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Valter Y, Rapallo F, Burlando B, Crossen M, Baeken C, Datta A, Deblieck C. Efficacy of non-invasive brain stimulation and neuronavigation for major depressive disorder: a systematic review and meta-analysis. Expert Rev Med Devices 2024; 21:643-658. [PMID: 38902968 DOI: 10.1080/17434440.2024.2370820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/28/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are increasingly used for major depressive disorder (MDD). Most tDCS and rTMS studies target the left dorsolateral prefrontal cortex, either with or without neuronavigation. We examined the effect of rTMS and tDCS, and the added value of neuronavigation in the treatment of MDD. METHODS A search on PubMed, Embase, and Cochrane databases for rTMS or tDCS randomized controlled trials of MDD up to 1 February 2023, yielded 89 studies. We then performed meta-analyses comparing tDCS efficacy to non-neuronavigated rTMS, tDCS to neuronavigated rTMS, and neuronavigated rTMS to non-neuronavigated rTMS. We assessed the significance of the effect in subgroups and in the whole meta-analysis with a z-test and subgroup differences with a chi-square test. RESULTS We found small-to-medium effects of both tDCS and rTMS on MDD, with a slightly greater effect from rTMS. No significant difference was found between neuronavigation and non-neuronavigation. CONCLUSION Although both tDCS and rTMS are effective in treating MDD, many patients do not respond. Additionally, current neuronavigation methods are not significantly improving MDD treatment. It is therefore imperative to seek personalized methods for these interventions.
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Affiliation(s)
- Yishai Valter
- Research and Development, Soterix Medical, Inc, Woodbridge, NJ, USA
- Department of Biomedical Engineering, City College of the City University of New York, New York, NY, USA
| | - Fabio Rapallo
- Faculty of Economics, University of Genoa, Genova, Italy
| | - Bruno Burlando
- Department of Pharmacy, University of Genoa, Genova, Italy
| | - Miah Crossen
- Research and Development, Soterix Medical, Inc, Woodbridge, NJ, USA
| | - Chris Baeken
- Faculty of Medicine and Health Sciences, Department of Head and Skin, Ghent Experimental Psychiatry (GHEP) lab, Ghent University, Ghent, Belgium
- Department of Psychiatry, University Hospital (UZBrussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Abhishek Datta
- Research and Development, Soterix Medical, Inc, Woodbridge, NJ, USA
- Department of Biomedical Engineering, City College of the City University of New York, New York, NY, USA
| | - Choi Deblieck
- Lab for Equilibrium Investigations and Aerospace (LEIA), University of Antwerp, Antwerp, Belgium
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Dragon K, Abdelnaim MA, Weber FC, Heuschert M, Englert L, Langguth B, Hebel T, Schecklmann M. Treating depression at home with transcranial direct current stimulation: a feasibility study. Front Psychiatry 2024; 15:1335243. [PMID: 38501089 PMCID: PMC10944921 DOI: 10.3389/fpsyt.2024.1335243] [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: 11/08/2023] [Accepted: 02/13/2024] [Indexed: 03/20/2024] Open
Abstract
Introduction Treating major depressive disorder (MDD) with transcranial direct current stimulation (tDCS) devices at home has various logistic advantages compared to tDCS treatment in the clinic. However, preliminary (controlled) studies showed side effects such as skin lesions and difficulties in the implementation of home-based tDCS. Thus, more data are needed regarding the feasibility and possible disadvantages of home-based tDCS. Methods Ten outpatients (23-69 years) with an acute depressive episode were included for this one-arm feasibility study testing home-based tDCS. All patients self-administered prefrontal tDCS (2 mA, 20 min, anodal left, cathodal right) at home on 30 consecutive working days supported by video consultations. Correct implementation of the home-based treatment was analyzed with tDCS recordings. Feasibility was examined by treatment compliance. For additional analyses of effectiveness, three depression scores were used: Hamilton depression rating scale (HDRS-21), Major Depression Inventory (MDI), and the subscale depression of the Depression-Anxiety-Stress Scale (DASS). Furthermore, usability was measured with the user experience questionnaire (UEQ). Tolerability was analyzed by the number of reported adverse events (AEs). Results Eight patients did not stick to the protocol. AEs were minimal. Four patients responded to the home treatment according to the MDI. Usability was judged positive by the patients. Conclusions Regular video consultations or other safety concepts are recommended regardless of the number of video sessions actually conducted. Home-based tDCS seems to be safe and handy in our feasibility study, warranting further investigation.
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Affiliation(s)
- Katharina Dragon
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Mohamed A. Abdelnaim
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Franziska C. Weber
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Markus Heuschert
- University Medical Center, University of Regensburg, Regensburg, Germany
| | - Leon Englert
- University Medical Center, University of Regensburg, Regensburg, Germany
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, 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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Jung B, Yang C, Lee SH. Vagus Nerves Stimulation: Clinical Implication and Practical Issue as a Neuropsychiatric Treatment. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2024; 22:13-22. [PMID: 38247408 PMCID: PMC10811398 DOI: 10.9758/cpn.23.1101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 01/23/2024]
Abstract
Vagus nerve stimulation (VNS) has been approved as an adjunctive treatment for epilepsy and depression. As the progress of VNS treatment for these neuropsychiatric disorders continues, its applications have expanded to a wide range of conditions, including inflammatory diseases to cognitive dysfunctions. The branches of the vagal nerves directly or indirectly innervate the anatomical structures implicated in these neuropsychiatric conditions, which has led to promising results regarding the effectiveness of VNS. Previous studies investigating the effectiveness of VNS have mostly utilized invasive forms of stimulation. However, current preclinical and clinical research indicates that non-invasive forms of VNS, such as transcutaneous vagus nerve stimulation, hold the promise for treating various neuropsychiatric conditions. This review aims to delve into relevant clinical studies of VNS in various illness states, different methods of VNS, and the potential mechanisms underlying the therapeutic effects in these neuropsychiatric conditions.
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Affiliation(s)
- Bori Jung
- Clinical Emotion and Cognition Research Laboratory, Inje University, Goyang, Korea
- Department of Psychology, Sogang University, Seoul, Korea
| | - Chaeyeon Yang
- Clinical Emotion and Cognition Research Laboratory, Inje University, Goyang, Korea
| | - Seung-Hwan Lee
- Clinical Emotion and Cognition Research Laboratory, Inje University, Goyang, Korea
- Department of Psychiatry, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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Alizadehgoradel J, Pouresmali A, Taherifard M. Safety and Efficacy of an Intensified and Repeated Transcranial Direct Current Stimulation Targeting Supplementary Motor Area and Dorsolateral Prefrontal Cortex in Trichotillomania (Hair Pulling Disorder): A Case Report. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2024; 22:188-193. [PMID: 38247425 PMCID: PMC10811400 DOI: 10.9758/cpn.23.1082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/12/2023] [Accepted: 05/24/2023] [Indexed: 01/23/2024]
Abstract
Trichotillomania (or hair pulling disorder) is a habitual condition in which patients constantly pull their hair. Although psychotherapies such as behavioral therapy and pharmacotherapy have shown relative effectiveness for trichotillomania, some patients fail to respond to these interventions or show only partial responses. Recently, noninvasive brain stimulation techniques such as transcranial direct current stimulation have shown promise in the treatment of psychiatric disorders. We designed a new protocol that included intensified and repeated during 16 sessions, every other day, 2 sessions one day, current intensity of 2 mA for 20 minutes, which regions dorsolateral prefrontal cortex (DLPFC) and supplementary motor area (SMA): Anodal (F3) and cathodal (SMA) were selected as stimulation target areas. The results showed that after the electrical stimulation intervention and also in the follow-up phase, there was a significant improvement in hair pulling behavior and psychiatric evaluations such as depression and anxiety. Therefore, there are many hopes in the effectiveness of the protocol used (intensified and repeated DLPFC and SMA areas) in the treatment of trichotillomania disorder, although there is a need for a future experimental study with a larger group of patients.
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Affiliation(s)
| | - Asghar Pouresmali
- Department of Family Health, Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Mina Taherifard
- Department of Psychology, Mohaghegh-Ardabili University, Ardabil, Iran
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Kumpf U, Ezim H, Stadler M, Burkhardt G, Palm U, Dechantsreiter E, Padberg F. Transcranial direct current stimulation as treatment for major depression in a home treatment setting (HomeDC trial): study protocol and methodology of a double-blind, placebo-controlled pilot study. Pilot Feasibility Stud 2023; 9:197. [PMID: 38102647 PMCID: PMC10722795 DOI: 10.1186/s40814-023-01423-x] [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] [Received: 10/31/2022] [Accepted: 11/21/2023] [Indexed: 12/17/2023] Open
Abstract
INTRODUCTION Transcranial direct current stimulation (tDCS) of prefrontal cortex regions has been reported to exert therapeutic effects in patients with major depressive disorder (MDD). Due to its beneficial safety profile, its easy mode of application, and its cost-effectiveness, tDCS has recently been proposed for treatment at home. This would offer new chances for regionally widespread and long-term application. However, tDCS at home must meet the new methodological challenges of handling and adherence. At the same time, data from randomized controlled trials (RCT) investigating this mode of application are still lacking. In this pilot RCT, we therefore investigate the feasibility, safety, and effectiveness of a new antidepressant tDCS application set-up. METHODS AND ANALYSIS The HomeDC trial will be conducted as a double-blind, placebo-controlled, parallel-group design trial. Thirty-two study participants with MDD will be randomly assigned to active or sham tDCS groups. Participants will self-administer prefrontal tDCS for 6 weeks. Active tDCS will be conducted with anode over F3, cathode over F4, for 5 sessions/week, with a duration of 30 min/day, and 2 mA stimulation intensity. Sham tDCS, conversely, follows an identical protocol in regard to electrode montage and timing, but with no electric stimulation between the ramp-in and ramp-out periods. Both conditions will be administered either as a monotherapy or an adjunctive treatment to a stable dose of antidepressant medication. Adjunctive magnetic resonance imaging (MRI) and electric field (E-field) modelling will be conducted at baseline. Primary outcome is feasibility based on successfully completed stimulations and drop-out rates. The intervention is considered feasible when 20 out of 30 sessions have been fully conducted by at least 75% of the participants. Effectiveness and safety will be assessed as secondary outcomes. DISCUSSION In the HomeDC trial, the technical requirements for a placebo-controlled tDCS study in a home-based treatment setting have been established. The trial addresses the crucial points of the home-based tDCS treatment approach: uniform electrode positioning, frequent monitoring of stimulation parameters, adherence, and ensuring an appropriate home treatment environment. This study will further identify constraints and drawbacks of this novel mode of treatment. TRIAL REGISTRATION www. CLINICALTRIALS gov . TRIAL REGISTRATION NUMBER NCT05172505. Registration date: 12/13/2021.
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Affiliation(s)
- Ulrike Kumpf
- Department of Psychiatry and Psychotherapy, Ludwig Maximilians University Munich, Nussbaumstr. 7, 80336, Munich, Germany.
| | - Harry Ezim
- Department of Psychiatry and Psychotherapy, Ludwig Maximilians University Munich, Nussbaumstr. 7, 80336, Munich, Germany
| | - Matthias Stadler
- Faculty of Psychology and Educational Sciences, Ludwig Maximilian University Munich, Munich, Germany
| | - Gerrit Burkhardt
- Department of Psychiatry and Psychotherapy, Ludwig Maximilians University Munich, Nussbaumstr. 7, 80336, Munich, Germany
| | - Ulrich Palm
- Medicalpark Chiemseeblick, Bernau-Felden, Germany
| | - Esther Dechantsreiter
- Department of Psychiatry and Psychotherapy, Ludwig Maximilians University Munich, Nussbaumstr. 7, 80336, Munich, Germany
| | - Frank Padberg
- Department of Psychiatry and Psychotherapy, Ludwig Maximilians University Munich, Nussbaumstr. 7, 80336, Munich, Germany
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Jin J, Al-Shamali HF, McWeeny R, Sawalha J, Shalaby R, Marshall T, Greenshaw AJ, Cao B, Zhang Y, Demas M, Dursun SM, Dennett L, Suleman R. Effects of Transcranial Direct Current Stimulation on Cognitive Deficits in Depression: A Systematic Review. PSYCHIAT CLIN PSYCH 2023; 33:330-343. [PMID: 38765850 PMCID: PMC11037476 DOI: 10.5152/pcp.2023.22583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/23/2023] [Indexed: 05/22/2024] Open
Abstract
Background Major depressive disorder is the leading cause of mental health-related burden globally and up to one-third of major depressive disorder patients never achieve remission. Transcranial Direct Current Stimulation is a non-invasive intervention used to treat individuals diagnosed with major depressive disorder and bipolar disorder. Since the last transcranial direct current stimulation review specifically focusing on cognitive symptoms in major depressive disorder, twice as many papers have been published. Methods A systematic review was conducted with 5 electronic databases from database inception until March 21, 2022. Randomized controlled trials with at least 1 arm evaluating transcranial direct current stimulation in adults (diagnosed with major depressive disorder or bipolar disorder using the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases criteria) aged 18 or older were included. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adopted. Results : A total of 972 participants were included across 14 studies (60.5% female; mean age of 47.0 years [SD = 16.8]). Nine studies focused on participants with major depressive disorder and all studies used the Diagnostic and Statistical Manual of Mental Disorders to diagnose the participants. Seven out of the 14 studies showed significant improvements in at least 1 cognitive outcome measure in the active transcranial direct current stimulation group compared to the sham group. Several cognitive measures were used across studies, and 12 of the 14 studies reported mild-to-moderate side effects from treatment. Conclusion : Current transcranial direct current stimulation literature has shown limited evidence for the treatment of cognitive impairments in major depressive disorder and bipolar disorder. Future research that applies machine learning algorithms may enable us to distinguish responders from non-responders, increasing clinical benefits of transcranial direct current stimulation.
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Affiliation(s)
- Jonathan Jin
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | | | - Robert McWeeny
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Jeff Sawalha
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Reham Shalaby
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Tyler Marshall
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | | | - Bo Cao
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Yanbo Zhang
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Michael Demas
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Serdar M. Dursun
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Liz Dennett
- Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - Raheem Suleman
- Department of Psychiatry, University of Alberta, Edmonton, Canada
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Kumpf U, Palm U, Eder J, Ezim H, Stadler M, Burkhardt G, Dechantsreiter E, Padberg F. TDCS at home for depressive disorders: an updated systematic review and lessons learned from a prematurely terminated randomized controlled pilot study. Eur Arch Psychiatry Clin Neurosci 2023; 273:1403-1420. [PMID: 37191697 PMCID: PMC10185954 DOI: 10.1007/s00406-023-01620-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 05/04/2023] [Indexed: 05/17/2023]
Abstract
The application of transcranial direct current stimulation (tDCS) at home for the treatment of major depressive disorder (MDD) is the subject of current clinical trials. This is due to its positive safety profile, cost-effectiveness, and potential scalability for a wide outreach in clinical practice. Here, we provide a systematic review of the available studies and also a report on the results of a randomized controlled trial (RCT) on tDCS at home for the treatment of MDD. This trial had to be prematurely terminated due to safety concerns. The HomeDC trial is a double-blinded, placebo-controlled, parallel-group study. Patients with MDD (DSM-5) were randomized to active or sham tDCS. Patients conducted tDCS at home for 6 weeks with 5 sessions/week (30 min at 2 mA) anode over F3, cathode over F4. Sham tDCS resembled active tDCS, with ramp-in and ramp-out periods, but without intermittent stimulation. The study was prematurely terminated due to an accumulation of adverse events (AEs, skin lesions), so that only 11 patients were included. Feasibility was good. Safety monitoring was not sufficient enough to detect or prevent AEs within an appropriate timeframe. Regarding antidepressant effects, the reduction in depression scales over time was significant. However, active tDCS was not superior to sham tDCS in this regard. Both the conclusions from this review and the HomeDC trial show that there are several critical issues with the use of tDCS at home that need to be addressed. Nevertheless the array of transcranial electric simulation (TES) methods that this mode of application offers, including tDCS, is highly interesting and warrants further investigation in high quality RCTs. TRIAL REGISTRATION www. CLINICALTRIALS gov . TRIAL REGISTRATION NUMBER NCT05172505. Registration date: 12/13/2021, https://clinicaltrials.gov/ct2/show/NCT05172505 . *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers) **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71 . For more information, visit: http://www.prisma-statement.org/.
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Affiliation(s)
- Ulrike Kumpf
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University Munich, Nussbaumstr. 7, 80336, Munich, Germany.
| | - Ulrich Palm
- Medicalpark Chiemseeblick, Bernau-Felden, Germany
| | - Julia Eder
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University Munich, Nussbaumstr. 7, 80336, Munich, Germany
| | - Harry Ezim
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University Munich, Nussbaumstr. 7, 80336, Munich, Germany
| | - Matthias Stadler
- Faculty of Psychology and Educational Sciences Ludwig Maximilian University Munich, Munich, Germany
| | - Gerrit Burkhardt
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University Munich, Nussbaumstr. 7, 80336, Munich, Germany
| | - Esther Dechantsreiter
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University Munich, Nussbaumstr. 7, 80336, Munich, Germany
| | - Frank Padberg
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University Munich, Nussbaumstr. 7, 80336, Munich, Germany
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Oh J, Jeon S, Ha TH, Myung W, Lee SH, Ko YH, Kim DH, Lee HY, Chae JH. Effect of Home-based Self-administered Transcranial Direct Stimulation in Patients with Mild to Moderate Major Depressive Disorder: A Single-arm, Multicentral Trial. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2023; 21:271-278. [PMID: 37119219 PMCID: PMC10157007 DOI: 10.9758/cpn.2023.21.2.271] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/31/2021] [Accepted: 01/06/2022] [Indexed: 05/01/2023]
Abstract
Objective Although the effects and safety of transcranial direct current stimulation (tDCS) treatment in depressive patients are largely investigated, whether the self-administration of tDCS treatment at patient's home is comparable to clinic-based treatment is still unknown. Methods In this single-arm, multi-center clinical trial, 61 patients with mild to moderate major depressive disorder were enrolled. tDCS treatment was delivered at the patient's home once a day, 5 to 7 times a week for 6 weeks, and each session lasted for 30 minutes. The primary outcome was a total Beck-Depression Inventory-II score, and no concurrent antidepressants were used. Results The remission rates in both Full-Analysis (FA) (n = 61) and Per-Protocol (PP) (n = 43) groups were statistically significant (FA: 57.4% [0.44-0.70], PP: 62.8% [0.47-0.77]; percent [95% confidence interval]). The degree of depression- related symptoms was also significantly improved in 2, 4, and 6 weeks after the treatment when compared with baseline. There was no significant association between treatment compliance and remission rate in both FA and PP groups. Conclusion These results suggest that acute treatment of patient-administered tDCS might be effective in improving the subjective feeling of depressive symptoms in mild to moderate major depressive disorder patients.
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Affiliation(s)
- Jihoon Oh
- Department of Psychiatry, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sekye Jeon
- Department of Psychiatry, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Hyon Ha
- Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Woojae Myung
- Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seung-Hwan Lee
- Department of Psychiatry, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Young-Hoon Ko
- Department of Psychiatry, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Korea
| | - Do Hoon Kim
- Department of Psychiatry, Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hwa-Young Lee
- Department of Psychiatry, Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jeong-Ho Chae
- Department of Psychiatry, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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