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

The Effectiveness of Transcranial Magnetic Stimulation in Suicidality: An Updated Systematic Review

Suicidal thoughts and behaviors (STB) have a substantial global burden, with over 14 million individuals attempting suicide annually. Existing biological therapies do not adequately reduce STB risk. Repetitive transcranial magnetic stimulation (rTMS) is an approved, non-invasive and low-risk treatment for several psychiatric disorders. Meta-analyses investigating TMS' effects on STB indicate therapeutic promise. Given the proliferation of TMS studies investigating its effect on STB, a repeat review of the literature is warranted.

Methods

A PRISMA-guided systematic review was conducted to evaluate the efficacy of rTMS in reducing STB. Studies assessing STB outcomes following rTMS to treat psychiatric disorders, either as monotherapy or adjunctive treatment, were included. Forty-five studies were identified (N=3515).

Results

Studies generally applied rTMS to treat primary psychiatric disorders, particularly depression, with change in suicidality evaluated as a secondary outcome. rTMS protocols differed across studies. Most studies targeted the left dorsolateral prefrontal cortex (dlPFC), although significant improvements to STB were also reported with rTMS targeting the visual cortex, right dlPFC and the bilateral PFC. High frequency rTMS and intermittent theta burst stimulation (iTBS) protocols were superior in reducing STB compared to other stimulation protocols, with studies reporting 40-100% treatment response rates. Adverse events (AEs) were mostly mild and transient.

Conclusion

rTMS appears to be a safe and effective treatment option for STB, with significant reductions observed, particularly when rTMS or iTBS is applied to the dlPFC. Mechanistically informed randomized controlled trials specifically designed to evaluate rTMS' treatment effects on STB are needed to validate this promising treatment approach.

Interventions for suicidal and self-injurious related behaviors in adolescents with psychiatric disorders: a systematic review and meta-analysis

As a leading cause of adolescent death, suicidal and self-injurious related behaviors (SSIRBs) is a devastating global health problem, particularly among patients with psychiatric disorders (PDs). Previous studies have shown that multiple interventions can alleviate symptoms and reduce risks. This review aimed to provide a systematic summary of interventions (i.e., medication, physical therapy, psychosocial therapy) for the treatment of SSIRBs among Chinese adolescents with PDs. From inception to September 17, 2023, twelve databases (PubMed, CINAHL, ScienceDirect, PsycINFO, EMBASE, Cochrane Library, Clinical Trial, Web of Science, CEPS, SinoMed, Wanfang and CNKI) were searched. We qualitatively and quantitatively synthesized the included studies. Standardized mean differences (SMDs), risk ratios and their 95% confidence intervals (CIs) used the Der Simonian and Laird random-effects model. Fifty-two studies covering 3709 eligible participants were included. Overall, the commonly used interventions targeting SSIRBs and negative feelings in PDs adolescents with SSIRBs included psychosocial therapy (e.g., cognitive behavioral therapy), medication (e.g., antidepressants), and physiotherapy (e.g., repetitive transcranial magnetic stimulation). Importantly, quetiapine fumarate in combination with sodium valproate (SV) had positive effects on reducing self-injury behaviors score [SMD: -2.466 (95% CI: -3.305, -1.628), I2 = 88.36%], depression [SMD: -1.587 (95% CI: -2.505, -0.670), I2 = 90.45%], anxiety [SMD: -1.925 (95% CI: -2.700, -1.150), I2 = 85.23%], impulsivity [SMD: -2.439 (95% CI: -2.748, -2.094), I2 = 0%], as well as its safety in comparison with SV alone. No significant difference of adverse reactions was found by low-dose QF (P > 0.05). This review systematically outlined the primary characteristics, safety and effectiveness of interventions for Chinese PDs adolescents with SSIRBs, which could serve as valuable evidence for guidelines aiming to formulate recommendations.

Association between polygenic risk scores combined with clinical characteristics and antidepressant efficacy

BACKGROUND

While millions of people suffer from major depressive disorder (MDD), research has shown that individual differences in antidepressant efficacy exist, potentially attributable to various factors. Polygenic risk scores (PRSs) carry clinical potential, but associations with treatment response are seldom reported. Here, we examined whether PRSs for MDD and schizophrenia (SCZ) are associated with antidepressant effectiveness and the influence of other factors.

METHODS

A total of 999 patients were included, and the PRSs for the MDD and SCZ were calculated. The main outcome was a change in the 17-item Hamilton Depression Rating Scale (HAMD17) scores from before to after 2-week treatment. The Mann-Whitney test, Spearman correlation analysis, multiple stepwise linear regression analysis, and interaction analysis were used for statistical analysis.

RESULTS

In the 912 subjects passing quality control, a difference in the HAM-D17 score reduction rate between the MDD phenotype PRS (MDD-PRS) high-risk and the low-risk groups was discovered (P = 0.009), and a correlation was found between the MDD-PRS and the HAM-D17 score reduction rate (r = -0.075, P = 0.024). Moreover, antidepressant efficacy was related to MDD-PRS (β = -4.086, P = 0.039), the Snaith-Hamilton Pleasure Scale-total score (β = -0.009, P = 0.005), and non-first episode (β = -0.039, P < 0.001). However, the result of the interaction analysis was nonsignificant.

LIMITATIONS

The main limitation was that only 1309 targeted genes were selected based on pathways known to be involved in MDD and/or antidepressant effects.

CONCLUSION

These findings suggest a difference in antidepressant efficacy between patients in different MDD-PRS groups. Moreover, the MDD-PRS combined with clinical characteristics partially explained inter-individual differences in antidepressant efficacy.

Predictors of response to accelerated rTMS in the treatment of treatment-resistant depression

Accelerated repetitive transcranial magnetic stimulation (rTMS) is a promising treatment for treatment-resistant depression (TRD). We aimed to investigate the existence of clinical predictive factors in response to accelerated rTMS in the treatment of TRD. In total, 119 TRD patients who received accelerated rTMS were included in this study. The stimulation protocol was 15 Hz stimulation over the the left dorsolateral prefrontal cortex. The protocol consisted of 25 sessions, each session lasting 30 min for a total of 3000 pulses. Five sessions were applied per day for 5 consecutive days. At baseline (T0), day 5 (immediately after treatment) (T1), 4 weeks after treatment (T2), depression severity was evaluated using the 17-item Hamilton Depression Rating Scale (HAMD-17), cognitive function was evaluated using Wisconsin Card Sorting Test (WCST), the intensity of suicidal ideation was evaluated using the Columbia-Suicide Severity Rating Scale (C-SSRS). Systemic immune-inflammation index (SII) was calculated at T0 and T2. The HAMD-17 scores, WCST performance, the C-SSRS scores at T1 and T2 were improved from T0 (P < 0.01). The SII at T2 was lower than at T0 (P < 0.01). The response rates at T1 and T2 were 57.98% (69/119) and 48.74% (58/119), respectively. The results of binary logistic analysis showed that shorter course of depression, two failed antidepressant trials, no history of ECT treatment, and lower levels of SII were predictive factors for accelerated rTMS treatment response at T1 and T2 (P < 0.05), while not having a history of hospitalization was a predictive factor for response at T2 (P < 0.05) but not at T1 (P > 0.05). Based on ROC curve analysis, the optimal cut-off values of SII for discriminating responders from non-responders at T1 and T2 were < 478.56 and < 485.03, respectively. The AUC of SII at T0 predicting response for T1 and T2 were 0.729 and 0.797. We found several clinical predictors of better responses to the accelerated rTMS. Identifying clinical predictors of response is relevant to personalize and adapt rTMS protocols in TRD patients.

A real-world retrospective cohort study comparing two bilateral stimulation protocols of add-on rTMS in patients with treatment resistant depression and severe anxiety

BACKGROUND

Transcranial magnetic stimulation (TMS) has been shown to improve response and remission in patients with treatment resistant depression. The objective of this study was to compare the efficacy of two bilateral rTMS protocols with different protocols in patients with treatment resistant depression and comorbid severe anxiety.

METHODS

A retrospective cohort study involving 67 patients who underwent two different bilateral TMS protocols and who met the specified eligibility criteria was conducted. Group 1 received stimulation with 85% RMT intermittent theta burst (iTBS) in the left DLPFC + 120% RMT (1 Hz) in the right DLPFC. Group 2 received stimulation with 100% RMT (iTBS) in the left DLPFC + 110% RMT (1 Hz) in the left DLPFC.

RESULTS

After the magnetic stimulation treatment, 55% (n=22) achieved response to depression symptoms in group 1 and 62% (n=18) in group 2. Remission of depression symptoms was achieved in 13% in group 1 (n=5) and 24% in group 2 (n=7). There were no significant differences between the two protocols after TMS CONCLUSIONS: Different bilateral protocol parameters in individuals undergoing TMS may have an impact on symptom response and remission. Further studies with larger sample sizes are needed.

Non-inferiority of intermittent theta burst stimulation over the left V1 vs. classical target for depression: A randomized, double-blind trial

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) targeting the visual cortex (VC) has shown antidepressant effects for major depressive disorder (MDD) in sham-controlled trials, but comparisons with rTMS targeting the left dorsolateral prefrontal cortex (DLPFC) are lacking. We aimed to determine the non-inferiority of intermittent theta-burst stimulation (iTBS) over VC vs DLPFC for MDD.

METHODS

Participants randomly received navigated iTBS over the left V1 or the left DLPFC twice daily for 14 days with a 3-month follow-up. The primary outcome was change in Hamilton Depression Rating Scale (HAMD-17) score from baseline to treatment end, with 2.5 points as the non-inferiority margin. Secondary outcomes included: improvement in Montgomery-Asberg Depression Rating Scale (MADRS), Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA); response and remission rates; suicidal ideation and adverse events.

RESULTS

Of 75 randomized patients, 67 completed full treatment, including 52 first-episode patients and 15 relapsers. The primary outcome indicated the non-inferiority of VC (adjusted difference 1.14, lower 97.5 % CI -1.24; p = .002), confirmed by improvements in objective cognitive task and protein levels, as did most secondary outcomes. Reduced suicidal ideation after treatment, incidence of eye discomfort and pain score were lower in the VC group.

CONCLUSIONS

Left VC iTBS has the potential to be non-inferior to DLPFC iTBS in most first-episode MDD in improving depressive symptoms and cognitive function, with less suicidal ideation and adverse events.

LIMITATIONS

Given the limited sample size, the lack of a sham control and the use of antidepressants, the findings should be interpreted with caution.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46830.

Pharmacological and nonpharmacological augmentation treatments for clozapine-resistant schizophrenia: A systematic review and network meta-analysis with normalized entropy assessment

OBJECTIVE

To integrate all evidence derived from randomized controlled trials (RCTs) of both pharmacological and nonpharmacological augmentation interventions for clozapine-resistant schizophrenia (CRS).

METHODS

Six major electronic databases were systematically searched for RCTs published until July 10, 2021. The primary outcome was change in overall symptoms, and the secondary outcomes were positive and negative symptoms and acceptability. We performed random-effects network meta-analysis. Normalized entropy was calculated to examine the uncertainty of treatment ranking.

RESULTS

We identified 35 RCTs (1472 patients with 23 active augmentation treatments) with a mean daily clozapine dose of 440.80 (91.27) mg for 1168.22 (710.28) days. Network meta-analysis of overall symptoms (reported as standardized mean difference; 95 % confidence interval) with consistent results indicated that mirtazapine (-4.41; -5.61, -3.21), electroconvulsive therapy (ECT) (-4.32; -5.43, -3.21), and memantine (-2.02; -3.14, -0.91) were ranked as the best three treatments. For positive symptoms, ECT (-5.18; -5.86, -4.49) was ranked the best with less uncertainty. For negative symptoms, memantine (-3.38; -4.50, -2.26), duloxetine (-3.27; -4.25, -2.29), and mirtazapine (-1.73; -2.71, -0.74) were ranked the best three treatments with less uncertainty. All antipsychotics, N-methyl d-aspartate receptor agonists, and antiepileptics were not associated with more efficacy than placebo. Compared to placebo, only amisulpride had statistically significant lower discontinuation rate (risk ratio: 0.21; 95 % CI: 0.05, 0.93).

CONCLUSION

Add-on mirtazapine, ECT, and memantine were the most efficacious augmentation options for CRS. Data on other important outcomes such as cognitive functioning or quality of life were rarely reported, making further large-scale, well-designed RCTs necessary. (PROSPERO number, CRD42021262197.).