Efficacy and safety of repetitive transcranial magnetic stimulation for generalised anxiety disorder: A meta-analysis

Sequential Navigated Multilocus Repetitive Transcranial Magnetic Stimulation for Concurrent Somatic and Psychiatric Conditions

OBJECTIVE

Repetitive transcranial magnetic stimulation (rTMS) is efficient in frequently coexisting neurological and psychiatric disorders. This retrospective study investigated potentially additive efficacy and feasibility of multilocus rTMS in patients treated for more than 1 concurrent disorder.

METHODS

Thirty-three consecutive patients underwent therapeutic rTMS with several cortical targets for more than 1 disorder. Two patients were excluded (insufficient data). The patients (19 women and 12 men, median age 49 years, range 17-75 years) had combinations of chronic pain (n = 15), depression (n = 30), tinnitus (n = 7), anxiety (n = 6), obsessive-compulsive disorder (n = 3), and eating disorder (n = 3). The combination of pain and depression was most frequent. E-field navigated TMS device (Nexstim Ltd, Helsinki, Finland) was used for a 10-day rTMS-trial (9 in 2 cases). Protocol and cortical target combinations varied according to indications. In addition to clinical evaluation, at least 30% decrease in severity on disorder-specific scales was response limit. All assessments were done at baseline and after 10-day treatment.

RESULTS

Response rate to multilocus rTMS in at least 1 condition was 84%. A response to treatment was observed for both indications in 19 patients, for a single indication in 7 patients, and for none in 5 patients. As available (n = 20), Global Impression of Change was positive in 85% of patients, and 15% reported no change.

CONCLUSIONS

Multilocus rTMS is an efficient tool for comorbid neurological and psychiatric disorders, with no serious adverse effects. Responder rate was rather high in patients with comorbidities, suggesting that rTMS efficacy may be associated with inherent patient-related factors.

Safety and Efficacy of Continuous Theta Burst "Intensive" Posterior Parietal Cortex Stimulation in Generalized Anxiety Disorder: A Randomized Double-Blind Sham-Controlled Trial

OBJECTIVES

Citing nonresponse to conventional treatments, neuromodulation based treatments are needed in generalized anxiety disorder (GAD). Data regarding continuous TBS (cTBS) in GAD has been anecdotal. Citing right posterior parietal cortex (PPC) hyperconnectivity in GAD, we aimed to study the effect of intensive cTBS targeting PPC in a randomized rater-blinded placebo-control design.

MATERIAL AND METHODS

Forty-four patients age range 18-59 years (baseline Hamilton Anxiety Rating Scale [HAM-A] score >18 or Clinical Global Impression Severity [CGI-S] score of ≥4) were randomly allocated to active cTBS (n = 22) and sham cTBS (n = 22) groups using block randomization method. They received 10 cTBS sessions, 2 sessions per day (total of 1200 pulses) for 5 days in a week at 80% motor threshold. HAM-A, World Health Organization's abbreviated quality of life assessment (WHOQOL-BREF), and CGI-S were assessed at baseline, after the last session, and at 2 weeks after cTBS with gender as covariate. Intention-to-treat analysis was conducted and missing values were replaced using the last observation carried forward method.

RESULTS

On repeated measures analysis of variance, a significant between-group time effect for HAM-A (F = 29.6; P = 0.001; ηp2 = 0.420), CGI-S (F = 24.7; P = 0.001; ηp2 = 0.376), and WHOQOL-BREF (F = 29.6; P = 0.001; ηp2 = 0.420). Logs of odds of response of >50% improvement in HAM-A between active and sham groups is 3.27 (95% CI [0.345, 6.20]). No major side effects were reported and none discontinued the trial because of side effects.

CONCLUSIONS

Our trial concludes that cTBS of posterior parietal cortex is safe, well-tolerated, and effective in GAD.

Dissociable salience and default mode network modulation in generalized anxiety disorder: a connectome-wide association study

Generalized anxiety disorder (GAD) is a common anxiety disorder experiencing psychological and somatic symptoms. Here, we explored the link between the individual variation in functional connectome and anxiety symptoms, especially psychological and somatic dimensions, which remains unknown. In a sample of 118 GAD patients and matched 85 healthy controls (HCs), we used multivariate distance-based matrix regression to examine the relationship between resting-state functional connectivity (FC) and the severity of anxiety. We identified multiple hub regions belonging to salience network (SN) and default mode network (DMN) where dysconnectivity associated with anxiety symptoms (P < 0.05, false discovery rate [FDR]-corrected). Follow-up analyses revealed that patient's psychological anxiety was dominated by the hyper-connectivity within DMN, whereas the somatic anxiety could be modulated by hyper-connectivity within SN and DMN. Moreover, hypo-connectivity between SN and DMN were related to both anxiety dimensions. Furthermore, GAD patients showed significant network-level FC changes compared with HCs (P < 0.01, FDR-corrected). Finally, we found the connectivity of DMN could predict the individual psychological symptom in an independent GAD sample. Together, our work emphasizes the potential dissociable roles of SN and DMN in the pathophysiology of GAD's anxiety symptoms, which may be crucial in providing a promising neuroimaging biomarker for novel personalized treatment strategies.

Singular and combined effects of transcranial infrared laser stimulation and exposure therapy on pathological fear: a randomized clinical trial

BACKGROUND

Preclinical findings suggest that transcranial infrared laser stimulation (TILS) improves fear extinction learning and cognitive function by enhancing prefrontal cortex (PFC) oxygen metabolism. These findings prompted our investigation of treating pathological fear using this non-invasive stimulation approach either alone to the dorsolateral PFC (dlPFC), or to the ventromedial PFC (vmPFC) in combination with exposure therapy.

METHODS

Volunteers with pathological fear of either enclosed spaces, contamination, public speaking, or anxiety-related bodily sensations were recruited for this randomized, single-blind, sham-controlled trial with four arms: (a) Exposure + TILS_vmPFC (n = 29), (b) Exposure + sham TILS_vmPFC (n = 29), (c) TILS_dlPFC alone (n = 26), or (d) Sham TILS _dlPFC alone (n = 28). Post-treatment assessments occurred immediately following treatment. Follow-up assessments occurred 2 weeks after treatment.

RESULTS

A total of 112 participants were randomized [age range: 18-63 years; 96 females (85.71%)]. Significant interactions of Group × Time and Group × Context indicated differential treatment effects on retention (i.e. between time-points, averaged across contexts) and on generalization (i.e. between contexts, averaged across time-points), respectively. Among the monotherapies, TILS_dlPFC outperformed SHAM_dlPFC in the initial context, b = -13.44, 95% CI (-25.73 to -1.15), p = 0.03. Among the combined treatments, differences between EX + TILS_vmPFC and EX + SHAM_vmPFC were non-significant across all contrasts.

CONCLUSIONS

TILS to the dlPFC, one of the PFC regions implicated in emotion regulation, resulted in a context-specific benefit as a monotherapy for reducing fear. Contrary to prediction, TILS to the vmPFC, a region implicated in fear extinction memory consolidation, did not enhance exposure therapy outcome.

Neuromodulation Treatments of Pathological Anxiety in Anxiety Disorders, Stressor-Related Disorders, and Major Depressive Disorder: A Dimensional Systematic Review and Meta-Analysis

Background

Pathological anxiety is responsible for major functional impairments and resistance to conventional treatments in anxiety disorders (ADs), posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Focal neuromodulation therapies such as transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS) and deep brain stimulation (DBS) are being developed to treat those disorders.

Methods

We performed a dimensional systematic review and meta-analysis to assess the evidence of the efficacy of TMS, tDCS and DBS in reducing anxiety symptoms across ADs, PTSD and MDD. Reports were identified through systematic searches in PubMed/Medline, Scopus and Cochrane library (inception to November 2020), followed by review according to the PRISMA guidelines. Controlled clinical trials examining the effectiveness of brain stimulation techniques on generic anxiety symptoms in patients with ADs, PTSD or MDD were selected.

Results

Nineteen studies (RCTs) met inclusion criteria, which included 589 participants. Overall, focal brain activity modulation interventions were associated with greater reduction of anxiety levels than controls [SMD: -0.56 (95% CI, -0.93 to-0.20, I 2 = 77%]. Subgroup analyses revealed positive effects for TMS across disorders, and of focal neuromodulation in generalized anxiety disorder and PTSD. Rates of clinical responses and remission were higher in the active conditions. However, the risk of bias was high in most studies.

Conclusions

There is moderate quality evidence for the efficacy of neuromodulation in treating pathological anxiety.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=233084, identifier: PROSPERO CRD42021233084. It was submitted on January 29th, 2021, and registered on March 1st, 2021. No amendment was made to the recorded protocol. A change was applied for the subgroup analyses based on target brain regions, we added the putative nature (excitatory/inhibitory) of brain activity modulation.

Efficacy and Tolerability of Cranial Electrotherapy Stimulation in the Treatment of Anxiety: A Systemic Review and Meta-Analysis

OBJECTIVE

We aimed to investigate the efficacy and tolerability of cranial electrotherapy stimulation (CES) for patients with anxiety symptoms.

METHOD

We searched the Pubmed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase and Medline for randomized control trials (RCTs) from the time of inception until November 15, 2021, following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data were pooled using a random-effects model. The primary outcomes were the mean change scores for anxiety symptoms. The secondary outcomes were the mean change scores for depressive symptoms.

RESULTS

Eleven RCTs were eligible (n = 794, mean age: 41.4, mean population of female: 64.8%). CES significantly reduced the anxiety symptoms compared to the control group [k = 11, n = 692, Hedge's g = -0.625, 95% confidence intervals (CIs) = -0.952 to -0.298, P < 0.001] with moderate effect size. The subgroup analysis showed that CES reduced both primary and secondary anxiety (primary anxiety, k =3, n = 288, Hedges' g = -1.218, 95% CIs = -1.418 to -0.968, P = 0.007; secondary anxiety, k = 8, n = 504, Hedges' g = -0.334, 95% CIs = -0.570 to -0.098, P = 0.006). After performing between group analysis, we found CES has significant better efficacy for patients with primary anxiety than those with secondary anxiety (P < 0.001). For secondary outcome, CES significantly reduced depressive symptoms in patients with anxiety disorders (k = 8, n = 552, Hedges' g = -0.648, 95% CIs = -1.062 to -0.234, P = 0.002). No severe side effects were reported and the most commonly reported adverse events were ear discomfort and ear pain.

CONCLUSION

We found CES is effective in reducing anxiety symptoms with moderate effect size in patients with both primary and secondary anxiety. Furthermore, CES was well-tolerated and acceptable.Systematic Review Registration: PROSPERO, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021267916.

Effectiveness of noninvasive brain stimulation in the treatment of anxiety disorders: a meta-analysis of sham or behaviour-controlled studies

BACKGROUND

The possibility of using noninvasive brain stimulation to treat mental disorders has received considerable attention recently. Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are considered to be effective treatments for depressive symptoms. However, no treatment recommendation is currently available for anxiety disorders, suggesting that evidence is still limited. We conducted a systematic review of the literature and a quantitative analysis of the effectiveness of rTMS and tDCS in the treatment of anxiety disorders.

METHODS

Following PRISMA guidelines, we screened 3 electronic databases up to the end of February 2020 for English-language, peer-reviewed articles that included the following: a clinical sample of patients with an anxiety disorder, the use of a noninvasive brain stimulation technique, the inclusion of a control condition, and pre/post scores on a validated questionnaire that measured symptoms of anxiety.

RESULTS

Eleven papers met the inclusion criteria, comprising 154 participants assigned to a stimulation condition and 164 to a sham or control group. We calculated Hedge's g for scores on disorder-specific and general anxiety questionnaires before and after treatment to determine effect size, and we conducted 2 independent random-effects meta-analyses. Considering the well-known comorbidity between anxiety and depression, we ran a third meta-analysis analyzing outcomes for depression scores. Results showed a significant effect of noninvasive brain stimulation in reducing scores on disorder-specific and general anxiety questionnaires, as well as depressive symptoms, in the real stimulation compared to the control condition.

LIMITATIONS

Few studies met the inclusion criteria; more evidence is needed to strengthen conclusions about the effectiveness of noninvasive brain stimulation in the treatment of anxiety disorders.

CONCLUSION

Our findings showed that noninvasive brain stimulation reduced anxiety and depression scores compared to control conditions, suggesting that it can alleviate clinical symptoms in patients with anxiety disorders.