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Loo C, Glozier N, Barton D, Baune BT, Mills NT, Fitzgerald P, Glue P, Sarma S, Galvez-Ortiz V, Hadzi-Pavlovic D, Alonzo A, Dong V, Martin D, Nikolin S, Mitchell PB, Berk M, Carter G, Hackett M, Leyden J, Hood S, Somogyi AA, Lapidus K, Stratton E, Gainsford K, Garg D, Thornton NLR, Fourrier C, Richardson K, Rozakis D, Scaria A, Mihalopoulos C, Chatterton ML, McDonald WM, Boyce P, Holtzheimer PE, Kozel FA, Riva-Posse P, Rodgers A. Efficacy and safety of a 4-week course of repeated subcutaneous ketamine injections for treatment-resistant depression (KADS study): randomised double-blind active-controlled trial. Br J Psychiatry 2023; 223:533-541. [PMID: 38108319 PMCID: PMC10727911 DOI: 10.1192/bjp.2023.79] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Prior trials suggest that intravenous racemic ketamine is a highly effective for treatment-resistant depression (TRD), but phase 3 trials of racemic ketamine are needed. AIMS To assess the acute efficacy and safety of a 4-week course of subcutaneous racemic ketamine in participants with TRD. Trial registration: ACTRN12616001096448 at www.anzctr.org.au. METHOD This phase 3, double-blind, randomised, active-controlled multicentre trial was conducted at seven mood disorders centres in Australia and New Zealand. Participants received twice-weekly subcutaneous racemic ketamine or midazolam for 4 weeks. Initially, the trial tested fixed-dose ketamine 0.5 mg/kg versus midazolam 0.025 mg/kg (cohort 1). Dosing was revised, after a Data Safety Monitoring Board recommendation, to flexible-dose ketamine 0.5-0.9 mg/kg or midazolam 0.025-0.045 mg/kg, with response-guided dosing increments (cohort 2). The primary outcome was remission (Montgomery-Åsberg Rating Scale for Depression score ≤10) at the end of week 4. RESULTS The final analysis (those who received at least one treatment) comprised 68 in cohort 1 (fixed-dose), 106 in cohort 2 (flexible-dose). Ketamine was more efficacious than midazolam in cohort 2 (remission rate 19.6% v. 2.0%; OR = 12.1, 95% CI 2.1-69.2, P = 0.005), but not different in cohort 1 (remission rate 6.3% v. 8.8%; OR = 1.3, 95% CI 0.2-8.2, P = 0.76). Ketamine was well tolerated. Acute adverse effects (psychotomimetic, blood pressure increases) resolved within 2 h. CONCLUSIONS Adequately dosed subcutaneous racemic ketamine was efficacious and safe in treating TRD over a 4-week treatment period. The subcutaneous route is practical and feasible.
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Affiliation(s)
- Colleen Loo
- Black Dog Institute, University of New South Wales, Randwick, New South Wales, Australia; and George Institute for Global Health, Newtown, New South Wales, Australia
| | - Nick Glozier
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; and Australian Research Council Centre of Excellence for Children and Families over the Life Course, University of Sydney, Sydney, New South Wales, Australia
| | - David Barton
- Australian Centre for Heart Health, Royal Melbourne Hospital, North Melbourne, Victoria, Australia; and NeuroCentrix, South Carlton, Victoria, Australia
| | - Bernhard T. Baune
- Department of Psychiatry, University of Münster, Münster, Germany; Department of Psychiatry, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia; and Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Natalie T. Mills
- Discipline of Psychiatry, University of Adelaide, Adelaide, South Australia, Australia
| | - Paul Fitzgerald
- Australian National University School of Medicine and Psychology, Canberra, Australian Capital Territory, Australia
| | - Paul Glue
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Shanthi Sarma
- Mental Health and Specialist Services, Gold Coast Health, Bond University, Robina, Queensland, Australia
| | - Veronica Galvez-Ortiz
- Department of Psychiatry and Mental Health, Hospital Universitari Parc Tauli, Sabadell, Spain; and Institut Investigacio I Innovacio Parc Tauli, Sabadell, Spain
| | - Dusan Hadzi-Pavlovic
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Angelo Alonzo
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia; University of New South Wales, Randwick, New South Wales, Australia; and George Institute for Global Health, Newtown, New South Wales, Australia
| | - Vanessa Dong
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia; University of New South Wales, Randwick, New South Wales, Australia; and George Institute for Global Health, Newtown, New South Wales, Australia
| | - Donel Martin
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia; University of New South Wales, Randwick, New South Wales, Australia; and George Institute for Global Health, Newtown, New South Wales, Australia
| | - Stevan Nikolin
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia; University of New South Wales, Randwick, New South Wales, Australia; and George Institute for Global Health, Newtown, New South Wales, Australia
| | - Philip B. Mitchell
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael Berk
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), School of Medicine, Barwon Health, Deakin University, Geelong, Australia
| | - Gregory Carter
- College of Health, Medicine and Wellbeing, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Maree Hackett
- George Institute for Global Health, Newtown, New South Wales, Australia
| | - John Leyden
- Royal North Shore Hospital, St Leonards, New South Wales, Australia; and Northern Sydney Anaesthetic Research Institute, St Leonards, New South Wales, Australia
| | - Sean Hood
- Division of Psychiatry, University of Western Australia, Perth, Western Australia, Australia
| | - Andrew A. Somogyi
- Discipline of Pharmacology, School of Biomedicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Kyle Lapidus
- Affective Care, Northwell Health, New York, New York, USA
| | - Elizabeth Stratton
- Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten Gainsford
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Monash University, Camberwell, Victoria, Australia
| | - Deepak Garg
- Mental Health and Specialist Services, Gold Coast Health, Bond University, Robina, Queensland, Australia
| | - Nicollette L. R. Thornton
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; and Australian Research Council Centre of Excellence for Children and Families over the Life Course, University of Sydney, Sydney, New South Wales, Australia
| | - Célia Fourrier
- Discipline of Psychiatry, University of Adelaide, Adelaide, South Australia, Australia; and Lysosomal Health in Ageing, Hopwood Centre for Neurobiology, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Karyn Richardson
- BrainPark, Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia; and Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Monash University, Camberwell, Victoria, Australia
| | | | - Anish Scaria
- George Institute for Global Health, Newtown, New South Wales, Australia
| | - Cathrine Mihalopoulos
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; and School of Health and Social Development, Deakin University, Geelong, Australia
| | - Mary Lou Chatterton
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - William M. McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Philip Boyce
- Specialty of Psychiatry, Westmead Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Paul E. Holtzheimer
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA; and Department of Surgery, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - F. Andrew Kozel
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, Florida, USA
| | - Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anthony Rodgers
- George Institute for Global Health, Newtown, New South Wales, Australia
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Le B, Alonzo A, Bull M, Kabourakis M, Martin D, Loo C. A Clinical Case Series of Acute and Maintenance Home Administered Transcranial Direct Current Stimulation in Treatment-Resistant Depression. J ECT 2022; 38:e11-e19. [PMID: 35613011 DOI: 10.1097/yct.0000000000000813] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Transcranial direct current stimulation (tDCS) is a noninvasive neurostimulation technique being translated clinically for the treatment of depression. There is limited research documenting the longer-term effectiveness and safety of tDCS treatment. This case series is the first report of remotely supervised, home-administered tDCS (HA-tDCS) for depression in a clinical setting. METHODS We report clinical, cognitive, and safety outcomes from 16 depressed patients who received acute and/or maintenance HA-tDCS. We retrospectively examined clinical data from up to 2.5 years of treatment. Descriptive statistics are reported to document patient outcomes. RESULTS Twelve patients received acute treatment for a current depressive episode and 4 commenced tDCS maintenance therapy after responding to ECT or repetitive transcranial magnetic stimulation (rTMS). The cohort was highly treatment-resistant wherein 15 of 16 patients failed 3 trials or more of antidepressant medication in the current episode, and 6 patients failed to gain significant benefit from prior ECT or rTMS. Five of 12 patients responded to acute tDCS within 6 weeks, and 9 patients who received tDCS for more than 12 weeks maintained improvements over several months. Cognitive tests showed no evidence of impairments in cognitive outcomes after up to 2 years of treatment. Two patients were withdrawn from treatment because of blurred vision or exacerbation of tinnitus. Transcranial direct current stimulation was otherwise safe and well tolerated. CONCLUSIONS Transcranial direct current stimulation given for at least 6 weeks may be of clinical benefit even in treatment-resistant depression. Results provide support for long-term effectiveness, safety, and feasibility of remotely supervised HA-tDCS and suggest a role for maintenance tDCS after acute treatment with tDCS, rTMS, or ECT.
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Affiliation(s)
- Brandon Le
- From the School of Psychiatry, University of New South Wales/ Black Dog Institute, Randwick, NSW, Australia
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Castello L, Di Fusco S, Leggio M, Alonzo A, Aiello A, Imperoli G, Colivicchi F. C85 IMPACT OF QUARANTINE ON CARDIOVASCULAR RISK FACTORS. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartj/suac011.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Background
Pandemic–related quarantine has led to critical lifestyle changes with possible detrimental consequences on health. The effects of lockdown on cardiovascular (CV) risk factors have been investigated to define patient–tailored strategies aimed at reducing the negative impact on CV health.
Methods
We administered a closed response survey to consecutive patients coming to our cardiac outpatient centre over a period of 10 days. Questions focused on quarantine–related lifestyle changes during March and April 2020.
Results
We enrolled 150 patients (62% male, mean age 65 years). The vast majority of subjects (73%) did not work due to retirement/unemployment, 14% worked in office and 13% worked from home. 50% had hypertension and/or diabetes and/or dyslipidemia, 33% had atrial fibrillation, 17% coronary artery disease, 6% had heart failure and 4% had a pacemaker/ICD implanted. Physical activity did not change for 44%, increased in 2%, decreased in 33% and was stopped in 21%. Dietary pattern remained the same in 73% while 22% consumed more junk food and 5% more healthy food. Body weight was not monitored in 35%, remained unchanged in 32%, increased in 28% and decreased in 5%. Among active smokers (22%), 86% reported higher cigarette consumption while 14% reduced/unchanged number of cigarettes per day. Sleep disorders were present in 73%. Regarding health needs, 16% had to reschedule medical check–ups due to personal choice or hospital unavailability.
Conclusions
Quarantine appeared to have different effects on CV risk factors. During lockdown, on–site work was limited, which may partially account for the observed lifestyle changes. Physical activity was reduced/interrupted in more than half of the population, whereas dietary pattern did not change in the vast majority of subjects, with only a small proportion reporting worse dietary habits. Body weight increased in only a minority of subjects, though this may be underestimated because most participants did not monitor their weight. Cigarette consumption was higher for the majority of active smokers. Similarly, sleep disorders were present in the vast majority of subjects. To conclude, consistent with current literature, our real–world data confirm that quarantine seems to have affected lifestyle habits defining CV risk profile differently. A patient–tailored approach should be implemented to minimise possible detrimental effects of quarantine on CV health.
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Alonzo A, Di Fusco S, Castello L, Spinelli A, Altamura V, Mocini D, Imperoli G, Colivicchi F. C86 TAKO–TSUBO SYNDROME IN PATIENTS WITH COVID–19: A SINGLE CENTRE RETROSPECTIVE CASE SERIES. Eur Heart J Suppl 2022. [PMCID: PMC9384022 DOI: 10.1093/eurheartj/suac011.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background COVID–19 presents with a wide range of symptoms, from mild flu–like complaints to severe acute respiratory distress and cardiovascular complications. Recent literature provides some case reports of Tako–Tsubo syndrome (TTS) in COVID–19 patients. However, its prevalence, pathophysiological mechanisms and prognostic impact in this setting is unknown. Methods We collected data of patients hospitalized for COVID–19 in our multidisciplinary COVID–19 department who had a diagnosis of TTS during hospitalization. The criteria for hospital admission were: 1) naso–pharyngeal polymerase chain reaction diagnosis of SARS–CoV–2 infection and 2) symptoms and signs of mild–moderate COVID–19 with a paO2/FIO2 ratio > 200. The period of the study covered the second and third wave of the pandemic in Italy. Results Of 635 patients admitted to our centre, we had four cases, two males and two females, with TTS associated with COVID–19. No patient had any classical trigger for TTS except for COVID–19. Mean age was 72 years (67–81) and all patients had a diagnosis of SARS–CoV–2–related interstitial pneumonia confirmed by computed tomography. One patient was admitted to our centre after stabilization of a critical respiratory distress syndrome that required intubation. All patients showed typical apical ballooning with a transitory reduction of left ventricle (LV) systolic function. The mean LV ejection fraction (LVEF) at TTS onset was 42% (40–48%). ECG showed ST–segment elevation in two cases, while an evolution with negative T waves and long QTc was observed in all patients. All patients were treated in the intensive care unit (ICU), with a median ICU stay of 9 days. The long ICU stay duration was due to intercurrent superinfections. All patients recovered a normal LVEF before discharge. The mean value of the high–sensitivity troponin T peak was 1092 ng/L. Three patients underwent coronary angiography. One patient needed vasopressors in the acute phase. Two patients had a previous diagnosis of cognitive impairment. The time interval from hospital admission to TTS onset was 4 (2–6) days, and the time interval from COVID–19 symptom onset to TTS diagnosis was 10 (8–12) days. The mean hospital stay was 32 days (26–37). Conclusion COVID–19 may be a trigger for TTS. Possible mechanisms to explain the contribution of COVID–19 to TTS development include the activation of the inflammatory cascade, direct myocardial injury, and stress–related conditions due to COVID–19.
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Affiliation(s)
- A Alonzo
- P.O. SAN FILIPPO NERI – ASL ROMA 1, ROMA
| | - S Di Fusco
- P.O. SAN FILIPPO NERI – ASL ROMA 1, ROMA
| | - L Castello
- P.O. SAN FILIPPO NERI – ASL ROMA 1, ROMA
| | - A Spinelli
- P.O. SAN FILIPPO NERI – ASL ROMA 1, ROMA
| | - V Altamura
- P.O. SAN FILIPPO NERI – ASL ROMA 1, ROMA
| | - D Mocini
- P.O. SAN FILIPPO NERI – ASL ROMA 1, ROMA
| | - G Imperoli
- P.O. SAN FILIPPO NERI – ASL ROMA 1, ROMA
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5
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Bayes A, Dong V, Martin D, Alonzo A, Kabourakis M, Loo C. Ketamine treatment for depression: A model of care. Aust N Z J Psychiatry 2021; 55:1134-1143. [PMID: 34384256 DOI: 10.1177/00048674211039166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Ketamine and related compounds are emerging as rapidly acting therapies for treatment-resistant depression. Ketamine differs from standard antidepressants in its speed of action, specific acute and cumulative side effects, risk of dependence and regulatory requirements. However, there is currently little guidance offering translation from research studies into clinical practice. We therefore detail a comprehensive model of care for ketamine treatment of depression. METHOD We formulated a set of policies and procedures for a 'compassionate use' ketamine programme that developed out of our clinical research in ketamine. These policies and procedures were formulated into a detailed model of care. RESULTS The current Australian and New Zealand regulatory frameworks and professional bodies' recommendations regarding ketamine are detailed along with clinical governance and infrastructure considerations. We next describe a four-step model comprising initial assessment, pre-treatment, treatment and post-treatment phases. The model comprises thorough psychiatric and medical assessments examining patient suitability, a rigorous consenting process and structured safety monitoring across an acute treatment course or maintenance therapy. Our ketamine dose-titration method is detailed allowing flexible dosing of patients across a treatment course enabling individualised treatment. CONCLUSION The model of care aims to bridge the gap between efficacy studies and clinical care outside of research settings as ketamine and related compounds become increasingly important therapies for treatment-resistant depression.
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Affiliation(s)
- Adam Bayes
- Black Dog Institute, Sydney Neurostimulation Centre (SyNC), Sydney, NSW, Australia.,School of Psychiatry, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Vanessa Dong
- School of Psychiatry, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Donel Martin
- School of Psychiatry, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Angelo Alonzo
- School of Psychiatry, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Michael Kabourakis
- School of Psychiatry, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Colleen Loo
- Black Dog Institute, Sydney Neurostimulation Centre (SyNC), Sydney, NSW, Australia.,School of Psychiatry, University of New South Wales Sydney, Sydney, NSW, Australia
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Martin DM, Wollny-Huttarsch D, Nikolin S, McClintock SM, Alonzo A, Lisanby SH, Loo CK. Neurocognitive subgroups in major depressive disorder. Neuropsychology 2020; 34:726-734. [DOI: 10.1037/neu0000626] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Martin DM, Mohan A, Alonzo A, Gates N, Gbadeyan O, Meinzer M, Sachdev P, Brodaty H, Loo C. A Pilot Double-Blind Randomized Controlled Trial of Cognitive Training Combined with Transcranial Direct Current Stimulation for Amnestic Mild Cognitive Impairment. J Alzheimers Dis 2020; 71:503-512. [PMID: 31424410 DOI: 10.3233/jad-190306] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is currently no effective intervention for improving memory in people at increased risk for dementia. Cognitive training (CT) has been promising, though effects are modest, particularly at follow-up. OBJECTIVE To investigate whether adjunctive non-invasive brain stimulation (transcranial direct current stimulation, tDCS) could enhance the memory benefits of CT in amnestic mild cognitive impairment (aMCI). METHODS Participants with aMCI were randomized to receive CT with either Active tDCS (2 mA for 30 min and 0.016 mA for 30 min) or Sham tDCS (0.016 mA for 60 min) for 15 sessions over a period of 5 weeks in a double-blind, sham-controlled, parallel group clinical trial. The primary outcome measure was the California Verbal Learning Task 2nd Edition. RESULTS 68 participants commenced the intervention. Intention-to-treat (ITT) analysis showed that the CT+Active tDCS group significantly improved at post treatment (p = 0.033), and the CT+Sham tDCS group did not (p = 0.050), but there was no difference between groups. At the 3-month follow-up, both groups showed large-sized memory improvements compared to pre-treatment (CT+Active tDCS: p < 0.01, d = 0.99; CT+Sham tDCS: p < 0.01, d = 0.74), although there was no significant difference between groups. CONCLUSION This study found that CT+Active tDCS did not produce greater memory improvement compared to CT+Sham tDCS. Large-sized memory improvements occurred in both conditions at follow-up. One possible interpretation, based on recent novel findings, is that low intensity tDCS (used as 'sham') may have contributed biological effects. Further work should use a completely inert tDCS sham condition.
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Affiliation(s)
- Donel M Martin
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Adith Mohan
- School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Angelo Alonzo
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Nicola Gates
- School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Oyetunde Gbadeyan
- University of Queensland Centre for Clinical Research, Brisbane, Australia
| | - Marcus Meinzer
- University of Queensland Centre for Clinical Research, Brisbane, Australia.,Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Perminder Sachdev
- School of Psychiatry, University of New South Wales, Sydney, Australia.,Centre for Healthy Brain Ageing, University of New South Wales, Sydney, Australia
| | - Henry Brodaty
- School of Psychiatry, University of New South Wales, Sydney, Australia.,Centre for Healthy Brain Ageing, University of New South Wales, Sydney, Australia
| | - Colleen Loo
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, University of New South Wales, Sydney, Australia.,St George Hospital, South Eastern Sydney Health, Sydney, Australia
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Moffa AH, Martin D, Alonzo A, Bennabi D, Blumberger DM, Benseñor IM, Daskalakis Z, Fregni F, Haffen E, Lisanby SH, Padberg F, Palm U, Razza LB, Sampaio-Jr B, Loo C, Brunoni AR. Efficacy and acceptability of transcranial direct current stimulation (tDCS) for major depressive disorder: An individual patient data meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry 2020; 99:109836. [PMID: 31837388 DOI: 10.1016/j.pnpbp.2019.109836] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/16/2019] [Accepted: 12/05/2019] [Indexed: 12/24/2022]
Abstract
We evaluated the efficacy and acceptability of transcranial direct current stimulation (tDCS) for treating acute depressive episodes using individual patient data that provide more precise estimates than aggregate data meta-analysis. A systematic review of placebo-controlled trials on tDCS as only intervention was conducted until December-2018. Data from each study was collated to estimate odds ratio (OR) and number needed to treat (NNT) of response and remission, and depression improvement. Endpoints were pre-determined. Nine eligible studies (572 participants), presenting moderate/high certainty of evidence, were included. Active tDCS was significantly superior to sham for response (30.9% vs. 18.9% respectively; OR = 1.96, 95%CI [1.30-2.95], NNT = 9), remission (19.9% vs. 11.7%, OR = 1.94 [1.19-3.16], NNT = 13) and depression improvement (effect size of β = 0.31, [0.15-0.47]). Moreover, continuous clinical improvement was observed even after the end of acute tDCS treatment. There were no differences in all-cause discontinuation rates and no predictors of response were identified. To conclude, active tDCS was statistically superior to sham in all outcomes, although its clinical effects were moderate.
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Affiliation(s)
- Adriano H Moffa
- School of Psychiatry, Black Dog Institute, University of New South Wales, Hospital Rd, Randwick, Sydney, NSW 2031, Australia; Laboratory of Neurosciences (LIM-27), Instituto Nacional de Biomarcadores em Neuropsiquiatria (INBioN), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, R Dr Ovidio Pires de Campos 785, 2o andar, 05403-000 São Paulo, Brazil
| | - Donel Martin
- School of Psychiatry, Black Dog Institute, University of New South Wales, Hospital Rd, Randwick, Sydney, NSW 2031, Australia
| | - Angelo Alonzo
- School of Psychiatry, Black Dog Institute, University of New South Wales, Hospital Rd, Randwick, Sydney, NSW 2031, Australia
| | - Djamila Bennabi
- Department of Clinical Psychiatry, Clinical Investigation Center 1431 Inserm, EA 481 Neurosciences, University Hospital of Besancon and FondaMental Foundation, Créteil, France
| | - Daniel M Blumberger
- Temerty Centre for Therapeutic Brain Intervention and Campbell Family Research Institute, Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Ontario, Canada
| | - Isabela M Benseñor
- Department of Internal Medicine, Faculdade de Medicina da Universidade de São Paulo & Hospital Universitário, Universidade de São Paulo, Av. Prof Lineu Prestes 2565, 05508-000 São Paulo, Brazil
| | - Zafiris Daskalakis
- Temerty Centre for Therapeutic Brain Intervention and Campbell Family Research Institute, Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Ontario, Canada
| | - Felipe Fregni
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
| | - Emmanuel Haffen
- Department of Clinical Psychiatry, Clinical Investigation Center 1431 Inserm, EA 481 Neurosciences, University Hospital of Besancon and FondaMental Foundation, Créteil, France
| | - Sarah H Lisanby
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Frank Padberg
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University Munich, Munich, Germany
| | - Ulrich Palm
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University Munich, Munich, Germany
| | - Lais B Razza
- Laboratory of Neurosciences (LIM-27), Instituto Nacional de Biomarcadores em Neuropsiquiatria (INBioN), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, R Dr Ovidio Pires de Campos 785, 2o andar, 05403-000 São Paulo, Brazil
| | - Bernardo Sampaio-Jr
- Laboratory of Neurosciences (LIM-27), Instituto Nacional de Biomarcadores em Neuropsiquiatria (INBioN), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, R Dr Ovidio Pires de Campos 785, 2o andar, 05403-000 São Paulo, Brazil
| | - Colleen Loo
- School of Psychiatry, Black Dog Institute, University of New South Wales, Hospital Rd, Randwick, Sydney, NSW 2031, Australia
| | - Andre R Brunoni
- Laboratory of Neurosciences (LIM-27), Instituto Nacional de Biomarcadores em Neuropsiquiatria (INBioN), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, R Dr Ovidio Pires de Campos 785, 2o andar, 05403-000 São Paulo, Brazil; Department of Internal Medicine, Faculdade de Medicina da Universidade de São Paulo & Hospital Universitário, Universidade de São Paulo, Av. Prof Lineu Prestes 2565, 05508-000 São Paulo, Brazil.
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McClintock SM, Martin DM, Lisanby SH, Alonzo A, McDonald WM, Aaronson ST, Husain MM, O'Reardon JP, Weickert CS, Mohan A, Loo CK. Neurocognitive effects of transcranial direct current stimulation (tDCS) in unipolar and bipolar depression: Findings from an international randomized controlled trial. Depress Anxiety 2020; 37:261-272. [PMID: 31944487 DOI: 10.1002/da.22988] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 10/03/2019] [Accepted: 11/19/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Transcranial direct current stimulation (tDCS) has been found to have antidepressant effects and may have beneficial neurocognitive effects. However, prior research has produced an unclear understanding of the neurocognitive effects of repeated exposure to tDCS. The study's aim was to determine the neurocognitive effects following tDCS treatment in participants with unipolar or bipolar depression. METHOD The study was a triple-masked, randomized, controlled clinical trial across six international academic medical centers. Participants were randomized to high dose (2.5 mA for 30 min) or low dose (0.034 mA, for 30 min) tDCS for 20 sessions over 4 weeks, followed by an optional 4 weeks of open-label high dose treatment. The tDCS anode was centered over the left dorsolateral prefrontal cortex at F3 (10/20 EEG system) and the cathode over F8. Participants completed clinical and neurocognitive assessments before and after tDCS. Genotype (BDNF Val66Met and catechol-o-methyltransferase [COMT] Val158Met polymorphisms) were explored as potential moderators of neurocognitive effects. RESULTS The study randomized 130 participants. Across the participants, tDCS treatment (high and low dose) resulted in improvements in verbal learning and recall, selective attention, information processing speed, and working memory, which were independent of mood effects. Similar improvements were observed in the subsample of participants with bipolar disorder. There was no observed significant effect of tDCS dose. However, BDNF Val66Met and COMT Val158Met polymorphisms interacted with tDCS dose and affected verbal memory and verbal fluency outcomes, respectively. CONCLUSIONS These findings suggest that tDCS could have positive neurocognitive effects in unipolar and bipolar depression. Thus, tDCS stimulation parameters may interact with interindividual differences in BDNF and COMT polymorphisms to affect neurocognitive outcomes, which warrants further investigation.
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Affiliation(s)
- Shawn M McClintock
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, Texas.,Division of Brain Stimulation and Neurophysiology, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Donel M Martin
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Sarah H Lisanby
- Division of Brain Stimulation and Neurophysiology, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina.,Noninvasive Neuromodulation Unit, Experimental Therapeutics Branch, Intramural Research Program, National Institute of Mental Health, Bethesda, Maryland
| | - Angelo Alonzo
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, University of New South Wales, Sydney, Australia
| | - William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Scott T Aaronson
- Department of Clinical Research Programs, Sheppard Pratt Health System, Baltimore, Maryland
| | - Mustafa M Husain
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, Texas.,Division of Brain Stimulation and Neurophysiology, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - John P O'Reardon
- Department of Psychiatry and Behavioral Sciences, Center for Mood Disorders and Neuromodulation Therapies, Rowan University School of Osteopathic Medicine, Cherry Hill, New Jersey
| | - Cynthia Shannon Weickert
- Neuroscience Research Australia, Sydney, Australia.,School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Department of Neuroscience & Physiology, Upstate Medical University, Syracuse, New York
| | - Adith Mohan
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Colleen K Loo
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, University of New South Wales, Sydney, Australia
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10
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Nikolin S, Alonzo A, Martin D, Gálvez V, Buten S, Taylor R, Goldstein J, Oxley C, Hadzi-Pavlovic D, Loo CK. Transcranial Random Noise Stimulation for the Acute Treatment of Depression: A Randomized Controlled Trial. Int J Neuropsychopharmacol 2020; 23:146-156. [PMID: 31899509 PMCID: PMC7171931 DOI: 10.1093/ijnp/pyz072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 11/27/2019] [Accepted: 12/31/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Transcranial electrical stimulation has broad potential as a treatment for depression. Transcranial random noise stimulation, which delivers randomly fluctuating current intensities, may have greater cortical excitatory effects compared with other forms of transcranial electrical stimulation. We therefore aimed to investigate the antidepressant efficacy of transcranial random noise stimulation. METHODS Depressed participants were randomly assigned by computer number generator to receive 20 sessions of either active or sham transcranial random noise stimulation over 4 weeks in a double-blinded, parallel group randomized-controlled trial. Transcranial random noise stimulation was delivered for 30 minutes with a direct current offset of 2 mA and a random noise range of 2 mA. Primary analyses assessed changes in depression severity using the Montgomery-Asperg Depression Rating Scale. Neuroplasticity, neuropsychological, and safety outcomes were analyzed as secondary measures. RESULTS Sixty-nine participants were randomized, of which 3 discontinued treatment early, leaving 66 (sham n = 34, active n = 32) for per-protocol analysis. Depression severity scores reduced in both groups (Montgomery-Asperg Depression Rating Scale reduction in sham = 7.0 [95% CI = 5.0-8.9]; and active = 5.2 [95% CI = 3.2-7.3]). However, there were no differences between active and sham groups in the reduction of depressive symptoms or the number of participants meeting response (sham = 14.7%; active = 3.1%) and remission criteria (sham = 5.9%; active = 0%). Erythema, paresthesia, fatigue, and dizziness/light-headedness occurred more frequently in the active transcranial random noise stimulation group. Neuroplasticity, neuropsychological, and acute cognitive effects were comparable between groups. CONCLUSION Our results do not support the use of transcranial random noise stimulation with the current stimulation parameters as a therapeutic intervention for the treatment of depression. CLINICAL TRIAL REGISTRATION AT CLINICALTRIALS gov/NCT01792414.
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Affiliation(s)
- Stevan Nikolin
- School of Psychiatry, University of New South Wales, Sydney, Australia,Black Dog Institute, Sydney, Australia,Correspondence: Stevan Nikolin, PhD, Black Dog Institute, Hospital Road, Randwick 2031 NSW, Australia ()
| | - Angelo Alonzo
- School of Psychiatry, University of New South Wales, Sydney, Australia,Black Dog Institute, Sydney, Australia
| | - Donel Martin
- School of Psychiatry, University of New South Wales, Sydney, Australia,Black Dog Institute, Sydney, Australia
| | - Veronica Gálvez
- School of Psychiatry, University of New South Wales, Sydney, Australia,Mental Health Department, Parc Taulí University Hospital, Institut d’Investigació I Innovació Sanitària Parc Taulí (I3PT), Barcelona, Spain
| | - Sara Buten
- School of Psychiatry, University of New South Wales, Sydney, Australia,Prince of Wales Hospital, Sydney, Australia
| | - Rohan Taylor
- School of Psychiatry, University of New South Wales, Sydney, Australia,Concord Centre for Mental Health, Concord, Australia
| | | | - Cristal Oxley
- Department of Child and Adolescent Psychiatry, Michael Rutter Centre – South London and Maudsley NHS Foundation Trust, UK
| | | | - Colleen K Loo
- School of Psychiatry, University of New South Wales, Sydney, Australia,Black Dog Institute, Sydney, Australia,St. George Hospital, Sydney, Australia
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11
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Alonzo A, Fong J, Ball N, Martin D, Chand N, Loo C. Pilot trial of home-administered transcranial direct current stimulation for the treatment of depression. J Affect Disord 2019; 252:475-483. [PMID: 31005790 DOI: 10.1016/j.jad.2019.04.041] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 03/13/2019] [Accepted: 04/07/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transcranial Direct Current Stimulation (tDCS) is a non-invasive, neuromodulation approach with promising efficacy for treating depression. To date, tDCS has been limited to clinical or research centre settings with treatment administered by staff. The aim of this study is to examine the efficacy, tolerability and feasibility of home-administered, remotely-supervised tDCS for depression. METHODS In an open label trial, 34 participants used a Soterix 1 × 1 mini-CT device to self-administer 20-28 tDCS sessions (2 mA, 30 min, F3-anode and F8-cathode montage according to 10-20 EEG placement) over 4 weeks followed by a taper phase of 4 sessions 1 week apart. Participants were initially monitored via video link and then through completion of an online treatment diary. Mixed effects repeated measures analyses assessed change in mood scores. RESULTS Mood improved significantly from baseline (27.47 on Montgomery-Asberg Depression Rating Scale) to 1 month after the end of acute treatment (15.48) (p < 0.001). Side effects were largely transient and minor. Outcomes were comparable to those reported in clinic-based trials. Protocol adherence was excellent with a drop-out rate of 6% and 93% of scheduled sessions completed. LIMITATIONS The tDCS and remote monitoring procedures employed in this study require a level of manual dexterity and computer literacy, which may be challenging for some patients. This study did not have a control condition. CONCLUSIONS This study provides initial evidence that home-based, remotely-supervised tDCS treatment may be efficacious and feasible for depressed patients and has high translational potential.
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Affiliation(s)
- Angelo Alonzo
- School of Psychiatry, University of New South Wales/Black Dog Institute, Hospital Road, Randwick, NSW 2031, Australia.
| | - Joanna Fong
- School of Psychiatry, University of New South Wales/Black Dog Institute, Hospital Road, Randwick, NSW 2031, Australia
| | - Nicola Ball
- School of Psychiatry, University of New South Wales/Black Dog Institute, Hospital Road, Randwick, NSW 2031, Australia
| | - Donel Martin
- School of Psychiatry, University of New South Wales/Black Dog Institute, Hospital Road, Randwick, NSW 2031, Australia
| | - Nicholas Chand
- School of Psychiatry, University of New South Wales/Black Dog Institute, Hospital Road, Randwick, NSW 2031, Australia
| | - Colleen Loo
- School of Psychiatry, University of New South Wales/Black Dog Institute, Hospital Road, Randwick, NSW 2031, Australia; St George Hospital, South Eastern Sydney Health, Level 2, James Laws House, Gray St, Kogarah, NSW 2217, Australia
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12
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Nikolin S, Huggins C, Martin D, Alonzo A, Loo C. Adverse events associated with repeated sessions of tDCS: A systematic review and meta-analysis. Brain Stimul 2019. [DOI: 10.1016/j.brs.2018.12.577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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13
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Moffa A, Martin D, Brunoni A, Alonzo A, Blumberger D, Bennabi D, Daskalakis Z, Fregni F, Padberg F, Palm U, Sampaio-Junior B, Loo C. Transcranial direct current stimulation for acute major depressive episodes: An updated meta-analysis of individual patient data. Brain Stimul 2019. [DOI: 10.1016/j.brs.2018.12.562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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14
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Gálvez Ortiz V, Glue P, Somogyi AA, Martin D, Alonzo A, Rodgers A, Mitchell PB, Li A, Huggins C, Loo CK. A reply to comments by Lee and colleagues on: Repeated intranasal ketamine for treatment resistant depression - the way to go? Results from a pilot randomised controlled trial. J Psychopharmacol 2019; 33:260-261. [PMID: 30773113 DOI: 10.1177/0269881118822147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Verónica Gálvez Ortiz
- 1 Mental Health Department, Parc Taulí University Hospital, Institut d'Investigació i Innovació Sanitària Parc Taulí (I3PT).,2 School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.,3 Black Dog Institute, Sydney, NSW, Australia
| | - Paul Glue
- 4 Department of Psychological Medicine, University of Otago, New Zealand
| | - Andrew A Somogyi
- 5 Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, SA, Australia
| | - Donel Martin
- 2 School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.,3 Black Dog Institute, Sydney, NSW, Australia
| | - Angelo Alonzo
- 2 School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.,3 Black Dog Institute, Sydney, NSW, Australia
| | - Anthony Rodgers
- 6 The George Institute for Global Health, University of Sydney, Australia
| | - Philip B Mitchell
- 2 School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.,3 Black Dog Institute, Sydney, NSW, Australia
| | - Adrienne Li
- 2 School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
| | - Christina Huggins
- 2 School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
| | - Colleen K Loo
- 2 School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.,3 Black Dog Institute, Sydney, NSW, Australia.,7 Wesley Hospital, Sydney, NSW, Australia.,8 St George Hospital, Sydney, NSW, Australia
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15
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Martin DM, McClintock SM, Aaronson ST, Alonzo A, Husain MM, Lisanby SH, McDonald WM, Mohan A, Nikolin S, O'Reardon J, Weickert CS, Loo CK. Pre-treatment attentional processing speed and antidepressant response to transcranial direct current stimulation: Results from an international randomized controlled trial. Brain Stimul 2018; 11:1282-1290. [DOI: 10.1016/j.brs.2018.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 08/14/2018] [Accepted: 08/18/2018] [Indexed: 01/30/2023] Open
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16
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Martin DM, Teng JZ, Lo TY, Alonzo A, Goh T, Iacoviello BM, Hoch MM, Loo CK. Clinical pilot study of transcranial direct current stimulation combined with Cognitive Emotional Training for medication resistant depression. J Affect Disord 2018; 232:89-95. [PMID: 29477590 DOI: 10.1016/j.jad.2018.02.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 01/19/2018] [Accepted: 02/15/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND While the clinical results from transcranial direct current stimulation (tDCS) for the treatment of depression have been promising, antidepressant effects in patients with medication resistance have been suboptimal. There is therefore a need to further optimise tDCS for medication resistant patients. In this clinical pilot study we examined the feasibility, safety, and clinical efficacy of combining tDCS with a psychological intervention which targets dysfunctional circuitry related to emotion regulation in depression, Cognitive Emotional Training (CET). METHODS tDCS was administered during CET three times a week for a total of 18 sessions over 6 weeks. Mood, cognition and emotion processing outcomes were examined at baseline and after 3 and 6 weeks of treatment. RESULTS Twenty patients with medication resistant depression participated, of whom 17 were study completers. tDCS combined with CET was found to be feasible, safe, and associated with significant antidepressant efficacy at 6 weeks, with 41% of study completers showing treatment response (≥ 50% improvement in depression score). There were no significant cognitive enhancing effects with the exception of improved emotion recognition. Responders demonstrated superior recognition for the emotions fear and surprise at pre-treatment compared to non-responders, suggesting that better pre-treatment emotion recognition may be associated with antidepressant efficacy. LIMITATIONS This was an open label study. CONCLUSIONS tDCS combined with CET has potential as a novel method for optimising the antidepressant efficacy of tDCS in medication resistant patients. Future controlled studies are required to determine whether tDCS combined with CET has greater antidepressant efficacy compared to either intervention alone.
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Affiliation(s)
- D M Martin
- School of Psychiatry, University of New South Wales, Sydney, Australia; The Black Dog Institute, Sydney, Australia.
| | - J Z Teng
- School of Psychiatry, University of New South Wales, Sydney, Australia; The Black Dog Institute, Sydney, Australia
| | - T Y Lo
- School of Psychiatry, University of New South Wales, Sydney, Australia; The Black Dog Institute, Sydney, Australia
| | - A Alonzo
- School of Psychiatry, University of New South Wales, Sydney, Australia; The Black Dog Institute, Sydney, Australia
| | - T Goh
- School of Psychiatry, University of New South Wales, Sydney, Australia; The Black Dog Institute, Sydney, Australia
| | - B M Iacoviello
- Click Therapeutics, Inc., New York, United States; Icahn School of Medicine at Mount Sinai, New York, United States
| | - M M Hoch
- Icahn School of Medicine at Mount Sinai, New York, United States
| | - C K Loo
- School of Psychiatry, University of New South Wales, Sydney, Australia; The Black Dog Institute, Sydney, Australia
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17
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Gálvez V, Li A, Huggins C, Glue P, Martin D, Somogyi AA, Alonzo A, Rodgers A, Mitchell PB, Loo CK. Repeated intranasal ketamine for treatment-resistant depression - the way to go? Results from a pilot randomised controlled trial. J Psychopharmacol 2018. [PMID: 29542371 DOI: 10.1177/0269881118760660] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ketamine research in depression has mostly used intravenous, weight-based approaches, which are difficult to translate clinically. Intranasal (IN) ketamine is a promising alternative but no controlled data has been published on the feasibility, safety and potential efficacy of repeated IN ketamine treatments. METHODS This randomised, double-blind, placebo-controlled pilot study compared a 4-week course of eight treatments of 100 mg ketamine or 4.5 mg midazolam. Each treatment was given as 10 separate IN sprays, self-administered 5 min apart. The study was stopped early due to poor tolerability after five treatment-resistant depressed participants were included. Feasibility, safety (acute and cumulative), cognitive and efficacy outcomes were assessed. Plasma ketamine and norketamine concentrations were assayed after the first treatment. RESULTS Significant acute cardiovascular, psychotomimetic and neurological side effects occurred at doses < 100 mg ketamine. No participants were able to self-administer all 10 ketamine sprays due to incoordination; treatment time occasionally had to be extended (>45 min) due to acute side effects. No hepatic, cognitive or urinary changes were observed after the treatment course in either group. There was an approximately two-fold variation in ketamine and norketamine plasma concentrations between ketamine participants. At course end, one participant had remitted in each of the ketamine and midazolam groups. CONCLUSIONS IN ketamine, with the drug formulation and delivery device used, was not a useful treatment approach in this study. Absorption was variable between individuals and acute tolerability was poor, requiring prolonged treatment administration time in some individuals. The drug formulation, the delivery device, the insufflation technique and individual patient factors play an important role in tolerability and efficacy when using IN ketamine for TRD.
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Affiliation(s)
- Verònica Gálvez
- 1 School of Psychiatry, University of New South Wales, Sydney, Australia.,2 Black Dog Institute, Sydney, Australia
| | - Adrienne Li
- 1 School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Christina Huggins
- 1 School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Paul Glue
- 3 Department of Psychological Medicine, University of Otago, New Zealand
| | - Donel Martin
- 1 School of Psychiatry, University of New South Wales, Sydney, Australia.,2 Black Dog Institute, Sydney, Australia
| | - Andrew A Somogyi
- 4 Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Australia
| | - Angelo Alonzo
- 1 School of Psychiatry, University of New South Wales, Sydney, Australia.,2 Black Dog Institute, Sydney, Australia
| | - Anthony Rodgers
- 5 The George Institute for Global Health, University of Sydney, Australia
| | - Philip B Mitchell
- 1 School of Psychiatry, University of New South Wales, Sydney, Australia.,2 Black Dog Institute, Sydney, Australia
| | - Colleen K Loo
- 1 School of Psychiatry, University of New South Wales, Sydney, Australia.,2 Black Dog Institute, Sydney, Australia.,6 Wesley Hospital, Sydney, Australia.,7 St George Hospital, Sydney, Australia
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18
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Loo CK, Husain MM, McDonald WM, Aaronson S, O'Reardon JP, Alonzo A, Weickert CS, Martin DM, McClintock SM, Mohan A, Lisanby SH, Lisanby SH, Krystal AD, Peterchev AV, McDonald WM, O'Reardon JP, Aaronson S, Davis W, Sklar J, Loo CK, Alonzo A, Weickert CS, Martin DM, Mohan A, Colagiuri B, Galvez V, Husain MM, McClintock SM. International randomized-controlled trial of transcranial Direct Current Stimulation in depression. Brain Stimul 2018; 11:125-133. [DOI: 10.1016/j.brs.2017.10.011] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 09/18/2017] [Accepted: 10/15/2017] [Indexed: 02/04/2023] Open
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19
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Moffa AH, Brunoni AR, Fregni F, Palm U, Padberg F, Blumberger DM, Daskalakis ZJ, Bennabi D, Haffen E, Alonzo A, Loo CK. Safety and acceptability of transcranial direct current stimulation for the acute treatment of major depressive episodes: Analysis of individual patient data. J Affect Disord 2017. [PMID: 28623732 DOI: 10.1016/j.jad.2017.06.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation modality that has been increasingly used for major depressive disorder (MDD) treatment. Although studies in healthy volunteers showed that the technique is well-tolerated, tDCS safety and acceptability have not been sufficiently explored in patients with MDD. METHODS We collected individual patient data from 6 randomized clinical trials that had been previously identified in a systematic review and meta-analysis. Primary outcomes were safety (rate of adverse events) and acceptability (rate of dropouts). Secondary outcomes were clinical, demographic and treatment predictors of the primary outcomes. RESULTS Dropout rates between active (8.8%) and sham (12%) groups were not significantly different (OR= 0.7, p=0.38). Adverse event rates between active (73.5%) and sham (68.3%) groups were not significantly different (OR= 1.4, p= 0.23). Higher current densities were associated with lower adverse event rates. LIMITATIONS Dropout reasons were not systematically reported and adverse events were not collected using questionnaires standardized across studies. CONCLUSIONS Active tDCS is as acceptable and safe as sham tDCS, as found in randomized clinical trials of MDD.
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Affiliation(s)
- Adriano H Moffa
- Interdisciplinary Center for Applied Neuromodulation, University Hospital & Service of Interdisciplinary Neuromodulation, Department and Institute of Psychiatry, Laboratory of Neurosciences (LIM-27), University of São Paulo, São Paulo, Brazil
| | - André R Brunoni
- Interdisciplinary Center for Applied Neuromodulation, University Hospital & Service of Interdisciplinary Neuromodulation, Department and Institute of Psychiatry, Laboratory of Neurosciences (LIM-27), University of São Paulo, São Paulo, Brazil
| | - Felipe Fregni
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
| | - Ulrich Palm
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University Munich, Munich, Germany
| | - Frank Padberg
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University Munich, Munich, Germany
| | - Daniel M Blumberger
- Temerty Centre for Therapeutic Brain Intervention and Campbell Family Research Institute, Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, ON, Canada
| | - Zafiris J Daskalakis
- Temerty Centre for Therapeutic Brain Intervention and Campbell Family Research Institute, Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, ON, Canada
| | - Djamila Bennabi
- Department of Clinical Psychiatry, Clinical Investigation Center 1431 Inserm, EA 481 Neurosciences, University Hospital of Besancon and FondaMental Foundation, Créteil, France
| | - Emmanuel Haffen
- Department of Clinical Psychiatry, Clinical Investigation Center 1431 Inserm, EA 481 Neurosciences, University Hospital of Besancon and FondaMental Foundation, Créteil, France
| | - Angelo Alonzo
- Black Dog Institute & School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Colleen K Loo
- Black Dog Institute & School of Psychiatry, University of New South Wales, Sydney, Australia
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Loo C, Martin D, Ho KA, Alonzo A, Bai S, Dokos S. Prefrontal anodal tDCS as a Neuropsychiatric treatment –factors beyond prefrontal stimulation. Brain Stimul 2017. [DOI: 10.1016/j.brs.2017.01.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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21
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Gálvez V, Nikolin S, Ho KA, Alonzo A, Somogyi AA, Loo CK. Increase in PAS-induced neuroplasticity after a treatment course of intranasal ketamine for depression. Report of three cases from a placebo-controlled trial. Compr Psychiatry 2017; 73:31-34. [PMID: 27886522 DOI: 10.1016/j.comppsych.2016.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 10/27/2016] [Accepted: 10/29/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Animal studies suggest that neural plasticity may play a role in the antidepressant effects of a single ketamine dose. However, the potential effects of repeated ketamine treatments on human neuroplasticity are unknown. METHODS This pilot RCT study measured plasticity-induced changes before and after a ketamine course, in three treatment-resistant depressed subjects, who were randomized to receive 8 intranasal treatments of 100mg ketamine or 4.5mg midazolam. Mood ratings were performed by a trained blinded rater at baseline and 24h-48h after the ketamine course, using the Montgomery Asberg Depression Rating Scale (MADRS). Neuroplasticity was assessed in the motor cortex using a paired associative stimulation (PAS) paradigm at baseline and 24h-48h after the treatment course. No changes in current psychotropic medication or dosage were permitted for 4weeks prior to trial entry and throughout the trial. RESULTS The subject receiving ketamine, but not those receiving midazolam, presented a marked increase in neural plasticity after the treatment course. However, mood changes were not associated with changes in neural plasticity. LIMITATIONS Pilot study with small sample size. Concomitant antidepressant medications taken. Plasticity was tested in the motor cortex only, thus the generalizability of these findings to other brain areas cannot be assumed. CONCLUSIONS These results suggest that a course of intranasal ketamine may enhance synaptic plasticity in subjects with depression, but this was not associated with antidepressant effects. Further research on this topic is warranted.
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Affiliation(s)
- Verònica Gálvez
- School of Psychiatry, University of New South Wales, Hospital Road, 2031, Randwick, Sydney, NSW, Australia; Black Dog Institute, Hospital Road, 2031, Randwick, Sydney, NSW, Australia.
| | - Stevan Nikolin
- School of Psychiatry, University of New South Wales, Hospital Road, 2031, Randwick, Sydney, NSW, Australia; Black Dog Institute, Hospital Road, 2031, Randwick, Sydney, NSW, Australia
| | - Kerrie-Anne Ho
- School of Psychiatry, University of New South Wales, Hospital Road, 2031, Randwick, Sydney, NSW, Australia; Black Dog Institute, Hospital Road, 2031, Randwick, Sydney, NSW, Australia
| | - Angelo Alonzo
- School of Psychiatry, University of New South Wales, Hospital Road, 2031, Randwick, Sydney, NSW, Australia; Black Dog Institute, Hospital Road, 2031, Randwick, Sydney, NSW, Australia
| | - Andrew A Somogyi
- Discipline of Pharmacology, School of Medicine, University of Adelaide, Adelaide, 5005, SA, Australia
| | - Colleen K Loo
- School of Psychiatry, University of New South Wales, Hospital Road, 2031, Randwick, Sydney, NSW, Australia; Black Dog Institute, Hospital Road, 2031, Randwick, Sydney, NSW, Australia; St. George Hospital, Department of Psychiatry, Gray St, Kogarah, 2217, NSW, Australia
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Charvet L, Kasschau M, Bikson M, Datta A, Knotkova H, Stevens MC, Alonzo A, Loo C, Krull K, Haider L. Remotely-Supervised Transcranial Direct Current Stimulation (tDCS). Brain Stimul 2017. [DOI: 10.1016/j.brs.2016.11.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Alonzo A, Aaronson S, Bikson M, Husain M, Lisanby S, Martin D, McClintock SM, McDonald WM, O'Reardon J, Esmailpoor Z, Loo C. Study design and methodology for a multicentre, randomised controlled trial of transcranial direct current stimulation as a treatment for unipolar and bipolar depression. Contemp Clin Trials 2016; 51:65-71. [DOI: 10.1016/j.cct.2016.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 10/04/2016] [Accepted: 10/10/2016] [Indexed: 01/17/2023]
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Brunoni AR, Moffa AH, Fregni F, Palm U, Padberg F, Blumberger DM, Daskalakis ZJ, Bennabi D, Haffen E, Alonzo A, Loo CK. Transcranial direct current stimulation for acute major depressive episodes: meta-analysis of individual patient data. Br J Psychiatry 2016; 208:522-31. [PMID: 27056623 PMCID: PMC4887722 DOI: 10.1192/bjp.bp.115.164715] [Citation(s) in RCA: 234] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 07/12/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND Transcranial direct current stimulation (tDCS) is a non-pharmacological intervention for depression. It has mixed results, possibly caused by study heterogeneity. AIMS To assess tDCS efficacy and to explore individual response predictors. METHOD Systematic review and individual patient data meta-analysis. RESULTS Data were gathered from six randomised sham-controlled trials, enrolling 289 patients. Active tDCS was significantly superior to sham for response (34% v. 19% respectively, odds ratio (OR) = 2.44, 95% CI 1.38-4.32, number needed to treat (NNT) = 7), remission (23.1% v. 12.7% respectively, OR = 2.38, 95% CI 1.22-4.64, NNT = 9) and depression improvement (B coefficient 0.35, 95% CI 0.12-0.57). Mixed-effects models showed that, after adjustment for other predictors and confounders, treatment-resistant depression and higher tDCS 'doses' were, respectively, negatively and positively associated with tDCS efficacy. CONCLUSIONS The effect size of tDCS treatment was comparable with those reported for repetitive transcranial magnetic stimulation and antidepressant drug treatment in primary care. The most important parameters for optimisation in future trials are depression refractoriness and tDCS dose.
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Affiliation(s)
- André R. Brunoni
- Correspondence: André R. Brunoni, MD, PhD, Interdisciplinary Center for Applied Neuromodulation, Av. Professor Lineu Prestes, 2565, 3o andar, CEP 05508-000, São Paulo (SP), Brazil.
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Martin DM, Chan HN, Alonzo A, Green MJ, Mitchell PB, Loo CK. Transcranial direct current stimulation to enhance cognition in euthymic bipolar disorder. Bipolar Disord 2015; 17:849-58. [PMID: 26667520 DOI: 10.1111/bdi.12350] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 09/08/2015] [Accepted: 10/12/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To investigate the use of transcranial direct current stimulation (tDCS) for enhancing working memory and sustained attention in euthymic patients with bipolar disorder. METHODS Fifteen patients with bipolar disorder received anodal left prefrontal tDCS with an extracephalic cathode (prefrontal condition), anodal left prefrontal and cathodal cerebellar tDCS (fronto-cerebellar condition), and sham tDCS given 'online' during performance on a working memory and sustained attention task in an intra-individual, cross-over, sham-controlled experimental design. Exploratory cluster analyses examined responders and non-responders for the different active tDCS conditions on both tasks. RESULTS For working memory, approximately one-third of patients in both active tDCS conditions showed performance improvement. For sustained attention, three of 15 patients showed performance improvement with prefrontal tDCS. Responders to active tDCS for working memory performed more poorly on the task during sham tDCS compared to non-responders. CONCLUSIONS A single session of active prefrontal or fronto-cerebellar tDCS failed to improve working memory or sustained attention performance in euthymic patients with bipolar disorder. Several important considerations are discussed in relation to future studies investigating tDCS for enhancing cognition in patients with bipolar disorder.
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Affiliation(s)
- Donel M Martin
- School of Psychiatry, Black Dog Institute, University of New South Wales, Sydney, Australia
| | | | - Angelo Alonzo
- School of Psychiatry, Black Dog Institute, University of New South Wales, Sydney, Australia
| | - Melissa J Green
- School of Psychiatry, Black Dog Institute, University of New South Wales, Sydney, Australia
| | - Philip B Mitchell
- School of Psychiatry, Black Dog Institute, University of New South Wales, Sydney, Australia
| | - Colleen K Loo
- School of Psychiatry, Black Dog Institute, University of New South Wales, Sydney, Australia
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Ho KA, Taylor JL, Chew T, Gálvez V, Alonzo A, Bai S, Dokos S, Loo CK. The Effect of Transcranial Direct Current Stimulation (tDCS) Electrode Size and Current Intensity on Motor Cortical Excitability: Evidence From Single and Repeated Sessions. Brain Stimul 2015; 9:1-7. [PMID: 26350410 DOI: 10.1016/j.brs.2015.08.003] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 08/03/2015] [Accepted: 08/10/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Current density is considered an important factor in determining the outcomes of tDCS, and is determined by the current intensity and electrode size. Previous studies examining the effect of these parameters on motor cortical excitability with small sample sizes reported mixed results. OBJECTIVE/HYPOTHESIS This study examined the effect of current intensity (1 mA, 2 mA) and electrode size (16 cm(2), 35 cm(2)) on motor cortical excitability over single and repeated tDCS sessions. METHODS Data from seven studies in 89 healthy participants were pooled for analysis. Single-session data were analyzed using mixed effects models and repeated-session data were analyzed using mixed design analyses of variance. Computational modeling was used to examine the electric field generated. RESULTS The magnitude of increases in excitability after anodal tDCS was modest. For single-session tDCS, the 35 cm(2) electrodes produced greater increases in cortical excitability compared to the 16 cm(2) electrodes. There were no differences in the magnitude of cortical excitation produced by 1 mA and 2 mA tDCS. The repeated-sessions data also showed that there were greater increases in excitability with the 35 cm(2) electrodes. Further, repeated sessions of tDCS with the 35 cm(2) electrodes resulted in a cumulative increase in cortical excitability. Computational modeling predicted higher electric field at the motor hotspot for the 35 cm(2) electrodes. CONCLUSIONS 2 mA tDCS does not necessarily produce larger effects than 1 mA tDCS in healthy participants. Careful consideration should be given to the exact positioning, size and orientation of tDCS electrodes relative to cortical regions.
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Affiliation(s)
- Kerrie-Anne Ho
- School of Psychiatry, University of New South Wales, Prince of Wales Hospital, Hospital Road, Randwick, NSW 2031, Australia; Black Dog Institute, Prince of Wales Hospital, Hospital Road, Randwick, NSW 2031, Australia
| | - Janet L Taylor
- Neuroscience Research Australia, Margarete Ainsworth Building, Barker Street, Randwick, NSW 2031, Australia; School of Medical Sciences, University of New South Wales, Sydney, NSW 2052, Australia
| | - Taariq Chew
- School of Psychiatry, University of New South Wales, Prince of Wales Hospital, Hospital Road, Randwick, NSW 2031, Australia; Black Dog Institute, Prince of Wales Hospital, Hospital Road, Randwick, NSW 2031, Australia
| | - Verònica Gálvez
- School of Psychiatry, University of New South Wales, Prince of Wales Hospital, Hospital Road, Randwick, NSW 2031, Australia; Black Dog Institute, Prince of Wales Hospital, Hospital Road, Randwick, NSW 2031, Australia
| | - Angelo Alonzo
- School of Psychiatry, University of New South Wales, Prince of Wales Hospital, Hospital Road, Randwick, NSW 2031, Australia; Black Dog Institute, Prince of Wales Hospital, Hospital Road, Randwick, NSW 2031, Australia
| | - Siwei Bai
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, NSW 2052, Australia; IMETUM, Technische Universität München, Garching 85748, Germany
| | - Socrates Dokos
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, NSW 2052, Australia
| | - Colleen K Loo
- School of Psychiatry, University of New South Wales, Prince of Wales Hospital, Hospital Road, Randwick, NSW 2031, Australia; Black Dog Institute, Prince of Wales Hospital, Hospital Road, Randwick, NSW 2031, Australia; St George Hospital, South Eastern Sydney Health, Level 2, James Laws House, Gray St, Kogarah, NSW 2217, Australia.
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Abstract
Depression is frequent in old age and its prognosis is poorer than in younger populations. The use of pharmacological treatments in geriatric depression is limited by specific pharmacodynamic age-related factors that can diminish tolerability and increase the risk of drug interactions. The possibility of modulating cerebral activity using brain stimulation techniques could result in treating geriatric depression more effectively while reducing systemic side effects and medication interactions. This may subsequently improve treatment adherence and overall prognosis in the older patient. Among clinically available neuromodulatory techniques, electroconvulsive therapy (ECT) remains the gold standard for the treatment of severe depression in the elderly. Studies have proven that ECT is more effective and has a faster onset of action than antidepressants in the treatment of severe, unipolar, geriatric depression and that older age is a predictor of rapid ECT response and remission. The application of novel and more tolerable forms of ECT for geriatric depression is currently being examined. Preliminary results suggest that right unilateral ultrabrief ECT (RUL-UB ECT) is a promising intervention, with similar efficacy to brief-pulse ECT and fewer adverse cognitive effects. Overall findings in repetitive transcranial magnetic stimulation (rTMS) suggest that it is a safe intervention in geriatric depression. Higher rTMS stimulation intensity and more treatments may need to be given in the elderly to achieve optimal results. There is no specific data on vagus nerve stimulation in the elderly. Transcranial direct current stimulation, magnetic seizure therapy and deep brain stimulation are currently experimental, and more data from geriatric samples is needed.
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Affiliation(s)
- Verònica Gálvez
- School of Psychiatry, University of New South Wales (UNSW), Hospital Road, 2031, Randwick, Sydney, NSW, Australia
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Ho KA, Bai S, Martin D, Alonzo A, Dokos S, Puras P, Loo CK. A pilot study of alternative transcranial direct current stimulation electrode montages for the treatment of major depression. J Affect Disord 2015; 167:251-8. [PMID: 24998841 DOI: 10.1016/j.jad.2014.06.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 06/12/2014] [Accepted: 06/12/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Typically, transcranial direct current stimulation (tDCS) treatments for depression have used bifrontal montages with anodal (excitatory) stimulation targeting the left dorsolateral prefrontal cortex (DLPFC). There is limited research examining the effects of alternative electrode montages. OBJECTIVE/HYPOTHESIS This pilot study aimed to examine the feasibility, tolerability and safety of two alternative electrode montages and provide preliminary data on efficacy. The montages, Fronto-Occipital (F-O) and Fronto-Cerebellar (F-C), were designed respectively to target midline brain structures and the cerebellum. METHODS The anode was placed over the left supraorbital region and the cathode over the occipital and cerebellar region for the F-O and F-C montages respectively. Computational modelling was used to determine the electric fields produced in the brain regions of interest compared to a standard bifrontal montage. The two montages were evaluated in an open label study of depressed participants (N=14). Mood and neuropsychological functioning were assessed at baseline and after four weeks of tDCS. RESULTS Computational modelling revealed that the novel montages resulted in greater activation in the anterior cingulate cortices and cerebellum than the bifrontal montage, while activation of the DLPFCs was higher for the bifrontal montage. After four weeks of tDCS, overall mood improvement rates of 43.8% and 15.9% were observed under the F-O and F-C conditions, respectively. No significant neuropsychological changes were found. LIMITATIONS The clinical pilot was open-label, without a control condition and computational modelling was based on one healthy participant. CONCLUSIONS Results found both montages safe and feasible. The F-O montage showed promising antidepressant potential.
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Affiliation(s)
- Kerrie-Anne Ho
- School of Psychiatry, University of New South Wales, Black Dog Institute, Sydney, NSW 2031, Australia
| | - Siwei Bai
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, Australia
| | - Donel Martin
- School of Psychiatry, University of New South Wales, Black Dog Institute, Sydney, NSW 2031, Australia
| | - Angelo Alonzo
- School of Psychiatry, University of New South Wales, Black Dog Institute, Sydney, NSW 2031, Australia
| | - Socrates Dokos
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, Australia
| | - Pablo Puras
- Department of Psychiatry, Hospital Universitario de Getafe, Getafe, Madrid, Spain; School of Psychiatry, University of New South Wales, Black Dog Institute, Sydney, NSW 2031, Australia
| | - Colleen K Loo
- School of Psychiatry, University of New South Wales, Black Dog Institute, Sydney, NSW 2031, Australia; Department of Psychiatry, St George Hospital, Sydney, Australia.
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29
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Player MJ, Taylor JL, Weickert CS, Alonzo A, Sachdev PS, Martin D, Mitchell PB, Loo CK. Increase in PAS-induced neuroplasticity after a treatment course of transcranial direct current stimulation for depression. J Affect Disord 2015; 167:140-7. [PMID: 24968188 DOI: 10.1016/j.jad.2014.05.063] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 05/28/2014] [Accepted: 05/29/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Several lines of evidence suggest that neuroplasticity is impaired in depression and improves with effective treatment. However until now, this evidence has largely involved measures such as learning and memory which can be influenced by subject effort and motivation. This pilot study aimed to objectively measure neuroplasticity in the motor cortex using paired associative stimulation (PAS), which induces short term neuroplastic changes. It is hypothesized that neuroplasticity would improve after effective treatment for depression. METHODS Neuroplasticity was measured in 18 depressed subjects before and after a course of anodal transcranial direct current stimulation (tDCS), given as treatment for depression. The relationships between PAS results, mood state and brain-derived neurotrophic factor (BDNF) serum levels were examined. RESULTS Neuroplasticity (PAS-induced change) was increased after a course of tDCS (t(17)=-2.651, p=0.017). Treatment with tDCS also led to significant mood improvement, but this did not correlate with improved neuroplasticity. Serum BDNF levels did not change after tDCS, or correlate with change in neuroplasticity after tDCS treatment. LIMITATIONS While this study showed evidence of improved neuroplasticity in the motor cortex after effective treatment, we are unable to present evidence that this change is generalized in the depressed brain. Also, the presence of antidepressant medications and the small sample of patients (n=18) meant the study could not definitively resolve the relationship between neuroplasticity, mood and BDNF. CONCLUSION This novel preliminary study provides evidence that a treatment course of tDCS can improve neuroplasticity in depressed patients.
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Affiliation(s)
- Michael J Player
- School of Psychiatry, University of New South Wales, Sydney, Australia; Black Dog Institute, Hospital Road, Randwick, Sydney, NSW 2031, Australia
| | - Janet L Taylor
- Neuroscience Research Australia, Sydney, Australia; School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Cynthia Shannon Weickert
- School of Psychiatry, University of New South Wales, Sydney, Australia; Neuroscience Research Australia, Sydney, Australia; Schizophrenia Research Institute, Darlinghurst, Sydney, Australia
| | - Angelo Alonzo
- School of Psychiatry, University of New South Wales, Sydney, Australia; Black Dog Institute, Hospital Road, Randwick, Sydney, NSW 2031, Australia
| | - Perminder S Sachdev
- School of Psychiatry, University of New South Wales, Sydney, Australia; Neuropsychiatric Institute, Prince of Wales Hospital, Sydney, Australia; Centre for Healthy Brain Ageing (CHeBA), University of New South Wales, Australia
| | - Donel Martin
- School of Psychiatry, University of New South Wales, Sydney, Australia; Black Dog Institute, Hospital Road, Randwick, Sydney, NSW 2031, Australia
| | - Philip B Mitchell
- School of Psychiatry, University of New South Wales, Sydney, Australia; Black Dog Institute, Hospital Road, Randwick, Sydney, NSW 2031, Australia
| | - Colleen K Loo
- School of Psychiatry, University of New South Wales, Sydney, Australia; Black Dog Institute, Hospital Road, Randwick, Sydney, NSW 2031, Australia; St. George Hospital, South Eastern Sydney Health, Australia.
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Charvet LE, Kasschau M, Datta A, Knotkova H, Stevens MC, Alonzo A, Loo C, Krull KR, Bikson M. Remotely-supervised transcranial direct current stimulation (tDCS) for clinical trials: guidelines for technology and protocols. Front Syst Neurosci 2015; 9:26. [PMID: 25852494 PMCID: PMC4362220 DOI: 10.3389/fnsys.2015.00026] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 02/13/2015] [Indexed: 11/13/2022] Open
Abstract
The effect of transcranial direct current stimulation (tDCS) is cumulative. Treatment protocols typically require multiple consecutive sessions spanning weeks or months. However, traveling to clinic for a tDCS session can present an obstacle to subjects and their caregivers. With modified devices and headgear, tDCS treatment can be administered remotely under clinical supervision, potentially enhancing recruitment, throughput, and convenience. Here we propose standards and protocols for clinical trials utilizing remotely-supervised tDCS with the goal of providing safe, reproducible and well-tolerated stimulation therapy outside of the clinic. The recommendations include: (1) training of staff in tDCS treatment and supervision; (2) assessment of the user’s capability to participate in tDCS remotely; (3) ongoing training procedures and materials including assessments of the user and/or caregiver; (4) simple and fail-safe electrode preparation techniques and tDCS headgear; (5) strict dose control for each session; (6) ongoing monitoring to quantify compliance (device preparation, electrode saturation/placement, stimulation protocol), with corresponding corrective steps as required; (7) monitoring for treatment-emergent adverse effects; (8) guidelines for discontinuation of a session and/or study participation including emergency failsafe procedures tailored to the treatment population’s level of need. These guidelines are intended to provide a minimal level of methodological rigor for clinical trials seeking to apply tDCS outside a specialized treatment center. We outline indication-specific applications (Attention Deficit Hyperactivity Disorder, Depression, Multiple Sclerosis, Palliative Care) following these recommendations that support a standardized framework for evaluating the tolerability and reproducibility of remote-supervised tDCS that, once established, will allow for translation of tDCS clinical trials to a greater size and range of patient populations.
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Affiliation(s)
- Leigh E Charvet
- Department of Neurology, Stony Brook Medicine Stony Brook, NY, USA
| | | | | | | | - Michael C Stevens
- Olin Neuropsychiatry Research Center, Yale University School of Medicine New Haven, CT, USA
| | - Angelo Alonzo
- School of Psychiatry, University of New South Wales, Black Dog Institute Randwick, Australia
| | - Colleen Loo
- School of Psychiatry, University of New South Wales, Black Dog Institute Randwick, Australia
| | - Kevin R Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital Memphis, Tennessee, USA
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York of CUNY NY, USA
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31
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Martin DM, Liu R, Alonzo A, Green M, Loo CK. Use of transcranial direct current stimulation (tDCS) to enhance cognitive training: effect of timing of stimulation. Exp Brain Res 2014; 232:3345-51. [PMID: 24992897 DOI: 10.1007/s00221-014-4022-x] [Citation(s) in RCA: 161] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 06/17/2014] [Indexed: 11/30/2022]
Abstract
The capacity for transcranial direct current stimulation (tDCS) to increase learning and cognition shows promise for the development of enhanced therapeutic interventions. One potential application is the combination of tDCS with cognitive training (CT), a psychological intervention which aims to improve targeted cognitive abilities. We have previously shown that tDCS enhanced performance accuracy, but not skill acquisition, on a dual n-back working memory (WM) CT task over repeated sessions. In the current study, we investigated the optimal timing for combining tDCS with the same CT task to enhance within and between session performance outcomes across two daily CT sessions. Twenty healthy participants received in a randomised order 30 min of anodal tDCS to the left dorsolateral prefrontal cortex immediately before ('offline' tDCS) and during performance ('online' tDCS) on a dual n-back WM CT task, in an intra-individual crossover design. Analyses examined within and between session consolidation effects of tDCS on CT performance outcomes. Results showed that 'online' tDCS was associated with better within session skill acquisition on the CT task, with a significant difference found between conditions the following day. These results suggest that 'online' tDCS is superior to 'offline' tDCS for enhancing skill acquisition when combining anodal tDCS with CT. This finding may assist with the development of enhanced protocols involving the combination of tDCS with CT and other rehabilitation protocols.
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Affiliation(s)
- Donel M Martin
- Black Dog Institute, School of Psychiatry, Prince of Wales Hospital, University of New South Wales, Barker St, Randwick, Sydney, 2031, Australia,
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Player MJ, Taylor JL, Weickert CS, Alonzo A, Sachdev P, Martin D, Mitchell PB, Loo CK. Neuroplasticity in depressed individuals compared with healthy controls. Neuropsychopharmacology 2013; 38:2101-8. [PMID: 23676792 PMCID: PMC3773676 DOI: 10.1038/npp.2013.126] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 04/22/2013] [Accepted: 04/29/2013] [Indexed: 01/03/2023]
Abstract
Several lines of evidence suggest that neuroplasticity is impaired in depression. This study aimed to compare neuroplasticity in 23 subjects with DSM-IV major depressive episode and 23 age- and gender-matched healthy controls, using an objective test that is independent of subject effort and motivation. Neuroplasticity was assessed in the motor cortex using a brain stimulation paradigm known as paired associative stimulation (PAS), which induces transient changes in motor cortical function. Motor cortical excitability was assessed before and after PAS using single-pulse transcranial magnetic stimulation (TMS) to induce motor evoked potentials (MEPs) in a hand muscle. After PAS, MEP amplitudes significantly increased in healthy controls compared with depressed subjects (P=0.002). The functional significance of motor cortical changes was assessed using a motor learning task-a computerized version of the rotor pursuit task. Healthy controls also performed better on motor learning (P=0.02). BDNF blood levels and genotype were assayed to determine any relationship with motor cortical plasticity. However, PAS results did not correlate with motor learning, nor appear to be related to BDNF measures. The significance of these findings is that it provides one of the first direct demonstrations of reduced neuroplasticity in depressed subjects, using an objective test.
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Affiliation(s)
- Michael J Player
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia,Black Dog Institute, Sydney, NSW, Australia
| | - Janet L Taylor
- Neuroscience Research Australia, Sydney, NSW, Australia,School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Cynthia Shannon Weickert
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia,Neuroscience Research Australia, Sydney, NSW, Australia,The Schizophrenia Research Institute, Sydney, NSW, Australia
| | - Angelo Alonzo
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia,Black Dog Institute, Sydney, NSW, Australia
| | - Perminder Sachdev
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia,Neuropsychiatric Institute, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Donel Martin
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia,Black Dog Institute, Sydney, NSW, Australia
| | - Philip B Mitchell
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia,Black Dog Institute, Sydney, NSW, Australia
| | - Colleen K Loo
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia,Black Dog Institute, Sydney, NSW, Australia,St George Hospital, South Eastern Sydney Health, Sydney, NSW, Australia,Black Dog Institute, Hospital Road, Randwick, Sydney, NSW 2031, Australia, Tel: +61 2 9382 8319, Fax: +61 2 9382 8208, E-mail:
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Gálvez V, Loo CK, Alonzo A, Cerrillo E, Menchón JM, Crespo JM, Urretavizcaya M. Do benzodiazepines moderate the effectiveness of bitemporal electroconvulsive therapy in major depression? J Affect Disord 2013; 150:686-90. [PMID: 23668903 DOI: 10.1016/j.jad.2013.03.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 03/27/2013] [Accepted: 03/27/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is the most effective treatment for depression. However, the use of concomitant medications during ECT is controversial, especially benzodiazepines, as some past evidence suggests these may reduce the efficacy of ECT. This study analysed the effect of benzodiazepines on treatment outcomes in a group of depressed patients treated with bitemporal (BT) ECT. METHODS 90 patients with major depression who received BT ECT were analysed. Clinical, demographic and ECT data were extracted from clinical records. Mood improvement was rated by trained psychiatrists using the Hamilton Depression Rating Scale (HDRS-21) at baseline and after the final ECT treatment. The association between benzodiazepine dose and mood outcomes over the ECT course was examined with regression analyses, controlling for variables that may affect ECT efficacy. RESULTS Hierarchical multiple regression analysis found only current episode duration (t=-4.77, p<0.001) was a significant predictor of change in HDRS. Benzodiazepine dose was not associated with a change in HDRS (p>0.05, R(2)=0.39). LIMITATIONS This was a retrospective study. The use of the half-age dosing method for ECT did not permit examination of the effects of benzodiazepines on seizure threshold. CONCLUSIONS Benzodiazepines did not affect the efficacy of BT ECT with the dosing method used. However, these results may not generalise to other forms of ECT, ECT given with other methods of dose determination or to other populations less responsive to ECT.
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Affiliation(s)
- Verònica Gálvez
- Neuroscience Group, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
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Alonzo A, Chan G, Martin D, Mitchell PB, Loo C. Transcranial direct current stimulation (tDCS) for depression: analysis of response using a three-factor structure of the Montgomery-Åsberg depression rating scale. J Affect Disord 2013; 150:91-5. [PMID: 23507370 DOI: 10.1016/j.jad.2013.02.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 02/13/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND There is growing evidence that transcranial direct current stimulation (tDCS) may be an effective treatment for depression. However, no study to date has profiled the antidepressant effects of tDCS using items or factors on depression symptom severity rating scales. This could potentially provide information about the mechanisms by which tDCS achieves its antidepressant effects and also identify clinical predictors of response. METHODS The present study analysed scores on the Montgomery-Åsberg depression rating scale (MADRS) from a randomised, sham-controlled trial of tDCS (Loo et al., 2012. British Journal of Psychiatry. 200, 52-59) using a three-factor model of MADRS items (Suzuki et al., 2005. Depression and Anxiety. 21, 95-97) encompassing dysphoria, retardation and vegetative symptoms. RESULTS Participants in the active tDCS treatment group showed significant improvement in dysphoria while participants in the sham treatment group did not. While both groups showed improvement in retardation symptoms, improvement was significantly greater in the active tDCS group. Both groups also showed improvement in vegetative symptoms but there were no between-group differences. LIMITATIONS Further studies with larger sample sizes are warranted to investigate the generalisability of results and whether the MADRS factor structure may change as a result of the specific treatment used. CONCLUSIONS tDCS appears to be particularly effective in treating dysphoria and retardation, but not vegetative symptoms of depression. This may have implications for selection of types of depression most likely to respond to this treatment.
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Affiliation(s)
- Angelo Alonzo
- School of Psychiatry, University of New South Wales, Sydney, NSW 2052, Australia.
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Martin DM, Alonzo A, Ho KA, Player M, Mitchell PB, Sachdev P, Loo CK. Continuation transcranial direct current stimulation for the prevention of relapse in major depression. J Affect Disord 2013; 144:274-8. [PMID: 23146197 DOI: 10.1016/j.jad.2012.10.012] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 10/18/2012] [Accepted: 10/18/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Transcranial direct current stimulation (tDCS) is gaining attention as an effective new treatment for major depression. Little is known, however, of the duration of antidepressant effects following acute treatment. In this study, we describe the use of continuation tDCS treatment for up to 6 months following clinical response to an acute treatment course. METHODS Twenty-six participants pooled from two different studies involving different tDCS protocols received continuation tDCS treatment on a weekly basis for 3 months and then once per fortnight for the final 3 months. Mood ratings were completed at 3 and 6 months. Analyses examined clinical predictors of relapse during continuation tDCS treatment. RESULTS The cumulative probability of surviving without relapse was 83.7% at 3 months and 51.1% at 6 months. Medication resistance was found to be a predictor of relapse during continuation tDCS. LIMITATIONS This was an open label prospective study with no control group. Two different forms of tDCS were used. CONCLUSION Similar to other antidepressant treatments, continuation tDCS appears to be a useful strategy to prevent relapse following clinical response. These preliminary data suggest that the majority of patients maintained antidepressant benefit with a continuation schedule of at least weekly treatment. Future controlled studies are required to confirm these findings.
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Affiliation(s)
- Donel M Martin
- Black Dog Institute, School of Psychiatry, University of New South Wales, Sydney, Australia
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Costamagna D, Pagano L, Caputo M, Leutner M, Mercalli F, Alonzo A. Incidental cancer in patients surgically treated for benign thyroid disease. Our experience at a single institution. G Chir 2013; 34:21-26. [PMID: 23463928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Increased incidence of incidental cancer in patients operated for benign thyroid disease has been reported. We report our experience about incidental thyroid cancer (ITC) in order to better characterize this nosologic entity. Between 2001 and 2009 a total of 568 patients underwent surgery for benign thyroid disease. Patients with preoperative cytology undetermined or positive for malignancy were excluded. The most frequent indication for surgery was multinodular or diffuse nontoxic goiter. We performed total thyroidectomy in 499 cases and emithyroidectomy in 69 cases. Final histology revealed ITC in 53 patients (9.3%): 44 had papillary carcinoma (20 classic variant and 24 follicular variant), 4 follicular carcinoma, 4 medullary carcinoma and 1 primitive thyroid paraganglioma. The preoperative diagnosis was multinodular or diffuse goiter in 45 cases of ITC and uninodular goiter in 8 cases. We performed total thyroidectomy in 46 case, emithyroidectomy in 4 patients with past history of lobectomy, emithyroidectomy in 3 patients with following radicalization and central neck dissection. In 14 patients the tumor was multifocal and in 12 of these patients the tumor foci were bilateral. The lesion was a microcarcinoma in 34 cases. Mean diameter of the ITC was 1.14 cm. We retrospectively reconsidered the results of preoperative ultrasound examinations in relation to the exact position of the tumor in the specimens and we found a statistically significant association between echogenicity and papillary histotype. Twenty-six patients were followed up at our Hospital. The mean follow-up period was 38.2 months. A relapse was observed in 3/26 patients. Incidental thyroid cancer in patients operated for benign disease has its own surgical and oncological relevance. A correct preoperative assessment, with a careful selection of nodules for fine-needle aspiration cytology on the basis of ultrasound pattern, could better address the choice of surgical procedure. The non irrelevant incidence of incidental thyroid cancer, the eventuality of multifocality and bilaterality and the possible occurrence of relapse, support that total thyroidectomy without residuum is a valuable option for treating benign thyroid conditions such as multinodular goitre. When an incidental cancer is diagnosed after emithyroidectomy, a radicalization with central neck dissection could be considered. We suggest that natural history of papillary microtumors and the correct surgical approach for these lesions could be better defined with a more extensive use of "Porto proposal" criteria.
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Affiliation(s)
- D Costamagna
- Maggiore della Carità University Hospital, Novara, Italy
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Schulman-Green D, Jaser S, Martin F, Alonzo A, Grey M, McCorkle R, Redeker NS, Reynolds N, Whittemore R. Processes of self-management in chronic illness. J Nurs Scholarsh 2012; 44:136-44. [PMID: 22551013 DOI: 10.1111/j.1547-5069.2012.01444.x] [Citation(s) in RCA: 388] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE Self-management is a dynamic process in which individuals actively manage a chronic illness. Self-management models are limited in their specification of the processes of self-management. The purpose of this article is to delineate processes of self-management in order to help direct interventions and improve health outcomes for individuals with a chronic illness. DESIGN Qualitative metasynthesis techniques were used to analyze 101 studies published between January 2000 and April 2011 that described processes of self-management in chronic illness. METHODS Self-management processes were extracted from each article and were coded. Similar codes were clustered into categories. The analysis continued until a final categorization was reached. FINDINGS Three categories of self-management processes were identified: focusing on illness needs; activating resources; and living with a chronic illness. Tasks and skills were delineated for each category. CONCLUSIONS This metasynthesis expands on current descriptions of self-management processes by specifying a more complete spectrum of self-management processes. CLINICAL RELEVANCE Healthcare providers can best facilitate self-management by coordinating self-management activities, by recognizing that different self-management processes vary in importance to patients over time, and by having ongoing communication with patients and providers to create appropriate self-management plans.
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Loo CK, Alonzo A, Martin D, Mitchell PB, Galvez V, Sachdev P. Transcranial direct current stimulation for depression: 3-week, randomised, sham-controlled trial. Br J Psychiatry 2012; 200:52-9. [PMID: 22215866 DOI: 10.1192/bjp.bp.111.097634] [Citation(s) in RCA: 307] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Preliminary evidence suggests transcranial direct current stimulation (tDCS) has antidepressant efficacy. AIMS To further investigate the efficacy of tDCS in a double-blind, sham-controlled trial (registered at www.clinicaltrials.gov: NCT00763230). METHOD Sixty-four participants with current depression received active or sham anodal tDCS to the left prefrontal cortex (2 mA, 15 sessions over 3 weeks), followed by a 3-week open-label active treatment phase. Mood and neuropsychological effects were assessed. RESULTS There was significantly greater improvement in mood after active than after sham treatment (P<0.05), although no difference in responder rates (13% in both groups). Attention and working memory improved after a single session of active but not sham tDCS (P<0.05). There was no decline in neuropsychological functioning after 3-6 weeks of active stimulation. One participant with bipolar disorder became hypomanic after active tDCS. CONCLUSIONS Findings confirm earlier reports of the antidepressant efficacy and safety of tDCS. Vigilance for mood switching is advised when administering tDCS to individuals with bipolar disorder.
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Affiliation(s)
- Colleen K Loo
- School of Psychiatry, University of New South Wales, Sydney, Australia.
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Alonzo A, Brassil J, Taylor JL, Martin D, Loo CK. Daily transcranial direct current stimulation (tDCS) leads to greater increases in cortical excitability than second daily transcranial direct current stimulation. Brain Stimul 2011; 5:208-213. [PMID: 22037139 DOI: 10.1016/j.brs.2011.04.006] [Citation(s) in RCA: 139] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 04/14/2011] [Accepted: 04/19/2011] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Evidence from recent clinical trials suggests that transcranial direct current stimulation (tDCS) may have potential in treating neuropsychiatric disorders. However, the optimal frequency at which tDCS sessions should be administered is unknown. OBJECTIVE/HYPOTHESIS This study investigated the effects of daily or second daily tDCS sessions on motor cortical excitability, over a 5-day period. METHODS Twelve healthy volunteers received daily or second daily sessions of tDCS to the left primary motor cortex over the study period, in a randomized, intraindividual crossover design. Motor cortical excitability was assessed before and after tDCS at each session through responses to transcranial magnetic stimulation. RESULTS Over a fixed 5-day period, tDCS induced greater increases in MEP amplitude when given daily rather than second daily. Analyses showed that this difference reflected greater cumulative effects between sessions rather than a greater response to each individual tDCS session. CONCLUSIONS These results demonstrate that in the motor cortex of healthy volunteers, tDCS alters cortical excitability more effectively when given daily rather than second daily over a 5-day period.
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Affiliation(s)
- Angelo Alonzo
- School of Psychiatry, University of New South Wales, Black Dog Institute, Sydney, Australia
| | - Joseph Brassil
- School of Psychiatry, University of New South Wales, Black Dog Institute, Sydney, Australia
| | - Janet L Taylor
- Neuroscience Research Australia, Sydney; School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Donel Martin
- School of Psychiatry, University of New South Wales, Black Dog Institute, Sydney, Australia
| | - Colleen K Loo
- School of Psychiatry, University of New South Wales, Black Dog Institute, Sydney, Australia; St. George Hospital, Sydney, Australia.
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Loo C, Trollor J, Alonzo A, Rendina N, Kavess R. Mental health legislation and psychiatric treatments in NSW: electroconvulsive therapy and deep brain stimulation. Australas Psychiatry 2010; 18:417-25. [PMID: 20863180 DOI: 10.3109/10398562.2010.508125] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this paper is to discuss the restriction of electroconvulsive therapy (ECT) to the treatment of psychiatric disorders and the prohibition of psychosurgery and deep brain stimulation (DBS) in the NSW Mental Health Act 2007 (MHA), and to examine these restrictions from clinical and human rights perspectives. METHOD Sections of the NSW MHA regulating the use of ECT, psychosurgery and DBS were reviewed. These were compared with corresponding regulations in mental health legislation in other Australian states. Reasons for discrepancies were explored. RESULTS Restrictions in the MHA on the use of ECT, psychosurgery and DBS are not in line with current clinical evidence of their efficacy and safety. The prohibitions aim to ensure safeguards are in place but the legislation fails to balance these objectives with the potential clinical benefit offered by these treatments. CONCLUSIONS By imposing restrictions which are not justifiable in terms of the clinical evidence available, the MHA discriminates against those with neurological disorders responsive to psychiatric treatments, and those with psychiatric disorders who would benefit from the development of DBS as a treatment.
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Affiliation(s)
- Colleen Loo
- School of Psychiatry, University of NSW, St George Hospital, Gray Street, Kogarah, NSW 2217, Australia.
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Volpe M, Calvieri C, Alonzo A. Modern cardiovascular risk management in clinical practice. Hipertensión y Riesgo Vascular 2009. [DOI: 10.1016/j.hipert.2009.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Moser DK, Kimble LP, Alberts MJ, Alonzo A, Croft JB, Dracup K, Evenson KR, Go AS, Hand MM, Kothari RU, Mensah GA, Morris DL, Pancioli AM, Riegel B, Zerwic JJ. Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council. J Cardiovasc Nurs 2007; 22:326-43. [PMID: 17589286 DOI: 10.1097/01.jcn.0000278963.28619.4a] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.
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Moser DK, Kimble LP, Alberts MJ, Alonzo A, Croft JB, Dracup K, Evenson KR, Go AS, Hand MM, Kothari RU, Mensah GA, Morris DL, Pancioli AM, Riegel B, Zerwic JJ. Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke. Circulation 2006; 114:168-82. [PMID: 16801458 DOI: 10.1161/circulationaha.106.176040] [Citation(s) in RCA: 443] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.
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Abstract
Research in English suggests that syllables can be analyzed in terms of two subunits-the onset (defined as the initial consonant or consonant cluster) and the rime (the unit formed by the vowel and following consonant/s). This study investigated whether nonnative readers of English, which in the case of the present study were native Filipino speakers, also make use of onset-rime units, particularly when some features of their native language (namely infixation and reduplication) appear to foster no awareness of such units. In two lexical decision experiments, monosyllabic English words were presented, divided in between their first and second consonants (e.g., B LIND), at their onset-rime boundary (e.g., BL IND), or at their antibody boundary (e.g., BLI ND). Results indicated that the processes of infixation and reduplication did not affect the English word processing of native Filipino speakers. Rather, results for both native Filipino and native English speakers suggest that onsets composed of an "s + consonant" sequence (e.g., STAMP) are less cohesive than onsets comprised of a stop-liquid sequence (e.g., BLIND). It was concluded that not only may sonority constraints underlie onset cohesiveness, but that such phonetic properties may also be involved in visual word recognition.
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Affiliation(s)
- Angelo Alonzo
- University of New South Wales, Sydney, New South Wales, Australia.
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Lee H, Bahler R, Chung C, Alonzo A, Zeller RA. Prehospital delay with myocardial infarction: the interactive effect of clinical symptoms and race. Appl Nurs Res 2000; 13:125-33. [PMID: 10960996 DOI: 10.1053/apnr.2000.7652] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This study examined prehospital delays and clinical symptoms of myocardial infarction (MI) in blacks and whites and the relationship between longer delays and types of clinical symptoms. The convenience sample included 128 patients, admitted consecutively, with acute MI. Data on types of clinical symptoms of MI and treatment-seeking behavior were collected on day 2 or 3 after admission, using face-to-face semistructured interviews. The total mean delay time differed significantly between blacks and whites (16 hours vs. 8.8 hours, p < .05). Although the frequency of chest pain was similar in both blacks and whites (78% vs. 77%), more than twice as many blacks as whites presented with symptoms of dyspnea (56% vs. 24%, p < .01) and fatigue (32% vs. 17%, p < .05). There was an interactive effect of race-ethnicity and types of symptoms on delay (p < .05) was present. Delay times for whites with chest pain were shorter than for whites without chest pain. Delay times for blacks with dyspnea were significantly shorter than for blacks without dyspnea, although delay times did not differ between whites with and without dyspnea.
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Affiliation(s)
- H Lee
- University of Colorado Health Sciences Center, School of Nursing, Denver 80262, USA.
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Abstract
The Stress Audit self-report inventory was used to measure the magnitude and types of stress experience as well as relative vulnerability of recovering male drug addicts in an urban substance abuse program. The means for the Stress Situations scale and each of the situations subscales showed significant elevations relative to the normative sample and control group of nonaddicted, nonalcoholic males. The mean for the Stress Symptoms scale and the means for all symptoms subscales were also significantly higher for the recovering drug addicts, with the highest values for cognitive and muscular symptoms. The Vulnerability scale was the only measure for which recovering drug addicts had a mean similar to published norms, with no significant elevation. This profile of substantially greater stress situations and symptoms despite normal vulnerability indicates that, whether stress is a cause or consequence of drug addiction, stress-management techniques should be a component of drug rehabilitation programs.
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Affiliation(s)
- B C Lamon
- Psychology Department, St. Mary's College, Moraga, CA 94575, USA
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Husain OA, Butler EB, Nayagam M, Mango L, Alonzo A. An analysis of the variation of human interpretation: Papnet a mini-challenge. Anal Cell Pathol 1994; 6:157-63. [PMID: 8167098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The Papnet was given a mini-challenge of 200 cervical smears loaded to 50% with varying degrees of abnormality as interpreted by the originating laboratory. The range of abnormality extended from 'atypia' to invasive cancer and a few 'glandular' lesions were included as were a few smears which had been reported as 'inadequate'. Three cytologists (two cytopathologists and one cytotechnologist) read and analysed the 128 monitor pictures per slide, selected by the Scanning Algorithm and Neural Network systems. These results were compared with a 'gold standard' report on the glass slide produced by two cytopathologists. The analysis was done for each individual cytologist, for cases in which all three agreed, for a consensus between two of the three and for the 'best of three'. The latter gave an error rate of 4% false negative (Papnet scan negative) and 10% 'false positive' (referred for glass slide examination). Individual cytologists had higher error rates demonstrating that errors could be due to human interaction and not necessarily to the Scanner. This also indicated that wide experience in interpretation of monitor images is needed to achieve high quality results.
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Abstract
An ethnobotanical survey was conducted among the Carib population of Guatemala in 1988-1989. In general terms, the sample surveyed possessed a relatively good standard of living. Results indicated that health services were utilized by the population, and that domestic medicine, mainly plants (96.9%) was used by 15% of the population. One hundred and nineteen plants used for medicinal purposes were collected, of which 102 (85.7%) could be identified; a list of these together with the information provided for each plant is presented. The most frequently reported plants used as medicine are: Acalypha arvensis, Cassia alata, Cymbopogon citratus, Melampodium divaricatum. Momordica charantia, Neurolaena lobata, Ocimum basilicum, Petiveria alliacea and Solanum nigrescens. Most of these plants are found in the region, but some are brought from the Highlands or outside of the country, such as Malva parviflora, Matricaria chamomilla, Peumus boldus, Pimpinella anisum, Rosmarinus officinalis and Tagetes lucida. This survey demonstrated that the Carib population of Guatemala has survived in a transcultural environment of African and native Amerindian beliefs.
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Affiliation(s)
- L M Girón
- Center for Mesoamerican Studies on Appropriate Technology (CEMAT), Guatemala City
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Fernandez N, Festenstein H, Alonzo A, Biro PA, Labeta M, Carolan E, Houlihan J, Mellor A, Flavell R. The expression of murine Qa region gene product(s) in L cell transformants. J Immunogenet 1986; 13:425-35. [PMID: 3624883 DOI: 10.1111/j.1744-313x.1986.tb01127.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The cosmid H3.5, containing genes mapping to the murine H-2 Qa region, was used to transfect L cells by the calcium phosphate co-precipitation method. The resultant transfected cells expressed a Qa-like determinant as detected by an immune serum raised against the transfectant cells and Qa specific monoclonal antibodies. Two-dimensional gel analysis revealed the expression of a class I-like heavy chain with a similar molecular mass to the Qa2 antigens of the positive strain B10 and B10.A but with a different isoelectric point. The cosmid H3.5 spans 40 kb of DNA and contains at least one complete Qa region gene which encodes the Qa-like determinant detected in this study.
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Francesca F, Franchini R, Messina G, Alonzo A, Romagnoli S, Ramponi A. [Repair of ruptures of the duodenum using a pedicled jejunal flap. Preliminary results of an experimental study in the rabbit]. MINERVA CHIR 1986; 41:1049-54. [PMID: 3736936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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