Sustained Efficacy of Stanford Neuromodulation Therapy (SNT) in Open-Label Repeated Treatment

A surface-based cross-sectional fMRI study on brain function differences between comorbid mild or moderate depression and insomnia

Background

The mechanisms of Comorbid mild or moderate depression and insomnia (CmiDaI or CmoDaI) are complex, and stratification remains poorly understood.

Methods

Resting-state fMRI data were collected from 32 patients with CmiDaI, 32 with CmoDaI, and 30 healthy controls (HCs). Data were analyzed using a surface-based computational method to examine differences in amplitude of low-frequency fluctuations (ALFF) and functional connectivity (FC) across the brain.

Results

Significant ALFF differences were found in the left dorsolateral prefrontal cortex (DLPFC) between CmiDaI and CmoDaI. Compared to CmoDaI, CmiDaI showed increased ALFF in the left DLPFC, decreased FC between left DLPFC and right superior temporal gyrus, and increased FC in the right supramarginal gyrus (SMG) and right inferior frontal gyrus (IFG). Correlation analysis suggests lower left DLPFC ALFF correlated with more severe depression and insomnia. Lower FC between left DLPFC and right IFG was associated with more severe depression, while lower FC between left DLPFC and right SMG correlated with more severe insomnia.

Conclusion

Our findings suggest that reduced ALFF in the left DLPFC may serve as the potential biomarker to distinguish CmiDaI from CmoDaI, and offer insights for the two disorders' treatments.

Durability of clinical benefit with Stanford Neuromodulation Therapy (SNT) in treatment-resistant depression

BACKGROUND

Depression, the leading cause of disability worldwide, is a chronic disease characterized by a relapsing-remitting course. Acute treatments such as electroconvulsive therapy, ketamine, and repetitive transcranial magnetic stimulation are often effective at initiating remission, but relapse to a major depressive episode is common without ongoing interventions. Stanford Neuromodulation Therapy (SNT) produces high rates of remission after five days of acute treatment; however, the duration of this remission following a single course of SNT in people suffering from treatment-resistant depression is unknown, which poses a significant limit on clinical decision-making.

METHODS

Forty-six participants with treatment-resistant depression (TRD), received five days of SNT. Functional connectivity derived from resting-state functional MRI (fMRI) was used to individually target the region of the left dorsolateral prefrontal cortex most functionally anticorrelated with the subgenual anterior cingulate cortex. The 6-item Hamilton Depression Rating Scale (HDRS-6) was collected fortnightly for up to 24 weeks. Relapse was defined as two consecutive HDRS-6 scores of 5 or above.

RESULTS

Seventy percent (32 of 46) of participants entered remission the week following treatment. After 12 weeks of treatment, 15 of 46 (33 %) participants remained in remission. Of the participants who entered remission, 15 of 32 (47 %) remained in remission.

CONCLUSIONS

At 12 weeks, a subset of participants remained in remission, suggesting that the durability of SNT warrants further study. Comparisons with conventional rTMS should be interpreted cautiously given differences in study design, populations, and outcome measures.

Extended course accelerated intermittent theta burst stimulation as a substitute for depressed patients needing electroconvulsive therapy

In response to restrictions on electroconvulsive therapy (ECT) access during COVID-19, we designed a trial to assess the clinical outcomes service impacts, employing an extended course of accelerated intermittent theta burst stimulation (aiTBS), in patients with moderate to severe depression in need of ECT. This open label clinical trial was comprised of 3 phases: (i) an acute phase, where iTBS treatments were administered 8 times daily, for up to 10 days; (ii) a tapering phase of 2 treatment days per week for 2 weeks, followed by 1 treatment day per week for 2 weeks; and (iii) a symptom-based relapse prevention phase, whereby treatments were scheduled based on symptom re-emergence, for up to 6 months. Of the 155 patients who completed the acute phase of the study, the remission rate was 16.1%. The mean reduction from baseline on the HRSD-24 was 29.4% (p < 0.001) and the response rate was 25.2%. Of the 110 patients who completed the tapering phase, the mean reduction from baseline was 42.6% (p < 0.001) and response and remission rates were 49.6% and 34.8%, respectively. Of the 61 patients who were eligible for the relapse prevention phase, 43 completed, with a mean reduction from baseline of 60.1% (p < 0.001); 7 patients relapsed during this phase. This study demonstrated that an extended aiTBS protocol safely led to meaningful clinical outcomes in patients with severe depression, who otherwise would have received ECT, and thus reduced pressure on ECT services during the pandemic. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04384965 ( https://clinicaltrials.gov/study/NCT04384965?term=NCT04384965&rank=1 ).

A Multisite, 6-Month, Open-Label Study of Maintenance Transcranial Magnetic Stimulation for Adolescents with Treatment-Resistant Depression

Introduction: Transcranial magnetic stimulation (TMS) is a promising intervention for adolescents with treatment-resistant depression (TRD). However, the durability of TMS-related improvement in adolescents is unclear. This 6-month study followed adolescents with TRD who had responded to TMS and provided TMS retreatment for adolescents with a partial relapse. Methods: The study enrolled adolescents (12-21 years) with TRD who had at least a partial response to sham or active TMS in a randomized controlled trial. Partial response was defined as ≥25% reduction of Hamilton Depression Rating Scale-24 (HAMD24). Participants with a partial relapse (≥1 point increase in Clinical Global Impression-Severity) received retreatment with daily 10 Hz TMS sessions until depressive symptom severity returned to the baseline score or after 30 TMS treatments. Results: There were 84 eligible participants, 66 were enrolled, and 41 completed the 6-month study. Twenty-eight participants (42%) were retreated with TMS. TMS retreatment courses had a mean of 22 sessions. At the 6-month follow-up, the complete sample exhibited reduced depressive symptoms (mean HAMD24 of 5.24) compared with baseline at entry into follow-up (mean HAMD24 of 8.21). Baseline depressive symptom severity was positively correlated with the risk of partial relapse, while the number of previous TMS interventions showed no correlation with the risk of partial relapse. TMS was well tolerated. Conclusions: This is the largest, long-term follow-up study with TMS retreatment for adolescents with TRD. These findings demonstrate the feasibility and clinical effects of a TMS retreatment protocol for adolescents with TRD, following a standard course of acute TMS.

Accelerated transcranial magnetic stimulation for psychological distress in advanced cancer: A phase 2a feasibility and preliminary efficacy clinical trial

BACKGROUND

Psychological and existential suffering affects many people with advanced illness, and current therapeutic options have limited effectiveness. Repetitive transcranial magnetic stimulation (rTMS) is a safe and effective therapy for refractory depression, but no previous study has used rTMS to treat psychological or existential distress in the palliative setting.

AIM

To determine whether a 5-day course of "accelerated" rTMS is feasible and can improve psychological and/or existential distress in a palliative care setting.

DESIGN

Open-label, single arm, feasibility, and preliminary efficacy study of intermittent theta-burst stimulation to the left dorsolateral prefrontal cortex, 600 pulses/session, 8 sessions/day (once per hour) for 5 days. The outcomes were the rates of recruitment, completion of intervention, and follow-up (Feasibility); and the proportion of participants achieving 50% improvement on the Hamilton Depression Rating Scale (HDRS) or Hospital Anxiety and Depression Scale (HADS) 2 weeks post-treatment (Preliminary Efficacy).

SETTING/PARTICIPANTS

Adults admitted to our academic Palliative Care Unit with advanced illness, life expectancy >1 month and psychological distress.

RESULTS

Due to COVID-19 pandemic-related interruptions, a total of nine participants were enrolled between August 2021 and April 2023. Two withdrew before starting rTMS, one stopped due to clinical deterioration unrelated to rTMS, and six completed the rTMS treatment. Five of six participants had a >50% improvement in HDRS, HADS-Anxiety, or both between baseline and the 2 week follow up; the sixth died prior to the 2-week follow-up. In this small sample, mean depression scores decreased from baseline to 2 weeks post-treatment (HDRS 18 vs 7, p = 0.03). Side effects of rTMS included transient mild scalp discomfort.

CONCLUSIONS

Accelerated rTMS improved symptoms of depression, anxiety, or both in this small feasibility and preliminary efficacy study. A larger, sham-controlled study is warranted to determine whether rTMS could be an effective, acceptable, and scalable treatment in the palliative setting.

TRIAL REGISTRATION

NCT04257227.