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Huang D, Zhong S, Song X, Zhang R, Lai S, Jia Y. Effect of novel accelerated intermittent theta burst stimulation on suicidal ideation in adolescent patients with major depressive episode: a randomised clinical trial. Gen Psychiatr 2024; 37:e101394. [PMID: 38665940 PMCID: PMC11043680 DOI: 10.1136/gpsych-2023-101394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/13/2024] [Indexed: 04/28/2024] Open
Affiliation(s)
- Dong Huang
- Department of Psychiatry, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Shuming Zhong
- Department of Psychiatry, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Xiaodong Song
- Department of Psychiatry, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Rongxu Zhang
- Department of Psychiatry, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Shunkai Lai
- Department of Psychiatry, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Yanbin Jia
- Department of Psychiatry, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
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Ramasubbu R, Brown EC, Selby B, McGirr A, Cole J, Hassan H, McAusland L. Accelerated sequential bilateral theta-burst stimulation in major depression: an open trial. Eur Arch Psychiatry Clin Neurosci 2024; 274:697-707. [PMID: 37470840 DOI: 10.1007/s00406-023-01648-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023]
Abstract
Theta burst stimulation (TBS) is approved and widely used in the treatment of treatment resistant-major depression. More recently, accelerated protocols delivering multiple treatments per day have been shown to be efficacious and potentially enhance outcomes compared to once daily protocols. Meanwhile, bilateral treatment protocols have also been increasingly tested to enhance outcomes. Here, we examined the efficacy and safety of accelerated bilateral TBS in major depressive disorder (MDD). In this open label pilot study, 25 patients with MDD (60%: women; mean age (SD): 45.24 (12.22)) resistant to at least one antidepressant, received bilateral TBS, consisting of 5 sequential bilateral intermittent TBS (iTBS) (600 pulses) and continuous TBS (cTBS) (600 pulses) treatments delivered to the left and right dorsolateral prefrontal cortex (DLPFC), respectively, daily for 5 days at 120% resting motor threshold. Outcome measures were post-treat treatment changes at day 5 and 2-weeks in Hamilton Depression Rating Scale (HDRS-17) scores and response (≥ 50% reduction from the baseline scores) and remission (≤ 7) rates. There was a significant reduction in HDRS scores at day 5 (p < 0.001) and 2-weeks post treatment (p < 0.001). The response rates increased from 20% at day 5 to 32% at 2-weeks post treatment suggesting delayed clinical effects. However, reduction in symptom scores between two post treatment endpoints was non-significant. 60% of patients could not tolerate the high intensity stimulation. No major adverse events occurred. Open label uncontrolled study with small sample size. These preliminary findings suggest that accelerated bilateral TBS may be clinically effective and safe for treatment resistant depression. Randomized sham-controlled trials are needed to establish the therapeutic role of accelerated bilateral TBS in depression.Trial registration: ClinicalTrials.gov, NCT10001858.
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Affiliation(s)
- Rajamannar Ramasubbu
- Department of Psychiatry/Clinical Neurosciences Cumming School of Medicine, Mathison Centre for Mental Health Research and Education, Non-Invasive Neurostimulation Network, Hotchkiss Brain Institute, University of Calgary, TRW Building, Room 4D64, 3280 Hospital Drive NW, Calgary, AB, T2N4Z6, Canada.
| | - Elliot C Brown
- School of Health and Care Management, Faculty of Business, Arden University, Berlin, Germany
| | - Ben Selby
- Non-Invasive Neurostimulation Network, University of Calgary, Calgary, AB, Canada
| | - Alexander McGirr
- Department of Psychiatry/Clinical Neurosciences Cumming School of Medicine, Mathison Centre for Mental Health Research and Education, Non-Invasive Neurostimulation Network, Hotchkiss Brain Institute, University of Calgary, TRW Building, Room 4D64, 3280 Hospital Drive NW, Calgary, AB, T2N4Z6, Canada
| | - Jaeden Cole
- Mathison Centre for Mental Health Research & Education, Non-Invasive Neurostimulation Network, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Hadi Hassan
- Mathison Centre for Mental Health Research and Education, University of Calgary, Calgary, AB, Canada
| | - Laina McAusland
- Mathison Centre for Mental Health Research & Education Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Shi R, Wang Z, Yang D, Hu Y, Zhang Z, Lan D, Su Y, Wang Y. Short-term and long-term efficacy of accelerated transcranial magnetic stimulation for depression: a systematic review and meta-analysis. BMC Psychiatry 2024; 24:109. [PMID: 38326789 PMCID: PMC10851556 DOI: 10.1186/s12888-024-05545-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 01/21/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND In recent years, accelerated transcranial magnetic stimulation (aTMS) has been developed, which has a shortened treatment period. The aim of this study was to evaluate the efficacy and long-term maintenance effects of aTMS in patients with major depressive disorder (MDD). METHODS We systematically searched online databases for aTMS studies in patients with MDD published before February 2023 and performed a meta-analysis on the extracted data. RESULTS Four randomized controlled trials (RCTs) and 10 before-and-after controlled studies were included. The findings showed that depression scores significantly decreased following the intervention (SMD = 1.80, 95% CI (1.31, 2.30), p < 0.00001). There was no significant difference in antidepressant effectiveness between aTMS and standard TMS (SMD = -0.67, 95% CI (-1.62, 0.27), p = 0.16). Depression scores at follow-up were lower than those directly after the intervention based on the depression rating scale (SMD = 0.22, 95% CI (0.06, 0.37), p = 0.006), suggesting a potential long-term maintenance effect of aTMS. Subgroup meta-analysis results indicated that different modes of aTMS may have diverse long-term effects. At the end of treatment with the accelerated repetitive transcranial magnetic stimulation (arTMS) mode, depressive symptoms may continue to improve (SMD = 0.29, 95% CI (0.10, 0.49), I2 = 22%, p = 0.003), while the accelerated intermittent theta burst stimulation (aiTBS) mode only maintains posttreatment effects (SMD = 0.01, 95% CI (-0.45, 0.47), I2 = 66%, p = 0.98). CONCLUSIONS Compared with standard TMS, aTMS can rapidly improve depressive symptoms, but there is no significant difference in efficacy. aTMS may also have long-term maintenance effects, but longer follow-up periods are needed to assess this possibility. TRIAL REGISTRATION This article is original and not under simultaneous consideration for publication. The study was registered on PROSPERO ( https://www.crd.york.ac.uk/prospero/ ) (number: CRD42023406590).
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Affiliation(s)
- Ruifeng Shi
- Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China, No. 32, West 2nd Section, 1st Ring Road, 610031, Chengdu, Qingyang District, China
| | - Zuxing Wang
- Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China, No. 32, West 2nd Section, 1st Ring Road, 610031, Chengdu, Qingyang District, China
| | - Dong Yang
- Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China, No. 32, West 2nd Section, 1st Ring Road, 610031, Chengdu, Qingyang District, China
| | - Yujie Hu
- Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China, No. 32, West 2nd Section, 1st Ring Road, 610031, Chengdu, Qingyang District, China
| | - Zhongyang Zhang
- Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China, No. 32, West 2nd Section, 1st Ring Road, 610031, Chengdu, Qingyang District, China
| | - Daotao Lan
- Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China, No. 32, West 2nd Section, 1st Ring Road, 610031, Chengdu, Qingyang District, China
| | - Yihan Su
- Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China, No. 32, West 2nd Section, 1st Ring Road, 610031, Chengdu, Qingyang District, China.
| | - Yunqiong Wang
- Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China, No. 32, West 2nd Section, 1st Ring Road, 610031, Chengdu, Qingyang District, China.
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Tang N, Shu W, Wang HN. Accelerated transcranial magnetic stimulation for major depressive disorder: A quick path to relief? WILEY INTERDISCIPLINARY REVIEWS. COGNITIVE SCIENCE 2024; 15:e1666. [PMID: 37779251 DOI: 10.1002/wcs.1666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 10/03/2023]
Abstract
Transcranial magnetic stimulation (TMS) is a safe, tolerable, and evidence-based intervention for major depressive disorder (MDD). However, even after decades of research, nearly half of the patients with MDD fail to respond to conventional TMS, with responding slowly and requiring daily attendance at the treatment site for 4-6 weeks. To intensify antidepressant efficacy and shorten treatment duration, accelerated TMS protocols, which involve multiple sessions per day over a few days, have been proposed and evaluated for safety and viability. We reviewed and summarized the current knowledge in accelerated TMS, including stimulation parameters, antidepressant efficacy, anti-suicidal efficacy, safety, and adverse effects. Limitations and suggestions for future directions are also addressed, along with a brief discussion on the application of accelerated TMS during the COVID-19 pandemic. This article is categorized under: Neuroscience > Clinical Neuroscience.
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Affiliation(s)
- Nailong Tang
- Department of Psychiatry, First Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, China
- Department of Psychiatry, the 907th Hospital of the PLA Joint Logistics Support Force, Nanping, Fujian, China
| | - Wanqing Shu
- Department of Psychiatry, First Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, China
| | - Hua-Ning Wang
- Department of Psychiatry, First Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, China
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Jin J, Wang X, Wang H, Li Y, Liu Z, Yin T. Train duration and inter-train interval determine the direction and intensity of high-frequency rTMS after-effects. Front Neurosci 2023; 17:1157080. [PMID: 37476832 PMCID: PMC10355321 DOI: 10.3389/fnins.2023.1157080] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023] Open
Abstract
Background and objective It has been proved that repetitive transcranial magnetic stimulation (rTMS) triggers the modulation of homeostatic metaplasticity, which causes the effect of rTMS to disappear or even reverse, and a certain length of interval between rTMS trains might break the modulation of homeostatic metaplasticity. However, it remains unknown whether the effects of high-frequency rTMS can be modulated by homeostatic metaplasticity by lengthening the train duration and whether homeostatic metaplasticity can be broken by prolonging the inter-train interval. Methods In this study, 15 subjects participated in two experiments including different rTMS protocols targeting the motor cortex. In the first experiment, high-frequency rTMS protocols with different train durations (2 s and 5 s) and an inter-train interval of 25 s were adopted. In the second experiment, high-frequency rTMS protocols with a train duration of 5 s and different inter-train intervals (50 s and 100 s) were adopted. A sham protocol was also included. Changes of motor evoked potential amplitude acquired from electromyography, power spectral density, and intra-region and inter-region functional connectivity acquired from electroencephalography in the resting state before and after each rTMS protocol were evaluated. Results High-frequency rTMS with 2 s train duration and 25 s inter-train interval increased cortex excitability and the power spectral density of bilateral central regions in the alpha frequency band and enhanced the functional connectivity between central regions and other brain regions. When the train duration was prolonged to 5 s, the after-effects of high-frequency rTMS disappeared. The after-effects of rTMS with 5 s train duration and 100 s inter-train interval were the same as those of rTMS with 2 s train duration and 25 s inter-train interval. Conclusion Our results indicated that train duration and inter-train interval could induce the homeostatic metaplasticiy and determine the direction of intensity of rTMS after-effects, and should certainly be taken into account when performing rTMS in both research and clinical practice.
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Affiliation(s)
- Jingna Jin
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Xin Wang
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - He Wang
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Ying Li
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Zhipeng Liu
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Tao Yin
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Neuroscience Center, Chinese Academy of Medical Sciences, Beijing, China
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Wrightson JG, Cole J, Sohn MN, McGirr A. The effects of D-Cycloserine on corticospinal excitability after repeated spaced intermittent theta-burst transcranial magnetic stimulation: A randomized controlled trial in healthy individuals. Neuropsychopharmacology 2023:10.1038/s41386-023-01575-7. [PMID: 37041205 PMCID: PMC10267195 DOI: 10.1038/s41386-023-01575-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/13/2023]
Abstract
Repeated spaced TMS protocols, also termed accelerated TMS protocols, are of increasing therapeutic interest. The long-term potentiation (LTP)-like effects of repeated spaced intermittent theta-burst transcranial magnetic stimulation (iTBS) are presumed to be N-Methyl-D-Aspartate receptor (NMDA-R) dependent; however, this has not been tested. We tested whether the LTP-like effects of repeated spaced iTBS are influenced by low-dose D-Cycloserine (100 mg), an NMDA-R partial-agonist. We conducted a randomized, double-blind, placebo-controlled crossover trial in 20 healthy adults from August 2021-Feb 2022. Participants received repeated spaced iTBS, consisting of two iTBS sessions 60 minutes apart, to the primary motor cortex. The peak-to-peak amplitude of the motor evoked potentials (MEP) at 120% resting motor threshold (RMT) was measured after each iTBS. The TMS stimulus-response (TMS-SR; 100-150% RMT) was measured at baseline, +30 min, and +60 min after each iTBS. We found evidence for a significant Drug*iTBS effect in MEP amplitude, revealing that D-Cycloserine enhanced MEP amplitudes relative to the placebo. When examining TMS-SR, pairing iTBS with D-Cycloserine increased the TMS-SR slope relative to placebo after both iTBS tetani, and this was due to an increase in the upper bound of the TMS-SR. This indicates that LTP-like and metaplastic effects of repeated-spaced iTBS involve NMDA-R, as revealed by two measures of corticospinal excitability, and that low-dose D-Cycloserine facilitates the physiological effects of repeated spaced iTBS. However, extension of these findings to clinical populations and therapeutic protocols targeting non-motor regions of cortex requires empirical validation.
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Affiliation(s)
- James G Wrightson
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Jaeden Cole
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Mathison Centre for Mental Health Research and Education, Calgary, AB, Canada
| | - Maya N Sohn
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Mathison Centre for Mental Health Research and Education, Calgary, AB, Canada
| | - Alexander McGirr
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Mathison Centre for Mental Health Research and Education, Calgary, AB, Canada.
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Chen L, Thomas EHX, Kaewpijit P, Miljevic A, Hughes R, Hahn L, Kato Y, Gill S, Clarke P, Ng F, Paterson T, Giam A, Sarma S, Hoy KE, Galletly C, Fitzgerald PB. Accelerated theta burst stimulation for the treatment of depression: A randomised controlled trial. Brain Stimul 2021; 14:1095-1105. [PMID: 34332155 DOI: 10.1016/j.brs.2021.07.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/24/2021] [Accepted: 07/26/2021] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Theta burst pattern repetitive transcranial magnetic stimulation (TBS) is increasingly applied to treat depression. TBS's brevity is well-suited to application in accelerated schedules. Sizeable trials of accelerated TBS are lacking; and optimal TBS parameters such as stimulation intensity are not established. METHODS We conducted a three arm, single blind, randomised, controlled, multi-site trial comparing accelerated bilateral TBS applied at 80 % or 120 % of the resting motor threshold and left unilateral 10 Hz rTMS. 300 patients with treatment-resistant depression (TRD) were recruited. TBS arms applied 20 bilateral prefrontal TBS sessions over 10 days, while the rTMS arm applied 20 daily sessions of 10 Hz rTMS to the left prefrontal cortex over 4 weeks. Primary outcome was depression treatment response at week 4. RESULTS The overall treatment response rate was 43.7 % and the remission rate was 28.2 %. There were no significant differences for response (p = 0.180) or remission (p = 0.316) across the three groups. Response rates between accelerated bilateral TBS applied at sub- and supra-threshold intensities were not significantly different (p = 0.319). Linear mixed model analysis showed a significant effect of time (p < 0.01), but not rTMS type (p = 0.680). CONCLUSION This is the largest accelerated bilateral TBS study to date and provides evidence that it is effective and safe in treating TRD. The accelerated application of TBS was not associated with more rapid antidepressant effects. Bilateral sequential TBS did not have superior antidepressant effect to unilateral 10 Hz rTMS. There was no significant difference in antidepressant efficacy between sub- and supra-threshold accelerated bilateral TBS.
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Affiliation(s)
- Leo Chen
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia; Monash Alfred Psychiatry Research Centre, Department of Psychiatry, Monash University, Melbourne, Victoria, Australia; Alfred Mental and Addiction Health, Alfred Health, Melbourne, Victoria, Australia.
| | - Elizabeth H X Thomas
- Monash Alfred Psychiatry Research Centre, Department of Psychiatry, Monash University, Melbourne, Victoria, Australia
| | - Pakin Kaewpijit
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia; Monash Alfred Psychiatry Research Centre, Department of Psychiatry, Monash University, Melbourne, Victoria, Australia; Bangkok Hospital, Bang Kapi, Bangkok, Thailand
| | - Aleksandra Miljevic
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia
| | - Rachel Hughes
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia
| | - Lisa Hahn
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia
| | - Yuko Kato
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia
| | - Shane Gill
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia
| | - Patrick Clarke
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia
| | - Felicity Ng
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia; Discipline of Psychiatry, The University of Adelaide, South Australia, Australia
| | - Tom Paterson
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia; Discipline of Psychiatry, The University of Adelaide, South Australia, Australia
| | - Andrew Giam
- Central Adelaide Local Health Network, South Australia, Australia
| | - Shanthi Sarma
- Department of Mental Health, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Kate E Hoy
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia
| | - Cherrie Galletly
- The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, South Australia, Australia; Discipline of Psychiatry, The University of Adelaide, South Australia, Australia; Northern Adelaide Local Health Network, South Australia, Australia
| | - Paul B Fitzgerald
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia
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Cheng CM, Li CT, Tsai SJ. Current Updates on Newer Forms of Transcranial Magnetic Stimulation in Major Depression. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1305:333-349. [PMID: 33834408 DOI: 10.1007/978-981-33-6044-0_18] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Repetitive transcranial magnetic stimulation (rTMS) is an FDA-approved technique for treating medication-resistant depression. Conventional rTMS includes high frequency (HF) to left dorsolateral prefrontal cortex (DLPFC) and low frequency to right DLPFC. However, not all depressed patients could benefit from standard rTMS protocols. Meta-analytical evidence indicated that there was an average response rate of 29.3% for patients receiving the most commonly adopted HF rTMS to the left DLPFC. Hence, newer forms of rTMS paradigms are warranted to improve antidepressant response and remission rate in patients with depression, especially those who are refractory to adequate antidepressant trials. In the current chapter, we review newer forms of rTMS paradigms and the content will cover standard theta burst stimulation (TBS), prolonged iTBS (piTBS), accelerated rTMS (aTMS), deep TMS (dTMS), priming TMS (pTMS), synchronized TMS (sTMS), and magnetic seizure therapy (MST).
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Affiliation(s)
- Chih-Ming Cheng
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Brain Science, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Ta Li
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan. .,Division of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Institute of Brain Science, School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Institute of Cognitive Neuroscience, National Central University, Jhongli, Taiwan.
| | - Shih-Jen Tsai
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan. .,Division of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Institute of Brain Science, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Thomson AC, Sack AT. How to Design Optimal Accelerated rTMS Protocols Capable of Promoting Therapeutically Beneficial Metaplasticity. Front Neurol 2020; 11:599918. [PMID: 33224103 PMCID: PMC7674552 DOI: 10.3389/fneur.2020.599918] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- Alix C Thomson
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands.,Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht, Netherlands.,Centre for Integrative Neuroscience, Faculty of Psychology and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Alexander T Sack
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands.,Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht, Netherlands.,Centre for Integrative Neuroscience, Faculty of Psychology and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
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Thomson AC, Kenis G, Tielens S, de Graaf TA, Schuhmann T, Rutten BP, Sack AT. Transcranial Magnetic Stimulation-Induced Plasticity Mechanisms: TMS-Related Gene Expression and Morphology Changes in a Human Neuron-Like Cell Model. Front Mol Neurosci 2020; 13:528396. [PMID: 33192288 PMCID: PMC7604533 DOI: 10.3389/fnmol.2020.528396] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 09/28/2020] [Indexed: 01/17/2023] Open
Abstract
Transcranial Magnetic Stimulation (TMS) is a form of non-invasive brain stimulation, used to alter cortical excitability both in research and clinical applications. The intermittent and continuous Theta Burst Stimulation (iTBS and cTBS) protocols have been shown to induce opposite after-effects on human cortex excitability. Animal studies have implicated synaptic plasticity mechanisms long-term potentiation (LTP, for iTBS) and depression (LTD, for cTBS). However, the neural basis of TMS effects has not yet been studied in human neuronal cells, in particular at the level of gene expression and synaptogenesis. To investigate responses to TBS in living human neurons, we differentiated human SH-SY5Y cells toward a mature neural phenotype, and stimulated them with iTBS, cTBS, or sham (placebo) TBS. Changes in (a) mRNA expression of a set of target genes (previously associated with synaptic plasticity), and (b) morphological parameters of neurite outgrowth following TBS were quantified. We found no general effects of stimulation condition or time on gene expression, though we did observe a significantly enhanced expression of plasticity genes NTRK2 and MAPK9 24 h after iTBS as compared to sham TBS. This specific effect provides unique support for the widely assumed plasticity mechanisms underlying iTBS effects on human cortex excitability. In addition to this protocol-specific increase in plasticity gene expression 24 h after iTBS stimulation, we establish the feasibility of stimulating living human neuron with TBS, and the importance of moving to more complex human in vitro models to understand the underlying plasticity mechanisms of TBS stimulation.
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Affiliation(s)
- Alix C. Thomson
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
- School for Mental Health and Neuroscience (MHeNS), Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
- Maastricht Brain Imaging Centre (MBIC), Maastricht University, Maastricht, Netherlands
- Center for Integrative Neuroscience, Faculty of Psychology and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Gunter Kenis
- School for Mental Health and Neuroscience (MHeNS), Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
- Center for Integrative Neuroscience, Faculty of Psychology and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Sylvia Tielens
- School for Mental Health and Neuroscience (MHeNS), Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Tom A. de Graaf
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
- Maastricht Brain Imaging Centre (MBIC), Maastricht University, Maastricht, Netherlands
- Center for Integrative Neuroscience, Faculty of Psychology and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Teresa Schuhmann
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
- Maastricht Brain Imaging Centre (MBIC), Maastricht University, Maastricht, Netherlands
- Center for Integrative Neuroscience, Faculty of Psychology and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Bart P.F. Rutten
- School for Mental Health and Neuroscience (MHeNS), Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
- Center for Integrative Neuroscience, Faculty of Psychology and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Alexander T. Sack
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
- School for Mental Health and Neuroscience (MHeNS), Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
- Maastricht Brain Imaging Centre (MBIC), Maastricht University, Maastricht, Netherlands
- Center for Integrative Neuroscience, Faculty of Psychology and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
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Cole EJ, Stimpson KH, Bentzley BS, Gulser M, Cherian K, Tischler C, Nejad R, Pankow H, Choi E, Aaron H, Espil FM, Pannu J, Xiao X, Duvio D, Solvason HB, Hawkins J, Guerra A, Jo B, Raj KS, Phillips AL, Barmak F, Bishop JH, Coetzee JP, DeBattista C, Keller J, Schatzberg AF, Sudheimer KD, Williams NR. Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression. Am J Psychiatry 2020; 177:716-726. [PMID: 32252538 DOI: 10.1176/appi.ajp.2019.19070720] [Citation(s) in RCA: 277] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE New antidepressant treatments are needed that are effective, rapid acting, safe, and tolerable. Intermittent theta-burst stimulation (iTBS) is a noninvasive brain stimulation treatment that has been approved by the U.S. Food and Drug Administration for treatment-resistant depression. Recent methodological advances suggest that the current iTBS protocol might be improved through 1) treating patients with multiple sessions per day at optimally spaced intervals, 2) applying a higher overall pulse dose of stimulation, and 3) precision targeting of the left dorsolateral prefrontal cortex (DLPFC) to subgenual anterior cingulate cortex (sgACC) circuit. The authors examined the feasibility, tolerability, and preliminary efficacy of Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT), an accelerated, high-dose resting-state functional connectivity MRI (fcMRI)-guided iTBS protocol for treatment-resistant depression. METHODS Twenty-two participants with treatment-resistant depression received open-label SAINT. fcMRI was used to individually target the region of the left DLPFC most anticorrelated with sgACC in each participant. Fifty iTBS sessions (1,800 pulses per session, 50-minute intersession interval) were delivered as 10 daily sessions over 5 consecutive days at 90% resting motor threshold (adjusted for cortical depth). Neuropsychological testing was conducted before and after SAINT. RESULTS One participant withdrew, leaving a sample size of 21. Nineteen of 21 participants (90.5%) met remission criteria (defined as a score <11 on the Montgomery-Åsberg Depression Rating Scale). In the intent-to-treat analysis, 19 of 22 participants (86.4%) met remission criteria. Neuropsychological testing demonstrated no negative cognitive side effects. CONCLUSIONS SAINT, an accelerated, high-dose, iTBS protocol with fcMRI-guided targeting, was well tolerated and safe. Double-blinded sham-controlled trials are needed to confirm the remission rate observed in this initial study.
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Affiliation(s)
- Eleanor J Cole
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Katy H Stimpson
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Brandon S Bentzley
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Merve Gulser
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Kirsten Cherian
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Claudia Tischler
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Romina Nejad
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Heather Pankow
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Elizabeth Choi
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Haley Aaron
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Flint M Espil
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Jaspreet Pannu
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Xiaoqian Xiao
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Dalton Duvio
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Hugh B Solvason
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Jessica Hawkins
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Austin Guerra
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Booil Jo
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Kristin S Raj
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Angela L Phillips
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Fahim Barmak
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - James H Bishop
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - John P Coetzee
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Charles DeBattista
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Jennifer Keller
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Alan F Schatzberg
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Keith D Sudheimer
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
| | - Nolan R Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, Calif. (all authors), and Department of Psychology (Stimpson, Cherian, Choi, Aaron, Guerra, Phillips), Palo Alto University, Palo Alto, Calif
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Yu F, Tang X, Hu R, Liang S, Wang W, Tian S, Wu Y, Yuan TF, Zhu Y. The After-Effect of Accelerated Intermittent Theta Burst Stimulation at Different Session Intervals. Front Neurosci 2020; 14:576. [PMID: 32670006 PMCID: PMC7330092 DOI: 10.3389/fnins.2020.00576] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/11/2020] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE The study aims to investigate the after-effect of three sessions of intermittent theta-burst stimulation (iTBS) on motor cortical excitability. The iTBS was induced over the primary motor cortex (M1) at different time intervals. METHODS The study has a crossover design. Sixteen participants were assigned to three groups and received different accelerated iTBS (aiTBS) protocols during each visit: (1) three continuous sessions with no interval (iTBS18000); (2) three iTBS sessions with 10-min intervals (iTBS600 × 3∗10); and (3) three iTBS sessions with 30-min intervals (iTBS600 × 3∗30). As washout period, each visit is separated by at least 7 days. We measured the motor cortical excitability changes and intracortical inhibition. RESULTS A dose of 1,800 pulses of aiTBS per day is tolerable. The iTBS1800 led to a reduced cortical excitability; whereas iTBS600 × 3∗10 and iTBS600 × 3∗30 enhanced cortical excitability to a differential extent. After a total dose of 1,800 pulses, iTBS600 × 3∗30 exhibited the longer effect and highest percentage of individuals with enhanced cortical excitability. CONCLUSION The results suggest that aiTBS protocols at different time intervals result in different motor cortical excitability after-effects.
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Affiliation(s)
- Fengyun Yu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
- School of Kinesiology, Shanghai University of Sport, Shanghai, China
| | - Xinwei Tang
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Ruiping Hu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Sijie Liang
- School of Kinesiology, Shanghai University of Sport, Shanghai, China
| | - Weining Wang
- School of Kinesiology, Shanghai University of Sport, Shanghai, China
| | - Shan Tian
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yi Wu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Ti-Fei Yuan
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Co-innovation Center of Neuroregeneration, Nantong University, Nantong, China
| | - Yulian Zhu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
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Fitzgerald PB, Chen L, Richardson K, Daskalakis ZJ, Hoy KE. A pilot investigation of an intensive theta burst stimulation protocol for patients with treatment resistant depression. Brain Stimul 2019; 13:137-144. [PMID: 31477542 DOI: 10.1016/j.brs.2019.08.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/12/2019] [Accepted: 08/20/2019] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Accelerated or intensive forms of repetitive transcranial magnetic stimulation (rTMS) are increasingly being explored for their potential to produce more efficient and rapid treatment benefits in major depressive disorder (MDD). However, accelerated or intensive protocols using standard forms of rTMS are still quite time-consuming to apply. Theta burst stimulation (TBS) is a novel form of magnetic stimulation with the potential to produce similar anti-depressant effects but in a much abbreviated period of time. The aim of this study was to investigate the comparative efficacy of an intensive TBS protocol compared to standard rTMS treatment. METHODS 74 outpatients (36 female, mean age 44.36 ± 12.1 years) with MDD received either intensive TBS (3 intermittent TBS treatments per day for 3 days in week 1, 3 treatments a day for 2 days in week 2, and 3 treatments in 1 day in week 3 and in week 4, or standard rTMS (5 daily sessions per week for 4 weeks). Patients were assessed weekly throughout the treatment course, and at 4 weeks after treatment end. RESULTS There were no significant differences in the degree of reduction in depressive symptoms, the rate of reduction in depressive symptoms, remission or response rates (response rates = 27.8% for intensive group, 26.3% for the standard group, p > 0.05 for all analyses) between the intensive TBS and standard rTMS treatment groups. However, the overall response and remission rates were limited in both groups. There was no difference in rates of side effects, no serious adverse events and no alterations in cognitive performance. CONCLUSION Intensively applied TBS appears to have similar efficacy to standard rTMS when these were applied as delivered in this study but does not produce more rapid clinical benefits. The overall response rates in both groups in this study were limited, most likely by the total doses provided in both study arms. CLINICAL TRIALS REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12616000443493.
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Affiliation(s)
- Paul B Fitzgerald
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare, The Epworth Clinic, Camberwell, Victoria, Australia; Monash Alfred Psychiatry Research Centre, The Alfred and Monash University Central Clinical School, Victoria, Australia.
| | - Leo Chen
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare, The Epworth Clinic, Camberwell, Victoria, Australia; Monash Alfred Psychiatry Research Centre, The Alfred and Monash University Central Clinical School, Victoria, Australia
| | - Karyn Richardson
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare, The Epworth Clinic, Camberwell, Victoria, Australia; Monash Alfred Psychiatry Research Centre, The Alfred and Monash University Central Clinical School, Victoria, Australia
| | - Zafiris J Daskalakis
- Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Ontario, Canada
| | - Kate E Hoy
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare, The Epworth Clinic, Camberwell, Victoria, Australia; Monash Alfred Psychiatry Research Centre, The Alfred and Monash University Central Clinical School, Victoria, Australia
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