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Pagali SR, Kumar R, LeMahieu AM, Basso MR, Boeve BF, Croarkin PE, Geske JR, Hassett LC, Huston J, Kung S, Lundstrom BN, Petersen RC, St Louis EK, Welker KM, Worrell GA, Pascual-Leone A, Lapid MI. Efficacy and safety of transcranial magnetic stimulation on cognition in mild cognitive impairment, Alzheimer's disease, Alzheimer's disease-related dementias, and other cognitive disorders: a systematic review and meta-analysis. Int Psychogeriatr 2024:1-49. [PMID: 38329083 DOI: 10.1017/s1041610224000085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
OBJECTIVE We aim to analyze the efficacy and safety of TMS on cognition in mild cognitive impairment (MCI), Alzheimer's disease (AD), AD-related dementias, and nondementia conditions with comorbid cognitive impairment. DESIGN Systematic review, Meta-Analysis. SETTING We searched MEDLINE, Embase, Cochrane database, APA PsycINFO, Web of Science, and Scopus from January 1, 2000, to February 9, 2023. PARTICIPANTS AND INTERVENTIONS RCTs, open-label, and case series studies reporting cognitive outcomes following TMS intervention were included. MEASUREMENT Cognitive and safety outcomes were measured. Cochrane Risk of Bias for RCTs and MINORS (Methodological Index for Non-Randomized Studies) criteria were used to evaluate study quality. This study was registered with PROSPERO (CRD42022326423). RESULTS The systematic review included 143 studies (n = 5,800 participants) worldwide, encompassing 94 RCTs, 43 open-label prospective, 3 open-label retrospective, and 3 case series. The meta-analysis included 25 RCTs in MCI and AD. Collectively, these studies provide evidence of improved global and specific cognitive measures with TMS across diagnostic groups. Only 2 studies (among 143) reported 4 adverse events of seizures: 3 were deemed TMS unrelated and another resolved with coil repositioning. Meta-analysis showed large effect sizes on global cognition (Mini-Mental State Examination (SMD = 0.80 [0.26, 1.33], p = 0.003), Montreal Cognitive Assessment (SMD = 0.85 [0.26, 1.44], p = 0.005), Alzheimer's Disease Assessment Scale-Cognitive Subscale (SMD = -0.96 [-1.32, -0.60], p < 0.001)) in MCI and AD, although with significant heterogeneity. CONCLUSION The reviewed studies provide favorable evidence of improved cognition with TMS across all groups with cognitive impairment. TMS was safe and well tolerated with infrequent serious adverse events.
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Affiliation(s)
- Sandeep R Pagali
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MI, USA
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MI, USA
| | - Rakesh Kumar
- Department of Psychiatry and Psychology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MI, USA
| | - Allison M LeMahieu
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MI, USA
| | - Michael R Basso
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MI, USA
| | | | - Paul E Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MI, USA
| | - Jennifer R Geske
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MI, USA
| | | | - John Huston
- Department of Radiology (Huston and Welker), Mayo Clinic, Rochester, MI, USA
| | - Simon Kung
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MI, USA
| | | | | | | | - Kirk M Welker
- Department of Radiology (Huston and Welker), Mayo Clinic, Rochester, MI, USA
| | | | - Alvaro Pascual-Leone
- Hinda and Arthur Marcus Institute for Aging Research and Deanna, Sidney Wolk Center for Memory Health, Hebrew SeniorLife, Roslindale, MA, USA
- Department of Neurology, Harvard Medical School, Cambridge, MA, USA
| | - Maria I Lapid
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MI, USA
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MI, USA
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Du XD, Li Z, Yuan N, Yin M, Zhao XL, Lv XL, Zou SY, Zhang J, Zhang GY, Li CW, Pan H, Yang L, Wu SQ, Yue Y, Wu YX, Zhang XY. Delayed improvements in visual memory task performance among chronic schizophrenia patients after high-frequency repetitive transcranial magnetic stimulation. World J Psychiatry 2022; 12:1169-1182. [PMID: 36186505 PMCID: PMC9521529 DOI: 10.5498/wjp.v12.i9.1169] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/24/2022] [Accepted: 07/22/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cognitive impairments are core characteristics of schizophrenia, but are largely resistant to current treatments. Several recent studies have shown that high-frequency repetitive transcranial magnetic stimulation (rTMS) of the left dor-solateral prefrontal cortex (DLPFC) can reduce negative symptoms and improve certain cognitive deficits in schizophrenia patients. However, results are inconsistent across studies.
AIM To examine if high-frequency rTMS of the DLPFC can improve visual memory deficits in patients with schizophrenia.
METHODS Forty-seven chronic schizophrenia patients with severe negative symptoms on stable treatment regimens were randomly assigned to receive active rTMS to the DLPFC (n = 25) or sham stimulation (n = 22) on weekdays for four consecutive weeks. Patients performed the pattern recognition memory (PRM) task from the Cambridge Neuropsychological Test Automated Battery at baseline, at the end of rTMS treatment (week 4), and 4 wk after rTMS treatment (week 8). Clinical symptoms were also measured at these same time points using the Scale for the Assessment of Negative Symptoms (SANS) and the Positive and Negative Syndrome Scale (PANSS).
RESULTS There were no significant differences in PRM performance metrics, SANS total score, SANS subscores, PANSS total score, and PANSS subscores between active and sham rTMS groups at the end of the 4-wk treatment period, but PRM performance metrics (percent correct and number correct) and changes in these metrics from baseline were significantly greater in the active rTMS group at week 8 compared to the sham group (all P < 0.05). Active rTMS treatment also significantly reduced SANS score at week 8 compared to sham treatment. Moreover, the improvement in visual memory was correlated with the reduction in negative symptoms at week 8. In contrast, there were no between-group differences in PANSS total score and subscale scores at either week 4 or week 8 (all P > 0.05).
CONCLUSION High-frequency transcranial magnetic stimulation improves visual memory and reduces negative symptoms in schizophrenia, but these effects are delayed, potentially due to the requirement for extensive neuroplastic changes within DLPFC networks.
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Affiliation(s)
- Xiang-Dong Du
- Suzhou Guangji Hospital, Affiliated Guangji Hospital of Soochow University, Suzhou 215008, Jiangsu Province, China
| | - Zhe Li
- Suzhou Guangji Hospital, Affiliated Guangji Hospital of Soochow University, Suzhou 215008, Jiangsu Province, China
| | - Nian Yuan
- Suzhou Guangji Hospital, Affiliated Guangji Hospital of Soochow University, Suzhou 215008, Jiangsu Province, China
| | - Ming Yin
- Suzhou Guangji Hospital, Affiliated Guangji Hospital of Soochow University, Suzhou 215008, Jiangsu Province, China
| | - Xue-Li Zhao
- Suzhou Guangji Hospital, Affiliated Guangji Hospital of Soochow University, Suzhou 215008, Jiangsu Province, China
| | - Xiao-Li Lv
- Suzhou Guangji Hospital, Affiliated Guangji Hospital of Soochow University, Suzhou 215008, Jiangsu Province, China
| | - Si-Yun Zou
- Suzhou Guangji Hospital, Affiliated Guangji Hospital of Soochow University, Suzhou 215008, Jiangsu Province, China
| | - Jun Zhang
- Suzhou Guangji Hospital, Affiliated Guangji Hospital of Soochow University, Suzhou 215008, Jiangsu Province, China
| | - Guang-Ya Zhang
- Suzhou Guangji Hospital, Affiliated Guangji Hospital of Soochow University, Suzhou 215008, Jiangsu Province, China
| | - Chuan-Wei Li
- Suzhou Guangji Hospital, Affiliated Guangji Hospital of Soochow University, Suzhou 215008, Jiangsu Province, China
| | - Hui Pan
- Department of Psychiatry, Third People’s Hospital of Changshu, Changshu 215501, Jiangsu Province, China
| | - Li Yang
- Department of Psychiatry, Third People’s Hospital of Changshu, Changshu 215501, Jiangsu Province, China
| | - Si-Qi Wu
- School of Psychology and Mental Health, North China University of Science and Technology, Langfang 065201, Hebei Province, China
| | - Yan Yue
- Department of Psychiatry, Medical College of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Yu-Xuan Wu
- Department of Psychiatry, Medical College of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Xiang-Yang Zhang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing 100101, China
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Bonotis K, Anargyros K, Liaskopoulos N, Barlogianni AM. Evaluation of memory performance in patients with brain disorders following rTMS treatment. A systematic review. Clin Neurophysiol 2021; 135:126-153. [DOI: 10.1016/j.clinph.2021.11.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 10/24/2021] [Accepted: 11/29/2021] [Indexed: 12/01/2022]
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Brandt SJ, Oral HY, Arellano-Bravo C, Plawecki MH, Hummer TA, Francis MM. Repetitive Transcranial Magnetic Stimulation as a Therapeutic and Probe in Schizophrenia: Examining the Role of Neuroimaging and Future Directions. Neurotherapeutics 2021; 18:827-844. [PMID: 33844154 PMCID: PMC8423934 DOI: 10.1007/s13311-021-01046-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 12/31/2022] Open
Abstract
Schizophrenia is a complex condition associated with perceptual disturbances, decreased motivation and affect, and disrupted cognition. Individuals living with schizophrenia may experience myriad poor outcomes, including impairment in independent living and function as well as decreased life expectancy. Though existing treatments may offer benefit, many individuals still experience treatment resistant and disabling symptoms. In light of the negative outcomes associated with schizophrenia and the limitations in currently available treatments, there is a significant need for novel therapeutic interventions. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation technique that can modulate the activity of discrete cortical regions, allowing direct manipulation of local brain activation and indirect manipulation of the target's associated neural networks. rTMS has been studied in schizophrenia for the treatment of auditory hallucinations, negative symptoms, and cognitive deficits, with mixed results. The field's inability to arrive at a consensus on the use rTMS in schizophrenia has stemmed from a variety of issues, perhaps most notably the significant heterogeneity amongst existing trials. In addition, it is likely that factors specific to schizophrenia, rather than the rTMS itself, have presented barriers to the interpretation of existing results. However, advances in approaches to rTMS as a biologic probe and therapeutic, many of which include the integration of neuroimaging with rTMS, offer hope that this technology may still play a role in improving the understanding and treatment of schizophrenia.
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Affiliation(s)
- Stephen J Brandt
- Indiana University School of Medicine, Department of Psychiatry, 355W 16 St., Indianapolis, IN, USA
| | - Halimah Y Oral
- Indiana University School of Medicine, Department of Psychiatry, 355W 16 St., Indianapolis, IN, USA
| | - Carla Arellano-Bravo
- Indiana University School of Medicine, Department of Psychiatry, 355W 16 St., Indianapolis, IN, USA
| | - Martin H Plawecki
- Indiana University School of Medicine, Department of Psychiatry, 355W 16 St., Indianapolis, IN, USA
| | - Tom A Hummer
- Indiana University School of Medicine, Department of Psychiatry, 355W 16 St., Indianapolis, IN, USA
| | - Michael M Francis
- Indiana University School of Medicine, Department of Psychiatry, 355W 16 St., Indianapolis, IN, USA.
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Sciortino D, Pigoni A, Delvecchio G, Maggioni E, Schiena G, Brambilla P. Role of rTMS in the treatment of cognitive impairments in Bipolar Disorder and Schizophrenia: a review of Randomized Controlled Trials. J Affect Disord 2021; 280:148-155. [PMID: 33212406 DOI: 10.1016/j.jad.2020.11.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Schizophrenia (SCZ) and Bipolar Disorder (BD) are severe psychiatric illnesses often characterized by mild-to-severe cognitive deficits. Since available pharmacotherapy showed poor efficacy in treating these cognitive impairments, new strategies are needed. Repeated Transcranial Magnetic Stimulation (rTMS) represents a safe non-invasive technique that has been hypothesized to improve cognitive symptoms in these pathologies. Therefore, our brief review aims at summarizing the results of Randomized Controlled Trials (RCTs) using rTMS for improving cognitive symptoms in SCZ and BD. METHODS We performed a bibliographic research on PubMed, Google Scholar and Medline of RCTs conducted in patients with BD and SCZ, which evaluated cognitive outcomes after rTMS treatment. RESULTS The inclusion criteria were met by fifteen RCTs, twelve in SCZ and three in BD. Regarding patients with SCZ, the results showed that rTMS seemed to have poor effects on improving cognitive performances, with mixed results also observed for schizoaffective patients. In BD, overall the RCTs showed that rTMS in these patients seemed to improve cognitive domains in euthymic patients, while its effect during acute phases, especially depression, appeared limited. LIMITATIONS Studies employed different rTMS protocols and evaluated different cognitive domains. CONCLUSIONS Although the available evidence from RCTs evaluating the efficacy of rTMS on cognitive deficits in SCZ and BD are still mixed and heterogenous, overall they suggest that rTMS represents a potential clinical tool that could ameliorate cognitive symptoms, especially in specific patients' subtypes. However, standardized protocols and further research are still necessary to evaluate the real efficacy of rTMS.
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Affiliation(s)
- Domenico Sciortino
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alessandro Pigoni
- MoMiLab Research Unit, IMT School for Advanced Studies Lucca, Lucca, Italy
| | - Giuseppe Delvecchio
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Eleonora Maggioni
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giandomenico Schiena
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Brambilla
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Begemann MJ, Brand BA, Ćurčić-Blake B, Aleman A, Sommer IE. Efficacy of non-invasive brain stimulation on cognitive functioning in brain disorders: a meta-analysis. Psychol Med 2020; 50:2465-2486. [PMID: 33070785 PMCID: PMC7737055 DOI: 10.1017/s0033291720003670] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 08/27/2020] [Accepted: 09/16/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cognition is commonly affected in brain disorders. Non-invasive brain stimulation (NIBS) may have procognitive effects, with high tolerability. This meta-analysis evaluates the efficacy of transcranial magnetic stimulation (TMS) and transcranial Direct Current Stimulation (tDCS) in improving cognition, in schizophrenia, depression, dementia, Parkinson's disease, stroke, traumatic brain injury, and multiple sclerosis. METHODS A PRISMA systematic search was conducted for randomized controlled trials. Hedges' g was used to quantify effect sizes (ES) for changes in cognition after TMS/tDCS v. sham. As different cognitive functions may have unequal susceptibility to TMS/tDCS, we separately evaluated the effects on: attention/vigilance, working memory, executive functioning, processing speed, verbal fluency, verbal learning, and social cognition. RESULTS We included 82 studies (n = 2784). For working memory, both TMS (ES = 0.17, p = 0.015) and tDCS (ES = 0.17, p = 0.021) showed small but significant effects. Age positively moderated the effect of TMS. TDCS was superior to sham for attention/vigilance (ES = 0.20, p = 0.020). These significant effects did not differ across the type of brain disorder. Results were not significant for the other five cognitive domains. CONCLUSIONS Our results revealed that both TMS and tDCS elicit a small trans-diagnostic effect on working memory, tDCS also improved attention/vigilance across diagnoses. Effects on the other domains were not significant. Observed ES were small, yet even slight cognitive improvements may facilitate daily functioning. While NIBS can be a well-tolerated treatment, its effects appear domain specific and should be applied only for realistic indications (i.e. to induce a small improvement in working memory or attention).
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Affiliation(s)
- Marieke J. Begemann
- Department of Biomedical Sciences of Cells & Systems, Section Cognitive Neurosciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bodyl A. Brand
- Department of Biomedical Sciences of Cells & Systems, Section Cognitive Neurosciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Branislava Ćurčić-Blake
- Department of Biomedical Sciences of Cells & Systems, Section Cognitive Neurosciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - André Aleman
- Department of Biomedical Sciences of Cells & Systems, Section Cognitive Neurosciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Iris E. Sommer
- Department of Biomedical Sciences of Cells & Systems, Section Cognitive Neurosciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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7
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Kar SK, Menon V. Repetitive Transcranial Magnetic Stimulation in Persistent Auditory Hallucination in Schizophrenia: Predictors of Response. Curr Behav Neurosci Rep 2020. [DOI: 10.1007/s40473-020-00218-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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8
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Xiu MH, Guan HY, Zhao JM, Wang KQ, Pan YF, Su XR, Wang YH, Guo JM, Jiang L, Liu HY, Sun SG, Wu HR, Geng HS, Liu XW, Yu HJ, Wei BC, Li XP, Trinh T, Tan SP, Zhang XY. Cognitive Enhancing Effect of High-Frequency Neuronavigated rTMS in Chronic Schizophrenia Patients With Predominant Negative Symptoms: A Double-Blind Controlled 32-Week Follow-up Study. Schizophr Bull 2020; 46:1219-1230. [PMID: 32185388 PMCID: PMC7505170 DOI: 10.1093/schbul/sbaa035] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Accumulating studies have shown that high-frequency (HF) repetitive transcranial magnetic stimulation (rTMS) may improve cognitive dysfunction of the patients with schizophrenia (SCZ), but with inconsistent results. The present study aims to assess the efficacy of different frequencies of neuronavigated rTMS in ameliorating cognitive impairments and alleviating the psychotic symptoms. A total of 120 patients were randomly assigned to 3 groups: 20 Hz rTMS (n = 40), 10 Hz rTMS (n = 40), or sham stimulation (n = 40) for 8 weeks, and then followed up at week 32. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was performed to assess the cognitive functions of the patients at baseline, at the end of week 8, and week 32 follow-up. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS) at baseline and at the end of week 2, week 4, week 6, week 8, and week 32 follow-up. Our results demonstrated that 20 Hz rTMS treatment produced an effective therapeutic benefit on immediate memory of patients with chronic SCZ at week 8, but not in the 10 Hz group. Interestingly, both 10 Hz and 20 Hz rTMS treatments produced delayed effects on cognitive functions at the 6-month follow-up. Moreover, in both 10 Hz rTMS and 20 Hz rTMS, the improvements in RBANS total score were positively correlated with the reduction of PANSS positive subscore at the 6-month follow-up. Stepwise regression analysis identified that the visuospatial/constructional index, immediate memory index, and prolactin at baseline were predictors for the improvement of cognitive impairments in the patients. Our results suggest that add-on HF rTMS could be an effective treatment for cognitive impairments in patients with chronic SCZ, with a delayed effect. Trial registration: clinicaltrials.gov identifier-NCT03774927.
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Affiliation(s)
- Mei Hong Xiu
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, China
| | - Heng Yong Guan
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Jian Min Zhao
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Ke Qiang Wang
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Yan Fen Pan
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Xiu Ru Su
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Yu Hong Wang
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Jin Ming Guo
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Long Jiang
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Hong Yu Liu
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Shi Guang Sun
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Hao Ran Wu
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Han Song Geng
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Xiao Wen Liu
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Hui Jing Yu
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Bao Chun Wei
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Xi Po Li
- Department of Psychiatry, Hebei Province Rong-Jun hospital, Baoding, China
| | - Tammy Trinh
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX
| | - Shu Ping Tan
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, China
| | - Xiang Yang Zhang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
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Non-Invasive Brain Stimulation Does Not Improve Working Memory in Schizophrenia: A Meta-Analysis of Randomised Controlled Trials. Neuropsychol Rev 2020; 31:115-138. [PMID: 32918254 DOI: 10.1007/s11065-020-09454-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 08/26/2020] [Indexed: 10/23/2022]
Abstract
Poor working memory functioning is commonly found in schizophrenia. A number of studies have now tested whether non-invasive brain stimulation can improve this aspect of cognitive functioning. This report used meta-analysis to synthesise the results of these studies to examine whether transcranial electrical stimulation (tES) or repetitive transcranial magnetic stimulation (rTMS) can improve working memory in schizophrenia. The studies included in this meta-analysis were sham-controlled, randomised controlled trials that utilised either tES or rTMS to treat working memory problems in schizophrenia. A total of 22 studies were included in the review. Nine studies administered rTMS and 13 administered tES. Meta-analysis revealed that compared to sham/placebo stimulation, neither TMS nor tES significantly improved working memory. This was found when working memory was measured with respect to the accuracy on working memory tasks (TMS studies: Hedges' g = 0.112, CI95: -0.082, 0.305, p = .257; tES studies Hedges' g = 0.080, CI95: -0.117, 0.277, p = .427) or the speed working memory tasks were completed (rTMS studies: Hedges' g = 0.233, CI95: -0.212, 0.678, p = .305; tES studies Hedges' g = -0.016, CI95: -0.204, 0.173, p = .871). For tES studies, meta-regression analysis found that studies with a larger number of stimulation sessions were associated with larger treatment effects. This association was not found for TMS studies. At present, rTMS and tES is not associated with a reliable improvement in working memory for individuals with schizophrenia.
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Güleken MD, Akbaş T, Erden SÇ, Akansel V, Al ZC, Özer ÖA. The effect of bilateral high frequency repetitive transcranial magnetic stimulation on cognitive functions in schizophrenia. SCHIZOPHRENIA RESEARCH-COGNITION 2020; 22:100183. [PMID: 32714846 PMCID: PMC7371913 DOI: 10.1016/j.scog.2020.100183] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 11/30/2022]
Abstract
Despite their major effects on positive symptoms, antipsychotics do not have a significant effect on cognition in schizophrenia Bilateral high frequency rTMS targeting dorsolateral prefrontal cortices has been effective on working memory Bilateral 20 Hz rTMS improved attention and verbal working memory in schizophrenia patients, It also improved the competence of switching the perceptional set up under a disruptive effect towards new instructions, in this study
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Affiliation(s)
- Mehmet Diyaddin Güleken
- Department of Psychiatry, Gazi Yaşargil Training and Research Hospital, Sağlık Bilimleri Üniversitesi, Diyarbakır, Turkey
| | - Taner Akbaş
- Department of Psychiatry, Şişli Hamidiye Etfal Training and Research Hospital, Sağlık Bilimleri Üniversitesi, İstanbul, Turkey
| | - Selime Çelik Erden
- Department of Psychiatry, Şişli Hamidiye Etfal Training and Research Hospital, Sağlık Bilimleri Üniversitesi, İstanbul, Turkey
| | - Veysel Akansel
- Department of Psychiatry, Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey
| | - Zeliha Cengiz Al
- Department of Psychiatry, Dr. Cevdet Aykan Psychiatry Hospital, Tokat, Turkey
| | - Ömer Akil Özer
- Department of Psychiatry, Şişli Hamidiye Etfal Training and Research Hospital, Sağlık Bilimleri Üniversitesi, İstanbul, Turkey
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11
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Hui J, Tremblay S, Daskalakis ZJ. The Current and Future Potential of Transcranial Magnetic Stimulation With Electroencephalography in Psychiatry. Clin Pharmacol Ther 2019; 106:734-746. [DOI: 10.1002/cpt.1541] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/07/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Jeanette Hui
- Temerty Centre for Therapeutic Brain Intervention Centre for Addiction and Mental Health Toronto Ontario Canada
- Institute of Medical Science University of Toronto Toronto Ontario Canada
| | - Sara Tremblay
- Royal's Institute of Mental Health Research Ottawa Ontario Canada
- School of Psychology University of Ottawa Ottawa Ontario Canada
| | - Zafiris J. Daskalakis
- Temerty Centre for Therapeutic Brain Intervention Centre for Addiction and Mental Health Toronto Ontario Canada
- Institute of Medical Science University of Toronto Toronto Ontario Canada
- Department of Psychiatry University of Toronto Toronto Ontario Canada
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12
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Popov MM, Pluzhnikov IV, Kaleda VG. [Procognitive effects of transcranial magnetic stimulation in the light of neurocognitive deficit in schizophrenia]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:120-126. [PMID: 31089106 DOI: 10.17116/jnevro2019119031120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Transcranial magnetic stimulation (TMS) is a relatively new method of non-invasive therapy of mental and neurological diseases that has great potential of therapeutic and diagnostic application. In schizophrenia, TMS may exert a positive effect on cognitive deficit. However this issue remains open. The authors analyze recent studies focused on the dynamics of neurocognitive deficit in TMS therapy and consider clinical effects of TMS in schizophrenia. The analysis has shown that TMS is successfully implemented in treatment of auditory positive symptoms and studies on its effect on negative symptoms of schizophrenia are perspective. Procognitive effect was found in working memory domain, and partially in perception domain within the perception of faces and facial expressions. The data on regulative functions, attention, speech, and nondeclarative memory remains controversial. It has been concluded that further research is needed to clarify the place of TMS in schizophrenia therapy.
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Affiliation(s)
- M M Popov
- Mental Health Research Center, Moscow, Russia
| | | | - V G Kaleda
- Mental Health Research Center, Moscow, Russia
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rTMS as an add-on treatment for maladaptive daydreaming over 10 years in patients with schizophrenia: A case report. Asian J Psychiatr 2019; 43:208-209. [PMID: 29108802 DOI: 10.1016/j.ajp.2017.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 10/22/2017] [Indexed: 11/22/2022]
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Effects of Repetitive Transcranial Magnetic Stimulation over Prefrontal Cortex on Attention in Psychiatric Disorders: A Systematic Review. J Clin Med 2019; 8:jcm8040416. [PMID: 30934685 PMCID: PMC6518000 DOI: 10.3390/jcm8040416] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/10/2019] [Accepted: 03/19/2019] [Indexed: 01/20/2023] Open
Abstract
Repetitive transcranial magnetic stimulation (rTMS) may be effective for enhancing cognitive functioning. In this review, we aimed to systematically evaluate the effects of rTMS on attention in psychiatric diseases. In particular, we searched PubMed and Embase to examine the effectiveness of rTMS administered to the dorsolateral prefrontal cortex (DLPFC) on this specific cognitive domain. The search identified 24 articles, 21 of which met inclusion and exclusion criteria. Among them, nine were conducted in patients with depression, four in patients with schizophrenia, three in patients with autism spectrum disorder (ASD), two in patients with attention deficit hyperactivity disorder, one each in patients with Alzheimer's disease and in patients with alcohol or methamphetamine addiction. No evidence for cognitive adverse effects was found in all the included rTMS studies. Several studies showed a significant improvement of attentional function in patients with depression and schizophrenia. The beneficial effects on attention and other executive functions suggest that rTMS has the potential to target core features of ASD. rTMS may influence the attentional networks in alcohol-dependent and other addicted patients. We also reviewed and discussed the studies assessing the effects of rTMS on attention in the healthy population. This review suggests that prefrontal rTMS could exert procognitive effects on attention in patients with many psychiatric disorders.
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High-frequency repetitive transcranial magnetic stimulation (rTMS) improves neurocognitive function in bipolar disorder. J Affect Disord 2019; 246:851-856. [PMID: 30795490 DOI: 10.1016/j.jad.2018.12.102] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 12/09/2018] [Accepted: 12/24/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with bipolar disorder (BD) present widespread and significant neurocognitive impairments during all stages of the disorder. Repetitive transcranial magnetic stimulation (rTMS) has been used to improve clinical outcomes in common psychiatric diseases, such as depression, anxiety disorders, schizophrenia, and BD. Whether rTMS can improve cognitive function in BD patients remains unclear. The present study explored the regulatory effects of rTMS on cognitive function in patients with BD. METHODS Fifty-two eligible subjects with BD were randomly assigned to receive active or sham rTMS via high-speed magnetic stimulator with a figure-of-eight coil for 10 consecutive days. In the active rTMS group, a total of 25,000 stimuli were applied over the left dorsolateral prefrontal cortex at 110% of the motor threshold. The sham group received corresponding sham stimulation. Clinical manifestations and cognitive functions were assessed using a modified 24-item Hamilton Depression Rating Scale (HDRS), the Young Mania Rating Scale (YMRS), and the MATRICS Consensus Cognitive Battery (MCCB). RESULTS Ten consecutive days of high-frequency active rTMS improved scores on the Wechsler Memory Scale-III Spatial Span, and the MCCB Category Fluency subtest, without intolerable adverse effects. No significant differences in HDRS or YMRS scores were found between groups. LIMITATIONS No follow-up after the intervention. The effect of the drug on cognitive function in subjects was not excluded. CONCLUSIONS Short-term rTMS can improve cognitive function in BD patients.
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Effectiveness of the prefrontal repetitive transcranial magnetic stimulation on cognitive profiles in depression, schizophrenia, and Alzheimer's disease: A systematic review. Prog Neuropsychopharmacol Biol Psychiatry 2019; 88:31-40. [PMID: 29953934 DOI: 10.1016/j.pnpbp.2018.06.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/23/2018] [Accepted: 06/23/2018] [Indexed: 01/30/2023]
Abstract
Repetitive transcranial magnetic stimulation (rTMS) is an effective clinical intervention for various neuropsychiatric diseases. However, it is still unclear whether rTMS has an effect on cognitive functioning. In this review, we aimed to systematically evaluate the cognitive effects of rTMS in depression, schizophrenia, and Alzheimer's disease. We searched PubMed (1996-2018) under the set terms to review randomized controlled trials (RCT) to examine the effectiveness of rTMS administered to the dorsolateral prefrontal cortex (DLPFC) and evaluated cognitive functions in patients with depression, schizophrenia, and Alzheimer's disease. Two authors reviewed each article and came to consensus on the inclusion and exclusion criteria. All eligible studies were reviewed, duplicates were removed, and data were extracted individually. The search identified 579 articles, 31 of which met inclusion and exclusion criteria. Among them, 15 were conducted in patients with depression, 11 in patients with schizophrenia, and 5 in patients with Alzheimer's disease. Specifically, 6 studies demonstrated a significant improvement of executive function across these diseases. Further, no evidence for cognitive adverse effects was found in these included rTMS studies. Although the heterogeneity between studies in terms of cognitive measures applied, stimulation parameters, and participants limits the ability to generalize conclusions, this review demonstrated that prefrontal rTMS could exert pro-cognitive effects on executive function and attention in some patients with depression but inconsistent cognitive impacts in any of the examined domains especially in patients with schizophrenia and Alzheimer's disease. The results warrant further rTMS studies that include systematic assessment of cognition across various neuropsychiatric diseases.
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Jiang Y, Guo Z, Xing G, He L, Peng H, Du F, McClure MA, Mu Q. Effects of High-Frequency Transcranial Magnetic Stimulation for Cognitive Deficit in Schizophrenia: A Meta-Analysis. Front Psychiatry 2019; 10:135. [PMID: 30984036 PMCID: PMC6450172 DOI: 10.3389/fpsyt.2019.00135] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 02/25/2019] [Indexed: 12/22/2022] Open
Abstract
Objective: Repetitive transcranial magnetic stimulation (rTMS) has been applied to dorsolateral prefrontal cortex (DLPFC) to improve cognitive function of patients with schizophrenia (SZs). The aim of this meta-analysis was to evaluate whether a high-frequency rTMS course could enhance cognitive function in SZs. Methods: Studies published in PubMed, Cochrane Library, Embase, ScienceDirect, and Web of science were searched until April 2018. The search terms included: "repetitive transcranial magnetic stimulation" or "Rtms," "SZ," or "schizophrenia," and "neuro-cognition" or "neurocognitive performance" or "cognitive effects" or "cognitive" or "cognition" or "working memory" or "executive function" or "language function" or "processing speed," After screening the literatures according to inclusion and exclusion criteria, extracting data, and evaluating the methodological quality of the included studies, a meta-analysis was performed using RevMan 5.3 software (The Cochrane Collaboration, USA). Results: A total of 9 studies on cognitive dysfunction of SZs were included and involved 351 patients. A significant efficacy of high-frequency rTMS on working memory in SZs was found compared to sham stimulation [p = 0.009, standardized mean difference (SMD) = 0.34]. Specifically, rTMS treatment positioned on the left DLPFC, with a total pluses <30,000 was more significantly more effective in improving the working memory (SMD = 0.33, p = 0.03). No improvement was found in other cognitive domains such as executive function, attention, processing speed, and language function. For the follow-up observations, high-frequency rTMS had long-lasting sustained effects on working memory (SMD = 0.45, p = 0.01) and language function (SMD = 0.77, p = 0.02) in SZs. Conclusions: High-frequency rTMS over the left DLPFC with a total pulses <30,000 stimulation could significantly improve working memory in SZs for an extended period of time.
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Affiliation(s)
- Yi Jiang
- Department of Radiology and Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China
| | - Zhiwei Guo
- Department of Radiology and Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China
| | - Guoqiang Xing
- Department of Radiology and Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China
| | - Lin He
- Department of Radiology and Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China
| | - Haitao Peng
- Department of Radiology and Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China
| | - Fei Du
- Department of Psychiatry, Harvard Medical School, Belmont, CA, United States
| | - Morgan A McClure
- Department of Radiology and Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China
| | - Qiwen Mu
- Department of Radiology and Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China.,Department of Radiology, Peking University Third Hospital, Beijing, China
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18
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Cognitive effects of bilateral high frequency repetitive transcranial magnetic stimulation in early phase psychosis: a pilot study. Brain Imaging Behav 2018; 13:852-861. [DOI: 10.1007/s11682-018-9902-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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19
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Hasan A, Wobrock T, Palm U, Strube W, Padberg F, Falkai P, Fallgatter A, Plewnia C. [Non-invasive brain stimulation for treatment of schizophrenic psychoses]. DER NERVENARZT 2016; 86:1481-91. [PMID: 26341690 DOI: 10.1007/s00115-015-4323-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Despite many different available pharmacological and psychosocial treatment options, an optimal control of symptoms is only partly possible for most schizophrenia patients. Especially, persistent auditory hallucinations, negative symptoms and cognitive impairment are difficult to treat symptoms. Several non-invasive brain stimulation techniques are increasingly being considered as new therapeutic add on options for the management of schizophrenia, targeting these symptom domains. The technique which has been available for the longest time and that is best established in clinical care is electroconvulsive therapy (ECT). New stimulation techniques, such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) allow a more pathophysiological-based approach. This review article introduces various non-invasive brain stimulation techniques and discusses recent treatment studies on schizophrenia. In total, the novel brain stimulation techniques discussed here can be considered relevant add on therapeutic approaches for schizophrenia. In this context, the best evidence is available for the application of rTMS for the treatment of negative symptoms and persistent auditory hallucinations; however, negative studies have also been published for both indications. Studies using other non-invasive brain stimulation techniques showed promising results but further research is needed to establish the clinical efficacy. Based on a growing pathophysiological knowledge, non-invasive brain stimulation techniques provide new treatment perspectives for patients with schizophrenia.
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Affiliation(s)
- A Hasan
- Klinik für Psychiatrie und Psychotherapie, Klinikum der Universität München Ludwig-Maximilians Universität, Nußbaumstr. 7, 80336, München, Deutschland.
| | - T Wobrock
- Zentrum für seelische Gesundheit, Kreiskliniken Darmstadt-Dieburg, Darmstadt-Dieburg, Deutschland.,Klinik für Psychiatrie und Psychotherapie, Georg-August-Universität Göttingen, Göttingen, Deutschland
| | - U Palm
- Klinik für Psychiatrie und Psychotherapie, Klinikum der Universität München Ludwig-Maximilians Universität, Nußbaumstr. 7, 80336, München, Deutschland
| | - W Strube
- Klinik für Psychiatrie und Psychotherapie, Klinikum der Universität München Ludwig-Maximilians Universität, Nußbaumstr. 7, 80336, München, Deutschland
| | - F Padberg
- Klinik für Psychiatrie und Psychotherapie, Klinikum der Universität München Ludwig-Maximilians Universität, Nußbaumstr. 7, 80336, München, Deutschland
| | - P Falkai
- Klinik für Psychiatrie und Psychotherapie, Klinikum der Universität München Ludwig-Maximilians Universität, Nußbaumstr. 7, 80336, München, Deutschland
| | - A Fallgatter
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinik Tübingen, Tübingen, Deutschland
| | - C Plewnia
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinik Tübingen, Tübingen, Deutschland
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20
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Hasan A, Strube W, Palm U, Wobrock T. Repetitive Noninvasive Brain Stimulation to Modulate Cognitive Functions in Schizophrenia: A Systematic Review of Primary and Secondary Outcomes. Schizophr Bull 2016; 42 Suppl 1:S95-S109. [PMID: 27460623 PMCID: PMC4960427 DOI: 10.1093/schbul/sbv158] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Despite many years of research, there is still an urgent need for new therapeutic options for the treatment of cognitive deficits in schizophrenia. Noninvasive brain stimulation (NIBS) has been proposed to be such a novel add-on treatment option. The main objective of this review was to systematically evaluate the cognitive effects of repetitive NIBS in schizophrenia. As most studies have not been specifically designed to investigate cognition as primary outcome, we have focused on both, primary and secondary outcomes. The PubMed/MEDLINE database (1985-2015) was systematically searched for interventional studies investigating the effects of repetitive NIBS on schizophrenia symptoms. All interventional clinical trials using repetitive transcranial stimulation, transcranial theta burst stimulation, and transcranial direct current stimulation for the treatment of schizophrenia were extracted and analyzed with regard to cognitive measures as primary or secondary outcomes. Seventy-six full-text articles were assessed for eligibility of which 33 studies were included in the qualitative synthesis. Of these 33 studies, only 4 studies included cognition as primary outcome, whereas 29 studies included cognitive measures as secondary outcomes. A beneficial effect of frontal NIBS could not be clearly established. No evidence for a cognitive disruptive effect of NIBS (temporal lobe) in schizophrenia could be detected. Finally, a large heterogeneity between studies in terms of inclusion criteria, stimulation parameters, applied cognitive measures, and follow-up intervals was observed. This review provides the first systematic overview regarding cognitive effects of repetitive NIBS in schizophrenia.
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Affiliation(s)
- Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany;
| | - Wolfgang Strube
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany
| | - Ulrich Palm
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany
| | - Thomas Wobrock
- County Hospitals Darmstadt-Dieburg, Groß-Umstadt, Germany; Department of Psychiatry and Psychotherapy, Georg-August-University, Göttingen, Germany
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Hasan A, Guse B, Cordes J, Wölwer W, Winterer G, Gaebel W, Langguth B, Landgrebe M, Eichhammer P, Frank E, Hajak G, Ohmann C, Verde PE, Rietschel M, Ahmed R, Honer WG, Malchow B, Karch S, Schneider-Axmann T, Falkai P, Wobrock T. Cognitive Effects of High-Frequency rTMS in Schizophrenia Patients With Predominant Negative Symptoms: Results From a Multicenter Randomized Sham-Controlled Trial. Schizophr Bull 2016; 42:608-18. [PMID: 26433217 PMCID: PMC4838079 DOI: 10.1093/schbul/sbv142] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cognitive impairments are one of the main contributors to disability and poor long-term outcome in schizophrenia. Proof-of-concept trials indicate that repetitive transcranial magnetic stimulation (rTMS) applied to the left dorsolateral prefrontal cortex (DLPFC) has the potential to improve cognitive functioning. We analyzed the effects of 10-Hz rTMS to the left DLPFC on cognitive deficits in schizophrenia in a large-scale and multicenter, sham-controlled study. A total of 156 schizophrenia patients with predominant negative symptoms were randomly assigned to a 3-week intervention (10-Hz rTMS, 15 sessions, 1000 stimuli per session) with either active or sham rTMS. The Rey Auditory Verbal Learning Test, Trail Making Test A and B, Wisconsin Card Sorting Test, Digit Span Test, and the Regensburg Word Fluency Test were administered before intervention and at day 21, 45, and 105 follow-up. From the test results, a neuropsychological composite score was computed. Both groups showed no differences in any of the outcome variables before and after intervention. Both groups improved markedly over time, but effect sizes indicate a numeric, but nonsignificant superiority of active rTMS in certain cognitive tests. Active 10-Hz rTMS applied to the left DLPFC for 3 weeks was not superior to sham rTMS in the improvement of various cognitive domains in schizophrenia patients with predominant negative symptoms. This is in contrast to previous preliminary proof-of-concept trials, but highlights the need for more multicenter randomized controlled trials in the field of noninvasive brain stimulation.
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Affiliation(s)
- Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany; These authors contributed equally to the article.
| | - Birgit Guse
- Department of Psychiatry and Psychotherapy, Georg-August-University Göttingen, Göttingen, Germany; These authors contributed equally to the article
| | - Joachim Cordes
- Department of Psychiatry and Psychotherapy, Heinrich-Heine University, Düsseldorf, Germany
| | - Wolfgang Wölwer
- Department of Psychiatry and Psychotherapy, Heinrich-Heine University, Düsseldorf, Germany
| | - Georg Winterer
- The Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfgang Gaebel
- Department of Psychiatry and Psychotherapy, Heinrich-Heine University, Düsseldorf, Germany
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Michael Landgrebe
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany; Department of Psychiatry, Psychosomatics and Psychotherapy, kbo-Lech-Mangfall-Klinik, Agatharied, Germany
| | - Peter Eichhammer
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Elmar Frank
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Göran Hajak
- Department of Psychiatry, Psychosomatics and Psychotherapy, Sozialstiftung Bamberg, Bamberg, Germany
| | - Christian Ohmann
- Coordination Centre for Clinical Trials, Heinrich-Heine University, Düsseldorf, Germany
| | - Pablo E Verde
- Coordination Centre for Clinical Trials, Heinrich-Heine University, Düsseldorf, Germany
| | - Marcella Rietschel
- Department of Genetic Epidemiology in Psychiatry, Institute of Central Mental Health, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Raees Ahmed
- Institut für anwendungsorientierte Forschung und klinische Studien GmbH, Göttingen, Germany
| | - William G Honer
- Institute of Mental Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Berend Malchow
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany
| | - Susanne Karch
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany
| | | | - Peter Falkai
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany
| | - Thomas Wobrock
- Department of Psychiatry and Psychotherapy, Georg-August-University Göttingen, Göttingen, Germany; County Hospitals Darmstadt-Dieburg, Groß-Umstadt, Germany
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Hara T, Abo M, Kakita K, Masuda T, Yamazaki R. Does a combined intervention program of repetitive transcranial magnetic stimulation and intensive occupational therapy affect cognitive function in patients with post-stroke upper limb hemiparesis? Neural Regen Res 2016; 11:1932-1939. [PMID: 28197189 PMCID: PMC5270431 DOI: 10.4103/1673-5374.197134] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) to the contralesional hemisphere and intensive occupational therapy (iOT) have been shown to contribute to a significant improvement in upper limb hemiparesis in patients with chronic stroke. However, the effect of the combined intervention program of LF-rTMS and iOT on cognitive function is unknown. We retrospectively investigated whether the combined treatment influence patient's Trail-Making Test part B (TMT-B) performance, which is a group of easy and inexpensive neuropsychological tests that evaluate several cognitive functions. Twenty-five patients received 11 sessions of LF-rTMS to the contralesional hemisphere and 2 sessions of iOT per day over 15 successive days. Patients with right- and left-sided hemiparesis demonstrated significant improvements in upper limb motor function following the combined intervention program. Only patients with right-sided hemiparesis exhibited improved TMT-B performance following the combined intervention program, and there was a significant negative correlation between Fugl-Meyer Assessment scale total score change and TMT-B performance. The results indicate the possibility that LF-rTMS to the contralesional hemisphere combined with iOT improves the upper limb motor function and cognitive function of patients with right-sided hemiparesis. However, further studies are necessary to elucidate the mechanism of improved cognitive function.
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Affiliation(s)
- Takatoshi Hara
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Masahiro Abo
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kiyohito Kakita
- Department of Rehabilitation Medicine, Kyoto Ohara Memorial Hospital, Kyoto, Japan
| | - Takeshi Masuda
- Department of Rehabilitation Medicine, Kyoto Ohara Memorial Hospital, Kyoto, Japan
| | - Ryunosuke Yamazaki
- Department of Rehabilitation Medicine, Kyoto Ohara Memorial Hospital, Kyoto, Japan
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Dougall N, Maayan N, Soares‐Weiser K, McDermott LM, McIntosh A. Transcranial magnetic stimulation (TMS) for schizophrenia. Cochrane Database Syst Rev 2015; 2015:CD006081. [PMID: 26289586 PMCID: PMC9395125 DOI: 10.1002/14651858.cd006081.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND People with schizophrenia often experience symptoms which fail to fully respond to antipsychotic medication. Transcranial magnetic stimulation (TMS) has been proposed as a new treatment for people with schizophrenia, especially those who experience persistent auditory hallucinations. OBJECTIVES To estimate the effects of TMS alone, compared with sham TMS or with 'standard management' and any other comparison interventions in reducing psychotic symptoms associated with schizophrenia. SEARCH METHODS We searched the Cochrane Schizophrenia Group Trials Register (June 2006, June 2008, April 2013). This register is compiled by methodical searches of MEDLINE, EMBASE, BIOSIS, CINAHL, Dissertation abstracts, LILACS, PSYNDEX, PsycINFO, RUSSMED, and Sociofile, and is supplemented with handsearching of relevant journals and numerous conference proceedings. SELECTION CRITERIA We included all randomised controlled trials recruiting at least five participants and comparing TMS with sham TMS or any other treatment for people with schizophrenia. DATA COLLECTION AND ANALYSIS We extracted data independently. For dichotomous data we calculated relative risks (RRs) and their 95% confidence intervals (CIs). For continuous data, we calculated mean differences (MD) and 95% CI. We used a fixed-effect model. We assessed overall quality of the evidence using the GRADE approach. MAIN RESULTS We included 41 studies with 1473 participants in the review. We found significant differences in favour of temporoparietal TMS compared to sham TMS for global state measured on the CGI scale (7 RCTs, n = 224, MD -0.5, 95% CI -0.76 to -0.23, very low-quality evidence) and positive symptoms measured on the PANSS scale (5 RCTs, n = 127, MD -6.09, 95% CI -10.95 to -1.22, very low-quality evidence). Participants experienced significantly more headaches in the temporoparietal TMS group (10 RCTs, n = 392, RR 2.65, 95% CI 1.56 to 4.50, very low-quality evidence). However, no more participants left the study early from the TMS group than from the sham group (very low-quality evidence). Cognitive state was assessed using 39 different measures, and all were equivocal (very low-quality evidence).We included only two trials which compared temporoparietal TMS with standard treatment. In both trials the participants received first- and second-generation antipsychotic medication in both treatment groups, therefore TMS was used an adjunctive therapy to medication. We found no significant differences in the number of participants that showed clinical improvement in global state (1 RCT, n = 100, RR 1.19, 95% CI 0.91 to 1.57) or left the study early (2 RCTs, n = 140, RR 0.33, 95% CI 0.08 to 1.46) (both very low-quality evidence). No studies reported on global state score, mental state, cognitive state and adverse effects.For prefrontal TMS compared to sham TMS, global state was measured on three different scales, all of which presented equivocal results (very low quality evidence). We could not pool data for mental state on the PANSS scale due to high heterogeneity. Cognitive state was assessed using 19 different measures, with 15/19 being equivocal (very low-quality evidence). Prefrontal TMS caused more headaches (6 RCTs, n = 164, RR 2.77, 95% CI 1.22 to 6.26, very low-quality evidence) but there was no difference in the number of participants leaving the study early (very low-quality evidence). No studies reported data for clinical improvement.We found a significant difference in favour of prefrontal theta burst stimulation TMS compared to sham TMS for mental state on the PANNS scale (3 RCTs, n = 108, MD -5.71, 95% CI -9.32 to -2.10, very low evidence). We found no difference for clinical improvement, cognitive state, number of headaches, and leaving the study early (very low-quality evidence).None of the included studies reported satisfaction with care. AUTHORS' CONCLUSIONS Based on this review, there is insufficient evidence to support or refute the use of TMS to treat symptoms of schizophrenia. Although some evidence suggests that TMS, and in particular temporoparietal TMS, may improve certain symptoms (such as auditory hallucinations and positive symptoms of schizophrenia) compared to sham TMS, the results were not robust enough to be unequivocal across the assessment measures used. There was insufficient evidence to suggest any added benefit with TMS used as an adjunctive therapy to antipsychotic medication.The overall quality of evidence was graded as very low due to risk of bias, and this was accompanied by an imprecision in estimates due to the relatively small number of participants in the studies. Thus, consideration is required in improving the quality of trial processes, as well as the quality of reporting of ongoing and future TMS trials, so as to facilitate accurate future judgements in assessing risk of bias. Differences in TMS techniques in relation to stimulation intensity, stimulation length, brain areas stimulated and variations in the design of sham TMS all contributed to the heterogeneity of study findings and limited the interpretation and applicability of the results. In addition, the trials assessed their outcomes with a variety of scales, and usable data were limited. Therefore, to better evaluate the treatment effects of TMS in people with schizophrenia, we favour the use of standardised treatment protocols and outcome measures.
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Affiliation(s)
- Nadine Dougall
- University of StirlingNMAHP Research UnitUnit 13 Scion HouseStirling University Innovation ParkStirlingUKFK9 4NF
| | - Nicola Maayan
- Enhance Reviews LtdCentral Office, Cobweb BuildingsThe Lane, LyfordWantageUKOX12 0EE
| | - Karla Soares‐Weiser
- Enhance Reviews LtdCentral Office, Cobweb BuildingsThe Lane, LyfordWantageUKOX12 0EE
| | - Lisa M McDermott
- King's College LondonPrimary Care and Public Health Sciences42 Weston StreetLondonUKSE1 3QD
| | - Andrew McIntosh
- University of Edinburgh, Royal Edinburgh HospitalEdinburghUKEH10 5HF
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Machado S, Arias-Carrión O, Paes F, Vieira RT, Caixeta L, Novaes F, Marinho T, Almada LF, Silva AC, Nardi AE. Repetitive transcranial magnetic stimulation for clinical applications in neurological and psychiatric disorders: an overview. Eurasian J Med 2015; 45:191-206. [PMID: 25610279 DOI: 10.5152/eajm.2013.39] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 07/01/2013] [Indexed: 01/01/2023] Open
Abstract
Neurological and psychiatric disorders are characterized by several disabling symptoms for which effective, mechanism-based treatments remain elusive. Consequently, more advanced non-invasive therapeutic methods are required. A method that may modulate brain activity and be viable for use in clinical practice is repetitive transcranial magnetic stimulation (rTMS). It is a non-invasive procedure whereby a pulsed magnetic field stimulates electrical activity in the brain. Here, we focus on the basic foundation of rTMS, the main stimulation parametters, the factors that influence individual responses to rTMS and the experimental advances of rTMS that may become a viable clinical application to treat neurological and psychiatric disorders. The findings showed that rTMS can improve some symptoms associated with these conditions and might be useful for promoting cortical plasticity in patients with neurological and psychiatric disorders. However, these changes are transient and it is premature to propose these applications as realistic therapeutic options, even though the rTMS technique has been evidenced as a potential modulator of sensorimotor integration and neuroplasticity. Functional imaging of the region of interest could highlight the capacity of rTMS to bring about plastic changes of the cortical circuitry and hint at future novel clinical interventions. Thus, we recommend that further studies clearly determine the role of rTMS in the treatment of these conditions. Finally, we must remember that however exciting the neurobiological mechanisms might be, the clinical usefulness of rTMS will be determined by its ability to provide patients with neurological and psychiatric disorders with safe, long-lasting and substantial improvements in quality of life.
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Affiliation(s)
- Sergio Machado
- Panic and Respiration Laboratory, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ); National Institute for Translational Medicine (INCT-TM), Brazil ; Quiropraxia Program of Faculty of Health Sciences, Central University (UCEN), Santiago, Chile ; Institute of Phylosophy of Federal University of Uberlândia (IFILO/UFU), Brazil ; Physical Activity Neuroscience Laboratory, Physical Activity Sciences Postgraduate Program of Salgado de Oliveira University, Niterói, Brazil
| | - Oscar Arias-Carrión
- Movement Disorders and Transcranial Magnetic Stimulation Unit, Hospital General Dr. Manuel Gea González, México DF, México
| | - Flávia Paes
- Panic and Respiration Laboratory, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ); National Institute for Translational Medicine (INCT-TM), Brazil
| | | | - Leonardo Caixeta
- Faculty of Medicine of Federal University of Goiás, Goiás-GO, Brazil
| | - Felipe Novaes
- Panic and Respiration Laboratory, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ); National Institute for Translational Medicine (INCT-TM), Brazil
| | - Tamires Marinho
- Panic and Respiration Laboratory, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ); National Institute for Translational Medicine (INCT-TM), Brazil
| | | | - Adriana Cardoso Silva
- Panic and Respiration Laboratory, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ); National Institute for Translational Medicine (INCT-TM), Brazil
| | - Antonio Egidio Nardi
- Panic and Respiration Laboratory, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ); National Institute for Translational Medicine (INCT-TM), Brazil
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Oberman L, Pascual-Leone A. Changes in plasticity across the lifespan: cause of disease and target for intervention. PROGRESS IN BRAIN RESEARCH 2014; 207:91-120. [PMID: 24309252 DOI: 10.1016/b978-0-444-63327-9.00016-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
We conceptualize brain plasticity as an intrinsic property of the nervous system enabling rapid adaptation in response to changes in an organism's internal and external environment. In prenatal and early postnatal development, plasticity allows for the formation of organized nervous system circuitry and the establishment of functional networks. As the individual is exposed to various sensory stimuli in the environment, brain plasticity allows for functional and structural adaptation and underlies learning and memory. We argue that the mechanisms of plasticity change over the lifespan with different slopes of change in different individuals. These changes play a key role in the clinical phenotype of neurodevelopmental disorders like autism and schizophrenia and neurodegenerative disorders such as Alzheimer's disease. Altered plasticity not only can trigger maladaptive cascades and can be the cause of deficits and disability but also offers opportunities for novel therapeutic interventions. In this chapter, we discuss the importance of brain plasticity across the lifespan and how neuroplasticity-based therapies offer promise for disorders with otherwise limited effective treatment.
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Affiliation(s)
- Lindsay Oberman
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Wölwer W, Lowe A, Brinkmeyer J, Streit M, Habakuck M, Agelink MW, Mobascher A, Gaebel W, Cordes J. Repetitive Transcranial Magnetic Stimulation (rTMS) Improves Facial Affect Recognition in Schizophrenia. Brain Stimul 2014; 7:559-63. [DOI: 10.1016/j.brs.2014.04.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 04/17/2014] [Accepted: 04/30/2014] [Indexed: 12/24/2022] Open
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Demirtas-Tatlidede A, Vahabzadeh-Hagh AM, Pascual-Leone A. Can noninvasive brain stimulation enhance cognition in neuropsychiatric disorders? Neuropharmacology 2012; 64:566-78. [PMID: 22749945 DOI: 10.1016/j.neuropharm.2012.06.020] [Citation(s) in RCA: 178] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 06/11/2012] [Accepted: 06/12/2012] [Indexed: 02/07/2023]
Abstract
Cognitive impairment is a core symptom of many neuropsychiatric diseases and a key contributor to the patient's quality of life. However, an effective therapeutic strategy has yet to be developed. Noninvasive brain stimulation techniques, namely transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), are promising techniques that are under investigation for a variety of otherwise treatment-resistant neuropsychiatric diseases. Notably, these tools can induce alterations in neural networks subserving cognitive operations and thus may provide a means for cognitive restoration. The purpose of this article is to review the available evidence concerning cognitive enhancing properties of noninvasive brain stimulation in neuropsychiatry. We specifically focus on major depression, Alzheimer's disease, schizophrenia, autism and attention deficit hyperactivity disorder (ADHD), where cognitive dysfunction is a major symptom and some studies have been completed with promising results. We provide a critical assessment of the available research and suggestions to guide future efforts. This article is part of a Special Issue entitled 'Cognitive Enhancers'.
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Affiliation(s)
- Asli Demirtas-Tatlidede
- Behavioral Neurology and Movement Disorders Unit, Department of Neurology, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey.
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McClintock SM, Freitas C, Oberman L, Lisanby SH, Pascual-Leone A. Transcranial magnetic stimulation: a neuroscientific probe of cortical function in schizophrenia. Biol Psychiatry 2011; 70:19-27. [PMID: 21571254 PMCID: PMC3270326 DOI: 10.1016/j.biopsych.2011.02.031] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 02/21/2011] [Accepted: 02/25/2011] [Indexed: 12/20/2022]
Abstract
Transcranial magnetic stimulation (TMS) is a neuropsychiatric tool that can serve as a useful method to better understand the neurobiology of cognitive function, behavior, and emotional processing. The purpose of this article is to examine the utility of TMS as a means to measure neocortical function in neuropsychiatric disorders in general, and schizophrenia in particular, for the Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia initiative. When incorporating TMS paradigms in research studies, methodologic considerations include technical aspects of TMS, cohort selection and confounding factors, and subject safety. Available evidence suggests benefits of TMS alone or in combination with neurophysiologic and neuroimaging methods, including positron emission tomography, single photon emission computed tomography, magnetic resonance imaging, functional magnetic resonance imaging, functional near infrared spectroscopy, magnetoencephalography, and electroencephalography, to explore neocortical function. With the multiple TMS techniques including single-pulse, paired-pulse, paired associative stimulation, and repetitive TMS and theta burst stimulation, combined with neurophysiologic and neuroimaging methods, there exists a plethora of TMS experimental paradigms to modulate neocortical physiologic processes. Specifically, TMS can measure cortical excitability, intracortical inhibitory and excitatory mechanisms, and local and network cortical plasticity. Coupled with functional and electrophysiologic modalities, TMS can provide insight into the mechanisms underlying healthy neurodevelopment and aging, as well as neuropsychiatric pathology. Thus, TMS could be a useful tool in the Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia armamentarium of biomarker methods. Future investigations are warranted to optimize TMS methodologies for this purpose.
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Affiliation(s)
- Shawn M. McClintock
- Brain Stimulation Lab, Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA, Division of Brain Stimulation and Therapeutic Modulation, Department of Psychiatry, New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Catarina Freitas
- Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Lindsay Oberman
- Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sarah H. Lisanby
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham North Carolina, USA
| | - Alvaro Pascual-Leone
- Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA, Institut Universitari de Neurorehabilitació Guttmann, Universidad Autónoma de Barcelona, Badalona, Spain., Corresponding Author: Alvaro Pascual-Leone, MD, PhD, Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA. T: 617.667-0203; Fax: 617.975-5322.
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