World Health Organization-Five Well-Being Index (WHO-5). Patient data will be analyzed with descriptive statistics, repeated measures, and correlational analyses. Qualitative data will be analyzed using the thematic analysis framework.

RESULTS

The results of the study are expected to be available 18 months from the start of recruitment. We hypothesize that participants enrolled in the rTMS plus Text4Support intervention treatment arm of the study will achieve superior outcomes compared with the outcomes of participants enrolled in the rTMS alone arm.

CONCLUSIONS

The application of the combination of rTMS and Text4Support has not been investigated previously. Therefore, we hope that this study will provide a concrete base of data to evaluate the practical application and efficacy of using the novel combination of these 2 treatment modalities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46830.

Comparing the effectiveness of CBT and low-frequency rTMS in reducing symptom severity and depression and improving working memory in adults with OCD: a clinical trial

OBJECTIVE

This study aims to compare the effectiveness of cognitive-behavioral therapy (CBT) and low-frequency (LF) repetitive transcranial magnetic stimulation (rTMS) in reducing symptom severity and depression and improving working memory in adults with obsessive-compulsive disorder (OCD).

METHODS

This is a randomized clinical trial conducted on 24 adults with OCD, randomly assigned into two groups of CBT (n = 12, received CBT with exposure and response prevention (ERP) individually at 20 sessions) and rTMS (n = 12, received LF (1-Hz) rTMS over the right dorsolateral prefrontal cortex (DLPFC) at 10 sessions). They completed the Yale-Brown Obsessive Compulsive Scale, the Hamilton Depression Rating Scale, and two N-Back tasks before, immediately, and 1 month after interventions.

RESULTS

Results showed a significant difference between the two methods in reducing the severity of OCD symptoms (p < 0.05) and depression (p = 0.002) immediately after interventions where the CBT with ERP was more effective, but no significant difference was found in terms of working memory (p > 0.05). No significant difference was found between groups in any study variables 1 month after interventions.

CONCLUSION

Individual CBT with ERP is superior to LF rTMS for reducing the severity of symptoms and depression in OCD patients. However, there is no difference between them in improving working memory.

Prefrontal hypoactivation induced via social stress is more strongly associated with state rumination than depressive symptomatology

Previous studies have consistently shown a pattern of prefrontal hypoactivation in depressed patients (DP); however, it remains unclear whether this neural correlate is a consequence or concomitant feature of depression and/or whether ruminative thinking might be underlying. Using a sample comprising 65 healthy controls (HC) and 77 DP, we investigated the behavioral and neural correlates in response to stress and their association with depressive symptomatology, trait and state rumination. Fitting repeated-measurement MANOVAs including 21 fNIRS-channels covering the bilateral Inferior Frontal Gyrus (IFG), Dorsolateral Prefrontal Cortex (DLPFC) and Somatosensory Association Cortex (SAC), we investigated the predictive value of diagnostic group (HC vs. DP) and state rumination. In DP, we observed significantly lower increases in cortical oxygenation under stress in channels of the right IFG and bilateral DLPFC. Participants reporting lower state rumination and no increases in state rumination under stress showed higher increases in cortical oxygenation compared to the other groups and in more channels compared to the analysis on diagnostic group. Re-running our fNIRS-analysis while correcting for performance resulted in time-dependent changes dependent on group (DP vs. HC) no longer yielding significance, however for the differentiation of state rumination groups.

Pattern of Compliance and Efficacy of Repetitive Transcranial Magnetic Stimulation Protocol for Treating Major Depressive Disorder Among Treatment Participants and Completers: A Report From Iran

Introduction

Since the introduction of the Food and Drug Administration (FDA)-approved repetitive transcranial magnetic stimulation (rTMS) intervention in 2008, a breakthrough has been made in treating major depressive disorder (MDD). However, many sessions of treatment and its cost make it inconvenient for those who seek treatment, especially in large cities as well as in developing countries.

Methods

A total of 22 patients (out of initial 24 referrals) who met diagnostic and statistical manual of mental disorders, 4th edition (DSM IV) criteria for MDD were enrolled in the study. All subjects had to fail at least one prior treatment for depression. The patients received the FDA-approved protocol of high-frequency (10 Hz) rTMS over the left dorsolateral prefrontal cortex.

Results

Seventeen out of twenty-two cases showed significant improvements after two weeks of treatment. Only six patients continued their treatments for the next two to four weeks.

Conclusion

We have replicated other studies showing that the use of rTMS is effective for many patients with MDD without major side effects and their improvements are measurable mostly after two weeks. Our data highlight the importance of the application of more convenient protocols that require fewer sessions on fewer days to help with compliance and outcome, particularly in large populated cities and countries, such as Iran going through economic hardship.

Highlights

Repetitive transcranial magnetic stimulation (rTMS) is effective for treating major depresion.Improvemens are measurable after 2 weeks of treating with rTMS.Compliance is a major factorto for completing rTMS protocols.

Plain Language Summary

Major depression is one of the most common psychiatric disorders leading to debilitating course causing significant burden for the society. Many cases with major depression are resistent to treatment as they try multiple interventions with no success. This condition is also called refractory depression. rTMS is a novel intervention introduced first almost two decades ago to treat refractory depression among some other psychiatric disorders. In this intervention pulses generated by magnetic stimulation over the brain leads to improvement is depression. As this treatment is safe with no pain and discomfort there have been much interest in the field to use it more frequently. rTMS is usually done over 15-30 sessions with its maximum effects appearing within the first two weeks of treatment. The number of sessions is a potential factor contributing to poor compliance in some cases especially those living in large metropolitan areas. In this paper we explored compliance and effect of treatment within the first two weeks among a group of patients in a private outpatient clinic of a large metropolitan area.

Repetitive transcranial magnetic stimulation and fluoxetine reverse depressive-like behavior but with differential effects on Olig2-positive cells in chronically stressed mice

Depression is a mood disorder coursing with several behavioral, cellular, and neurochemical alterations. The negative impact of chronic stress may precipitate this neuropsychiatric disorder. Interestingly, downregulation of oligodendrocyte-related genes, abnormal myelin structure, and reduced numbers and density of oligodendrocytes in the limbic system have been identified in patients diagnosed with depression, but also in rodents exposed to chronic mild stress (CMS). Several reports have emphasized the importance of pharmacological or stimulation-related strategies in influencing oligodendrocytes in the hippocampal neurogenic niche. Repetitive transcranial magnetic stimulation (rTMS) has gained attention as an intervention to revert depression. Here, we hypothesized that 5 Hz (Hz) of rTMS or Fluoxetine (Flx) would revert depressive-like behaviors by influencing oligodendrocytes and revert neurogenic alterations caused by CMS in female Swiss Webster mice. Our results showed that 5 Hz rTMS or Flx revert depressive-like behavior. Only rTMS influenced oligodendrocytes by increasing the number of Olig2-positive cells in the hilus of the dentate gyrus and the prefrontal cortex. However, both strategies exerted effects on some events of the hippocampal neurogenic processes, such as cell proliferation (Ki67-positive cells), survival (CldU-positive cells), and intermediate stages (doublecortin-positive cells) along the dorsal-ventral axis of this region. Interestingly, the combination of rTMS-Flx exerted antidepressant-like effects, but the increased number of Olig2-positive cells observed in mice treated only with rTMS was canceled. However, rTMS-Flx exerted a synergistic effect by increasing the number of Ki67-positive cells. It also increased the number of CldU- and doublecortin-positive cells in the dentate gyrus. Our results demonstrate that 5 Hz rTMS has beneficial effects, as it reverted depressive-like behavior by increasing the number of Olig2-positive cells and reverting the decrement in hippocampal neurogenesis in CMS-exposed mice. Nevertheless, the effects of rTMS on other glial cells require further investigation.

Real world transcranial magnetic stimulation for major depression: A multisite, naturalistic, retrospective study

BACKGROUND

In 2008, the U.S. FDA approved rTMS as a treatment against medication-resistant depression. However, real-world rTMS outcomes remain understudied. This study investigates how rTMS for depression is delivered in routine clinical practice in France, and measures its effectiveness as well as its moderators.

METHODS

Five centers provided retrospective data on patients who were treated with rTMS for treatment-resistant depression from January 2015 to December 2020. Patients were assessed twice using a hetero-questionnaire, with baseline and immediate post-treatment assessments. We conducted univariate analyses to study which factors were significantly associated with rTMS effectiveness. We then included age, gender, and significant factors in a multivariate model.

RESULTS

We collected data from 435 patients with a mean age of 51.27 (14.91): 66 % were female, and 26 % suffered from bipolar depression. Stimulation was delivered using four different stimulation parameters: 1 Hz (7 % of the individuals), 10 Hz (43 %), 20 Hz (12 %), and 50 Hz (intermittent Theta Burst Stimulation, iTBS) (38 %). The mean improvement of depressive symptoms was 33 % (p < 0.001, effect-size: 0.79). Response and remission rates were of 31 % and 22.8 %, respectively. In the multivariate analysis, improvement in depressive symptoms was associated with higher baseline symptoms.

CONCLUSION

This is one of the largest studies that investigates, with careful clinician-rated scales by trained psychiatrists, the effect of rTMS in naturalistic settings. Repetitive TMS appears to be effective in routine clinical practice, although its efficacy could be improved by analyzing predictors of response, as well as personalized targeting of specific brain areas.

Machine learning approaches and non-linear processing of extracted components in frontal region to predict rTMS treatment response in major depressive disorder

Predicting the therapeutic result of repetitive transcranial magnetic stimulation (rTMS) treatment could save time and costs as ineffective treatment can be avoided. To this end, we presented a machine-learning-based strategy for classifying patients with major depression disorder (MDD) into responders (R) and nonresponders (NR) to rTMS treatment. Resting state EEG data were recorded using 32 electrodes from 88 MDD patients before treatment. Then, patients underwent 7 weeks of rTMS, and 46 of them responded to treatment. By applying Independent Component Analysis (ICA) on EEG, we identified the relevant brain sources as possible indicators of neural activity in the dorsolateral prefrontal cortex (DLPFC). This was served through estimating the generators of activity in the sensor domain. Subsequently, we added physiological information and placed certain terms and conditions to offer a far more realistic estimation than the classic EEG. Ultimately, those components mapped in accordance with the region of the DLPFC in the sensor domain were chosen. Features extracted from the relevant ICs time series included permutation entropy (PE), fractal dimension (FD), Lempel-Ziv Complexity (LZC), power spectral density, correlation dimension (CD), features based on bispectrum, frontal and prefrontal cordance, and a combination of them. The most relevant features were selected by a Genetic Algorithm (GA). For classifying two groups of R and NR, K-Nearest Neighbor (KNN), Support Vector Machine (SVM), and Multilayer Perceptron (MLP) were applied to predict rTMS treatment response. To evaluate the performance of classifiers, a 10-fold cross-validation method was employed. A statistical test was used to assess the capability of features in differentiating R and NR for further research. EEG characteristics that can predict rTMS treatment response were discovered. The strongest discriminative indicators were EEG beta power, the sum of bispectrum diagonal elements in delta and beta bands, and CD. The Combined feature vector classified R and NR with a high performance of 94.31% accuracy, 92.85% specificity, 95.65% sensitivity, and 92.85% precision using SVM. This result indicates that our proposed method with power and nonlinear and bispectral features from relevant ICs time-series can predict the treatment outcome of rTMS for MDD patients only by one session pretreatment EEG recording. The obtained results show that the proposed method outperforms previous methods.

An effective brain connectivity technique to predict repetitive transcranial magnetic stimulation outcome for major depressive disorder patients using EEG signals

One of the most effective treatments for drug-resistant Major depressive disorder (MDD) patients is repetitive transcranial magnetic stimulation (rTMS). To improve treatment efficacy and reduce health care costs, it is necessary to predict the treatment response. In this study, we intend to predict the rTMS treatment response in MDD patients from electroencephalogram (EEG) signals before starting the treatment using machine learning approaches. Effective brain connectivity of 19-channel EEG data of MDD patients was calculated by the direct directed transfer function (dDTF) method. Then, using three feature selection methods, the best features were selected and patients were classified as responders or non-responders to rTMS treatment by using the support vector machine (SVM). Results on the 34 MDD patients indicated that the Fp2 region in the delta and theta frequency bands has a significant difference between the two groups and can be used as a significant brain biomarker to assess the rTMS treatment response. Also, the highest accuracy (89.6%) using the SVM classifier for the best features of the dDTF method based on the area under the receiver operating characteristic curve (AUC-ROC) criteria was obtained by combining the delta and theta frequency bands. Consequently, the proposed method can accurately detect the rTMS treatment response in MDD patients before starting treatment on the EEG signal to avoid financial and time costs to patients and medical centers.

Low-Frequency Repetitive Transcranial Magnetic Stimulation for Chronic Tension-Type Headache: A Randomized Controlled Study

BACKGROUND

Nearly 1-3% of the population is affected by chronic tension-type headaches (CTTH). However, it is still difficult to treat owing to the lack of knowledge of the disease's pathophysiology. Available literature suggests a role for pericranial muscle activity and abnormal modulation of central pain. Repetitive transcranial magnetic stimulation (rTMS) therapy done at the dorsolateral prefrontal cortex (DLPFC) can help modulate pericranial muscle overactivity and central pain modulation in subjects with CTTH.

AIM

This randomized controlled study aimed to assess the effect of rTMS used in the low-frequency dorsolateral prefrontal cortex on pain and muscle activity in subjects with a chronic tension-type headache.

MATERIALS AND METHODS

The present randomized controlled clinical study was commenced in a health care center on 20 subjects with chronic tension-type headaches who were given either sham or low-frequency repetitive transcranial magnetic stimulation at the right dorsolateral prefrontal cortex. The therapy effect was evaluated statistically using Welch's corrected t-test.

RESULTS

The study results depicted that daily use of rTMS therapy for two weeks led to a considerable reduction in the intensity of the pain, the activity of pericranial muscles, and headache impact, along with an increase in the nociceptive excitability thresholds in subjects with CTTH, with p=0.001 compared to the sham group.

CONCLUSION

Considering its limitations, the present study depicts that rTMS is an efficacious management tool for reducing pain associated with CTTH and can serve as the cornerstone for additional investigations.

Are neuromodulation interventions associated with changes in the gut microbiota? A systematic review

The microbiota-gut-brain axis (MGBA) refers to the bidirectional communication between the brain and the gut microbiota and recent studies have linked the MGBA to health and disease. Research has so far investigated this axis mainly from microbiota to brain but less is known about the other direction. One approach to examine the MGBA from brain to microbiota is through understanding if and how neuromodulation might impact microbiota. Neuromodulation encompasses a wide range of stimulation techniques and is used to treat neurological, psychiatric and metabolic disorders, like Parkinson's Disease, depression and obesity. Here, we performed a systematic review to investigate whether neuromodulation is associated with subsequent changes in the gut microbiota. Searches in PsycINFO and MEDLINE were performed up to March 2022. Included studies needed to be clinical or preclinical studies comparing the effects of deep brain stimulation, electroconvulsive therapy, repetitive transcranial magnetic stimulation, transcranial direct current stimulation or vagal nerve stimulation on the gut microbiota before and after treatment or between active and control groups. Seven studies were identified. Neuromodulation was associated with changes in relative bacterial abundances, but not with (changes in) α-diversity or β-diversity. Summarizing, currently reported findings suggest that neuromodulation interventions are associated with moderate changes in the gut microbiome. However, findings remain inconclusive due to the limited number and varying quality of included studies, as well as the large heterogeneity between studies. More research is required to more conclusively establish whether, and if so, via which mechanism(s) of action neuromodulation interventions might influence the gut microbiota.

Evaluating the treatment outcomes of repetitive transcranial magnetic stimulation in patients with moderate-to-severe Alzheimer's disease

The repetitive transcranial magnetic stimulation (rTMS) shows great potential in the treatment of Alzheimer's disease (AD). However, its treatment efficacy for AD patients in moderate to severe stage is relatively evaluated. Here, we proposed a randomized, sham-controlled, clinical trial of rTMS among 35 moderate-to-severe AD patients. A high frequency (10 Hz) stimulation of the left dorsal lateral prefrontal cortex (DLPFC), 60-session long treatment lasting for 3 months procedure was adopted in the trial. Each participant completed a battery of neuropsychological tests at baseline and post-treatment for evaluation of the rTMS therapeutic effect. Twelve of them completed baseline resting-state functional magnetic resonance imaging (fMRI) for exploration of the underlying neural contribution to individual difference in treatment outcomes. The result showed that the rTMS treatment significantly improved cognitive performance on the severe impairment battery (SIB), reduced psychiatric symptoms on the neuropsychiatric inventory (NPI), and improved the clinician's global impression of change (CIBIC-Plus). Furthermore, the result preliminarily proposed resting-state multivariate functional connectivity in the (para) hippocampal region as well as two clusters in the frontal and occipital cortices as a pre-treatment neuroimaging marker for predicting individual differences in treatment outcomes. The finding could brought some enlightenment and reference for the rTMS treatment of moderate and severe AD patients.

Causally mapping human threat extinction relevant circuits with depolarizing brain stimulation methods

Laboratory threat extinction paradigms and exposure-based therapy both involve repeated, safe confrontation with stimuli previously experienced as threatening. This fundamental procedural overlap supports laboratory threat extinction as a compelling analogue of exposure-based therapy. Threat extinction impairments have been detected in clinical anxiety and may contribute to exposure-based therapy non-response and relapse. However, efforts to improve exposure outcomes using techniques that boost extinction - primarily rodent extinction - have largely failed to date, potentially due to fundamental differences between rodent and human neurobiology. In this review, we articulate a comprehensive pre-clinical human research agenda designed to overcome these failures. We describe how connectivity guided depolarizing brain stimulation methods (i.e., TMS and DBS) can be applied concurrently with threat extinction and dual threat reconsolidation-extinction paradigms to causally map human extinction relevant circuits and inform the optimal integration of these methods with exposure-based therapy. We highlight candidate targets including the amygdala, hippocampus, ventromedial prefrontal cortex, dorsal anterior cingulate cortex, and mesolimbic structures, and propose hypotheses about how stimulation delivered at specific learning phases could strengthen threat extinction.

Transcranial low-intensity ultrasound stimulation for treating central nervous system disorders: A promising therapeutic application

Transcranial ultrasound stimulation is a neurostimulation technique that has gradually attracted the attention of researchers, especially as a potential therapy for neurological disorders, because of its high spatial resolution, its good penetration depth, and its non-invasiveness. Ultrasound can be categorized as high-intensity and low-intensity based on the intensity of its acoustic wave. High-intensity ultrasound can be used for thermal ablation by taking advantage of its high-energy characteristics. Low-intensity ultrasound, which produces low energy, can be used as a means to regulate the nervous system. The present review describes the current status of research on low-intensity transcranial ultrasound stimulation (LITUS) in the treatment of neurological disorders, such as epilepsy, essential tremor, depression, Parkinson's disease (PD), and Alzheimer's disease (AD). This review summarizes preclinical and clinical studies using LITUS to treat the aforementioned neurological disorders and discusses their underlying mechanisms.

Psychological Effects of Repetitive Transcranial Magnetic Stimulation on Individuals With Methamphetamine Use Disorder: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effects of rTMS on drug craving, depression, anxiety, sleep, and cognitive function in methamphetamine (MA) dependent individuals.

DATA SOURCES AND METHODS

Randomized controlled trials (RCTs) of rTMS interventions for MA-dependent patients were searched through PubMed, Embase, Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Wanfang database, Chongqing Vipers (VIP) and China Biomedical Literature Database (CBLD). The included literature was statistically processed using Revman 5.4, and STATA 16.0 for sensitivity and bias analysis.

RESULTS

A total of 13 papers were included, and the results of the meta-analysis showed that rTMS was effective in reducing craving scores (SMD = -1.53, 95%CI:-2.08 ∼ -0.98, p < 0.00001), improving depression (SMD = -0.32, 95%CI:-0.58 ∼ -0.07, p = 0.01) and sleep scores (WMD = -1.26, 95%CI:-2.26 ∼ -0.27, p = 0.01), but had no effect on anxiety scores (SMD = -0.42, 95%CI:-0.88 ∼ 0.03, p = 0.07); in terms of cognitive function, there were improvements in the international shopping list task (ISL), Groton maze learning task (GML) and continuous paired association learning task (CPAL), except for no effect on the social emotional cognition task (SEC) and two back task (TWOB). Subgroup analysis showed significant differences in the effects of different intervention period on craving in MA-dependent individuals.

CONCLUSION

rTMS was effective in reducing MA dependent individuals' cravings, alleviating depressive symptoms, improving sleep quality and language learning, collaborative learning and executive skills. Due to the small sample size of this study, a large number of RCTs are needed to validate this.

The Location Reliability of the Resting-State fMRI FC of Emotional Regions Towards rTMS Therapy

Resting-state magnetic resonance imaging (RS-fMRI) studies indicated that the repetitive transcranial magnetic stimulation (rTMS) exerts antidepression effect through the functional connectivity (FC) of the DLPFC with the subgenual anterior cingulate cortex (sgACC), pregneual ACC (pgACC), or nucleus accumbens (NAc). It is proposed that the FC-guided individualized precise stimulation on the DLPFC would be more effective. The current study systematically investigated the reliability of the RS-fMRI FC location as well as the FC strength with multiple potential factors. We aimed to provide a stable stimulation target for future FC-guided TMS therapy for affective related disorders. Twenty-one subjects under RS-fMRI conditions with the first two times (V1, V2) scanned on a GE 3 T scanner and the third visit (V3) on a Siemens 3 T scanner. Then the FC strength and location reliability were assessed by using intra-class correlation (ICC) and intra-individual distance, respectively. The factors included deep seed ROIs (midline (mid-) sgACC, left pgACC, mid-pgACC, and left NAc), eyes closed (EC) vs eyes open (EO), frequency bands, FC algorithm (Pearson vs Spearman), scanning length (half a session vs whole session), and location method (FC peak vs center of gravity (COG)). The reliability of the voxel-wise FC strength was low to moderate. The intra-individual distances of the COG were 3.8-7.3 mm across all factors, much smaller than that of FC peak (approximately 30 mm). The COG of seed-based FC might be a potential rTMS stimulation target. Anyway, all potential stimulation targets should be tested in future rTMS treatment studies.

Intensive rTMS for treatment-resistant depression patients with suicidal ideation: An open-label study

The advantages of intensive repetitive transcranial magnetic stimulation (rTMS) protocol are in the possible acute effect of the stimulation and in the possible reduction in the time required to achieve remission in depression. Here, we investigated the antidepressant effects and antisuicidal effects of a more intensive rTMS protocol for treatment-resistant depression (TRD) patients with suicidal ideation. Thirty-one outpatients were included in this study, including 22 military veterans and 9 non- militaries. The rTMS treatment consisted of 25 sessions, each session lasting 30 min (60 trains of 50 pulsations, 110 % resting motor threshold intensity) for a total of 3000 pulse. The total amount of stimulation (750,000 pulses) applied by our rTMS protocol was equivalent to that of a 5-week standard rTMS protocol. We found a significant effect of time on the 17-item Hamilton Depression Rating Scale (HAMD-17) scores and the Sheehan Disability Scale (SDS) scores. There was no difference in change in the HAMD-17 scores and SDS scores between the military veteran group and the non-military group between baseline and the week 4 assessment time point. The response rate of depression was 64.52 %, and the remission rate of depression was 51.61 % at day 5. 48.39 % and 35.48 % at week 4, respectively. All patients (100 %) met response criteria of suicidal ideation, and the remission rate was 87.09 % at day 5. The response rate was 83.87 % %, and the remission rate was 77.42 % at week 4. The accelerated high-dose rTMS treatment was well tolerated by all patients. Our intensive rTMS protocol is preliminarily safe and feasible. The TRD patients with suicidal ideation could benefit from much shorter exposure to this protocol with more efficacy in comparison with conventional rTMS protocol. In addition, intensive rTMS offers a promising treatment for military veteran populations.

Repetitive Transcranial Magnetic Stimulation for Neuropathic Pain and Neuropsychiatric Symptoms in Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Neuropathic pain and neuropsychiatric symptoms are common complications reported by the traumatic brain injury (TBI) population. Although a growing body of research has indicated the effectiveness of repetitive transcranial magnetic stimulation (rTMS) for the management of neurological and psychiatric disorders, little evidence has been presented to support the effects of rTMS on neuropathic pain and neuropsychiatric symptoms in patients with TBI in all age groups. In addition, a better understanding of the potential factors that might influence the therapeutic effect of rTMS is necessary. The objective of this preregistered systematic review and meta-analysis was to quantify the effects of rTMS on physical and psychological symptoms in individuals with TBI. We systematically searched six databases for randomized controlled trials (RCTs) of rTMS in TBI patients reporting pain and neuropsychiatric outcomes published until March 20, 2022. The mean difference (MD) with 95% confidence intervals (CIs) was estimated separately for outcomes to understand the mean effect size. Twelve RCTs with 276 TBI patients were ultimately selected from 1605 records for systematic review, and 11 of the studies were included in the meta-analysis. Overall, five of the included studies showed a low risk of bias. The effects of rTMS on neuropathic pain were statistically significant ( $\text{MD}=-1.00$ , 95% CI -1.76 to -0.25, $P=0.009$ ), with high heterogeneity ( $I^2=76\%$ ). A significant advantage of 1 Hz rTMS over the right dorsolateral prefrontal cortex (DLPFC) in improving depression ( $\text{MD}=-6.52$ , 95% CI -11.58 to -1.46, $P=0.01$ ) was shown, and a significant improvement was noted in the Rivermead Post-Concussion Symptoms Questionnaire-13 (RPQ-13) scores of mild TBI patients after rTMS ( $\text{MD}=-5.87$ , 95% CI -10.63 to -1.11, $P=0.02$ ). However, no significance was found in cognition measurement. No major adverse events related to rTMS were reported. Moderate evidence suggests that rTMS can effectively and safely improve neuropathic pain, while its effectiveness on depression, postconcussion symptoms, and cognition is limited. More trials with a larger number of participants are needed to draw firm conclusions. This trial is registered with PROSPERO (PROSPERO registration number: CRD42021242364.

Cold Cognition as Predictor of Treatment Response to rTMS; A Retrospective Study on Patients With Unipolar and Bipolar Depression

Background

Cognitive impairments are prevalent in patients with unipolar and bipolar depressive disorder (UDD and BDD, respectively). Considering the fact assessing cognitive functions is increasingly feasible for clinicians and researchers, targeting these problems in treatment and using them at baseline as predictors of response to treatment can be very informative.

Method

In a naturalistic, retrospective study, data from 120 patients (Mean age: 33.58) with UDD (n = 56) and BDD (n = 64) were analyzed. Patients received 20 sessions of bilateral rTMS (10 Hz over LDLPFC and 1 HZ over RDLPFC) and were assessed regarding their depressive symptoms, sustained attention, working memory, and executive functions, using the Beck Depression Inventory (BDI-II) and Neuropsychological Test Automated Battery Cambridge, at baseline and after the end of rTMS treatment course. Generalized estimating equations (GEE) and logistic regression were used as the main statistical methods to test the hypotheses.

Results

Fifty-three percentage of all patients (n = 64) responded to treatment. In particular, 53.1% of UDD patients (n = 34) and 46.9% of BDD patients (n = 30) responded to treatment. Bilateral rTMS improved all cognitive functions (attention, working memory, and executive function) except for visual memory and resulted in more modulations in the working memory of UDD compared to BDD patients. More improvements in working memory were observed in responded patients and visual memory, age, and sex were determined as treatment response predictors. Working memory, visual memory, and age were identified as treatment response predictors in BDD and UDD patients, respectively.

Conclusion

Bilateral rTMS improved cold cognition and depressive symptoms in UDD and BDD patients, possibly by altering cognitive control mechanisms (top-down), and processing negative emotional bias.

Evidence and expert consensus based German guidelines for the use of repetitive transcranial magnetic stimulation in depression

INTRODUCTION

Non-invasive brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) offer a promising alternative to psychotherapeutic and pharmacological treatments for depression. This paper aims to present a practical guide for its clinical implementation based on evidence from the literature as well as on the experience of a group of leading German experts in the field.

METHODS

The current evidence base for the use of rTMS in depression was examined via review of the literature. From the evidence and from clinical experience, recommendations for the use of rTMS in clinical practice were derived. All members of the of the German Society for Brain Stimulation in Psychiatry and all members of the sections Clinical Brain Stimulation and Experimental Brain Stimulation of the German Society for Psychiatry, Psychotherapy, Psychosomatics and Mental Health were invited to participate in a poll on whether they consent with the recommendations.

FINDINGS

Among rTMS experts, a high consensus rate could be identified for clinical practice concerning the setting and the technical parameters of rTMS treatment in depression, indications and contra-indications, the relation of rTMS to other antidepressive treatment modalities and the frequency and management of side effects.

Repetitive Transcranial Magnetic Stimulation for Fibromyalgia: An Updated Systematic Review and Meta-Analysis

OBJECTIVE

Meta-analysis was performed to evaluate the effectiveness of repetitive transcranial magnetic stimulation (rTMS) in fibromyalgia on the domains of pain, depression, anxiety and quality of life.

METHOD

Publications were searched with the keywords "repetitive transcranial magnetic stimulation" and "fibromyalgia" for randomized controlled trials that compare rTMS with sham stimulation for treating pain, depression, anxiety, and quality of life. Trials available until April 2021 were searched through PubMed, Scopus, Web of Science, and Cochrane Controlled Trials Register. The postintervention scores after 4 weeks for pain, depression, anxiety, and quality of life were extracted to compare the effects of rTMS and sham. Subgroup analysis was conducted based on the stimulation site.

RESULTS

From 265 screened articles, 11 eligible randomized controlled trials involving 303 patients were included. The results show that rTMS is more effective than sham stimulation in improving pain (standardized mean difference [SMD] = -0.35; 95% confidence interval [CI] = -0.62 to -0.08; p = .01) and quality of life (SMD = -0.51; 95% CI = -0.78 to -0.23; p = .0003). It is not more effective than sham stimulation for depression, and anxiety. After sensitivity analysis, subgroup analysis revealed that primary motor cortex stimulation was more effective than sham for improving pain (SMD = -0.57; 95% CI = -0.91 to -0.23; p = <0.01). Neither dorsolateral prefrontal cortex nor primary motor cortex stimulation was more effective than sham in improving depression and anxiety.

CONCLUSIONS

rTMS is more effective than sham in improving pain and quality of life, but it does not demonstrate reduction in depression or anxiety.

Connectivity-Guided Theta Burst Transcranial Magnetic Stimulation Versus Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Moderate to Severe Depression: Magnetic Resonance Imaging Protocol and SARS-CoV-2-Induced Changes for a Randomized Double-blind Controlled Trial

Background

Depression is a substantial health and economic burden. In approximately one-third of patients, depression is resistant to first-line treatment; therefore, it is essential to find alternative treatments. Transcranial magnetic stimulation (TMS) is a neuromodulatory treatment involving the application of magnetic pulses to the brain that is approved in the United Kingdom and the United States in treatment-resistant depression. This trial aims to compare the clinical effectiveness, cost-effectiveness, and mechanism of action of standard treatment repetitive TMS (rTMS) targeted at the F3 electroencephalogram site with a newer treatment—a type of TMS called theta burst stimulation (TBS) targeted based on measures of functional brain connectivity. This protocol outlines brain imaging acquisition and analysis for the Brain Imaging Guided Transcranial Magnetic Stimulation in Depression (BRIGhTMIND) study trial that is used to create personalized TMS targets and answer the proposed mechanistic hypotheses.

Objective

The aims of the imaging arm of the BRIGhTMIND study are to identify functional and neurochemical brain signatures indexing the treatment mechanisms of rTMS and connectivity-guided intermittent theta burst TMS and to identify imaging-based markers predicting response to treatment.

Methods

The study is a randomized double-blind controlled trial with 1:1 allocation to either 20 sessions of TBS or standard rTMS. Multimodal magnetic resonance imaging (MRI) is acquired for each participant at baseline (before TMS treatment) with T1-weighted and task-free functional MRI during rest used to estimate TMS targets. For participants enrolled in the mechanistic substudy, additional diffusion-weighted sequences are acquired at baseline and at posttreatment follow-up 16 weeks after treatment randomization. Core data sets of T1-weighted and task-free functional MRI during rest are acquired for all participants and are used to estimate TMS targets. Additional sequences of arterial spin labeling, magnetic resonance spectroscopy, and diffusion-weighted images are acquired depending on the recruitment site for mechanistic evaluation. Standard rTMS treatment is targeted at the F3 electrode site over the left dorsolateral prefrontal cortex, whereas TBS treatment is guided using the coordinate of peak effective connectivity from the right anterior insula to the left dorsolateral prefrontal cortex. Both treatment targets benefit from the level of MRI guidance, but only TBS is provided with precision targeting based on functional brain connectivity.

Results

Recruitment began in January 2019 and is ongoing. Data collection is expected to continue until January 2023.

Conclusions

This trial will determine the impact of precision MRI guidance on rTMS treatment and assess the neural mechanisms underlying this treatment in treatment-resistant depressed patients.

Trial Registration

ISRCTN Registry ISRCTN19674644; https://www.isrctn.com/ISRCTN19674644

International Registered Report Identifier (IRRID)

DERR1-10.2196/31925

Revisiting Hemispheric Asymmetry in Mood Regulation: Implications for rTMS for Major Depressive Disorder

Hemispheric differences in emotional processing have been observed for over half a century, leading to multiple theories classifying differing roles for the right and left hemisphere in emotional processing. Conventional acceptance of these theories has had lasting clinical implications for the treatment of mood disorders. The theory that the left hemisphere is broadly associated with positively valenced emotions, while the right hemisphere is broadly associated with negatively valenced emotions, drove the initial application of repetitive transcranial magnetic stimulation (rTMS) for the treatment of major depressive disorder (MDD). Subsequent rTMS research has led to improved response rates while adhering to the same initial paradigm of administering excitatory rTMS to the left prefrontal cortex (PFC) and inhibitory rTMS to the right PFC. However, accumulating evidence points to greater similarities in emotional regulation between the hemispheres than previously theorized, with potential implications for how rTMS for MDD may be delivered and optimized in the near future. This review will catalog the range of measurement modalities that have been used to explore and describe hemispheric differences, and highlight evidence that updates and advances knowledge of TMS targeting and parameter selection. Future directions for research are proposed that may advance precision medicine and improve efficacy of TMS for MDD.

Habenular Involvement in Response to Subcallosal Cingulate Deep Brain Stimulation for Depression

The habenula (Hb) is a small, evolutionarily conserved epithalamic structure implicated in functions such as reward and mood regulation. Prior imaging work suggests that Hb's structural and functional properties may relate to treatment response in depression and other mood disorders. We used multimodal MRI techniques to investigate the potential involvement of Hb in response to subcallosal cingulate area deep brain stimulation (SCC-DBS) for treatment-resistant mood disorders. Using an automated segmentation technique, we compared Hb volume at baseline and at a subsequent post-operative timepoint (4.4 ± 3.0 years after surgery) in a cohort of 32 patients who received SCC-DBS. Clinical response to treatment (≥50% decrease in HAMD-17 from baseline to 12 months post-operation) was significantly associated with longitudinal Hb volume change: responders tended to have increased Hb volume over time, while non-responders showed decreased Hb volume (t = 2.4, p = 0.021). We additionally used functional MRI (fMRI) in a subcohort of SCC-DBS patients (n = 12) to investigate immediate within-patient changes in Hb functional connectivity associated with SCC-DBS stimulation. Active DBS was significantly associated with increased Hb connectivity to several prefrontal and corticolimbic regions (TFCE-adjusted p _Bonferroni < 0.0001), many of which have been previously implicated in the neurocircuitry of depression. Taken together, our results suggest that Hb may play an important role in the antidepressant effect of SCC-DBS.

Antidepressant efficacy of low-frequency repetitive transcranial magnetic stimulation in antidepressant-nonresponding bipolar depression: a single-blind randomized sham-controlled trial

BACKGROUND

To examine the antidepressant efficacy and response predictors of R-DLPFC-LF rTMS for antidepressant-nonresponding BD.

METHODS

We conducted a single-blind randomized sham-controlled trial for 54 (28 sham, 26 active) patients with antidepressant-nonresponding BD (baseline MADRS ≥ 20). Patients received 15 daily sessions of active or sham neuronavigated rTMS (Figure-of-8 coil, five 1 Hz 60 s 110% RMT trains). Outcome measures included depressive response (≥ 50% MADRS reduction, CGI ≤ 2) and remission (MADRS < 7, CGI = 1) rates, treatment emergent hypo/mania (YMRS), depressive and anxiety symptoms (HAM-A).

RESULTS

48 patients (25 sham, 23 active) completed treatment, with 3 drop-outs each in active and sham groups. Active rTMS did not produce superior response or remission rates at endpoint or 6 or 12 weeks (ps > 0.05). There was no significant group * time interaction (ps > 0.05) in a multivariate ANOVA with MADRS, HAMA and YMRS as dependent variables. Exploratory analysis found MADRS improvement to be moderated by baseline anxiety (p = 0.02) and melancholia (p = 0.03) at week 3, and depressive onset at weeks 6 (p = 0.03) and 12 (p = 0.04). In subjects with below-mean anxiety (HAMA < 20.7, n = 24), MADRS improvement from active rTMS was superior to sham at week 3 (ITT, t = 2.49, p = 0.04, Cohen's d = 1.05). No seizures were observed. Groups did not differ in treatment-emergent hypomania (p = 0.1).

LIMITATIONS

Larger sample size might be needed to power subgroup analyses. Moderation analyses were exploratory. Single-blind design. Unblinding before follow-up assessments due to ethical reasons.

CONCLUSIONS

1-Hz 110% RMT (5 × 60 s trains) R-DLPFC-LF rTMS was not effective for antidepressant non-responding BD but may be further investigated at increased dosage and/or in BD patients with low anxiety. Trial registration CCRB Clinical Trials Registry, CUHK, CUHK_CCT00440. Registered 04 December 2014, https://www2.ccrb.cuhk.edu.hk/registry/public/279.

Treatment of mixed depression with theta-burst stimulation (TBS): results from a double-blind, randomized, sham-controlled clinical trial

Mixed depression is probably different in terms of clinical course and response to treatment. Repetitive transcranial magnetic stimulation (rTMS) is well established in non-mixed depression, and theta-burst stimulation (TBS) protocol is replacing conventional protocols because of noninferiority and reduced delivery time. However, TBS has not been adequately studied in mixed states. This study was a double-blind, six-week, sham-controlled, and randomized clinical trial of bilateral TBS targeting the right and left dorsolateral prefrontal cortex, respectively. Adults with bipolar and major depressive disorder experiencing an acute mixed depression were eligible if they had not benefited from a first- or second-line treatment for acute unipolar or bipolar depression recommended by the Canadian Network for Mood and Anxiety Treatments. Out of 100 patients included, 90 composed modified intention-to-treat sample, which was patients that completed at least one week of the intervention. There were no significant differences in Montgomery-Asberg depression rating scale score changes (least squares mean difference between groups at week 3, -0.06 [95% CI, - 3.39 to 3.51; P = 0.97] in favor of sham TBS). Response and remission rates per MADRS were also not statistically different among active and sham groups (35.7% vs. 43.7%, and 28.5% vs. 37.5% respectively at week 6, ps > 0.51). No other analyses from baseline to weeks 3 or 6 revealed significant time x group interaction or mean differences among groups in the mITT sample. Bilateral TBS targeting the DLPFC is not efficacious as an add-on treatment of acute bipolar and unipolar mixed depression. ClinicalTrials.govIdentifier: NCT04123301.

Electroencephalographic connectivity predicts clinical response to repetitive transcranial magnetic stimulation in patients with insomnia disorder

BACKGROUND

Accumulating evidence suggests that low frequency repetitive transcranial magnetic stimulation (rTMS), which generally decreases cortical excitability and remodels plastic connectivity, improves sleep quality in patients with insomnia disorder. However, the effects of rTMS vary substantially across individuals and treatment is sometimes unsatisfactory, calling for biomarkers for predicting clinical outcomes.

OBJECTIVE

This study aimed to investigate whether functional connectivity of the target network in electroencephalography is associated with the clinical response to low frequency rTMS in patients with insomnia disorder.

METHODS

Twenty-five patients with insomnia disorder were subjected to 10 sessions of treatment with 1 Hz rTMS over the right dorsolateral prefrontal cortex. Resting-state electroencephalography was collected before rTMS. Pittsburgh Sleep Quality Index, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, and Mini-Mental State Exam were performed before and after rTMS treatment, with a follow-up after one month. Electroencephalographic connectivity was measured by the power envelope connectivity at the source level. Partial least squares regression identified models of connectivity that maximally accounted for the rTMS response.

RESULTS

Scores of Pittsburgh Sleep Quality Index, Hamilton Depression Rating Scale, and Hamilton Anxiety Rating Scale were decreased after rTMS and one-month later. Baseline weaker connectivity of a network in the beta and alpha bands between a brain region approximating the stimulated right dorsolateral prefrontal cortex and areas located in the frontal, insular, and limbic cortices was associated with a greater change in Pittsburgh Sleep Quality Index and Hamilton Depression Rating Scale following rTMS.

CONCLUSIONS

Low frequency rTMS could improve sleep quality and depressive moods in patients with insomnia disorder. Moreover, electroencephalographic functional connectivity would potentially be a robust biomarker for predicting the therapeutic effects.

Insights from a laboratory and naturalistic investigation on stress, rumination and frontal brain functioning in MDD: An fNIRS study

Recent research has emphasized rumination as an important maintaining factor in various mental disorders. However, operationalization and therefore induction of rumination in experimental settings poses a major challenge in terms of ecological validity. As stress seems to play a key role in everyday situations eliciting rumination, we conducted two stress paradigms while assessing behavioral and neurophysiological measures. Aiming to replicate previous findings on induced rumination by means of the Trier Social Stress Test (TSST) and comparing them to physiological (pain) stress, a clinical sample of patients with Major Depressive Disorder (MDD; n = 22) and healthy controls (HC; n = 23) was recruited. Cortical blood oxygenation was assessed during the stress paradigms using functional near-infrared spectroscopy (fNIRS). Further, we used ecological momentary assessment (EMA) of stress, rumination and mood to be able to correlate ruminative responses during induced stress and everyday rumination. Our results showed that social stress but not physiological stress induced depressive rumination in MDD but not in HC. Further, rumination reactivity in response to social stress but not to physiological stress was significantly associated with rumination reactivity in everyday life as assessed with EMA. With respect to cortical oxygenation, MDD subjects showed hypoactivity in the Cognitive Control Network during the TSST, which mediated the differences between MDD and HC in post-stress rumination. Our findings emphasize the role of negative social triggers in depressive rumination and validate the TSST as an induction method for depressive rumination. The results inform future developments in psychotherapeutic treatment for depressive rumination.

Effect of repetitive transcranial magnetic stimulation on depression and cognition in individuals with traumatic brain injury: a systematic review and meta-analysis

Repetitive transcranial magnetic stimulation (rTMS) is an FDA-approved therapy in major depressive disorder. However, its treatment efficacy on depression after traumatic brain injury (TBI) remains inconclusive. We conducted a meta-analysis to assess the effectiveness of executing rTMS over dorsolateral prefrontal cortex (DLPFC) on depression, cognitive impairment and post-concussion syndrome in individuals with traumatic brain injury. This study contained seven randomized controlled trials that published before April 5, 2020 in PubMed, Embase, Scopus, Cochrane, and Web of Science databases. The rTMS had significant anti-depressant effect (SMD = 1.03, p = 0.02), but the effects dissipated at 1-month follow-up (SMD = 0.39, p = 0.62). In the subgroup analysis, only applying rTMS to left DLPFC area of post-TBI patients showed significant anti-depressant effect (SMD = 0.98, p = 0.04). Moreover, current data observed that rTMS on post-TBI patients possessed substantial improvement in visuospatial memory (SMD = 0.39, p < 0.0001), but wasn't in processing speed (SMD = - 0.18, p = 0.32) and selective attention (SMD = 0.21, p = 0.31). In addition, the effect of rTMS is not superior to sham on postconcussion syndrome. In conclusion, the short-term antidepressant effect of left DLPFC rTMS in patients with TBI was significant. However, the effectiveness of rTMS on cognition and postconcussion syndrome in patients with post-TBI depression was limited.

[Contemporary methods of non-drug therapy for depression]

The review presents information on the most effective current non-drug methods of treatment of depression used in practice. A review of publications in PubMed and PsycINFO and Cochrane Library over the past 10 years was conducted. Non-drug biological therapies demonstrate high efficacy in the reduction of depressive symptoms in patients with recurrent depressive disorder. The use of non-drug therapy does not preclude the continuation of pharmacological therapy. In order to choose an optimal method of treatment, the psychophysical state of a patient, severity of depressive symptoms, response to drug therapy, and possibility of prescribing pharmacological therapy should be taken into account, and the principles of evidence-based medicine should be taken into consideration when making a decision.

Personalization of Repetitive Transcranial Magnetic Stimulation for the Treatment of Major Depressive Disorder According to the Existing Psychiatric Comorbidity

Repetitive transcranial magnetic stimulation (rTMS) and intermittent theta-burst stimulation (iTBS) are evidenced-based treatments for patients with major depressive disorder (MDD) who fail to respond to standard first-line therapies. However, although various TMS protocols have been proven to be clinically effective, the response rate varies across clinical applications due to the heterogeneity of real-world psychiatric comorbidities, such as generalized anxiety disorder, posttraumatic stress disorder, panic disorder, or substance use disorder, which are often observed in patients with MDD. Therefore, individualized treatment approaches are important to increase treatment response by assigning a given patient to the most optimal TMS treatment protocol based on his or her individual profile. This literature review summarizes different rTMS or TBS protocols that have been applied in researches investigating MDD patients with certain psychiatric comorbidities and discusses biomarkers that may be used to predict rTMS treatment response. Furthermore, we highlight the need for the validation of neuroimaging and electrophysiological biomarkers associated with rTMS treatment responses. Finally, we discuss on which directions future efforts should focus for developing the personalization of the treatment of depression with rTMS or iTBS.

Targeting repetitive transcranial magnetic stimulation in depression: do we really know what we are stimulating and how best to do it?

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is an established treatment for patients with depression who have not achieved optimal outcomes with one or more trials of antidepressant medication. It is an effective antidepressant treatment but there remains considerable scope for improving clinical outcomes. One method to potentially enhance the efficacy of rTMS is through the improvement of methods of stimulation localization.

OBJECTIVE

The purpose of this paper is to review the literature pertaining to rTMS localization methods and approaches relevant to the treatment of major depressive disorder (MDD) and provide specific opinions on the state of the art in regards to targeting of rTMS treatment in depression.

METHODS

A targeted review of the literature on rTMS targeting in depression.

RESULTS

There is emerging evidence that optimal rTMS treatment outcomes are likely to be achieved with stimulation at a relatively anterior stimulation site in the left dorsolateral prefrontal cortex (DLPFC). However, some lines of research suggest that there may be two effective stimulation sites: one quite posterior, and one more anterior, in the DLPFC. The 'Beam F3' method provides reasonable localization to the anterior stimulation site and the posterior stimulation site corresponds to that typically used in studies using the '5 cm method'. Neuro-navigational methods are generally most likely to consistently ensure placement of the TMS coil such that it results in stimulation of a selected cortical site. fMRI - connectivity based approaches to targeting specific circuits in the DLPFC are intellectually attractive but it may not be possible to demonstrate differential effectiveness of these over the methods most commonly been used in clinical practice.

CONCLUSIONS

There is an emerging literature helping to improve our understanding of the optimal methods for targeting rTMS treatment for depression. However, we lack substantive prospective clinical trials demonstrating improved clinical outcomes with these techniques.

Optimized repetitive transcranial magnetic stimulation techniques for the treatment of major depression: A proof of concept study

Although effective in major depressive disorder (MDD), repetitive transcranial magnetic stimulation (rTMS) is costly and complex, limiting accessibility. To address this, we tested the feasibility of novel rTMS techniques with cost-saving opportunities, such as an open-room setting, large non-focal parabolic coils, and custom-built coil arms. We employed a low-frequency (LF) 1 Hz stimulation protocol (360 pulses per session), delivered on the most affordable FDA-approved device. MDD participants received an initial accelerated rTMS course (arTMS) of 6 sessions/day over 5 days (30 total), followed by a tapering course of daily sessions (up to 25) to decrease the odds of relapse. The self-reported Beck Depression Inventory II (BDI-II) was used to measure severity of depression. Forty-eight (48) patients completed the arTMS course. No serious adverse events occurred, and all patients reported manageable pain levels. Response and remission rates were 35.4% and 27.1% on the BDI-II, respectively, at the end of the tapering course. Repeated measures ANOVA showed significant changes of BDI-II scores over time. Even though our protocol will require further improvements, some of the concepts we introduced here could help guide the design of future trials aiming at increasing accessibility to rTMS.

Application of transcranial magnetic stimulation for major depression: Coil design and neuroanatomical variability considerations

High-frequency repeated transcranial magnetic stimulation (rTMS) as a treatment for major depressive disorder (MDD) has received FDA clearance for both the figure-of-8 coil (figure-8 coil) and the H1 coil. The FDA-cleared MDD protocols for both coils include high frequency (10-18 Hz) stimulation targeting the dorsolateral prefrontal cortex (dlPFC) at an intensity that is 120% of the right-hand resting motor threshold. Despite these similar parameters, the two coils generate distinct electrical fields (e-fields) which result in differences in the cortical stimulation they produce. Due to the differences in coil designs, the H1 coil induces a stimulation e-field that is broader and deeper than the one induced by the figure-8 coil. In this paper we review theoretical and clinical implications of these differences between the two coils and compare evidence of their safety and efficacy in treating MDD. We present the design principles of the coils, the challenges of identifying, finding, and stimulating the optimal brain target of each individual (both from functional and connectivity perspectives), and the possible implication of stimulating outside that target. There is only one study that performed a direct comparison between clinical effectiveness of the two coils, using the standard FDA-approved protocols in MDD patients. This study indicated clinical superiority of the H1 coil but did not measure long-term effects. Post-marketing data suggest that both coils have a similar safety profile in clinical practice, whereas effect size comparisons of the two respective FDA pivotal trials suggests that the H1 coil may have an advantage in efficacy. We conclude that further head-to-head experiments are needed, especially ones that will compare long-term effects and usage of similar temporal stimulation parameters and similar number of pulses.

A double-blind randomized clinical trial of high frequency rTMS over the DLPFC on nicotine dependence, anxiety and depression

High frequency repetitive transcranial magnetic stimulation (HF-rTMS) over the left dorsolateral prefrontal cortex (L-DLPFC) is a widely applied treatment protocol for chronic smoking and major depressive disorder. However, no previous study has measured the effects of rTMS on both nicotine consumption and anxiety/depression in the same volunteers despite the relationship between them. The aim of this work was to evaluate the efficacy of 10 daily sessions of HF-rTMS over the L-DLPFC in chronic cigarette smokers' addiction and investigate the possible beneficial effects of this treatment procedure on symptoms of depression and anxiety in the same subjects. The study included 40 treatment-seeking nicotine-dependent cigarette smokers. Onset/duration of smoking, number of cigarettes/day, Fagerstrom Test of Nicotine Dependence (FTND), Tobacco Craving Questionnaire-Short Form (TCQ-SF), Hamilton depression and anxiety scales (HAM-D and HAM-A) were recorded. Participants were randomly assigned to the active or the sham treatment group. Those in the active group received 10 trains of 20 Hz stimulation, at 80% of the resting motor threshold (rMT) for 10 consecutive working days over L-DLPFC. Participants were reassessed immediately after treatment, and then 3 months later using all rating scales. There were no differences between active and sham groups at baseline. The cigarette consumption/day, and scores on FTND, and TCQ decreased significantly in both groups (p = 0.0001 for each) immediately after treatment. However, improvement persisted to 3 months in the active group but not in the sham group. Moreover, there was a significant reduction in HAM-D and HAM-A scores immediately after treatment in the active but not the sham group. Subjects with a longer history of smoking had a lower percent improvement in FTND (p = 0.005). Our findings revealed that HF-rTMS over L-DLPCF for 10 days reduced cigarette consumption, craving, dependence, and improved associated symptoms of anxiety and depression.ClinicalTrials.gov Identifier: NCT03264755 registered at 29/08/2017.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility.

METHODS

Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg²⁰²⁰) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care.

CONCLUSION

The MDcpg²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

Neurostimulation Methods in the Treatment of Depression: A Comparison of rTMS, tDCS, and Venlafaxine Using a Pooled Analysis of Two Studies

BACKGROUND

There are no head-to-head studies comparing the antidepressant effect of transcranial direct current stimulation (tDCS) with repetitive transcranial magnetic stimulation (rTMS). This pooled analysis compared indirectly the antidepressant efficacy and acceptability of rTMS, tDCS, and the antidepressant venlafaxine (VNF) extended-release.

METHODS

The analysis (n=117, both patients with treatment-resistant depression (TRD) and non-TRD were included) examined pooled data from two 4-week, single-centered, two-armed, double-blind, randomized studies (EUDRACT n. 2005-000826-22 and EUDRACT n. 2015-001639-19). The antidepressant efficacy of right-sided low-frequency rTMS (n=29) vs VNF (n=31) and left-sided anodal tDCS (n=29) vs VNF (n=28) was evaluated. The primary outcome was a change in the Montgomery-Åsberg Depression Rating Scale (MADRS) score from baseline to the treatment endpoint at week 4. The response was defined as a ≥50% reduction in the MADRS score and remission as the MADRS score ≤10 points, both were calculated for the primary treatment endpoint at week 4.

RESULTS

Mean change in total MADRS scores from baseline to week 4 was 7.0 (95% CI, 4.8-9.1) points in the rTMS group, 7.6 (95% CI, 5.5-9.8) in the tDCS group, and 8.9 (95% CI, 7.4-10.4) among patients in the VNF group, a non-significant difference (F(2111)=0.62, p=0.54). Similarly, neither the response rates nor remission rates for rTMS (response 31%; remission 17%), tDCS (24%, 17%), or VNF (41%; 27%) significantly differed among treatment groups (χ ²=2.59, p=0.28; χ ²=1.66, p=0.44). Twenty patients (17%) dropped out of the studies in a similar proportion across groups (rTMS 3/29, tDCS 6/29, VNF 11/59, χ ²=1.41, p=0.52).

CONCLUSION

Our current analysis found a comparable efficacy and acceptability in all three treatment modalities (rTMS, tDCS, and VNF) and clinical relevance for the acute treatment of major depressive disorder.

An update on the clinical use of repetitive transcranial magnetic stimulation in the treatment of depression

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is an increasingly used treatment for patients with depression. The use of rTMS in depression is supported by over 20 years of clinical trials. There has been a significant increase in knowledge around the use of rTMS in recent years.

OBJECTIVE

The aim of this paper was to review the use of rTMS in depression to provide an update for rTMS practitioners and clinicians interested in the clinical use of this treatment.

METHODS

A targeted review of the literature around the use of rTMS treatment of depression with a specific focus on studies published in the last 3 years.

RESULTS

High-frequency rTMS applied to the left dorsolateral prefrontal cortex is an effective treatment for acute episodes of major depressive disorder. There are several additional methods of rTMS delivery that are supported by clinical trials and meta-analyses but no substantive evidence that any one approach is any more effective than any other. rTMS is effective in unipolar depression and most likely bipolar depression. rTMS courses may be repeated in the management of depressive relapse but there is less evidence for the use of rTMS in the maintenance phase.

CONCLUSIONS

The science around the use of rTMS is rapidly evolving and there is a considerable need for practitioners to remain abreast of the current state of this literature and its implications for clinical practice. rTMS is an effective antidepressant treatment but its optimal use should be continually informed by knowledge of the state of the art.

Bilateral sequential theta burst stimulation for multiple-therapy-resistant depression: A naturalistic observation study

Depression is a significant health issue with treatment resistance reported in about one third of patients. Treatment resistance results in significant disability, impaired quality of life, and increased healthcare costs. Repetitive transcranial magnetic stimulation (rTMS) is a treatment option for treatment resistant depression (TRD) with response and remission rates in open-label studies being as high as 58% and 37% respectively. Theta-burst is a faster and novel rTMS paradigm that has shown promise as a treatment for TRD in some preliminary studies. In a naturalistic design, we evaluated the response, remission and tolerability of bilateral sequential (right then left) prefrontal theta-burst rTMS (bsTBS) in 50 patients with TRD (600 pulses/session, 20 sessions, 100% of resting motor threshold (80% if intolerant to 100%, n = 2), F4/F3 of 10-20-20 EEG localization). Data was collected over 36 months from a specialized academic TMS clinic. Patients had multiple-treatment resistance with at least two failed trials of different antidepressants with 20% also having failed electroconvulsive therapy and 66% having received professional therapy. We found a 28% remission rate (HAMD-17 score of ≤7) and a 52% response rate (≥50% reduction in HAMD-17) with a 42% reduction in average HAMD-17 score. The treatment was well tolerated, with muscle contractions, mild pain or discomfort, headache, scalp irritation, and changes to vitals being captured as occasional adverse events with two instances of syncope (0.22% of treatments). This naturalistic study shows that bsTBS is a promising paradigm for a multiple-TRD patient population with approximately one-third of treatments achieving remission and over half achieving significant response.

Low-Frequency Repetitive Transcranial Magnetic Stimulation over Right Dorsolateral Prefrontal Cortex in Parkinson's Disease

Background

Repetitive transcranial magnetic stimulation (rTMS) is a promising therapeutic tool for Parkinson's disease (PD), and many stimulation targets have been implicated. We aim to explore whether low-frequency rTMS over the right dorsolateral prefrontal cortex (DLPFC) improves motor and nonmotor symptoms of individuals with PD.

Methods

We conducted a randomized, single-blind, sham-controlled parallel trial to compare the effect of 10 consecutive daily sessions of 1 Hz rTMS over right DLPFC on individuals with idiopathic PD between active and sham rTMS group. Primary outcomes were changes in Unified Parkinson's Disease Rating Scale (UPDRS) part III and Nonmotor Symptom Questionnaire (NMSQ). Secondary outcomes were changes in UPDRS total score, Hamilton Rating Scale for Depression (HRSD), Pittsburgh Sleep Quality Index (PSQI), and Montreal Cognitive Assessment (MoCA). Assessments were completed at baseline, after treatment, and at 1 month, 3 months, and 6 months after treatment.

Results

A total of 33 participants with PD were randomized. All participants completed the study and no severe adverse effect was noticed. Compared to baseline, active rTMS showed significant improvements in UPDRS part III and NMSQ at 1 month. Change of scores on UPDRS part III, HRSD, and PSQI persisted for 3 months after rTMS intervention. The beneficial effect on cognitive performance assessed by MoCA was maintained for at least 6 months in the follow-up. No significant changes were observed in the group with sham rTMS.

Conclusions

Low-frequency rTMS of right DLPFC could be a potential selection in managing motor and nonmotor symptoms in PD.