Current clinical practice of electroconvulsive therapy and repetitive transcranial magnetic stimulation in psychiatry, a German sample

Association between rTMS-induced changes in inflammatory markers and improvement in psychiatric diseases: a systematic review

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) has recently gained relevance in treating different psychiatric disorders. Limited evidence suggests that the beneficial effects of rTMS on psychopathology could be at least partly mediated through changes in inflammatory response. This systematic review summarizes the literature on whether rTMS can modulate inflammatory markers and thus positively influence the course of psychiatric illnesses.

MATERIALS AND METHODS

A systematic review of rTMS and inflammatory markers in psychiatric diseases was conducted according to PRISMA guidelines. Information on the association between rTMS treatment response and changes of inflammatory markers was extracted. The quality of the studies was assessed using the National Heart, Lung, and Blood Institute for human studies and the Systematic Review Center for Laboratory Animal Experimentation for animal studies.

RESULTS

This review includes 17 studies (2 animal and 15 human studies) on the relationship between rTMS treatment response and changes of inflammatory markers. Positive changes in microglial activity and anti-inflammatory effects were associated with behavioral improvement in animal models of depression. However, these findings have not been consistently replicated in human studies focusing on treatment-resistant depression. While several studies reported rTMS-induced alterations in peripheral inflammatory markers, only two could demonstrate their association to clinical treatment response. Notably, most studies showed poor or moderate quality in the bias assessment.

CONCLUSIONS

While certain human studies suggest an association between rTMS-induced anti-inflammatory effects and improvement in psychopathology, heterogeneity, and underpowered analyses constrain the generalizability of these results. The discrepancy between animal and human findings highlights the need for larger, standardized human studies.

TRIAL REGISTRATION

(PROSPERO Registration: CRD42023492732).

Noninvasive Brain Stimulation for Neurorehabilitation in Post-Stroke Patients

Characterized by high morbidity, mortality, and disability, stroke usually causes symptoms of cerebral hypoxia due to a sudden blockage or rupture of brain vessels, and it seriously threatens human life and health. Rehabilitation is the essential treatment for post-stroke patients suffering from functional impairments, through which hemiparesis, aphasia, dysphagia, unilateral neglect, depression, and cognitive dysfunction can be restored to various degrees. Noninvasive brain stimulation (NIBS) is a popular neuromodulatory technology of rehabilitation focusing on the local cerebral cortex, which can improve clinical functions by regulating the excitability of corresponding neurons. Increasing evidence has been obtained from the clinical application of NIBS, especially repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS). However, without a standardized protocol, existing studies on NIBS show a wide variation in terms of stimulation site, frequency, intensity, dosage, and other parameters. Its application for neurorehabilitation in post-stroke patients is still limited. With advances in neuronavigation technologies, functional near-infrared spectroscopy, and functional MRI, specific brain regions can be precisely located for stimulation. On the basis of our further understanding on neural circuits, neuromodulation in post-stroke rehabilitation has also evolved from single-target stimulation to co-stimulation of two or more targets, even circuits and the network. The present study aims to review the findings of current research, discuss future directions of NIBS application, and finally promote the use of NIBS in post-stroke rehabilitation.

Risk Assessment of Electroconvulsive Therapy in Clinical Routine: A 3-Year Analysis of Life-Threatening Events in More Than 3,000 Treatment Sessions

Background: Extensive research has reported that electroconvulsive therapy (ECT) can be highly effective in approximately 80% of patients suffering from depression. Its clinical use is mainly limited by historical objections and the concern about unwanted adverse effects (AEs), including serious and potentially life-threatening adverse events (pLTAEs), induced either by ECT or by anesthesia. Objective risk estimation is, therefore, a decisive factor in determining an indication for ECT. Methods: This paper presents a retrospective analysis of 3-year safety protocols and patient files of 157 patients who received a total of 3,106 ECT applications in a psychiatric inpatient setting at a psychiatric community hospital. This patient group comprises 5.3% of inpatients admitted with comparable diagnoses. Adverse events were analyzed from standardized safety protocols and patient files with a focus on pLTAEs. Results: Adverse events were reported for 30 (19.1%) of the 157 participants during 39 (6.1%) of 641 hospital stays. Serious pLTAEs occurred during three electroconvulsive stimulations in three patients, who needed action through the administration of medication or mechanical respiration. No patient suffered permanent damage to health, and no patient died. The incidence of these and other AEs was independent of sex, age, and diagnosis of patients, and anesthesia medication. Minor AEs occurred more often with higher stimulus doses and an increasing number of treatments. Conclusion: The low incidence rate of 0.097% of serious pLTAEs that require medical action may allow the conclusion that ECT is a rather safe treatment when performed in a controlled setting. The beneficial risk profile of ECT performed in the standard care of psychiatric hospitals suggests a more generous indication of this treatment method. We recommend that ECT facilities collect individual safety data to allow a reliable judgment of their institutional ECT risk profile.

Willingness to pay for a quality-adjusted life year for depressive disorders compared to heart disease based on population preferences

PURPOSE

According to estimations of the World Health Organization, depressive disorders, and cardiovascular disease will be the leading causes for global burden of disease in 2030. The aim of the present study was to estimate the value a representative sample of the German population places on quality-adjusted life years (QALYs) for depressive disorders compared to heart disease.

METHODS

A representative sample of N = 967 of the German general public was randomly presented with one of two hypothetical health-loss scenarios: One version of the questionnaire presented respondents with health loss due to depression, while the other version dealt with health loss due to experiencing a heart disease. Respondents were asked to indicate their willingness to pay (WTP) for four hypothetical health-gain scenarios with different treatment options.

RESULTS

In the depression questionnaire median WTP values ranged from 1000 to 1500 EUR; in the heart disease questionnaire from 1000 to 2000 EUR. Results of the Mann-Whitney U-Test and Median Test indicate higher WTP values for heart disease compared to depressive disorders when QALY gains were minor and stretched over a long period of time, and when treatment with bypass operation (rather than treatment with ECT) was offered. Zero WTP was significantly higher in all scenarios of the depression questionnaire in comparison to the hearth disease questionnaire.

CONCLUSION

Results indicate that respondents valued the necessity of paying for treatment higher when presented with heart disease compared to depression.

Sex differences in pharmacological treatment of major depressive disorder: results from the AMSP pharmacovigilance program from 2001 to 2017

Data on drug prescription for outpatients with major depressive disorder (MDD) suggest women are more likely to be treated with psychotropic drugs, while data on sex differences regarding pharmacological treatment of psychiatric inpatients are currently not available. Drug utilization data from the program "Drug Safety in Psychiatry" (German: Arzneimittelsicherheit in der Psychiatrie, AMSP) of 44,418 psychiatric inpatients with MDD were analyzed for sex differences between 2001 and 2017. Sex differences were analyzed using relative risks (RR) and 95% confidence intervals (95% CI). Time trends were analyzed by comparing the first (2001-2003) with the last time period (2015-2017). In general, men and women were equally likely to use psychotropic drugs. Monotherapy was more common in men. Women were more likely to utilize ≥ 4 psychotropic drugs. Antidepressant drugs (ADDs) were the most prescribed drug class. Men had a higher utilization of noradrenergic and specific serotonergic antidepressants (RR 1.15; 95% CI 1.12-1.19), especially mirtazapine (RR 1.16; 95% CI 1.12-1.19), but also of other ADDs such as bupropion (RR 1.50; 95% CI 1.35-1.68). Males had a slightly higher utilization of second-generation antipsychotic drugs (RR 1.06; 95% CI 1.03-1.09) and were less often treated with low-potency first-generation antipsychotic drugs (RR 0.86; 95% CI 0.83-0.90). Tranquilizing (e.g., benzodiazepines; RR 0.89; 95% CI 0.86-0.92) and hypnotic drugs (e.g., Z-drugs; RR 0.85; 95% CI 0.81-0.89) were less utilized in the treatment of male patients. Not all sex differences were stable over time. More sex differences were detectable in 2015-2017 than in 2001-2003. Findings suggest that certain psychotropic drugs are preferred in the treatment of men vs. women, however, sex differences found in this study are not as large as in ambulatory settings. To make evidence-based sex-specific recommendations in the treatment of MDD, differences in drug response and tolerability need to be further researched.