Adjunctive home-based transcranial direct current stimulation treatment for major depression with real-time remote supervision: An open-label, single-arm feasibility study with long term outcomes

Home-based transcranial direct current stimulation for major depressive disorder: 6-month follow-up from randomised sham-controlled trial and open-label treatment phases

Transcranial direct current stimulation (tDCS) is a potential home-based treatment for major depressive disorder (MDD). In our double-blind randomised controlled trial (RCT) (n = 174; UK and USA), a 10-week course of home-based tDCS demonstrated clinical efficacy (clinical response: 58.3 % active treatment arm and 37.8 % sham (p = 0.017). tDCS was delivered in a bifrontal montage, with anode over left dorsolateral prefrontal cortex (DLPFC) and cathode over right DLPFC. Each session was 30 min, with active stimulation at 2 mA and sham at 0 mA, incorporating brief ramp-up and ramp-down phased. Following the 10-week RCT, all participants were offered active tDCS in a 10-week open-label treatment phase, with 111 participants completing this phase. UK cohort (n = 77 MDD) were invited for additional 3-month and 6-month follow-ups, extending the total study period to 11 months post-randomisation. Participants were able to continue using the tDCS device during follow-up. At least one follow-up visit was attended by 42 MDD participants (27 women). Device usage rates were 59 % at 3-month follow-up and 55 % at 6-month follow-up. Clinical response rate was 64 % at 3-month follow-up and 76 % at 6-month follow-up. Among participants who had shown a clinical response after the open-label phase, 90 % maintained their response at the 6-month follow-up. In summary, long-term follow-up showed high and sustained clinical response rates regardless of continued tDCS device use.

Acceptability of home-based transcranial direct current stimulation (tDCS) in bipolar depression: thematic analysis of individual views

BACKGROUND

Acceptability is a multifaceted concept that reflects how a treatment is viewed, which impacts patient engagement, adherence, and provider implementation. Transcranial direct current stimulation (tDCS) is emerging as a novel non-invasive treatment for bipolar depression. We developed a home-based protocol for tDCS, which has demonstrated efficacy in unipolar and bipolar depression. We sought to explore the acceptability of home-based tDCS in bipolar depression.

METHODS

Participants were 35 adults (26 women) with bipolar disorder (mean age 47.37 years, SD ± 13.78) in a current depressive episode of at least moderate severity. tDCS was provided in a bifrontal montage, 2 mA for 30 min each session, over 6 weeks with real-time supervision. Acceptability was assessed in a questionnaire and individual interviews, conducted at two timepoints: baseline and post treatment. Individual interviews were analysed by thematic analysis.

RESULTS

Six main themes were found: helpfulness, side effects, burden, gratitude, ethicality and comparison to medications. The themes of gratitude and comparison with medications were novel in this group compared to unipolar depression.

CONCLUSION

Themes reflected high acceptability of tDCS treatment in bipolar depression and indicated strong interest in novel treatments in this population. Qualitative analysis can provide novel insights into individual experiences, understand barriers to treatment, and offer guidance for improving clinical treatments.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05436613 registered on 23 June 2022 https// www.

CLINICALTRIALS

gov/study/NCT05436613 .

Acceptability of Home-Based Transcranial Direct Current Stimulation (tDCS) in Bipolar Depression: Thematic Analysis of Individual Views

Background

Acceptability is a multifaceted concept that reflects how a treatment is viewed, which impacts on patient engagement, adherence, and provider implementation. Transcranial direct current stimulation (tDCS) is emerging as a novel non-invasive treatment for bipolar depression. We developed a home-based protocol for tDCS which has demonstrated efficacy in unipolar and bipolar depression. We sought to explore the acceptability of home-based tDCS in bipolar depression.

Methods

Participants were 35 (26 women) with bipolar disorder (mean age 47.37 years, SD ± 13.78) in a current depressive episode of at least moderate severity. tDCS was provided in a bifrontal montage 2 mA for 30 minutes in sessions over 6 weeks with real-time supervision. Acceptability was assessed in a questionnaire and individual interviews, conducted at two timepoints: baseline and post treatment. Individual interviews were analysed by thematic analysis.

Results

Six main themes were found: helpfulness, side effects, burden, gratitude, ethicality and comparison to medications. The themes of gratitude and comparison with medications were novel in this group compared to unipolar depression.

Conclusion

Themes reflected high acceptability of tDCS treatment in bipolar depression and indicated strong interest in novel treatments in this population. Qualitative analysis can provide novel insights into individual experiences, understanding barriers to treatment, and offer guidance for improving clinical treatments.

Trial registration

ClinicalTrials.gov: NCT05436613 registered on 23 June 2022 https//www.clinicaltrials.gov/study/NCT05436613.

Effect of home-based transcranial direct current stimulation (tDCS) on cognitive functioning in bipolar depression: an open-label, single-arm acceptability and feasibility study

Bipolar depression is commonly accompanied by cognitive impairments. Transcranial direct current stimulation (tDCS) is emerging as a novel non-invasive treatment for bipolar depression. Given the portability and safety of tDCS, we developed a home-based protocol with real-time supervision. Our aim was to assess the cognitive effects of a course of tDCS treatment in bipolar depression. 44 participants (31 women, mean age 47.27 years, SD 12.89) with bipolar depression of at least a moderate severity received 21 sessions of home-based tDCS over 6 weeks in an open-label design. The stimulation protocol involved 2 mA in a bilateral frontal montage (F3 anode, F4 cathode) for 30 min per session. Cognitive assessments were conducted at baseline and after the course of treatment: Rey Auditory Verbal Learning Test (RAVLT) to assess verbal learning and memory and Symbol Digit Modalities Test (SDMT) to assess psychomotor processing speed and visuospatial attention. 93.18% (n = 41) completed RAVLT and 59.09% of participants (n = 26) completed SDMT. A significant improvement was observed in RAVLT verbal learning score post-treatment (p = 0.002), which was not maintained following adjustment for improvement in depressive symptoms. In summary, a course of home-based tDCS in bipolar depression was associated with an improvement in verbal learning, which appeared to be related to improvement in depressive symptoms. These findings suggest potential benefits of tDCS for addressing cognitive impairments in bipolar depression, which can be investigated further in a sham-controlled design.

Enhanced network synchronization connectivity following transcranial direct current stimulation (tDCS) in bipolar depression: Effects on EEG oscillations and deep learning-based predictors of clinical remission

AIM

To investigate oscillatory networks in bipolar depression, effects of a home-based tDCS treatment protocol, and potential predictors of clinical response.

METHODS

20 participants (14 women) with bipolar disorder, mean age 50.75 ± 10.46 years, in a depressive episode of severe severity (mean Montgomery-Åsberg Rating Scale (MADRS) score 24.60 ± 2.87) received home-based transcranial direct current stimulation (tDCS) treatment for 6 weeks. Clinical remission defined as MADRS score < 10. Resting-state EEG data were acquired at baseline, prior to the start of treatment, and at the end of treatment, using a portable 4-channel EEG device (electrode positions: AF7, AF8, TP9, TP10). EEG band power was extracted for each electrode and phase locking value (PLV) was computed as a functional connectivity measure of phase synchronization. Deep learning was applied to pre-treatment PLV features to examine potential predictors of clinical remission.

RESULTS

Following treatment, 11 participants (9 women) attained clinical remission. A significant positive correlation was observed with improvements in depressive symptoms and delta band PLV in frontal and temporoparietal regional channel pairs. An interaction effect in network synchronization was observed in beta band PLV in temporoparietal regions, in which participants who attained clinical remission showed increased synchronization following tDCS treatment, which was decreased in participants who did not achieve clinical remission. Main effects of clinical remission status were observed in several PLV bands: clinical remission following tDCS treatment was associated with increased PLV in frontal and temporal regions and in several frequency bands, including delta, theta, alpha and beta, as compared to participants who did not achieve clinical remission. The highest deep learning prediction accuracy 69.45 % (sensitivity 71.68 %, specificity 66.72 %) was obtained from PLV features combined from theta, beta, and gamma bands.

CONCLUSIONS

tDCS treatment enhances network synchronization, potentially increasing inhibitory control, which underscores improvement in depressive symptoms. Baseline EEG-based measures might aid predicting clinical response.

Home-based transcranial direct current stimulation treatment for major depressive disorder: a fully remote phase 2 randomized sham-controlled trial

Transcranial direct current stimulation (tDCS) has been proposed as a new treatment in major depressive disorder (MDD). This is a fully remote, multisite, double-blind, placebo-controlled, randomized superiority trial of 10-week home-based tDCS in MDD. Participants were 18 years or older, with MDD in current depressive episode of at least moderate severity as measured using the Hamilton Depression Rating Scale (mean = 19.07 ± 2.73). A total of 174 participants (120 women, 54 men) were randomized to active (n = 87, mean age = 37.09 ± 11.14 years) or sham (n = 87, mean age = 38.32 ± 10.92 years) treatment. tDCS consisted of five sessions per week for 3 weeks then three sessions per week for 7 weeks in a 10-week trial, followed by a 10-week open-label phase. Each session lasted 30 min; the anode was placed over the left dorsolateral prefrontal cortex and the cathode over the right dorsolateral prefrontal cortex (active tDCS 2 mA and sham tDCS 0 mA, with brief ramp up and down to mimic active stimulation). As the primary outcome, depressive symptoms showed significant improvement when measured using the Hamilton Depression Rating Scale: active 9.41 ± 6.25 point improvement (10-week mean = 9.58 ± 6.02) and sham 7.14 ± 6.10 point improvement (10-week mean = 11.66 ± 5.96) (95% confidence interval = 0.51-4.01, P = 0.012). There were no differences in discontinuation rates. In summary, a 10-week home-based tDCS treatment with remote supervision in MDD showed high efficacy, acceptability and safety. ClinicalTrials.gov registration: NCT05202119.

Home-based transcranial direct current stimulation in bipolar depression: an open-label treatment study of clinical outcomes, acceptability and adverse events

BACKGROUND

Current treatments for bipolar depression have limited effectiveness, tolerability and acceptability. Transcranial direct current stimulation (tDCS) is a novel non-invasive brain stimulation method that has demonstrated treatment efficacy for major depressive episodes. tDCS is portable, safe, and individuals like having sessions at home. We developed a home-based protocol with real-time remote supervision. In the present study, we have examined the clinical outcomes, acceptability and feasibility of home-based tDCS treatment in bipolar depression.

RESULTS

Participants were 44 individuals with bipolar disorder (31 women), mean age 47.27 ± 12.89 years, in current depressive episode of at least moderate severity (mean Montgomery Asberg Depression Rating Scale (MADRS) score 24.59 ± 2.64). tDCS was provided in bilateral frontal montage, F3 anode, F4 cathode, 2 mA, for 30 min, in a 6-week trial, for total 21 sessions, a follow up visit was conducted 5 months from baseline. Participants maintained their current treatment (psychotherapy, antidepressant or mood stabilising medication) or maintained being medication-free. A research team member was present by video conference at each session. 93.2% participants (n = 41) completed the 6-week treatment and 72.7% of participants (n = 32) completed the 5 month follow up. There was a significant improvement in depressive symptoms following treatment (mean MADRS 8.77 ± 5.37) which was maintained at the 5 month follow up (mean MADRS 10.86 ± 6.90), rate of clinical response was 77.3% (MADRS improvement of 50% or greater from baseline), and rate of clinical remission was 47.7% (MADRS rating of 9 or less). Acceptability was endorsed as "very acceptable" or "quite acceptable" by all participants. No participants developed mania or hypomania.

CONCLUSIONS

In summary, home-based tDCS with real-time supervision was associated with significant clinical improvements and high acceptability in bipolar depression. Due to the open-label design, efficacy findings are preliminary.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT05436613 registered on 23 June 2022 https//www.

CLINICALTRIALS

gov/study/NCT05436613.

Efficacy of non-invasive brain stimulation and neuronavigation for major depressive disorder: a systematic review and meta-analysis

INTRODUCTION

Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are increasingly used for major depressive disorder (MDD). Most tDCS and rTMS studies target the left dorsolateral prefrontal cortex, either with or without neuronavigation. We examined the effect of rTMS and tDCS, and the added value of neuronavigation in the treatment of MDD.

METHODS

A search on PubMed, Embase, and Cochrane databases for rTMS or tDCS randomized controlled trials of MDD up to 1 February 2023, yielded 89 studies. We then performed meta-analyses comparing tDCS efficacy to non-neuronavigated rTMS, tDCS to neuronavigated rTMS, and neuronavigated rTMS to non-neuronavigated rTMS. We assessed the significance of the effect in subgroups and in the whole meta-analysis with a z-test and subgroup differences with a chi-square test.

RESULTS

We found small-to-medium effects of both tDCS and rTMS on MDD, with a slightly greater effect from rTMS. No significant difference was found between neuronavigation and non-neuronavigation.

CONCLUSION

Although both tDCS and rTMS are effective in treating MDD, many patients do not respond. Additionally, current neuronavigation methods are not significantly improving MDD treatment. It is therefore imperative to seek personalized methods for these interventions.

Treating depression at home with transcranial direct current stimulation: a feasibility study

Introduction

Treating major depressive disorder (MDD) with transcranial direct current stimulation (tDCS) devices at home has various logistic advantages compared to tDCS treatment in the clinic. However, preliminary (controlled) studies showed side effects such as skin lesions and difficulties in the implementation of home-based tDCS. Thus, more data are needed regarding the feasibility and possible disadvantages of home-based tDCS.

Methods

Ten outpatients (23-69 years) with an acute depressive episode were included for this one-arm feasibility study testing home-based tDCS. All patients self-administered prefrontal tDCS (2 mA, 20 min, anodal left, cathodal right) at home on 30 consecutive working days supported by video consultations. Correct implementation of the home-based treatment was analyzed with tDCS recordings. Feasibility was examined by treatment compliance. For additional analyses of effectiveness, three depression scores were used: Hamilton depression rating scale (HDRS-21), Major Depression Inventory (MDI), and the subscale depression of the Depression-Anxiety-Stress Scale (DASS). Furthermore, usability was measured with the user experience questionnaire (UEQ). Tolerability was analyzed by the number of reported adverse events (AEs).

Results

Eight patients did not stick to the protocol. AEs were minimal. Four patients responded to the home treatment according to the MDI. Usability was judged positive by the patients.

Conclusions

Regular video consultations or other safety concepts are recommended regardless of the number of video sessions actually conducted. Home-based tDCS seems to be safe and handy in our feasibility study, warranting further investigation.

Transcranial direct current stimulation as treatment for major depression in a home treatment setting (HomeDC trial): study protocol and methodology of a double-blind, placebo-controlled pilot study

INTRODUCTION

Transcranial direct current stimulation (tDCS) of prefrontal cortex regions has been reported to exert therapeutic effects in patients with major depressive disorder (MDD). Due to its beneficial safety profile, its easy mode of application, and its cost-effectiveness, tDCS has recently been proposed for treatment at home. This would offer new chances for regionally widespread and long-term application. However, tDCS at home must meet the new methodological challenges of handling and adherence. At the same time, data from randomized controlled trials (RCT) investigating this mode of application are still lacking. In this pilot RCT, we therefore investigate the feasibility, safety, and effectiveness of a new antidepressant tDCS application set-up.

METHODS AND ANALYSIS

The HomeDC trial will be conducted as a double-blind, placebo-controlled, parallel-group design trial. Thirty-two study participants with MDD will be randomly assigned to active or sham tDCS groups. Participants will self-administer prefrontal tDCS for 6 weeks. Active tDCS will be conducted with anode over F3, cathode over F4, for 5 sessions/week, with a duration of 30 min/day, and 2 mA stimulation intensity. Sham tDCS, conversely, follows an identical protocol in regard to electrode montage and timing, but with no electric stimulation between the ramp-in and ramp-out periods. Both conditions will be administered either as a monotherapy or an adjunctive treatment to a stable dose of antidepressant medication. Adjunctive magnetic resonance imaging (MRI) and electric field (E-field) modelling will be conducted at baseline. Primary outcome is feasibility based on successfully completed stimulations and drop-out rates. The intervention is considered feasible when 20 out of 30 sessions have been fully conducted by at least 75% of the participants. Effectiveness and safety will be assessed as secondary outcomes.

DISCUSSION

In the HomeDC trial, the technical requirements for a placebo-controlled tDCS study in a home-based treatment setting have been established. The trial addresses the crucial points of the home-based tDCS treatment approach: uniform electrode positioning, frequent monitoring of stimulation parameters, adherence, and ensuring an appropriate home treatment environment. This study will further identify constraints and drawbacks of this novel mode of treatment.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov .

TRIAL REGISTRATION NUMBER

NCT05172505. Registration date: 12/13/2021.

Home-administered transcranial direct current stimulation with asynchronous remote supervision in the treatment of depression: feasibility, tolerability, and clinical effectiveness

Introduction Background

Depression is an often chronic condition, characterized by wide-ranging physical, cognitive and psychosocial symptoms that can lead to disability, premature mortality or suicide. It affects 350 million people globally, yet up to 30% do not respond to traditional treatment, creating an urgent need for novel non-pharmacological treatments. This open-label naturalistic study assesses the practical feasibility, tolerability, and clinical effectiveness of home-administered transcranial direct current stimulation (tDCS) with asynchronous remote supervision, in the treatment of depression.

Method

Over the course of 3 weeks, 40 patients with depression received psychotherapy and half of this group also received daily bi-frontal tDCS stimulation of the dorsolateral prefrontal cortex. These patients received tDCS for 30 min per session with the anode placed over F3 and the cathode over F4, at an intensity of 2 mA for 21 consecutive days. We measured patients' level of depression symptoms at four time points using the Beck Depression Inventory, before treatment and at 1-week intervals throughout the treatment period. We monitored practical feasibility such as daily protocol compliance and tolerability including side effects, with the PlatoScience cloud-based remote supervision platform.

Results

Of the 20 patients in the tDCS group, 90% were able to comply with the protocol by not missing more than three of their assigned sessions, and none dropped out of the study. No serious adverse events were reported, with only 14 instances of mild to moderate side effects and two instances of scalp pain rated as severe, out of a total of 420 stimulation sessions. Patients in the tDCS group showed a significantly greater reduction in depression symptoms after 3 weeks of treatment, compared to the treatment as usual (TAU) group [t(57.2) = 2.268, p = 0.027]. The tDCS group also showed greater treatment response (50%) and depression remission rates (75%) compared to the TAU group (5 and 30%, respectively).

Discussion Conclusion

These findings provide a possible indication of the clinical effectiveness of home-administered tDCS for the treatment of depression, and its feasibility and tolerability in combination with asynchronous supervision.

TDCS at home for depressive disorders: an updated systematic review and lessons learned from a prematurely terminated randomized controlled pilot study

The application of transcranial direct current stimulation (tDCS) at home for the treatment of major depressive disorder (MDD) is the subject of current clinical trials. This is due to its positive safety profile, cost-effectiveness, and potential scalability for a wide outreach in clinical practice. Here, we provide a systematic review of the available studies and also a report on the results of a randomized controlled trial (RCT) on tDCS at home for the treatment of MDD. This trial had to be prematurely terminated due to safety concerns. The HomeDC trial is a double-blinded, placebo-controlled, parallel-group study. Patients with MDD (DSM-5) were randomized to active or sham tDCS. Patients conducted tDCS at home for 6 weeks with 5 sessions/week (30 min at 2 mA) anode over F3, cathode over F4. Sham tDCS resembled active tDCS, with ramp-in and ramp-out periods, but without intermittent stimulation. The study was prematurely terminated due to an accumulation of adverse events (AEs, skin lesions), so that only 11 patients were included. Feasibility was good. Safety monitoring was not sufficient enough to detect or prevent AEs within an appropriate timeframe. Regarding antidepressant effects, the reduction in depression scales over time was significant. However, active tDCS was not superior to sham tDCS in this regard. Both the conclusions from this review and the HomeDC trial show that there are several critical issues with the use of tDCS at home that need to be addressed. Nevertheless the array of transcranial electric simulation (TES) methods that this mode of application offers, including tDCS, is highly interesting and warrants further investigation in high quality RCTs.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov .

TRIAL REGISTRATION NUMBER

NCT05172505. Registration date: 12/13/2021, https://clinicaltrials.gov/ct2/show/NCT05172505 . *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers) **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71 . For more information, visit: http://www.prisma-statement.org/.