Effects of neuronavigation-guided rTMS on serum BDNF, TrkB and VGF levels in depressive patients with suicidal ideation

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.

Brain connectivity and transcriptional changes induced by rTMS in first-episode major depressive disorder

Repetitive transcranial magnetic stimulation (rTMS) is a widely utilized non-invasive brain stimulation technique with demonstrated efficacy in treating major depressive disorder (MDD). However, the mechanisms underlying its therapeutic effects, particularly in modulating neural connectivity and influencing gene expression, remain incompletely understood. In this study, we investigated the voxel-wise degree centrality (DC) induced by 10 Hz rTMS targeting the left dorsolateral prefrontal cortex, as well as their associations with transcriptomic data from the Allen Human Brain Atlas. The results indicated that the active treatment significantly reduced clinical symptoms and increased DC in the left superior medial frontal gyrus, left middle occipital gyrus, and right anterior cingulate cortex. Partial least squares regression analysis revealed that genes associated with DC alternations were enriched biological processes related to neural plasticity and synaptic connectivity. Furthermore, protein-protein interaction (PPI) analysis identified key hub genes, including SCN1A, SNAP25, and PVALB, whose expression levels were positively correlated with DC changes. Notably, SCN1A emerged as a significant predictor on DC changes. These findings suggest that rTMS may exert its therapeutic effects in MDD by modulating specific molecular pathways and neural networks, providing valuable insights into its mechanisms of action.

Repetitive transcranial magnetic stimulation elevates the serum levels of neurotrophic factors and serotonin and its metabolites in patients with ischemic stroke

Objective

Repetitive transcranial magnetic stimulation (rTMS) can effectively treat cognitive impairment in stroke patients; however, its mechanism of action remains unclear. The aim of this study was to investigate whether rTMS improves cognitive function by regulating the levels of brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF), 5-hydroxytryptamine (5-HT), and 5-hydroxyindoleacetic acid (5-HIAA).

Methods

In a 4-week study, 70 patients with ischemic stroke were randomly assigned to two groups: one received rTMS (n = 35) and the other received sham-stimulation (n = 35) in addition to conventional medication and rehabilitation training. Patients in the rTMS group were treated with rTMS at 10 Hz for 20 min per session. The Montreal Cognitive Assessment (MoCA) and response time in the n-back task were used to assess the severity of the disease. Fasting venous blood was collected in the early morning, both before and after the treatment. The peripheral blood levels of BDNF, NGF, 5-HT, and 5-HIAA were measured using the enzyme-linked immunosorbent assay (ELISA).

Results

The levels of BDNF and NGF were higher in the rTMS group than in the sham group (p = 0.017, p = 0.008), after the rTMS treatment, and the levels of 5-HT and 5-HIAA were also elevated in the rTMS group (p = 0.049, p = 0.004). The changes in serum 5-HT and 5-HIAA levels after the rTMS treatment correlated with the changes in the MoCA and response time in the n-back task. There was a positive correlation between the serum 5-HT and BDNF levels (r = 0.4034).

Conclusion

Our results showed that the BDNF, NGF, 5-HT, and 5-HIAA levels were upregulated after the rTMS treatment, which likely contributed to improvements in cognitive function and quality of life in the patients with stroke.

Clinical trial registration

https://www.chictr.org.cn/showproj.html?proj=216761, ChiCTR2400082383.

The associations of brain-derived neurotrophic factor (BDNF) levels with psychopathology and lipid metabolism parameters in adolescents with major depressive disorder

Brain-derived neurotrophic factor (BDNF) is crucial for the growth, differentiation and maintenance of neuronal systems, which is closely associated with major depressive disorder (MDD). The objective of this study was to investigate the BDNF levels and their associations with psychopathology and lipid metabolism parameters in adolescents with MDD. From January to December 2021, the study included 141 adolescents with MDD and 90 healthy controls (HCs). The Center for Epidemiological Studies Depression Scale (CES-D), the Insomnia Severity Index Scale (ISI), the Epworth Sleepiness Scale (ESS) and the Positive and Negative Suicidal Ideation Scale (PANSI) were used to assess depressive symptoms, insomnia, excessive daytime sleepiness, and suicidal ideation, respectively. BDNF levels and lipid metabolism parameters were also measured. Compared to HCs, adolescents with MDD had significantly lower BDNF levels (p < 0.001). In patients, BDNF levels were positively correlated with age, BMI, total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C); and negatively correlated with the scores of CES-D and ISI (all p < 0.05). The results of the multivariate linear regression analyses indicated that BDNF levels were positively associated with age (β = 0.198, t = 2.447, p = 0.016), first-episode MDD (β = 0.176, t = 2.234, p = 0.027) and TC level (β = 0.240, t = 3.048, p = 0.003), and negatively associated with the scores of ESS (β = -0.171, t = -2.203, p = 0.029) and ISI (β = -0.231, t = -2.996, p = 0.003). Of note, the associations between BDNF and psychopathology were observed only in female and first-episode patients. BDNF levels were decreased in adolescents with MDD. Patients with low BDNF levels were in a more severe psychiatric state and had changes in lipid metabolism parameters. This study provided preliminary evidence that BDNF may play a role in the onset and progression of MDD.

Investigating the predictive models of efficacy of accelerated neuronavigation-guided rTMS for suicidal depression based on multimodal large-scale brain networks

Background

Accelerated neuronavigation-guided high-dose repetitive transcranial magnetic stimulation (NH-rTMS) can rapidly reduce suicidal ideation and alleviate depressive symptoms in one week. Exploring accelerated NH-rTMS-related biomarkers will enhance the precision of treatment decisions for patients with major depressive disorder (MDD). This study aimed to establish predictive models of treatment response to accelerated NH-rTMS in MDD based on multimodal large-scale brain networks.

Method

In this study, morphological, structural, and functional brain networks were constructed for untreated MDD patients with suicidal ideation before accelerated NH-rTMS treatment. Linear support vector regression methods were utilized to examine the ability of multimodal brain networks in predicting antidepressant and anti-suicidal effects of accelerated NH-rTMS.

Results

We found that both the morphological and structural networks predicted the percentage changes of total Beck Scale of Suicidal Ideation and 24-item Hamilton Depression Rating Scale (HAMD-24) scores. Additionally, the functional networks predicted the percentage changes of total HAMD-24 scores. Further analyses revealed that the structural networks outperformed the morphological and functional networks and the somatomotor module outperformed other subnetworks in the prediction.

Conclusions

In summary, our study provides brain connectome-based predictive models of treatment response to accelerated NH-rTMS in MDD patients with suicidal ideation.

Investigation of the effects of Periplaneta americana (L.) extract on ischemic stroke based on combined multi-omics of gut microbiota

Ischemic stroke (IS) is a highly lethal type of cardiovascular and cerebrovascular disease. Improving survival rates and promoting recovery in patients with IS pose significant challenges, however, recent research has identified the gut-brain axis as a therapeutic target. In this study, we evaluated the regulatory effect of Periplaneta americana (L.) extract (PAS840), which has established anti-inflammatory, antioxidant, and neuroprotective effects, on the gut microbiota using a rat model of temporary middle cerebral artery occlusion (tMCAO). We evaluated the protective effects of PAS840 on brain damage in IS rats through TTC (triphenyltetrazolium chloride), Nissl staining, and pathological section analysis. Additionally, we investigated the impact of PAS840 on the gut microbiota and metabolites using 16S rRNA sequencing, untargeted metabolomics of gut contents, and transcriptomics analyses of brain tissues to explore its mechanism of action. PAS840 intervention resulted in significant changes in the gut microbiota, including an increase in the abundance of probiotic flora, decrease in the abundance of harmful flora, and significant changes in metabolite profiles. It also attenuated brain damage, decreased platelet activity, inhibited oxidative stress and genes related to inflammation, and improved neurological function in rats. These findings suggest that PAS840 has preventive and therapeutic effects against IS via the gut-brain axis by regulating the gut microbiota and related metabolites. Accordingly, PAS840 is a candidate therapeutic drug for further research.

Acute treatment of bilateral rTMS combined with antidepressants on the plasma fatty acids for major depressive episodes

Bilateral repetitive transcranial magnetic stimulation (B-rTMS) has been largely used in the treatment of major depressive disorder (MDD). Nonetheless, information on the acute treatment by B-rTMS combined with antidepressants (ADs) on the plasma fatty acids in MDD is limited. The present study focused on depressive symptoms; Plasma was obtained from 27 adult patients with MDD at baselinephase (MDD), after 2 weeks of treatment (MDD-2w), and 27 healthy controls (HC). Meanwhile, we evaluated the composition of short-chain fatty acids (SCFAs) and medium-and long-chain fatty acids (MLCFAs) in the plasma. Consequently, the levels of Isobutyric acid, Caproic acid, and Propionic acid were low both in the MDD and MDD-2w groups and negatively correlated with the scores of HAMD and HAMA. Besides, minimal changes were observed between the MDD and HC groups, whereas significant MLCFA levels were high in the MDD-2w group. Moreover, we developed combined panels that could effectively differentiate MDD from HCs (AUC=0.99), MDD-2w from HC (AUC=0.983), and MDD from MDD-2w (AUC=0.852). These findings may provide a reference for the use of B-rTMS combined with ADs against the acute phase of depressive episodes and shed light on the relationship between plasma FAs and MDD.

Should rTMS be considered a first-line treatment for major depressive episodes in adults?

Treatment-resistant depression (TRD) is an epidemic with rising social, economic, and political costs. In a patient whose major depressive episode (MDE) persists through an adequate antidepressant trial, insurance companies often cover alternative treatments which may include repetitive transcranial magnetic stimulation (rTMS). RTMS is an FDA-cleared neuromodulation technique for TRD which is safe, efficacious, noninvasive, and well-tolerated. Recent developments in the optimization of rTMS algorithms and targeting have increased the efficacy of rTMS in treating depression, improved the clinical convenience of these treatments, and decreased the cost of a course of rTMS. In this opinion paper, we make a case for why conventional FDA-cleared rTMS should be considered as a first-line treatment for all adult MDEs. RTMS is compared to other first-line treatments including psychotherapy and SSRIs. These observations suggest that rTMS has similar efficacy, fewer side-effects, lower risk of serious adverse events, comparable compliance, the potential for more rapid relief, and cost-effectiveness. This suggestion, however, would be strengthened by further research with an emphasis on treatment-naive subjects in their first depressive episode, and trials directly contrasting rTMS with SSRIs or psychotherapy.

Status and trends of TMS research in depressive disorder: a bibliometric and visual analysis

Background

Depression is a chronic psychiatric condition that places significant burdens on individuals, families, and societies. The rapid evolution of non-invasive brain stimulation techniques has facilitated the extensive clinical use of Transcranial Magnetic Stimulation (TMS) for depression treatment. In light of the substantial recent increase in related research, this study aims to employ bibliometric methods to systematically review the global research status and trends of TMS in depression, providing a reference and guiding future studies in this field.

Methods

We retrieved literature on TMS and depression published between 1999 and 2023 from the Science Citation Index Expanded (SCIE) and Social Science Citation Index (SSCI) databases within the Web of Science Core Collection (WoSCC). Bibliometric analysis was performed using VOSviewer and CiteSpace software to analyze data on countries, institutions, authors, journals, keywords, citations, and to generate visual maps.

Results

A total of 5,046 publications were extracted covering the period from 1999 to 2023 in the field of TMS and depression. The publication output exhibited an overall exponential growth trend. These articles were published across 804 different journals, BRAIN STIMULATION is the platform that receives the most articles in this area. The literature involved contributions from over 16,000 authors affiliated with 4,573 institutions across 77 countries. The United States contributed the largest number of publications, with the University of Toronto and Daskalakis ZJ leading as the most prolific institution and author, respectively. Keywords such as "Default Mode Network," "Functional Connectivity," and "Theta Burst" have recently garnered significant attention. Research in this field primarily focuses on TMS stimulation patterns, their therapeutic efficacy and safety, brain region and network mechanisms under combined brain imaging technologies, and the modulation effects of TMS on brain-derived neurotrophic factor (BDNF) and neurotransmitter levels.

Conclusion

In recent years, TMS therapy has demonstrated extensive potential applications and significant implications for the treatment of depression. Research in the field of TMS for depression has achieved notable progress. Particularly, the development of novel TMS stimulation patterns and the integration of TMS therapy with multimodal techniques and machine learning algorithms for precision treatment and investigation of brain network mechanisms have emerged as current research hotspots.

Efficacy of MRI-guided rTMS for post-traumatic stress disorder by modulating amygdala activity: study protocol for a randomised controlled trial

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a prevalent and severe psychiatric disorder. Repetitive transcranial magnetic stimulation (rTMS) targeting the dorsolateral prefrontal cortex provides limited relief for symptoms of PTSD. This study will be conducted to validate the efficacy of MRI-guided rTMS in targeting the sites most closely associated with the amygdala for patients with PTSD. We hypothesise that the intervention will improve clinical symptoms by decreasing amygdala activity in patients.

METHODS AND ANALYSIS

A randomised, double-blind, sham-controlled trial will be conducted. Forty-eight eligible patients with PTSD will be randomly assigned to receive either active or sham MRI-guided rTMS for 10 consecutive days after the initial MRI scans. MRI scans will be recollected at the end of the intervention. Clinical assessments will be performed at baseline, treatment day 5, treatment day 10, and 2 weeks, 4 weeks, 8 weeks after completion of the intervention to monitor changes in clinical symptoms. The primary assessment outcome is the change in PTSD symptoms between baseline and treatment day 10, as measured by the PTSD Checklist for DSM-5. Repeated measures analysis of variance will be performed using statistical software SPSS V.26.0. The significance level will be set at 0.05.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Ethics Committee of Xijing Hospital in Xi'an, China (KY20222176-X-1), and the trial has been registered on ClinicalTrials.gov. The findings of this trial will be disseminated at academic conferences or published in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT05544110.

Comparisons of Accelerated Continuous and Intermittent Theta Burst Stimulation for Treatment-Resistant Depression and Suicidal Ideation

BACKGROUND

Suicidal ideation is a substantial clinical challenge in treatment-resistant depression (TRD). Recent work demonstrated promising antidepressant effects in TRD patients with no or mild suicidal ideation using a specific protocol termed intermittent theta burst stimulation (iTBS). Here, we examined the clinical effects of accelerated schedules of iTBS and continuous TBS (cTBS) in patients with moderate to severe suicidal ideation.

METHODS

Patients with TRD and moderate to severe suicidal ideation (n = 44) were randomly assigned to receive accelerated iTBS or cTBS treatment. Treatments were delivered in 10 daily TBS sessions (1800 pulses/session) for 5 consecutive days (total of 90,000 pulses). Neuronavigation was employed to target accelerated iTBS and cTBS to the left and right dorsolateral prefrontal cortex (DLPFC), respectively. Clinical outcomes were evaluated in a 4-week follow-up period.

RESULTS

Accelerated cTBS was superior to iTBS in the management of suicidal ideation (pweek 1 = .027) and anxiety symptoms (pweek 1 = .01). Accelerated iTBS and cTBS were comparable in antidepressant effects (p < .001; accelerated cTBS: mean change at weeks 1, 3, 5 = 49.55%, 54.99%, 53.11%; accelerated iTBS: mean change at weeks 1, 3, 5 = 44.52%, 48.04%, 51.74%). No serious adverse events occurred during the trial. One patient withdrew due to hypomania. The most common adverse event was discomfort at the treatment site (22.73% in both groups).

CONCLUSIONS

These findings provide the first evidence that accelerated schedules of left DLPFC iTBS and right DLPFC cTBS are comparably effective in managing antidepressant symptoms and indicate that right DLPFC cTBS is potentially superior in reducing suicidal ideation and anxiety symptoms.

Repetitive Transcranial Magnetic Stimulation-Induced Neuroplasticity and the Treatment of Psychiatric Disorders: State of the Evidence and Future Opportunities

Neuroplasticity, or activity-dependent neuronal change, is a crucial mechanism underlying the mechanisms of effect of many therapies for neuropsychiatric disorders, one of which is repetitive transcranial magnetic stimulation (rTMS). Understanding the neuroplastic effects of rTMS at different biological scales and on different timescales and how the effects at different scales interact with each other can help us understand the effects of rTMS in clinical populations and offers the potential to improve treatment outcomes. Several decades of research in the fields of neuroimaging and blood biomarkers is increasingly showing its clinical relevance, allowing measurement of the synaptic, functional, and structural changes involved in neuroplasticity in humans. In this narrative review, we describe the evidence for rTMS-induced neuroplasticity at multiple levels of the nervous system, with a focus on the treatment of psychiatric disorders. We also describe the relationship between neuroplasticity and clinical effects, discuss methods to optimize neuroplasticity, and identify future research opportunities in this area.

Ononin ameliorates depression-like behaviors by regulating BDNF-TrkB-CREB signaling in vitro and in vivo

ETHNOPHARMACOLOGICAL RELEVANCE

Ononin is a flavonoid compound found in several medicinal plants, including Astragalus membranaceus, Sophora flavescens, and Ononis spinosa. These plants have been traditionally used in various parts of the world for their medicinal properties, including anti-inflammatory, antioxidant, and antitumor effects. Major depression is a common, long-lasting, and recurrent psychiatric disorder with a high suicide rate. Naturally occurring flavonoids treat depression via poorly understood mechanisms.

AIM OF THE STUDY

The present study aimed to determine whether ononin conferred an antidepressant-like effect in PC12 cell models and chronic mild stress (CMS)-induced depressive rat models and to explore its possible mechanisms.

MATERIALS AND METHODS

Depression-related behaviors were measured using sucrose preference, tail suspension and open-field tests. Furthermore, to explore these mechanisms, we employed in vitro and in vivo assay methods, including neurite outgrowth, western blotting, quantitative RT-PCR, and staining methods.

RESULTS

Treatment with ononin or BDNF significantly increased PC12 cells' neuronal growth and differentiation. Furthermore, ononin promotes the activation of TrkB and growth factors and upregulates the PI3K/Akt and BDNF/TrkB/CREB signaling pathways. The in vitro results were consistent with CMS-induced depressive rat models, in which ononin treatment significantly decreased depression-like behaviors and activated TrkB, growth factors, and BDNF/TrkB/CREB signaling pathways in the frontal cortex and hippocampus. Depression-induced microscopic alterations in the frontal cortex and hippocampus of rats with CMS-induced depression were also mitigated following ononin treatment.

CONCLUSION

Based on these findings, we suggest that ononin is a promising antidepressant candidate for treating depression.

Repetitive transcranial magnetic stimulation in the treatment of middle-aged and elderly major depressive disorder: A randomized controlled trial

BACKGROUND

Studies have reported the use of repetitive transcranial magnetic stimulation (rTMS) in patients with major depressive disorder (MDD). However, most studies focus on antidepressant effect of rTMS, but few on cognitive aspects. The present study aimed to explore the effect of rTMS on BDNF levels and cognitive function in the treatment of middle-aged and elderly MDD.

METHODS

This was a randomized controlled trial. A total of 120 elderly patients with MDD treated in The Second Affiliated Hospital of Xi'an Medical University from January 2021 to January 2023 were selected as research subjects. The patients were randomly divided into control group (n = 60, patients received simple oral treatment with escitalopram and sham rTMS) and study group (n = 60, patients received oral treatment with escitalopram combined with rTMS) according to the random number table method. We compared the clinical efficacy, serum BDNF levels, and cognitive function between the 2 groups.

RESULTS

After treatment, the HAMD-17 score in the study group was lower than that in the control group [13.00 (12.00-16.00) vs 17.00 (15.00-19.00), P < .05], and the RBANS score was higher than that in the control group [166.00 (161.25-171.75) vs 133.00 (130.00-136.75), P < .05]. The total effective rate of the research group was 95.0%, which was higher than the 82.0% of the control group (P < .05). The serum BDNF levels [36.00 (33.00-38.00) vs 30.00 (28.00-32.00), P < .05] and MoCA scores [24.00 (22.00-26.75) vs 23.00 (21.00-25.00), P < .05] of the study group were higher than those of the control group. There were no significant adverse reactions during the treatment of both groups.

CONCLUSIONS

Compared with oral escitalopram alone, repeated transcranial magnetic stimulation in the treatment of middle-aged and elderly patients with major depressive disorder can further improve the efficacy, and can more effectively improve the BDNF level and cognitive function, with ideal safety.