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Zhan D, Gregory EC, Humaira A, Wong H, Klonsky ED, Levit A, Ridgway L, Vila-Rodriguez F. Trajectories of suicidal ideation during rTMS for treatment-resistant depression. J Affect Disord 2024; 360:108-113. [PMID: 38788857 DOI: 10.1016/j.jad.2024.05.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/29/2024] [Accepted: 05/21/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND rTMS is a safe and effective intervention for treatment-resistant depression (TRD). However, there is limited data on its specific impact on suicidal ideation (SI), and the trajectory of SI over the treatment course. OBJECTIVE This open-label clinical trial investigated SI outcomes and trajectories in patients with TRD receiving low-frequency rTMS (LFR) to the right dorsolateral prefrontal cortex (DLPFC; N = 55). METHODS A latent class mixed-effect model was used to identify response trajectories for SI as well as core mood symptoms. Logistic regression analyses investigated risk factors associated with identified trajectories. RESULTS For each symptom domain, we identified two distinct trajectories during LFR, one tracking improvement (SI: n = 35, 60 %; mood: n = 29, 53 %) and the other tracking no improvement (SI: n = 20, 40 %; mood: n = 26, 47 %). Male sex, higher baseline anxiety, and higher baseline SI were risk factors for no improvement of SI; while higher baseline anxiety and benzodiazepine use were risk factors for no improvement of mood. Mediation analyses showed that anxiety was a risk factor for no improvement of SI and mood independent of benzodiazepine treatment. CONCLUSIONS This is the first study to investigate trajectories of response to LFR to the right DLPFC. SI and mood improved with LFR in most patients but the severity of anxiety symptoms was a factor of poor prognosis for both. Nuanced characterization of SI response to rTMS may lead to critical insights for individualized targeting strategies.
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Affiliation(s)
- Denghuang Zhan
- Non-Invasive Neurostimulation Therapies (NINET) Laboratory, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; Centre for Advancing Health Outcomes, St Paul's Hospital, Vancouver, BC, Canada; School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Elizabeth C Gregory
- Non-Invasive Neurostimulation Therapies (NINET) Laboratory, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Afifa Humaira
- Non-Invasive Neurostimulation Therapies (NINET) Laboratory, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Hubert Wong
- Centre for Advancing Health Outcomes, St Paul's Hospital, Vancouver, BC, Canada; School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - E David Klonsky
- Department of Psychology, University of British Columbia, Vancouver, BC, Canada
| | - Alexander Levit
- Non-Invasive Neurostimulation Therapies (NINET) Laboratory, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Lisa Ridgway
- Non-Invasive Neurostimulation Therapies (NINET) Laboratory, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Fidel Vila-Rodriguez
- Non-Invasive Neurostimulation Therapies (NINET) Laboratory, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada.
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Blank E, Gilbert DL, Wu SW, Larsh T, Elmaghraby R, Liu R, Smith E, Westerkamp G, Liu Y, Horn PS, Greenstein E, Sweeney JA, Erickson CA, Pedapati EV. Accelerated Theta Burst Transcranial Magnetic Stimulation for Refractory Depression in Autism Spectrum Disorder. J Autism Dev Disord 2024:10.1007/s10803-024-06244-2. [PMID: 38744742 DOI: 10.1007/s10803-024-06244-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE Major depressive disorder (MDD) disproportionately affects those living with autism spectrum disorder (ASD) and is associated with significant impairment and treatment recidivism. METHODS We studied the use of accelerated theta burst stimulation (ATBS) for the treatment of refractory MDD in ASD (3 treatments daily x 10 days). This prospective open-label 12-week trial included 10 subjects with a mean age of 21.5 years, randomized to receive unilateral or bilateral stimulation of the dorsolateral prefrontal cortex. RESULTS One participant dropped out of the study due to intolerability. In both treatment arms, depressive symptoms, scored on the Hamilton Depression Rating Scale scores, diminished substantially. At 12 weeks post-treatment, full remission was sustained in 5 subjects and partial remission in 3 subjects. Treatment with ATBS, regardless of the site of stimulation, was associated with a significant, substantial, and sustained improvement in depressive symptomatology via the primary outcome measure, the Hamilton Depression Rating Scale. Additional secondary measures, including self-report depression scales, fluid cognition, and sleep quality, also showed significant improvement. No serious adverse events occurred during the study. Mild transient headaches were infrequently reported, which are expected side effects of ATBS. CONCLUSION Overall, ATBS treatment was highly effective and well-tolerated in individuals with ASD and co-occurring MDD. The findings support the need for a larger, sham-controlled randomized controlled trial to further evaluate efficacy of ATBS in this population.
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Affiliation(s)
- Elizabeth Blank
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Donald L Gilbert
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Steve W Wu
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Travis Larsh
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Rana Elmaghraby
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Rui Liu
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Elizabeth Smith
- Division of Behavioral Medicine and Child Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Grace Westerkamp
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Yanchen Liu
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Paul S Horn
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Ethan Greenstein
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - John A Sweeney
- Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Craig A Erickson
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Ernest V Pedapati
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
- Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
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Croarkin PE, Zuckerman S, Middleton VJ, Monira N, Kriske J, Bowman J, Kriske J, Donachie N, Downar J. Clinical outcomes in adolescents undergoing sequential bilateral 1 Hz/20 Hz transcranial magnetic stimulation for treatment resistant depression. Brain Stimul 2024; 17:431-433. [PMID: 38570160 DOI: 10.1016/j.brs.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 03/24/2024] [Indexed: 04/05/2024] Open
Affiliation(s)
- Paul E Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA.
| | - Seth Zuckerman
- Salience Timothy J. Kriske Research Institute, Plano, TX, USA
| | | | - Naima Monira
- Salience Timothy J. Kriske Research Institute, Plano, TX, USA
| | | | - Jennifer Bowman
- Salience Timothy J. Kriske Research Institute, Plano, TX, USA
| | - John Kriske
- Salience TMS Neuro Solutions, Plano, TX, USA
| | | | - Jonathan Downar
- Institute of Medical Science and Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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4
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Croarkin PE, Dojnov A, Middleton VJ, Bowman J, Kriske J, Donachie N, Siddiqi SH, Downar J. Accelerated 1 Hz dorsomedial prefrontal transcranial magnetic stimulation for generalized anxiety disorder in adolescents and young adults: A case series. Brain Stimul 2024; 17:269-271. [PMID: 38442801 DOI: 10.1016/j.brs.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 02/28/2024] [Indexed: 03/07/2024] Open
Affiliation(s)
- Paul E Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA; Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA.
| | | | | | | | | | | | - Shan H Siddiqi
- Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, USA
| | - Jonathan Downar
- Institute of Medical Science and Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada.
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Liu J, Shu Y, Wu G, Hu L, Cui H. A neuroimaging study of brain activity alterations in treatment-resistant depression after a dual target accelerated transcranial magnetic stimulation. Front Psychiatry 2024; 14:1321660. [PMID: 38288056 PMCID: PMC10822961 DOI: 10.3389/fpsyt.2023.1321660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 12/13/2023] [Indexed: 01/31/2024] Open
Abstract
In this study, we designed a new transcranial magnetic stimulation (TMS) protocol using a dual-target accelerated transcranial magnetic stimulation (aTMS) for patients with treatment resistant depression (TRD). There are 58 TRD patients were recruited from the Second People's Hospital of Guizhou Province, who were, respectively, received dual-target (real continuous theta burst stimulation (cTBS) at right orbitofrontal cortex (OFC) and real repetitive transcranial magnetic stimulation (rTMS) at left dorsolateral prefrontal cortex (DLPFC)), single- target (sham cTBS at right OFC and real rTMS at left DLPFC), and sham stimulation (sham cTBS at right OFC and sham rTMS at left DLPFC). Resting-state functional magnetic resonance imaging (rs-fMRI) was acquired before and after aTMS treatment to compare characteristics of brain activities by use of amplitude of low-frequency fluctuations (ALFF), fractional low-frequency fluctuations (fALFF) and functional connectivity (FC). At the same time, Hamilton Depression Scale-24 (HAMD24) were conducted to assess the effect. HAMD24 scores reduced significantly in dual group comparing to the single and sham group. Dual-target stimulation decreased not only the ALFF values of right fusiform gyrus (FG) and fALFF values of the left superior temporal gyrus (STG), but also the FC between the right FG and the bilateral middle frontal gyrus (MFG), left triangular part of inferior frontal gyrus (IFG). Higher fALFF value in left STG at baseline may predict better reaction for bilateral arTMS. Dual-targe stimulation can significantly change resting-state brain activities and help to improve depressive symptoms.
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Affiliation(s)
- Jiaoying Liu
- Department of Clinical Medicine, Zunyi Medical University, Zunyi, China
| | - Yanping Shu
- Department of Clinical Medicine, Zunyi Medical University, Zunyi, China
- Department of Psychiatry, The Second People's Hospital of Guizhou Province, Guiyang, China
| | - Gang Wu
- Department of Psychiatry, The Second People's Hospital of Guizhou Province, Guiyang, China
| | - Lingyan Hu
- Department of Psychiatry, The Second People's Hospital of Guizhou Province, Guiyang, China
| | - Hailun Cui
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
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Yuruk D, Ozger C, Garzon JF, Leffler JM, Shekunov J, Vande Voort JL, Zaccariello MJ, Nakonezny PA, Croarkin PE. Sequential bilateral accelerated theta burst stimulation in adolescents with suicidal ideation associated with major depressive disorder: Protocol for a randomized controlled trial. PLoS One 2023; 18:e0280010. [PMID: 37053246 PMCID: PMC10101506 DOI: 10.1371/journal.pone.0280010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 01/26/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Suicide is a leading cause of death in adolescents worldwide. Previous research findings suggest that suicidal adolescents with depression have pathophysiological dorsolateral prefrontal cortex (DLPFC) deficits in γ-aminobutyric acid neurotransmission. Interventions with transcranial magnetic stimulation (TMS) directly address these underlying pathophysiological deficits in the prefrontal cortex. Theta burst stimulation (TBS) is newer dosing approach for TMS. Accelerated TBS (aTBS) involves administering multiple sessions of TMS daily as this dosing may be more efficient, tolerable, and rapid acting than standard TMS. MATERIALS AND METHODS This is a randomized, double-blind, sham-controlled trial of sequential bilateral aTBS in adolescents with major depressive disorder (MDD) and suicidal ideation. Three sessions are administered daily for 10 days. During each session, continuous TBS is administered first to the right DPFC, in which 1,800 pulses are delivered continuously over 120 seconds. Then intermittent TBS is applied to the left DPFC, in which 1,800 pulses are delivered in 2-second bursts and repeated every 10 seconds for 570 seconds. The TBS parameters were adopted from prior research, with 3-pulse, 50-Hz bursts given every 200 ms (at 5 Hz) with an intensity of 80% active motor threshold. The comparison group will receive 3 daily sessions of bilateral sham TBS treatment for 10 days. All participants will receive the standard of care for patients with depression and suicidal ideation including daily psychotherapeutic skill sessions. Long-interval intracortical inhibition (LICI) biomarkers will be measured before and after treatment. Exploratory measures will be collected with TMS and electroencephalography for biomarker development. DISCUSSION This is the first known randomized controlled trial to examine the efficacy of sequential bilateral aTBS for treating suicidal ideation in adolescents with MDD. Results from this study will also provide opportunities to further understand the neurophysiological and molecular mechanisms of suicidal ideation in adolescents. TRIAL REGISTRATION Investigational device exemption (IDE) Number: G200220, ClinicalTrials.gov (ID: NCT04701840). Registered August 6, 2020. https://clinicaltrials.gov/ct2/show/NCT04502758?term=NCT04701840&draw=2&rank=1.
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Affiliation(s)
- Deniz Yuruk
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Can Ozger
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Juan F. Garzon
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jarrod M. Leffler
- Virginia Treatment Center for Children, Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - Julia Shekunov
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, United States of America
- Mayo Clinic Depression Center, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jennifer L. Vande Voort
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, United States of America
- Mayo Clinic Depression Center, Mayo Clinic, Rochester, Minnesota, United States of America
- Mayo Clinic Children’s Research Center, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Michael J. Zaccariello
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, United States of America
- Mayo Clinic Children’s Research Center, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Paul A. Nakonezny
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, Texas, United States of America
| | - Paul E. Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, United States of America
- Mayo Clinic Depression Center, Mayo Clinic, Rochester, Minnesota, United States of America
- Mayo Clinic Children’s Research Center, Mayo Clinic, Rochester, Minnesota, United States of America
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7
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Dantas AM, Sack AT, Bruggen E, Jiao P, Schuhmann T. The functional relevance of right DLPFC and VMPFC in risk-taking behavior. Cortex 2023; 159:64-74. [PMID: 36608421 DOI: 10.1016/j.cortex.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/20/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The prefrontal cortex can be partialized in various anatomical and functional sub regions. Among those regions, both right dorsolateral prefrontal cortex (rDLPFC) and ventromedial prefrontal cortex (VMPFC) have been associated with risk-taking behavior based on neuroimaging studies. Noninvasive brain stimulation (NIBS) studies aiming at demonstrating the functional relevance of neural activity in these areas almost exclusively focused on the rDLPFC, where its experimental stimulation with a (generally) inhibitory protocol lead to a measurable increase in risk-taking behavior due to reduced cognitive control. The functional relevance of VMPFC in risk-taking behavior has not yet been addressed using NIBS, although multiple neuroimaging studies correlate this area's activity with valuation. OBJECTIVE/HYPOTHESIS Here, we used NIBS to investigate the functional relevance of both, the rDLPFC and VMPFC in risk-taking behavior. We hypothesized that, compared to sham stimulation, VMPFC suppression leads to a reduction in risk-taking behavior by reducing the appeal to higher value options and consequently the attractiveness of riskier options, whereas rDLPFC suppression leads to an increase in risk taking, replicating previous findings. METHODS We applied continuous theta burst stimulation (cTBS), a generally inhibitory protocol, to stimulate either VMPFC or DLPFC before the execution of the computerized Maastricht Gambling Task (MGT) in a within-subject design with 30 participants. The MGT allowed the analysis of potential brain region-specific effects of cTBS on risk-taking behavior such as participants' choices of average values, probabilities, and response time. RESULTS cTBS applied to either rDLPFC or VMPFC both led to an increase in risk-taking behavior and in the average value chosen as compared to sham transcranial magnetic stimulation. No effect on the choice of probabilities was found. A significant increase in response time was observed exclusively after suppressing rDLPFC. We speculate that these similar behavioral consequences following cTBS over DLPFC and VMPFC are likely due to the strong anatomical and functional interconnection between both brain regions.
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Affiliation(s)
- Aline M Dantas
- Section Brain Stimulation and Cognition, Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands; Maastricht Brain Imaging Centre, Maastricht University, Maastricht, the Netherlands; Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Brain+Nerve Centre, Maastricht University Medical Centre+ (MUMC+), Maastricht, the Netherlands.
| | - Alexander T Sack
- Section Brain Stimulation and Cognition, Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands; Maastricht Brain Imaging Centre, Maastricht University, Maastricht, the Netherlands; Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Brain+Nerve Centre, Maastricht University Medical Centre+ (MUMC+), Maastricht, the Netherlands.
| | - Elisabeth Bruggen
- Department of Marketing and Supply Chain Management, School of Business and Economics, Maastricht University, Maastricht, the Netherlands.
| | - Peiran Jiao
- Department of Finance, School of Business and Economics, Maastricht University, Maastricht, the Netherlands.
| | - Teresa Schuhmann
- Section Brain Stimulation and Cognition, Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands; Maastricht Brain Imaging Centre, Maastricht University, Maastricht, the Netherlands.
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8
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Benster LL, Weissman CR, Daskalakis ZJ. Suicidal Ideation and Obsessive-Compulsive Disorder: Links and Knowledge. Psychol Res Behav Manag 2022; 15:3793-3807. [PMID: 36573087 PMCID: PMC9789712 DOI: 10.2147/prbm.s368585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Suicidal ideation (SI) is understudied in obsessive-compulsive disorder (OCD). Nonetheless, evidence suggests increased risk for SI in individuals with OCD compared to the general population. Understanding the relationship between SI and OCD involves investigating risk factors associated with SI. Furthering knowledge of links is essential for enhancing outcomes and decreasing experiences of SI through improving treatment interventions. Additionally, increasing awareness of factors that lead SI to suicide attempts (SA) is vital. To best illustrate the current state of knowledge, this scoping review examines risk factors for SI, including symptom profiles or phenotypes, comorbid diagnoses, sociodemographic and lifestyle factors, childhood trauma, and genetic and familial contributions. Important treatment considerations for targeting SI within the context of OCD are detailed with respect to the current evidence for psychotherapy, pharmacology, brain stimulation, and neurosurgery. Gaps in the literature and future directions are identified, broadly with respect to studies examining the treatment of SI within the context of OCD, particular OCD phenotypes, and factors influencing SI in pediatric OCD. Due to the relative novelty of this area of exploration, many unknowns persist regarding onset of SI in OCD, factors contributing to the maintenance of SI in OCD, and relevant treatment protocols. Findings suggest that individuals with previous SI or SA, history of childhood trauma, significant life stress, and psychiatric comorbidities, particularly depression, should be closely monitored and screened for SI.
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Affiliation(s)
- Lindsay L Benster
- Joint Doctoral Program in Clinical Psychology, SDSU/UC San Diego, San Diego, CA, USA,Correspondence: Lindsay L Benster, Joint Doctoral Program in Clinical Psychology, SDSU/UC San Diego, 6363 Alvarado Ct, San Diego, CA, 92120, USA, Tel +1206 230 0707, Email
| | - Cory R Weissman
- Department of Psychiatry, UC San Diego School of Medicine, San Diego, CA, USA
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9
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Wilkening J, Witteler F, Goya-Maldonado R. Suicidality and relief of depressive symptoms with intermittent theta burst stimulation in a sham-controlled randomized clinical trial. Acta Psychiatr Scand 2022; 146:540-556. [PMID: 36163686 DOI: 10.1111/acps.13502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Suicidality is a serious public health problem and is closely associated with the severity of depression. In this work, we examined the effects of accelerated intermittent theta burst stimulation (iTBS) on suicidal status, risk factors for suicide, and severity of depressive symptoms in subjects with major depressive disorder (MDD). METHODS We present data from a quadruple-blind (patient, care provider, investigator, rater) sham-controlled crossover randomized clinical trial. During a 6-week observation period, each participant underwent 2 weeks of stimulation - each week with 20 sessions of active or sham iTBS. A suicide score was created using a composite of individual items from Montgomery-Åsberg Depression Scale (MADRS), Hamilton Depression Scale, and Beck Depression Inventory. The severity of depression was determined by MADRS total scores. In addition, we used demographic and Columbia Suicidality Rating Scale information to assess suicide risk. RESULTS Among 81 participants, we observed a significant reduction in suicidality and this change was positively correlated with a change in depressive symptoms. A significant difference between active and sham iTBS provided evidence for antidepressant effects. Higher changes in levels of anxiety and impulsiviness also correlated with larger changes in suicidality. CONCLUSIONS As neither suicide nor other serious adverse events were evidenced, this intervention was a safe and viable procedure to reduce suicidality and severity of depressive symptoms. Moreover, we identified more pronounced anti-suicidal effects in those with higher risk profiles. Unlike MADRS, composite suicidal scores did not provide evidence of an effect between stimulation conditions in this crossover design study. Even so, based on our promising results, parallel and larger studies could contribute to a better characterization of the anti-suicidal placebo effect and the benefit of using iTBS against suicidal symptoms.
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Affiliation(s)
- Jonas Wilkening
- Laboratory of Systems Neuroscience and Imaging in Psychiatry (SNIP-Lab), Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Göttingen, Germany
| | - Fabian Witteler
- Laboratory of Systems Neuroscience and Imaging in Psychiatry (SNIP-Lab), Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Göttingen, Germany
| | - Roberto Goya-Maldonado
- Laboratory of Systems Neuroscience and Imaging in Psychiatry (SNIP-Lab), Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Göttingen, Germany
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10
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Chammas F, Januel D, Bouaziz N. Inpatient suicide in psychiatric settings: Evaluation of current prevention measures. Front Psychiatry 2022; 13:997974. [PMID: 36386981 PMCID: PMC9650354 DOI: 10.3389/fpsyt.2022.997974] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/05/2022] [Indexed: 12/01/2022] Open
Abstract
The risk of suicide in psychiatric hospitals is 50 times higher than in the general population, despite patient safety being a priority for any hospital. However, to date, due to the complexity of assessing suicide risk, there has been no consensus on the suicide prevention measures that should be in place in hospitals. The aim of this work is: To provide an overview of the progress that has been made in the field of inpatient suicide prevention in recent years; discuss the problems that remain; and suggest potential future developments. As new clinical dimensions (notably anhedonia, psychological pain and hopelessness) develop, they should become new therapeutic targets. Team training (like the Gatekeeper Training Program) and the latest advances in suicide risk assessment (such as the Collaborative Assessment and Management of Suicidality) should be implemented in psychiatric wards. Suicide prevention plans (e.g., ASSIP, SAFE-T, etc.) represent easy-to-administer, low-cost interventions. The Mental Health Environment of Care Checklist has been proven effective to reduce suicide risk at hospitals. Furthermore, the types of psychotherapy recommended to reduce suicide risk are cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). There are several pharmacological treatments for suicide risk, such as lithium and clozapine, which have been shown to be effective in the long term, as well as ketamine and esketamine, which are more effective in the short term. Following some encouraging recent results, buprenorphine may also be proposed to patients with a suicide risk. Triple chronotherapy rapidly improves depressive symptoms over 9 weeks. Regarding brain stimulation techniques, rTMS has proven to be effective in alleviating multiple dimensions of suicidality.
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Affiliation(s)
- Francesca Chammas
- Centre de Recherche Clinique, EPS Ville-Evrard, Neuilly-sur-Marne, France
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11
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Mehta S, Downar J, Mulsant BH, Voineskos D, Daskalakis ZJ, Weissman CR, Vila-Rodriguez F, Blumberger DM. Effect of high frequency versus theta-burst repetitive transcranial magnetic stimulation on suicidality in patients with treatment-resistant depression. Acta Psychiatr Scand 2022; 145:529-538. [PMID: 35188677 PMCID: PMC9007836 DOI: 10.1111/acps.13412] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/08/2022] [Accepted: 02/01/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate the effect of 10 Hz repetitive transcranial magnetic stimulation (rTMS) and intermittent theta-burst stimulation (iTBS) on suicidality in patients with treatment-resistant depression (TRD). METHODS We used data from a three-site randomized clinical trial comparing 10 Hz rTMS and iTBS applied to the left dorsolateral prefrontal cortex (DLPFC) in patients with TRD. We compared the effect of 10Hz rTMS and iTBS on suicidality as measured by the suicide item of the Hamilton Depression Rating Scale 17-item (HDRS-17). RESULTS Suicidality remitted in 71 (43.7%) participants randomized to 10Hz stimulation and 91 (49.1%) participants randomized to iTBS, without a significant difference between the proportions in the two groups (Χ2 = 0.674, df = 1, p = 0.4117). There was a significant correlation between change in suicidality and change in depression severity for both modalities (10 Hz, Pearson's r = 0.564; iTBS, Pearson's r = 0.502), with a significantly larger decrease in depression severity for those in whom suicidality remitted compared to those in whom it did not (t = 10.912, df = 276.8, p < 0.001). CONCLUSIONS Both 10 Hz and iTBS rTMS were effective in reducing suicidality in TRD. Future trials of iTBS for depression should include discrete measures of suicidality.
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Affiliation(s)
- Shobha Mehta
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Ontario, M5J 1H4, Canada,Department of Psychiatry, University of Toronto, Toronto, Ontario, M5T 1R8, Canada
| | - Jonathan Downar
- Department of Psychiatry, University of Toronto, Toronto, Ontario, M5T 1R8, Canada,Centre for Mental Health and Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Benoit H. Mulsant
- Department of Psychiatry, University of Toronto, Toronto, Ontario, M5T 1R8, Canada,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, M5T 1R8, Canada
| | - Daphne Voineskos
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Ontario, M5J 1H4, Canada,Department of Psychiatry, University of Toronto, Toronto, Ontario, M5T 1R8, Canada,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, M5T 1R8, Canada
| | - Zafiris J. Daskalakis
- Department of Psychiatry, University of California San Diego, La Jolla, California, 92093-0021, United States
| | - Cory R. Weissman
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Ontario, M5J 1H4, Canada,Department of Psychiatry, University of Toronto, Toronto, Ontario, M5T 1R8, Canada
| | - Fidel Vila-Rodriguez
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, V6T 1Z4, Canada,Non-Invasive Neurostimulation Therapies (NINET) Laboratory, Vancouver, British Columbia, V6T 2A1, Canada
| | - Daniel M. Blumberger
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Ontario, M5J 1H4, Canada,Department of Psychiatry, University of Toronto, Toronto, Ontario, M5T 1R8, Canada,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, M5T 1R8, Canada
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12
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Konstantinou G, Hui J, Ortiz A, Kaster TS, Downar J, Blumberger DM, Daskalakis ZJ. Repetitive transcranial magnetic stimulation (rTMS) in bipolar disorder: A systematic review. Bipolar Disord 2022; 24:10-26. [PMID: 33949063 DOI: 10.1111/bdi.13099] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Repetitive transcranial magnetic stimulation (rTMS) is commonly used in unipolar depression; yet, its evidence in bipolar disorder (BD) is limited. We sought to review the evidence on the use of rTMS across the different stages of BD. METHODS MEDLINE database was systematically searched using the PubMed interface following the PRISMA guidelines. Inclusion criteria were as follows: (i) randomized clinical trials (RCTs), open-label studies, and case series; (ii) specific evaluation of the treatment outcomes using psychometric scales; (iii) clinical studies in adults; and (iv) articles in the English language. The systematic review has been registered on PROSPERO (CRD42020192788). RESULTS Thirty-one papers were included in the review. Most studies included participants diagnosed with a bipolar depressive episode (N = 24), have yielded mixed findings, and have yet to reach a consensus on the most effective rTMS protocol. Few studies examined the effect of rTMS during manic (N = 5) or mixed episode (N = 1), or as maintenance treatment (N = 1). The limited data thus far suggest rTMS to be relatively safe and well tolerated. Small sample sizes, heterogeneity among study designs, patients and control groups recruited, rTMS parameters, and outcome measures are among the most significant limitations to these studies. CONCLUSION The current data regarding the application of rTMS in BD patients remain limited. More adequately powered sham-controlled studies are required to verify its efficacy. Large-scale clinical trials are needed to also determine whether its effects extend to manic and mixed episodes, as well as its role in mood stabilization and amelioration of suicidal behavior.
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Affiliation(s)
- Gerasimos Konstantinou
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Temerty Centre for Therapeutic Brain Intervention and Campbell Family Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Jeanette Hui
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Abigail Ortiz
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Mood and Anxiety Ambulatory Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Tyler S Kaster
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Temerty Centre for Therapeutic Brain Intervention and Campbell Family Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Jonathan Downar
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Mental Health and Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Daniel M Blumberger
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Temerty Centre for Therapeutic Brain Intervention and Campbell Family Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Zafiris J Daskalakis
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Temerty Centre for Therapeutic Brain Intervention and Campbell Family Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
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13
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Chen GW, Hsu TW, Ching PY, Pan CC, Chou PH, Chu CS. Efficacy and Tolerability of Repetitive Transcranial Magnetic Stimulation on Suicidal Ideation: A Systemic Review and Meta-Analysis. Front Psychiatry 2022; 13:884390. [PMID: 35599760 PMCID: PMC9120615 DOI: 10.3389/fpsyt.2022.884390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/14/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in treating suicidal ideation in patients with mental illness. METHOD We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Major electronic databases were systematically searched from the time of their inception until July 22, 2021. The primary outcome was the mean change in the scores for suicidal ideation. The secondary outcome was the mean change in depression severity. RESULTS Ten randomized controlled trials were eligible with 415 participants in the active treatment group (mean age = 53.78 years; mean proportion of women = 54.5%) and 387 participants in the control group (mean age = 55.52 years; mean proportion of women = 51.78%). rTMS significantly reduced suicidal ideation (k = 10, n = 802, Hedges' g = -0.390, 95% confidence interval [CI] = -0.193 to -0.588, p <.001) and severity of depressive symptoms (k = 9, n = 761, Hedges' g = -0.698, 95% CI = -1.023 to -0.372, p < 0.001) in patients with major mental disorders. In the subgroup analysis, rTMS reduced suicidal ideation among patients with non-treatment-resistant depression (non-TRD) (-0.208) but not in those with TRD. rTMS as combination therapy had a larger effect than did monotherapy (-0.500 vs. -0.210). Suicidal ideation significantly reduced in patients receiving more than ten treatment sessions (-0.255). Importantly, the rTMS group showed favorable tolerability without major adverse events. CONCLUSION The study showed that rTMS was effective and well-tolerated in reducing suicidal ideation and depression severity in patients with major mental disorders.
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Affiliation(s)
- Guan-Wei Chen
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Tien-Wei Hsu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Pao-Yuan Ching
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Chuan Pan
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Po-Han Chou
- Department of Psychiatry, China Medical University Hsinchu Hospital, China Medical University, Hsinchu, Taiwan
| | - Che-Sheng Chu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Center for Geriatric and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Non-invasive Neuromodulation Consortium for Mental Disorders, Society of Psychophysiology, Taipei, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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14
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Godi SM, Spoorthy MS, Purushotham A, Tikka SK. Repetitive transcranial magnetic stimulation and its role in suicidality - A systematic review. Asian J Psychiatr 2021; 63:102755. [PMID: 34284199 DOI: 10.1016/j.ajp.2021.102755] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/28/2021] [Accepted: 07/07/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) as a brain stimulation modality is approved for the treatment of resistant depression and its efficacy in depression is also well supported in several studies. However, its effect on suicidality is still unclear, unlike electroconvulsive therapy. METHODOLOGY This paper provides a systematic review of the literature published till June 2021. Studies that used rTMS as either monotherapy or adjunctive treatment in patients with suicidality, irrespective of their diagnosis, were included. The Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines was followed. A total of 20 studies (N = 1584) were included for the qualitative synthesis. The quality of studies was assessed using the Cochrane Risk of Bias tool for Randomised control trials (RCT) and the Newcastle-Ottawa Scale tool for Non-Randomised studies (NRS). RESULTS Of the 20 articles selected for qualitative synthesis, 11 were RCTs and 9 were NRS. The results are categorized in domains of type of the study, size of population, type of population, diagnosis, assessment scales, mode of rTMS, stimulus parameters, safety and efficacy. CONCLUSIONS The high frequency rTMS at left dorsolateral prefrontal cortex as an adjunct to antidepressant medication is promising in reducing suicidal behaviour in treatment resistant depression. However, role of TMS targeting other areas of stimulation in mitigating suicide risk in other disorders could not be established due to scarcity of such studies. The results should be interpreted cautiously as considerable risk of bias was present in the reviewed studies.
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Affiliation(s)
- Sangha Mitra Godi
- Department of Psychiatry, All India Institute of Medical Sciences, Raipur, India.
| | | | - A Purushotham
- Department of Psychiatry, All India Institute of Medical Sciences, Raipur, India.
| | - Sai Krishna Tikka
- Department of Psychiatry, All India Institute of Medical Sciences, Bibinagar, Hyderabad, India.
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15
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Barredo J, Berlow Y, Swearingen HR, Greenberg BD, Carpenter LL, Philip NS. Multimodal Elements of Suicidality Reduction After Transcranial Magnetic Stimulation. Neuromodulation 2021; 24:930-937. [PMID: 33650209 PMCID: PMC8295183 DOI: 10.1111/ner.13376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/15/2021] [Accepted: 02/01/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Repetitive transcranial magnetic stimulation (TMS) is a promising treatment for suicidality, but it is underlying neural mechanisms remain poorly understood. Our prior findings indicated that frontostriatal functional connectivity correlates with the severity of suicidal thoughts and behaviors. In this secondary analysis of data from an open label trial, we evaluated whether changes in frontostriatal functional connectivity would accompany suicidality reductions following TMS. We also explored the relationship between frontostriatal connectivity change and underlying white matter (WM) organization. MATERIALS AND METHODS We conducted seed-based functional connectivity analysis on participants (N = 25) with comorbid post-traumatic stress disorder and depression who received eight weeks of 5 Hz TMS to left dorsolateral prefrontal cortex. We measured clinical symptoms with the Inventory of Depressive Symptomatology-Self Report (IDS-SR) and the PTSD Checklist for DSM-5 (PCL-5). We derived suicidality from IDS-SR item 18. Magnetic resonance imaging data were collected before TMS, and at treatment end point. These data were entered into analyses of covariance, evaluating the effect of suicidality change across treatment on striatal and thalamic functional connectivity. Changes in other PTSD and depression symptoms were included as covariates and results were corrected for multiple comparisons. Diffusion connectometry in a participant subsample (N = 17) explored the relationship between frontal WM integrity at treatment baseline and subsequent functional connectivity changes correlated with differences in suicidality. RESULTS Suicidal ideation decreased in 65% of participants. Reductions in suicidality and functional connectivity between the dorsal striatum and frontopolar cortex were correlated (p-False Discover Rate-corrected < 0.001), after covariance for clinical symptom change. All other results were nonsignificant. Our connectometry results indicated that the integrity of frontostriatal WM may circumscribe functional connectivity response to TMS for suicide. CONCLUSIONS Targeted reduction of fronto-striatal connectivity with TMS may be a promising treatment for suicidality. Future research can build on this multimodal approach to advance individualized stimulation approaches in high-risk patients.
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Affiliation(s)
- Jennifer Barredo
- Department of Psychiatry and Human Behavior, Alpert Medical SchoolBrown UniversityProvidenceRIUSA
- Center for Neurorestoration and Neurotechnology, Providence VA Medical CenterProvidenceRIUSA
- COBRE Center for Neuromodulation at Butler HospitalProvidenceRIUSA
| | - Yosef Berlow
- Department of Psychiatry and Human Behavior, Alpert Medical SchoolBrown UniversityProvidenceRIUSA
- Center for Neurorestoration and Neurotechnology, Providence VA Medical CenterProvidenceRIUSA
| | - Hannah R. Swearingen
- Center for Neurorestoration and Neurotechnology, Providence VA Medical CenterProvidenceRIUSA
| | - Benjamin D. Greenberg
- Department of Psychiatry and Human Behavior, Alpert Medical SchoolBrown UniversityProvidenceRIUSA
- Center for Neurorestoration and Neurotechnology, Providence VA Medical CenterProvidenceRIUSA
- COBRE Center for Neuromodulation at Butler HospitalProvidenceRIUSA
| | - Linda L. Carpenter
- Department of Psychiatry and Human Behavior, Alpert Medical SchoolBrown UniversityProvidenceRIUSA
- COBRE Center for Neuromodulation at Butler HospitalProvidenceRIUSA
| | - Noah S. Philip
- Department of Psychiatry and Human Behavior, Alpert Medical SchoolBrown UniversityProvidenceRIUSA
- Center for Neurorestoration and Neurotechnology, Providence VA Medical CenterProvidenceRIUSA
- COBRE Center for Neuromodulation at Butler HospitalProvidenceRIUSA
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16
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Kucuker MU, Almorsy AG, Sonmez AI, Ligezka AN, Doruk Camsari D, Lewis CP, Croarkin PE. A Systematic Review of Neuromodulation Treatment Effects on Suicidality. Front Hum Neurosci 2021; 15:660926. [PMID: 34248523 PMCID: PMC8267816 DOI: 10.3389/fnhum.2021.660926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/17/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction: Neuromodulation is an important group of therapeutic modalities for neuropsychiatric disorders. Prior studies have focused on efficacy and adverse events associated with neuromodulation. Less is known regarding the influence of neuromodulation treatments on suicidality. This systematic review sought to examine the effects of various neuromodulation techniques on suicidality. Methods: A systematic review of the literature from 1940 to 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was conducted. Any reported suicide-related outcome, including suicidal ideation, suicide intent, suicide attempt, completed suicide in reports were considered as a putative measure of treatment effect on suicidality. Results: The review identified 129 relevant studies. An exploratory analysis of a randomized controlled trial comparing the effects of sertraline and transcranial direct-current stimulation (tDCS) for treating depression reported a decrease in suicidal ideation favoring tDCS vs. placebo and tDCS combined with sertraline vs. placebo. Several studies reported an association between repetitive transcranial magnetic stimulation and improvements in suicidal ideation. In 12 of the studies, suicidality was the primary outcome, ten of which showed a significant improvement in suicidal ideation. Electroconvulsive therapy (ECT) and magnetic seizure therapy was also shown to be associated with lower suicidal ideation and completed suicide rates. There were 11 studies which suicidality was the primary outcome and seven of these showed an improvement in suicidal ideation or suicide intent and fewer suicide attempts or completed suicides in patients treated with ECT. There was limited literature focused on the potential protective effect of vagal nerve stimulation with respect to suicidal ideation. Data were mixed regarding the potential effects of deep brain stimulation on suicidality. Conclusions: Future prospective studies of neuromodulation that focus on the primary outcome of suicidality are urgently needed. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=125599, identifier: CRD42019125599.
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Affiliation(s)
- Mehmet Utku Kucuker
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Ammar G. Almorsy
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Ayse Irem Sonmez
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, United States
| | - Anna N. Ligezka
- Department of Clinical Genomics, Mayo Clinic, Rochester, MN, United States
| | - Deniz Doruk Camsari
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Charles P. Lewis
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, United States
| | - Paul E. Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
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17
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Predictors of change in suicidal ideation across treatment phases of major depressive disorder: analysis of the STAR*D data. Neuropsychopharmacology 2021; 46:1293-1299. [PMID: 33479508 PMCID: PMC7819691 DOI: 10.1038/s41386-020-00953-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 12/19/2022]
Abstract
The effects of common antidepressants on suicidal ideation (SI) is unclear. In the landmark STAR*D trial antidepressants were effective for Major Depressive Disorder (MDD) in early treatment phases, but less effective in later phases. The effects of antidepressants on SI across the entire sample of the STAR*D trial has never been investigated. We performed a secondary analysis of the STAR*D data with the primary outcome of change in score on the suicide item (item three) of the Hamilton Rating Scale for Depression (HRSD17) across all four study levels. We used descriptive statistics and logistic regression analyses. Pearson correlation was used for change in SI versus change in depression (HRSD16). Reduction in mean (SD) SI was greater in levels one: 0.29 (±0.78) (p < 0.001) and two: 0.26 (±0.88) (p < 0.001) than in levels three: 0.16 (±0.92) (p = 0.005) and four: 0.18 (±0.93) (p = 0.094). A history of past suicide attempts (OR 1.72, p = 0.007), comorbid medical illness (OR 2.23, p = 0.005), and a family history of drug abuse (OR 1.69, p = 0.008) were correlated with worsening of SI across level one. Treatment with bupropion (OR 0.24, p < 0.001) or buspirone (OR 0.24, p = 0.001) were correlated with lowering of SI across level two. Improvement in SI was correlated with improvement in overall depression (HRSD16) at level one: r(3756) = 0.48; level two: r(1027) = 0.38; level three: r(249) = 0.31; and level four: r(75) = 0.42 (p < 0.001 for all levels). Improvement in SI is limited with pharmacotherapy in patients with treatment-resistant depression. Treatments with known anti-suicidal effects in MDD, such as ECT, should be considered in these patients.
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18
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Chen Y, Magnin C, Brunelin J, Leaune E, Fang Y, Poulet E. Can seizure therapies and noninvasive brain stimulations prevent suicidality? A systematic review. Brain Behav 2021; 11:e02144. [PMID: 33838000 PMCID: PMC8119823 DOI: 10.1002/brb3.2144] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/13/2021] [Accepted: 03/17/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Suicide is a major public health issue and the majority of those who attempt suicide suffer from mental disorders. Beyond psychopharmacotherapy, seizure therapies and noninvasive brain stimulation interventions have been used to treat such patients. However, the effect of these nonpharmacological treatments on the suicidal ideation and incidence of suicidality remains unclear. Here, we aimed to provide an update on the effects of seizure therapies and noninvasive brain stimulation on suicidality. METHODS We conducted a systematic review of the literature in the PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Elsevier ScienceDirect, and Wiley Online Library databases using the MeSH terms "Electroconvulsive Therapy", "Magnetic Seizure Stimulation", "repetitive Transcranial Magnetic Stimulation", "transcranial Direct Current Stimulation", "Cranial Electrostimulation" and "suicide". We included studies using seizure therapies and noninvasive brain stimulation as a main intervention that evaluated suicidality, regardless of diagnosis. RESULTS Among 1,019 records screened, 26 studies met the inclusion criteria using either electroconvulsive therapy (n = 14), magnetic seizure therapy (n = 2), repetitive transcranial magnetic stimulation (n = 9), or transcranial direct current stimulation (n = 1). We observed that studies reported significant results, suggesting these techniques can be effective on the suicidal dimension of mental health pathologies, but a general statement regarding their efficacy is premature due to limitations. CONCLUSIONS Future enquiry is necessary to address methodological limitations and evaluate the long-term efficacy of these methods both alone and in combination with pharmacotherapy and/or psychotherapy.
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Affiliation(s)
- Yiming Chen
- Shanghai Mental Health CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Charline Magnin
- Department of Emergency PsychiatryEdouard Herriot HospitalHospices Civils de LyonLyonFrance
| | - Jérome Brunelin
- INSERM U1028, CNRS UMR5292Lyon Neuroscience Research Center, PSYR2 TeamUniversity of Lyon, CH Le VinatierLyonFrance
| | - Edouard Leaune
- INSERM U1028, CNRS UMR5292Lyon Neuroscience Research Center, PSYR2 TeamUniversity of Lyon, CH Le VinatierLyonFrance
| | - Yiru Fang
- Shanghai Mental Health CenterShanghai Jiao Tong University School of MedicineShanghaiChina
- CAS Center for Excellence in Brain Science and Intelligence TechnologyShanghaiChina
- Shanghai Key Laboratory of Psychotic disordersShanghaiChina
| | - Emmanuel Poulet
- Department of Emergency PsychiatryEdouard Herriot HospitalHospices Civils de LyonLyonFrance
- INSERM U1028, CNRS UMR5292Lyon Neuroscience Research Center, PSYR2 TeamUniversity of Lyon, CH Le VinatierLyonFrance
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19
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Serafini G, Canepa G, Aguglia A, Amerio A, Bianchi D, Magnani L, Dell'Osso B, Pompili M, Fitzgerald PB, Amore M. Effects of repetitive transcranial magnetic stimulation on suicidal behavior: A systematic review. Prog Neuropsychopharmacol Biol Psychiatry 2021; 105:109981. [PMID: 32485190 DOI: 10.1016/j.pnpbp.2020.109981] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/20/2020] [Accepted: 05/20/2020] [Indexed: 01/29/2023]
Abstract
The efficacy and tolerability of repetitive transcranial magnetic stimulation (rTMS) in major depression is well-known and documented by existing studies. However, whether rTMS may be effective on suicidal behavior is unclear and needs to be further investigated. This systematic review is aimed to investigate the available literature about the effects of rTMS on suicidal behavior and provide a comprehensive overview of the available evidence. A systematic search regarding the association between rTMS and suicidal behavior was carried out. All relevant articles concerning this association were comprehensively searched on PubMed, Scopus, Science Direct, and PsycInfo databases. After a careful search, 16 articles (7 sham-controlled studies, 5 uncontrolled studies, 4 case-series) met inclusion criteria and were selected in this systematic review. Overall, the left dorsolateral prefrontal cortex (DLPFC) was identified as the most frequent stimulation target by most studies. Unfortunately, actually it is not clear whether suicidal behavior reduction may be mediated, at least in some cases, by depression attenuation. While some methodological heterogeneity was found in terms of stimulation parameters (e.g., frequency, number of sessions, intensity of stimulation), most of the analyzed articles showed that rTMS is a safe, applicable, well tolerated and reproducible method in treating suicidal behavior. The most effective treatment seems to be the bilateral rTMS as well as the combination with antidepressants. Further longitudinal studies are required in order to replicate the mentioned study results.
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Affiliation(s)
- Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Giovanna Canepa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Aguglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Amerio
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Mood Disorders Program, Tufts Medical Center, Boston, MA 02111, USA
| | - Davide Bianchi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Luca Magnani
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Bernardo Dell'Osso
- Department of Mental Health, Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy; Department of Psychiatry and Behavioral Sciences, Bipolar Disorders Clinic, Stanford University, CA, USA; CRC "Aldo Ravelli" Center for Neurotechnology and Brain Therapeutic, University of Milan, Milan, Italy; Centro per lo studio dei meccanismi molecolari alla base delle patologie neuro-psico-geriatriche, University of Milan, Italy
| | - Maurizio Pompili
- Department of Neurosciences, Suicide Prevention Center, Sant'Andrea Hospital, University of Rome, Rome, Italy
| | - Paul B Fitzgerald
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Monash Universitty Department of Psychiatry, Camberwell, VIC, Australia
| | - Mario Amore
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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20
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Khazanov GK, Xu C, Hollon SD, DeRubeis RJ, Thase ME. Adding cognitive therapy to antidepressant medications decreases suicidal ideation. J Affect Disord 2021; 281:183-191. [PMID: 33326891 PMCID: PMC7855962 DOI: 10.1016/j.jad.2020.12.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/19/2020] [Accepted: 12/05/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Psychotherapy for depression and antidepressant medications have both been associated with decreases in suicidal ideation. Studies have not examined whether adding psychotherapy to antidepressant medications further reduces suicidal ideation relative to medications alone in adults. METHODS Participants (N = 452) were randomized to 7 months of treatment with antidepressant medications or combined treatment with both medications and cognitive therapy for depression. We examined change in the suicide items from the Beck Depression Inventory (BDI) and Hamilton Depression Rating Scale (HDRS) across treatment using Bayesian generalized linear mixed models for non-continuous outcomes. RESULTS Suicidal ideation decreased across treatment. When measured with the BDI, participants receiving both cognitive therapy and antidepressant medications showed 17% greater reductions in suicidal ideation relative to those receiving medications alone; this effect remained significant when controlling for depression severity. While the same pattern was observed when suicidal ideation was measured with the HDRS, the effect was smaller (7%) and not statistically significant. When BDI and HDRS scores were combined, participants receiving both therapy and medications showed 9% greater reductions in suicidal ideation relative to those receiving medications alone; this effect was marginally significant when controlling for depression severity. LIMITATIONS This is a secondary analysis of a randomized clinical trial designed to treat depression, in which suicidal ideation was assessed using single-item measures. CONCLUSIONS Adding cognitive therapy to antidepressant medications may reduce suicidal ideation to a greater extent than medications alone. Pending replication, combination treatment may be preferred for individuals with suicidal ideation. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00057577.
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Affiliation(s)
- Gabriela K Khazanov
- Mental Illness Research, Education, and Clinical Center of the Veterans Integrated Service Network 4, Crescenz Veterans Affairs Medical Center.
| | - Colin Xu
- Department of Psychology, University of Pennsylvania
| | | | | | - Michael E Thase
- Mental Illness Research, Education, and Clinical Center of the Veterans Integrated Service Network 4, Crescenz Veterans Affairs Medical Center
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21
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Cui Y, Fang H, Bao C, Geng W, Yu F, Li X. Efficacy of Transcranial Magnetic Stimulation for Reducing Suicidal Ideation in Depression: A Meta-Analysis. Front Psychiatry 2021; 12:764183. [PMID: 35115959 PMCID: PMC8803905 DOI: 10.3389/fpsyt.2021.764183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/20/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES This study aimed to systematically review the efficacy of transcranial magnetic stimulation treatment in reducing suicidal ideation in depression. METHODS PubMed, Web of Science, CBMdisc, WanFang, Chongqing VIP, and CNKI databases were electronically searched for randomized controlled trials of transcranial magnetic stimulation (TMS) intervention in the management of suicidal ideation from inception to February 24, 2021. Two reviewers independently screened studies, extracted data, and assessed the quality of included studies. Meta-analysis was then performed using STATA 15.1 software. RESULTS A total of eight articles involving 566 patients were included. The meta-analysis results showed that the suicidal ideation scores of the group who received TMS treatment were significantly lower [standardized mean difference (SMD) = -0.415, 95% confidence interval (CI): -0.741 to -0.090, P = 0.012] than those of the control group. Subgroup analysis showed that age, TMS pattern, frequency of intervention, and stimulation threshold altered the TMS efficacy. CONCLUSIONS Evidence showed that TMS achieved superior results in reducing suicidal ideation. Because of the limited quality and quantity of the included studies, more high-quality studies are required to verify the conclusions. SYSTEMATIC REVIEW REGISTRATION https://inplasy.com/, identifier: INPLASY202180065.
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Affiliation(s)
- Yanan Cui
- School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
| | - Haijian Fang
- School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
| | - Cui Bao
- School of the First College for Clinical Medicine, Anhui Medical University, Hefei, China
| | - Wanyue Geng
- School of the First College for Clinical Medicine, Anhui Medical University, Hefei, China
| | - Fengqiong Yu
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Department of Mental Health and Psychological Science, The Second Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
| | - Xiaoming Li
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Department of Mental Health and Psychological Science, The Second Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
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22
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Rossi S, Antal A, Bestmann S, Bikson M, Brewer C, Brockmöller J, Carpenter LL, Cincotta M, Chen R, Daskalakis JD, Di Lazzaro V, Fox MD, George MS, Gilbert D, Kimiskidis VK, Koch G, Ilmoniemi RJ, Lefaucheur JP, Leocani L, Lisanby SH, Miniussi C, Padberg F, Pascual-Leone A, Paulus W, Peterchev AV, Quartarone A, Rotenberg A, Rothwell J, Rossini PM, Santarnecchi E, Shafi MM, Siebner HR, Ugawa Y, Wassermann EM, Zangen A, Ziemann U, Hallett M. Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clin Neurophysiol 2021; 132:269-306. [PMID: 33243615 PMCID: PMC9094636 DOI: 10.1016/j.clinph.2020.10.003] [Citation(s) in RCA: 512] [Impact Index Per Article: 170.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 12/11/2022]
Abstract
This article is based on a consensus conference, promoted and supported by the International Federation of Clinical Neurophysiology (IFCN), which took place in Siena (Italy) in October 2018. The meeting intended to update the ten-year-old safety guidelines for the application of transcranial magnetic stimulation (TMS) in research and clinical settings (Rossi et al., 2009). Therefore, only emerging and new issues are covered in detail, leaving still valid the 2009 recommendations regarding the description of conventional or patterned TMS protocols, the screening of subjects/patients, the need of neurophysiological monitoring for new protocols, the utilization of reference thresholds of stimulation, the managing of seizures and the list of minor side effects. New issues discussed in detail from the meeting up to April 2020 are safety issues of recently developed stimulation devices and pulse configurations; duties and responsibility of device makers; novel scenarios of TMS applications such as in the neuroimaging context or imaging-guided and robot-guided TMS; TMS interleaved with transcranial electrical stimulation; safety during paired associative stimulation interventions; and risks of using TMS to induce therapeutic seizures (magnetic seizure therapy). An update on the possible induction of seizures, theoretically the most serious risk of TMS, is provided. It has become apparent that such a risk is low, even in patients taking drugs acting on the central nervous system, at least with the use of traditional stimulation parameters and focal coils for which large data sets are available. Finally, new operational guidelines are provided for safety in planning future trials based on traditional and patterned TMS protocols, as well as a summary of the minimal training requirements for operators, and a note on ethics of neuroenhancement.
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Affiliation(s)
- Simone Rossi
- Department of Scienze Mediche, Chirurgiche e Neuroscienze, Unit of Neurology and Clinical Neurophysiology, Brain Investigation and Neuromodulation Lab (SI-BIN Lab), University of Siena, Italy.
| | - Andrea Antal
- Department of Clinical Neurophysiology, University Medical Center, Georg-August University of Goettingen, Germany; Institue of Medical Psychology, Otto-Guericke University Magdeburg, Germany
| | - Sven Bestmann
- Department of Movement and Clinical Neurosciences, UCL Queen Square Institute of Neurology, London, UK and Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London, UK
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York, New York, NY, USA
| | - Carmen Brewer
- National Institute on Deafness and Other Communication Disorders, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Jürgen Brockmöller
- Department of Clinical Pharmacology, University Medical Center, Georg-August University of Goettingen, Germany
| | - Linda L Carpenter
- Butler Hospital, Brown University Department of Psychiatry and Human Behavior, Providence, RI, USA
| | - Massimo Cincotta
- Unit of Neurology of Florence - Central Tuscany Local Health Authority, Florence, Italy
| | - Robert Chen
- Krembil Research Institute and Division of Neurology, Department of Medicine, University of Toronto, Canada
| | - Jeff D Daskalakis
- Center for Addiction and Mental Health (CAMH), University of Toronto, Canada
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico, Roma, Italy
| | - Michael D Fox
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Mark S George
- Medical University of South Carolina, Charleston, SC, USA
| | - Donald Gilbert
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Vasilios K Kimiskidis
- Laboratory of Clinical Neurophysiology, Aristotle University of Thessaloniki, AHEPA University Hospital, Greece
| | | | - Risto J Ilmoniemi
- Department of Neuroscience and Biomedical Engineering (NBE), Aalto University School of Science, Aalto, Finland
| | - Jean Pascal Lefaucheur
- EA 4391, ENT Team, Faculty of Medicine, Paris Est Creteil University (UPEC), Créteil, France; Clinical Neurophysiology Unit, Henri Mondor Hospital, Assistance Publique Hôpitaux de Paris, (APHP), Créteil, France
| | - Letizia Leocani
- Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS-San Raffaele Hospital, Vita-Salute San Raffaele University, Milano, Italy
| | - Sarah H Lisanby
- National Institute of Mental Health (NIMH), National Institutes of Health (NIH), Bethesda, MD, USA; Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Carlo Miniussi
- Center for Mind/Brain Sciences - CIMeC, University of Trento, Rovereto, Italy
| | - Frank Padberg
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Alvaro Pascual-Leone
- Hinda and Arthur Marcus Institute for Aging Research and Center for Memory Health, Hebrew SeniorLife, USA; Department of Neurology, Harvard Medical School, Boston, MA, USA; Guttmann Brain Health Institut, Institut Guttmann, Universitat Autonoma Barcelona, Spain
| | - Walter Paulus
- Department of Clinical Neurophysiology, University Medical Center, Georg-August University of Goettingen, Germany
| | - Angel V Peterchev
- Departments of Psychiatry & Behavioral Sciences, Biomedical Engineering, Electrical & Computer Engineering, and Neurosurgery, Duke University, Durham, NC, USA
| | - Angelo Quartarone
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Alexander Rotenberg
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - John Rothwell
- Department of Movement and Clinical Neurosciences, UCL Queen Square Institute of Neurology, London, UK and Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London, UK
| | - Paolo M Rossini
- Department of Neuroscience and Rehabilitation, IRCCS San Raffaele-Pisana, Roma, Italy
| | - Emiliano Santarnecchi
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mouhsin M Shafi
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Hartwig R Siebner
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark; Department of Neurology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark; Institute for Clinical Medicine, Faculty of Medical and Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Yoshikatzu Ugawa
- Department of Human Neurophysiology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Eric M Wassermann
- National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Abraham Zangen
- Zlotowski Center of Neuroscience, Ben Gurion University, Beer Sheva, Israel
| | - Ulf Ziemann
- Department of Neurology & Stroke, and Hertie-Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA.
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Weissman CR, Blumberger DM, Dimitrova J, Throop A, Voineskos D, Downar J, Mulsant BH, Rajji TK, Fitzgerald PB, Daskalakis ZJ. Magnetic Seizure Therapy for Suicidality in Treatment-Resistant Depression. JAMA Netw Open 2020; 3:e207434. [PMID: 32809030 PMCID: PMC7435344 DOI: 10.1001/jamanetworkopen.2020.7434] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/01/2020] [Indexed: 11/14/2022] Open
Abstract
Importance There is an unmet need for effective treatments for suicidality in mental disorders. Magnetic seizure therapy (MST) has been investigated as an alternative to electroconvulsive therapy, a known effective treatment for suicidality, in the management of treatment-resistant major depressive disorder, with promising findings. Yet, there are very limited data on the association of MST with suicidality directly. It is important to explore the potential of MST as a viable treatment alternative to electroconvulsive therapy for suicidality. Objective To determine the association of MST with suicidality in patients with treatment-resistant major depressive disorder. Design, Setting, and Participants This nonrandomized controlled trial took place at a single tertiary care psychiatric facility in Canada. It followed an open-label study design with consecutive treatment cohorts. Consecutive groupings of 67 patients with treatment-resistant major depressive disorder and with baseline suicidality present were treated for up to 24 treatments. The study was run from February 2012 through June 2019. Patients were followed up for 6 months at the end of the treatment period. This post hoc secondary analysis of the trial was performed from January to November 2019. Interventions MST was delivered at 100% stimulator output over the prefrontal cortex with low (25 Hz), moderate (50 or 60 Hz), or high (100 Hz) frequency, for a maximum of 24 sessions. Main Outcomes and Measures Remission from suicidality was measured as an end point score of 0 on the Beck Scale for Suicidal Ideation. A linear mixed model was used to assess the trajectory of Beck Scale for Suicidal Ideation scores. Results A total of 67 patients (mean [SD] age, 46.3 [13.6] years; 40 women [60.0%]) received a mean (SD) of 19.5 (5.1) MST treatments. The overall number of patients achieving remission was 32 (47.8%). Sixteen patients (55.2%) receiving low-frequency MST achieved remission, as well as 12 patients (54.5%) in the moderate-frequency group, and 4 patients (25.0%) in the high-frequency group. The linear mixed model revealed an association of time with Beck Scale for Suicidal Ideation scores (F8,293.95 = 5.73; P < .001). Conclusions and Relevance These findings suggest that MST may be an effective treatment for suicidality, and sensitivity analysis shows this may be particularly so at low and moderate frequencies. Future studies should directly compare MST with electroconvulsive therapy for treating suicidality and should evaluate MST as a treatment for suicidality across mental disorders. Trial Registration ClinicalTrials.gov Identifier: NCT01596608.
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Affiliation(s)
- Cory R. Weissman
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Daniel M. Blumberger
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Julia Dimitrova
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Alanah Throop
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Daphne Voineskos
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Downar
- Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Benoit H. Mulsant
- Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Tarek K. Rajji
- Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Paul B. Fitzgerald
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Monash University Department of Psychiatry, Camberwell, Victoria, Australia
| | - Zafiris J. Daskalakis
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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24
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Bozzay ML, Primack J, Barredo J, Philip NS. Transcranial magnetic stimulation to reduce suicidality - A review and naturalistic outcomes. J Psychiatr Res 2020; 125:106-112. [PMID: 32251917 PMCID: PMC7197489 DOI: 10.1016/j.jpsychires.2020.03.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/14/2020] [Accepted: 03/26/2020] [Indexed: 02/07/2023]
Abstract
Although there is growing interest in the use of repetitive Transcranial Magnetic Stimulation (TMS) as a treatment for suicidality, efficacy data in this area, and knowledge of potential treatment mechanisms, remains limited. The first objective of this study was to systematically review clinical trial data examining the effectiveness of TMS as a treatment for suicidal ideation. Our secondary objective was to investigate the extent to which changes in suicidality are independent of improvements in depression in a clinical sample of veterans who received TMS treatment. In Study 1, we searched the Pubmed and biRxiv databases from inception until July 2019 to identify studies that examined the efficacy of TMS for suicidal thoughts and/or behaviors. Data regarding sample characteristics, treatment parameters, and results were synthesized from six randomized controlled trials and five unblinded trials (total n = 593). Our systematic review indicated that while TMS was consistently associated with reduced depression, its impact on suicidality is unclear. Interpretation of results related to suicidality were complicated by study design elements and modest sample sizes. In Study 2, we conducted a retrospective analysis of 43 patients who received care for depression in a neuromodulation clinic at a Veteran's Affairs hospital. Results found significant decreases in suicidal ideation, and depressive symptom change did not always account for improvements in ideation. Taken together, our literature review and clinic study indicate preliminary promise of TMS for suicide, and underscore the need for more fine-grained, suicide-specific TMS research.
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Affiliation(s)
- Melanie L Bozzay
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence RI USA
- VA RR&D Center for Neurorestoration and Neurotechnology, Providence VA Medical Center, Providence RI USA
| | - Jennifer Primack
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence RI USA
- VA RR&D Center for Neurorestoration and Neurotechnology, Providence VA Medical Center, Providence RI USA
- Address correspondence to: Noah S. Philip, M.D. ; Telephone: + 1 (401) 273-7100 x2369. Providence VA Medical Center, 830 Chalkstone Boulevard, Providence, Rhode Island 02908, United States
| | - Jennifer Barredo
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence RI USA
- VA RR&D Center for Neurorestoration and Neurotechnology, Providence VA Medical Center, Providence RI USA
- Address correspondence to: Noah S. Philip, M.D. ; Telephone: + 1 (401) 273-7100 x2369. Providence VA Medical Center, 830 Chalkstone Boulevard, Providence, Rhode Island 02908, United States
| | - Noah S. Philip
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence RI USA
- VA RR&D Center for Neurorestoration and Neurotechnology, Providence VA Medical Center, Providence RI USA
- Address correspondence to: Noah S. Philip, M.D. ; Telephone: + 1 (401) 273-7100 x2369. Providence VA Medical Center, 830 Chalkstone Boulevard, Providence, Rhode Island 02908, United States
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25
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Ozcan S, Gica S, Gulec H. Suicidal behavior in treatment resistant major depressive disorder patients treated with transmagnetic stimulation(TMS) and its relationship with cognitive functions. Psychiatry Res 2020; 286:112873. [PMID: 32114209 DOI: 10.1016/j.psychres.2020.112873] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 02/10/2020] [Accepted: 02/18/2020] [Indexed: 12/28/2022]
Abstract
The aim of this study is to investigate the effects of rTMS treatment on suicidal thoughts/behaviors and to determine the cognitive mechanisms underlying the effects of rTMS treatment on suicidal thoughts/behaviors in treatment-resistant depression(TRD). Thirty patients with TRD received rTMS 5 sessions per week for 4-6 weeks. Montgomery-Asberg Depression Rating Scale(MADRS), Columbia Suicide Severity Rating Scale(C-SSRS), Suicidal Ideation Scale(SIS), Beck Hopelessness Scale(BHS) and Cambridge Neuropsychological Test Automated Battery(CANTAB) were administered before and after treatment. After rTMS treatment, there was a significant decrease in depressive complaints and suicidal thoughts and improvement in emotional recognition. However, there was no significant change in cognitive functions such as cognitive flexibility, motor response inhibition and decision making. Pre-treatment decision-making and flexible thinking skills were related to the change in suicidal ideation. In TRD patients, rTMS has a positive effect on depressive symptoms and suicidal thoughts/behaviors and emotion recognition abilities. Although there is no negative effect on other cognitive functions, the positive effect of rTMS on cognitive functions is limited. At this point, we think that the TRD would be treated more effectively with treatments targeting specific symptom clusters such as other cognitive functions and suicidal thoughts.
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Affiliation(s)
- Selma Ozcan
- University of Health Sciences Antalya Training and Research Hospital, Department of Psychiatry, Antalya, Turkey
| | - Sakir Gica
- Necmettin Erbakan University, Meram Medical Faculty, Department of Psychiatry, Konya, Turkey.
| | - Huseyin Gulec
- University of Health Sciences Istanbul Erenkoy Mental Health and Neurological Disease Education and Research Hospital Psychiatry, Istanbul, Turkey
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26
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Attenuation of antidepressant and antisuicidal effects of ketamine by opioid receptor antagonism. Mol Psychiatry 2019; 24:1779-1786. [PMID: 31467392 DOI: 10.1038/s41380-019-0503-4] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 04/30/2019] [Accepted: 05/17/2019] [Indexed: 12/12/2022]
Abstract
We recently reported that naltrexone blocks antidepressant effects of ketamine in humans, indicating that antidepressant effects of ketamine require opioid receptor activation. However, it is unknown if opioid receptors are also involved in ketamine's antisuicidality effects. Here, in a secondary analysis of our recent clinical trial, we test whether naltrexone attenuates antisuicidality effects of ketamine. Participants were pretreated with naltrexone or placebo prior to intravenous ketamine in a double-blinded crossover design. Suicidality was measured with the Hamilton Depression Rating Scale item 3, Montgomery-Åsberg Depression Rating Scale item 10, and Columbia Suicide Severity Rating Scale. In the 12 participants who completed naltrexone and placebo conditions, naltrexone attenuated the antisuicidality effects of ketamine on all three suicidality scales/subscales (linear mixed model, fixed pretreatment effect, p < 0.01). Results indicate that opioid receptor activation plays a significant role in the antisuicidality effects of ketamine.
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27
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Trevizol AP, Blumberger DM. An Update on Repetitive Transcranial Magnetic Stimulation for the Treatment of Major Depressive Disorder. Clin Pharmacol Ther 2019; 106:747-762. [PMID: 31206624 DOI: 10.1002/cpt.1550] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/15/2019] [Indexed: 12/15/2022]
Abstract
Repetitive transcranial magnetic stimulation (rTMS) has emerged as an evidenced-based treatment for major depression that does not respond to standard first-line therapies. The majority of data support the use of high-frequency (10 Hz) treatment delivered to the left dorsolateral prefrontal cortex. Intermittent theta burst stimulation is a new emerging treatment that reduces the time required to deliver treatment and can increase capacity and access to this treatment. This review will comprehensively cover recent advancements in the field of rTMS for depression, including stimulation parameters and targets aimed at enhancing outcomes. In addition, efforts to use modern neuroscience tools to personalize this treatment and optimize outcomes will be reviewed.
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Affiliation(s)
- Alisson P Trevizol
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Temerty Centre for Therapeutic Brain Intervention, Campbell Family Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Daniel M Blumberger
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Temerty Centre for Therapeutic Brain Intervention, Campbell Family Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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28
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Lin CH, Park C, McIntyre RS. Early improvement in HAMD-17 and HAMD-7 scores predict response and remission in depressed patients treated with fluoxetine or electroconvulsive therapy. J Affect Disord 2019; 253:154-161. [PMID: 31035216 DOI: 10.1016/j.jad.2019.04.082] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/13/2019] [Accepted: 04/21/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Compared to the 17-Item Hamilton Rating Scale for Depression (HAMD-17), the 7-Item Hamilton Rating Scale for Depression (HAMD-7) would be more practical for use in busy clinical settings. Herein, we aim to evaluate (1) whether the HAMD-7 is a reliable and valid measure that is sensitive to changes in depressive symptoms, and (2) whether early improvement of depressive symptoms, as measured by the HAMD-7, is capable of predicting response and remission in patients with major depressive disorder (MDD) during acute treatment with fluoxetine or electroconvulsive therapy (ECT). METHODS This is a post-hoc analysis of two clinical trials in MDD. Internal consistency, validity, and sensitivity-to-change of the HAMD-17 and HAMD-7 were compared during acute treatment and at 3-month follow-up. Receiver operating characteristic analyses were used to evaluate the discriminative capacity of the HAMD-17 and HAMD-7. RESULTS The HAMD-7 is a reliable and valid measure that is sensitive to changes in depressive symptoms. Early improvement, as measured by either the HAMD-17 or HAMD-7, was capable of predicting response and remission to acute treatment with fluoxetine or ECT with good discriminative capacity. LIMITATIONS This is a post-hoc analysis of two open-label clinical trials with limited sample sizes. All patients were Taiwanese, which limits the generalizability of our results. CONCLUSIONS HAMD-7 is a clinically useful measure that is capable of detecting early improvement of depressive symptoms. The HAMD-7 may have the potential to inform clinical assessment as part of measurement-based care.
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Affiliation(s)
- Ching-Hua Lin
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Caroline Park
- Institute of Medical Science, University of Toronto, Toronto, Canada; Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Roger S McIntyre
- Department of Psychiatry, University of Toronto, Toronto, Canada; Brain and Cognition Discovery Foundation (BCDF), Toronto, Canada; Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.
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29
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Abdelnaim MA, Langguth B, Deppe M, Mohonko A, Kreuzer PM, Poeppl TB, Hebel T, Schecklmann M. Anti-Suicidal Efficacy of Repetitive Transcranial Magnetic Stimulation in Depressive Patients: A Retrospective Analysis of a Large Sample. Front Psychiatry 2019; 10:929. [PMID: 31969842 PMCID: PMC6960193 DOI: 10.3389/fpsyt.2019.00929] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/22/2019] [Indexed: 01/08/2023] Open
Abstract
Background: Suicide is a major public health problem. About 90% of suicide victims have one or more major psychiatric disorder, with a reported 20-fold increased risk for suicide in patients with affective disorders in comparison with healthy subjects. Repetitive transcranial magnetic stimulation (rTMS) has been established as an effective alternative or adjunctive treatment option for patients with depressive disorders, but little is known about its effects on suicide risk. Objective: For the assessment of the effectiveness of rTMS on suicidal ideation and behaviors, we performed a retrospective analysis of a large sample of patients with depressive disorders, who were treated with rTMS. Methods: We analyzed the records of 711 TMS in- and out-patients with depressive affective disorders in a tertiary referral hospital between 2002 and 2017. Out of these patients we were able to collect Hamilton depression rating scale (HAMD) data of 332 patients (180 females, 152 males; age range 20 to 79 years; mean age 47.3 ± 12.3) for which we analyzed the change of suicidal ideation by using item 3 (suicidality) of HAMD. Results: Out of all 711 patients treated with rTMS for their depression, one patient (0.1%) committed suicide during the TMS treatment. In the statistical analysis of the subsample with 332 patients there was an overall amelioration of depressive symptoms accompanied by a significant decrease in the suicidality item with a medium effect size. Decrease in suicidality was not inferior to changes in other items as indicated by effect sizes. Forty-seven percent of patients showed an amelioration in suicidality, 41.3% of patients did not show a change in their suicidality's scores, and 11.7% of patients showed an increase in suicidality's scores from baseline to final rating. Correlation of item 3 (suicidality) and item 7 (drive) demonstrated a significant positive association, revealing improved drive with a parallel decreased suicidality. Conclusion: Based on the proposed data, there is no evidence that rTMS increases the risk for suicide during the course of the treatment. Conversely, rTMS tends to reduce suicidal ideation. Our findings call for further rTMS controlled studies using large sample sizes and specific suicidality assessment measures to obtain more conclusive results.
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Affiliation(s)
- Mohamed A Abdelnaim
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Markus Deppe
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Alexey Mohonko
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Peter M Kreuzer
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Timm B Poeppl
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany.,Department of Psychiatry, Psychotherapy, and Psychosomatics, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Tobias Hebel
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Martin Schecklmann
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
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