Low-Frequency Right Repetitive Transcranial Magnetic Stimulation for the Treatment of Depression After Traumatic Brain Injury: A Randomized Sham-Controlled Pilot Study

The effect of repetitive transcranial magnetic stimulation on the Hamilton Depression Rating Scale-17 criterion in patients with major depressive disorder without psychotic features: a systematic review and meta-analysis of intervention studies

AIM

In line with the publication of clinical information related to the therapeutic process of repetitive transcranial magnetic stimulation (rTMS) and the updating of relevant treatment guidelines, the present meta-analysis study was designed and conducted to determine the effect of repetitive transcranial magnetic stimulation (rTMS) on the Hamilton Depression Rating Scale-17 (HDRS-17) criterion in patients with major depressive disorder (MDD) without psychotic features.

METHODS

In this study, a systematic search was conducted in electronic databases such as PubMed [Medline], Scopus, Web of Science, Embase, Ovid, Cochrane Library, and ClinicalTrials. gov using relevant keywords. The search period in this study was from January 2000 to January 2022, which was updated until May 2023. Randomized controlled trials (RCTs) that determined the effect of repetitive transcranial magnetic stimulation (rTMS) on the Hamilton Depression Rating Scale-17 (HDRS-17) criterion in patients with major depressive disorder (MDD) without psychotic features were included in the analysis. The quality of the included RCTs was assessed using the Cochrane Risk of Bias checklist. Statistical analyses were performed using STATA (Version 16) and RevMan (Version 5).

RESULTS

Following the combination of results from 16 clinical trial studies in the present meta-analysis, it was found that the mean Hamilton Depression Rating Scale-17 (HDRS-17) in patients with major depressive disorder (MDD) decreases by an average of 1.46 units (SMD: -1.46; % 95 CI: -1.65, -1.27, I square: 45.74%; P heterogeneity: 0.56). Subgroup analysis results indicated that the standardized mean difference of Hamilton Depression Rating Scale-17 (HDRS-17) varied based on the number of treatment sessions: patients receiving 10 or fewer repetitive transcranial magnetic stimulation (rTMS) sessions showed a mean Hamilton Depression Rating Scale-17 (HDRS-17) reduction of 2.60 units (SMD: -2.60; % 95 CI: -2.86, -2.33, I square: 55.12%; P heterogeneity: 0.55), while those receiving 11 to 20 sessions showed a mean Hamilton Depression Rating Scale-17 (HDRS-17) reduction of 0.28 units (SMD: -0.28; % 95 CI: -0.65, -0.09, I square: 39.91%; P heterogeneity: 0.89).

CONCLUSION

In conclusion, our meta-analysis demonstrates the efficacy of repetitive transcranial magnetic stimulation (rTMS) in reducing depressive symptoms in major depressive disorder (MDD) patients. The complex results of subgroup analysis revealed insight on the possible benefits of a more focused strategy with fewer sessions, as well as the impact of treatment session frequency. These findings add to our understanding of repetitive transcranial magnetic stimulation (rTMS) as a therapeutic intervention for the treatment of major depressive illnesses.

Is non-invasive neuromodulation a viable technique to improve neuroplasticity in individuals with acquired brain injury? A review

Objective

This study aimed to explore and evaluate the efficacy of non-invasive brain stimulation (NIBS) as a standalone or coupled intervention and understand its mechanisms to produce positive alterations in neuroplasticity and behavioral outcomes after acquired brain injury (ABI).

Data sources

Cochrane Library, Web of Science, PubMed, and Google Scholar databases were searched from January 2013 to January 2024.

Study selection

Using the PICO framework, transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) randomized controlled trials (RCTs), retrospective, pilot, open-label, and observational large group and single-participant case studies were included. Two authors reviewed articles according to pre-established inclusion criteria.

Data extraction

Data related to participant and intervention characteristics, mechanisms of change, methods, and outcomes were extracted by two authors. The two authors performed quality assessments using SORT.

Results

Twenty-two studies involving 657 participants diagnosed with ABIs were included. Two studies reported that NIBS was ineffective in producing positive alterations or behavioral outcomes. Twenty studies reported at least one, or a combination of, positively altered neuroplasticity and improved neuropsychological, neuropsychiatric, motor, or somatic symptoms. Twenty-eight current articles between 2020 and 2024 have been studied to elucidate potential mechanisms of change related to NIBS and other mediating or confounding variables.

Discussion

tDCS and TMS may be efficacious as standalone interventions or coupled with neurorehabilitation therapies to positively alter maladaptive brain physiology and improve behavioral symptomology resulting from ABI. Based on postintervention and follow-up results, evidence suggests NIBS may offer a direct or mediatory contribution to improving behavioral outcomes post-ABI.

Conclusion

More research is needed to better understand the extent of rTMS and tDCS application in affecting changes in symptoms after ABI.

Repetitive transcranial magnetic stimulation for post-traumatic stress disorder in adults

BACKGROUND

The estimated lifetime prevalence of post-traumatic stress disorder (PTSD) in adults worldwide has been estimated at 3.9%. PTSD appears to contribute to alterations in neuronal network connectivity patterns. Current pharmacological and psychotherapeutic treatments for PTSD are associated with inadequate symptom improvement and high dropout rates. Repetitive transcranial magnetic stimulation (rTMS), a non-invasive therapy involving induction of electrical currents in cortical brain tissue, may be an important treatment option for PTSD to improve remission rates and for people who cannot tolerate existing treatments.

OBJECTIVES

To assess the effects of repetitive transcranial magnetic stimulation (rTMS) on post-traumatic stress disorder (PTSD) in adults.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register, CENTRAL, MEDLINE, Embase, three other databases, and two clinical trials registers. We checked reference lists of relevant articles. The most recent search was January 2023.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing the efficacy and safety of rTMS versus sham rTMS for PTSD in adults from any treatment setting, including veterans. Eligible trials employed at least five rTMS treatment sessions with both active and sham conditions. We included trials with combination interventions, where a pharmacological agent or psychotherapy was combined with rTMS for both intervention and control groups. We included studies meeting the above criteria regardless of whether they reported any of our outcomes of interest.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias in accordance with Cochrane standards. Primary outcomes were PTSD severity immediately after treatment and serious adverse events during active treatment. Secondary outcomes were PTSD remission, PTSD response, PTSD severity at two follow-up time points after treatment, dropouts, and depression and anxiety severity immediately after treatment.

MAIN RESULTS

We included 13 RCTs in the review (12 published; 1 unpublished dissertation), with 577 participants. Eight studies included stand-alone rTMS treatment, four combined rTMS with an evidence-based psychotherapeutic treatment, and one investigated rTMS as an adjunctive to treatment-as-usual. Five studies were conducted in the USA, and some predominantly included white, male veterans. Active rTMS probably makes little to no difference to PTSD severity immediately following treatment (standardized mean difference (SMD) -0.14, 95% confidence interval (CI) -0.54 to 0.27; 3 studies, 99 participants; moderate-certainty evidence). We downgraded the certainty of evidence by one level for imprecision (sample size insufficient to detect a difference of medium effect size). We deemed one study as having a low risk of bias and the remaining two as having 'some concerns' for risk of bias. A sensitivity analysis of change-from-baseline scores enabled inclusion of a greater number of studies (6 studies, 252 participants). This analysis yielded a similar outcome to our main analysis but also indicated significant heterogeneity in efficacy across studies, including two studies with a high risk of bias. Reported rates of serious adverse events were low, with seven reported (active rTMS: 6; sham rTMS: 1). The evidence is very uncertain about the effect of active rTMS on serious adverse events (odds ratio (OR) 5.26, 95% CI 0.26 to 107.81; 5 studies, 251 participants; very low-certainty evidence [Active rTMS: 23/1000, sham rTMS: 4/1000]). We downgraded the evidence by one level for risk of bias and two levels for imprecision. We rated four of five studies as having a high risk of bias, and the fifth as 'some concerns' for bias. We were unable to assess PTSD remission immediately after treatment as none of the included studies reported this outcome.

AUTHORS' CONCLUSIONS

Based on moderate-certainty evidence, our review suggests that active rTMS probably makes little to no difference to PTSD severity immediately following treatment compared to sham stimulation. However, significant heterogeneity in efficacy was detected when we included a larger number of studies in sensitivity analysis. We observed considerable variety in participant and protocol characteristics across studies included in this review. For example, studies tended to be weighted towards inclusion of either male veterans or female civilians. Studies varied greatly in terms of the proportion of the sample with comorbid depression. Study protocols differed in treatment design and stimulation parameters (e.g. session number/duration, treatment course length, stimulation intensity/frequency, location of stimulation). These differences may affect efficacy, particularly when considering interactions with participant factors. Reported rates of serious adverse events were very low (< 1%) across active and sham conditions. It is uncertain whether rTMS increases the risk of serious adverse event occurrence, as our certainty of evidence was very low. Studies frequently lacked clear definitions for serious adverse events, as well as detail on tracking/assessment of data and information on the safety population. Increased reporting on these elements would likely aid the advancement of both research and clinical recommendations of rTMS for PTSD. Currently, there is insufficient evidence to meta-analyze PTSD remission, PTSD treatment response, and PTSD severity at different periods post-treatment. Further research into these outcomes could inform the clinical use of rTMS. Additionally, the relatively large contribution of data from trials that focused on white male veterans may limit the generalizability of our conclusions. This could be addressed by prioritizing recruitment of more diverse participant samples.

A Scoping Review on the Use of Non-Invasive Brain Stimulation Techniques for Persistent Post-Concussive Symptoms

BACKGROUND

In the context of managing persistent post-concussive symptoms (PPCS), existing treatments like pharmacotherapy, cognitive behavioral therapy, and physical rehabilitation show only moderate effectiveness. The emergence of neuromodulation techniques in PPCS management has led to debates regarding optimal stimulation parameters and their overall efficacy.

METHODS

this scoping review involved a comprehensive search of PubMed and ScienceDirect databases, focusing on controlled studies examining the therapeutic potential of non-invasive brain stimulation (NIBS) techniques in adults with PPCS.

RESULTS

Among the 940 abstracts screened, only five studies, encompassing 103 patients (12 to 29 per study), met the inclusion criteria. These studies assessed the efficacy of transcranial direct current stimulation (tDCS), or repetitive transcranial magnetic stimulation (rTMS), applied to specific brain regions (i.e., the left dorsolateral pre-frontal cortex (DLPFC) or left motor cortex (M1)) for addressing cognitive and psychological symptoms, headaches, and general PPCSs. The results indicated improvements in cognitive functions with tDCS. In contrast, reductions in headache intensity and depression scores were observed with rTMS, while no significant findings were noted for general symptoms with rTMS.

CONCLUSION

although these pilot studies suggest promise for rTMS and tDCS in PPCS management, further research with larger-scale investigations and standardized protocols is imperative to enhance treatment outcomes for PPCS patients.

Effectiveness of rTMS and tDCS treatment for chronic TBI symptoms: A systematic review and meta-analysis

INTRODUCTION

Traumatic brain injury (TBI) is a major cause of long-term disability with conventional treatments frequently falling short to restore a good quality-of-life. Non-invasive brain stimulation (NIBS) techniques have shown potential as therapeutic options for neuropsychiatric conditions, including TBI sequelae. This study aims at providing a systematic review and meta-analysis on the effectiveness of repetitive transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) on post-TBI symptoms.

METHODS

Fifteen randomized controlled trials (RCTs) on adult TBI patients that examined the effects of multiple treatment sessions of NIBS techniques were selected from five databases. Symptoms were clustered into four categories: depression, anxiety, headache and cognitive dysfunctions. Meta-analysis was performed using correlated and hierarchical effects models.

RESULTS

There were only few and heterogeneous studies with generally small sample sizes. Most studies targeted the dorsolateral prefrontal cortex (dlPFC). Overall, the effects of NIBS were small. However, there was a significant effect for overall symptoms (0.404, p = 0.031). Moreover, subgroup analyses revealed significant overall effects for anxiety (0.195, p = 0.020) and headache (0.354, p = 0.040).

CONCLUSIONS

To date, there is limited evidence supporting the effectiveness of NIBS concerning treatment for TBI sequelae. The observed effect sizes were modest, suggesting subtle improvements rather than drastic changes. While NIBS techniques remain promising for treating neuropsychiatric conditions, larger RCT studies with longer follow-ups, optimized stimulation parameters and standardized methodology are required to establish their efficacy in addressing TBI sequelae.

Neural mechanisms of emotional health in traumatic brain injury patients undergoing rTMS treatment

Emotional dysregulation such as that seen in depression, are a long-term consequence of mild traumatic brain injury (TBI), that can be improved by using neuromodulation treatments such as repetitive transcranial magnetic stimulation (rTMS). Previous studies provide insights into the changes in functional connectivity related to general emotional health after the application of rTMS procedures in patients with TBI. However, these studies provide little understanding of the underlying neuronal mechanisms that drive the improvement of the emotional health in these patients. The current study focuses on inferring the effective (causal) connectivity changes and their association with emotional health, after rTMS treatment of cognitive problems in TBI patients (N = 32). Specifically, we used resting state functional magnetic resonance imaging (fMRI) together with spectral dynamic causal model (spDCM) to investigate changes in brain effective connectivity, before and after the application of high frequency (10 Hz) rTMS over left dorsolateral prefrontal cortex. We investigated the effective connectivity of the cortico-limbic network comprised of 11 regions of interest (ROIs) which are part of the default mode, salience, and executive control networks, known to be implicated in emotional processing. The results indicate that overall, among extrinsic connections, the strength of excitatory connections decreased while that of inhibitory connections increased after the neuromodulation. The cardinal region in the analysis was dorsal anterior cingulate cortex (dACC) which is considered to be the most influenced during emotional health disorders. Our findings implicate the altered connectivity of dACC with left anterior insula and medial prefrontal cortex, after the application of rTMS, as a potential neural mechanism underlying improvement of emotional health. Our investigation highlights the importance of these brain regions as treatment targets in emotional processing in TBI.

Treatment of cognitive and mood disorders secondary to traumatic brain injury by the association of bilateral occipital nerve stimulation and a combined protocol of multisite repetitive transcranial magnetic stimulation and cognitive training: A case report

Purpose

Cognitive impairment secondary to traumatic brain injury (TBI) is difficult to treat and usually results in severe disability.

Method

A 48-year-old man presented with chronic refractory headaches and persistent disabling cognitive impairment after TBI. He was first treated with occipital nerve stimulation (ONS) implanted bilaterally to relieve headaches (8 years after the head trauma). Two years later, he was treated with a 6-week protocol combining repetitive transcranial magnetic stimulation (rTMS) delivered to multiple cortical sites (prefrontal cortex, language areas, and areas involved in visuo-spatial functions) and computerized cognitive training (CogT) (targeting memory, language, and visuo-spatial functions) to improve cognitive performance.

Results

Executive and cognitive functions (attention, ability to perform calculations, and verbal fluency) improved in association with pain relief after ONS (33-42% improvement) and then improved even more after the rTMS-CogT protocol with an additional improvement of 36-40% on apathy, depression, and anxiety, leading to a significant reduction in caregiver burden. The functional improvement persisted and even increased at 6 months after the end of the rTMS-CogT procedure (10 years after the onset of TBI and 2 years after ONS implantation).

Conclusion

This is the first observation describing sustained improvement in post-TBI refractory headache, depression, and cognitive impairment by the association of bilaterally implanted ONS and a combined procedure of multisite rTMS and CogT to target various brain functions.

The Rehabilitation Potential of Neurostimulation for Mild Traumatic Brain Injury in Animal and Human Studies

Neurostimulation carries high therapeutic potential, accompanied by an excellent safety profile. In this review, we argue that an arena in which these tools could provide breakthrough benefits is traumatic brain injury (TBI). TBI is a major health problem worldwide, with the majority of cases identified as mild TBI (mTBI). MTBI is of concern because it is a modifiable risk factor for dementia. A major challenge in studying mTBI is its inherent heterogeneity across a large feature space (e.g., etiology, age of injury, sex, treatment, initial health status, etc.). Parallel lines of research in human and rodent mTBI can be collated to take advantage of the full suite of neuroscience tools, from neuroimaging (electroencephalography: EEG; functional magnetic resonance imaging: fMRI; diffusion tensor imaging: DTI) to biochemical assays. Despite these attractive components and the need for effective treatments, there are at least two major challenges to implementation. First, there is insufficient understanding of how neurostimulation alters neural mechanisms. Second, there is insufficient understanding of how mTBI alters neural function. The goal of this review is to assemble interrelated but disparate areas of research to identify important gaps in knowledge impeding the implementation of neurostimulation.

Efficacy of Non-Invasive Brain Stimulation for Treating Depression in Patients with Traumatic Brain Injury: A Meta-Analysis and Meta-Regression of Randomized Controlled Trials

OBJECTIVE

This meta-analysis aimed to ascertain the efficacy of non-invasive brain stimulation (NIBS)-comprising repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS)-for depression in traumatic brain injury (TBI) patients.

METHODS

Comprehensive searches were conducted in PubMed, Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials up to 28 January 2023. Random-effects models assessed the treatment effects, and heterogeneity was evaluated through I2 statistics and funnel plot inspection.

RESULTS

From 10 trials (234 participants; 8 rTMS, 2 tDCS), NIBS was found significantly more effective than sham in alleviating depressive symptoms (SMD: 0.588, 95% CI: 0.264-0.912; p < 0.001). rTMS, specifically, showed higher efficacy (SMD: 0.707, 95% CI: 0.306-1.108; p = 0.001) compared to sham, whereas tDCS outcomes were inconclusive (SMD: 0.271, 95% CI: -0.230 to 0.771; p = 0.289). Meta-regression found no correlation with the number of sessions, treatment intensity, or total dose. Notably, while post-treatment effects were significant, they diminished 1-2 months post intervention. Adverse events associated with NIBS were minimal, with no severe outcomes like seizures and suicide reported.

CONCLUSIONS

rTMS emerged as a potent short-term intervention for depression in TBI patients, while tDCS findings remained equivocal. The long-term efficacy of NIBS is yet to be established, warranting further studies. The low adverse event rate reaffirms NIBS's potential safety.

A review of combined neuromodulation and physical therapy interventions for enhanced neurorehabilitation

Rehabilitation approaches for individuals with neurologic conditions have increasingly shifted toward promoting neuroplasticity for enhanced recovery and restoration of function. This review focuses on exercise strategies and non-invasive neuromodulation techniques that target neuroplasticity, including transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), and peripheral nerve stimulation (PNS). We have chosen to focus on non-invasive neuromodulation techniques due to their greater potential for integration into routine clinical practice. We explore and discuss the application of these interventional strategies in four neurological conditions that are frequently encountered in rehabilitation settings: Parkinson's Disease (PD), Traumatic Brain Injury (TBI), stroke, and Spinal Cord Injury (SCI). Additionally, we discuss the potential benefits of combining non-invasive neuromodulation with rehabilitation, which has shown promise in accelerating recovery. Our review identifies studies that demonstrate enhanced recovery through combined exercise and non-invasive neuromodulation in the selected patient populations. We primarily focus on the motor aspects of rehabilitation, but also briefly address non-motor impacts of these conditions. Additionally, we identify the gaps in current literature and barriers to implementation of combined approaches into clinical practice. We highlight areas needing further research and suggest avenues for future investigation, aiming to enhance the personalization of the unique neuroplastic responses associated with each condition. This review serves as a resource for rehabilitation professionals and researchers seeking a comprehensive understanding of neuroplastic exercise interventions and non-invasive neuromodulation techniques tailored for specific diseases and diagnoses.

Repetitive Transcranial Magnetic Stimulation for Depression and Posttraumatic Stress Disorder in Veterans With Mild Traumatic Brain Injury

OBJECTIVES

Mild traumatic brain injury (mTBI) is a signature injury of military conflicts and is prevalent in veterans with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). Although therapeutic transcranial magnetic stimulation (TMS) can reduce symptoms of depression and PTSD, whether traumatic brain injury (TBI) affects TMS responsiveness is not yet known. We hypothesized mTBI would be associated with higher pretreatment symptom burden and poorer TMS response.

MATERIALS AND METHODS

We investigated a registry of veterans (N = 770) who received TMS for depression across the US Veterans Affairs system. Of these, 665 (86.4%) had data on TBI and lifetime number of head injuries while 658 had complete data related to depression outcomes. Depression symptoms were assessed using the nine-item Patient Health Questionnaire and PTSD symptoms using the PTSD Checklist for DSM-5. Linear mixed effects models and t-tests evaluated whether head injuries predicted symptom severity before treatment, and how TBI status affected clinical TMS outcomes.

RESULTS

Of the 658 veterans included, 337 (50.7%) reported previous mTBI, with a mean of three head injuries (range 1-20). TBI status did not predict depressive symptom severity or TMS-associated changes in depression (all p's > 0.1). TBI status was associated with a modest attenuation of TMS-associated improvement in PTSD (in patients with PTSD Checklist for DSM-5 scores > 33). There was no correlation between the number of head injuries and TMS response (p > 0.1).

CONCLUSIONS

Contrary to our hypothesis, presence of mTBI did not meaningfully change TMS outcomes. Veterans with mTBI had greater PTSD symptoms, yet neither TBI status nor cumulative head injuries reduced TMS effectiveness. Limitations include those inherent to retrospective registry studies and self-reporting. Although these findings are contrary to our hypotheses, they support the safety and effectiveness of TMS for MDD and PTSD in patients who have comorbid mTBI.

Transcranial Magnetic Stimulation and its Imaging Features in Patients With Depression, Post-traumatic Stress Disorder, and Traumatic Brain Injury

Transcranial magnetic stimulation (TMS) is a type of noninvasive neurostimulation used increasingly often in clinical medicine. While most studies to date have focused on TMS's ability to treat major depressive disorder, it has shown promise in several other conditions including post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). As different treatment protocols are often used across studies, the ability to predict patient outcomes and evaluate immediate and long-term changes using imaging becomes increasingly important. Several imaging features, such as thickness, connectedness, and baseline activity of a variety of cortical and subcortical areas, have been found to be correlated with a greater response to TMS therapy. Intrastimulation imaging can reveal in real time how TMS applied to superficial areas activates or inhibits activity in deeper brain regions. Functional imaging performed weeks to months after treatment can offer an understanding of how long-term effects on brain activity relate to clinical improvement. Further work should be done to expand our knowledge of imaging features relevant to TMS therapy and how they vary across patients with different neurological and psychiatric conditions.

Repetitive Transcranial Magnetic Stimulation for Neuropathic Pain and Neuropsychiatric Symptoms in Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Neuropathic pain and neuropsychiatric symptoms are common complications reported by the traumatic brain injury (TBI) population. Although a growing body of research has indicated the effectiveness of repetitive transcranial magnetic stimulation (rTMS) for the management of neurological and psychiatric disorders, little evidence has been presented to support the effects of rTMS on neuropathic pain and neuropsychiatric symptoms in patients with TBI in all age groups. In addition, a better understanding of the potential factors that might influence the therapeutic effect of rTMS is necessary. The objective of this preregistered systematic review and meta-analysis was to quantify the effects of rTMS on physical and psychological symptoms in individuals with TBI. We systematically searched six databases for randomized controlled trials (RCTs) of rTMS in TBI patients reporting pain and neuropsychiatric outcomes published until March 20, 2022. The mean difference (MD) with 95% confidence intervals (CIs) was estimated separately for outcomes to understand the mean effect size. Twelve RCTs with 276 TBI patients were ultimately selected from 1605 records for systematic review, and 11 of the studies were included in the meta-analysis. Overall, five of the included studies showed a low risk of bias. The effects of rTMS on neuropathic pain were statistically significant ( $\text{MD}=-1.00$ , 95% CI -1.76 to -0.25, $P=0.009$ ), with high heterogeneity ( $I^2=76\%$ ). A significant advantage of 1 Hz rTMS over the right dorsolateral prefrontal cortex (DLPFC) in improving depression ( $\text{MD}=-6.52$ , 95% CI -11.58 to -1.46, $P=0.01$ ) was shown, and a significant improvement was noted in the Rivermead Post-Concussion Symptoms Questionnaire-13 (RPQ-13) scores of mild TBI patients after rTMS ( $\text{MD}=-5.87$ , 95% CI -10.63 to -1.11, $P=0.02$ ). However, no significance was found in cognition measurement. No major adverse events related to rTMS were reported. Moderate evidence suggests that rTMS can effectively and safely improve neuropathic pain, while its effectiveness on depression, postconcussion symptoms, and cognition is limited. More trials with a larger number of participants are needed to draw firm conclusions. This trial is registered with PROSPERO (PROSPERO registration number: CRD42021242364.

rTMS/iTBS and Cognitive Rehabilitation for Deficits Associated With TBI and PTSD: A Theoretical Framework and Review

Rehabilitation of cognitive and psychosocial deficits resulting from traumatic brain injury (TBI) continues to be an area of concern in health care. Commonly co-occurring psychiatric disorders, such as major depressive disorder and posttraumatic stress disorder, create additional hurdles when attempting to remediate cognitive sequelae. There is increased need for procedures that will yield consistent gains indicative of recovery of function. Intermittent theta-burst stimulation (iTBS), a form of repetitive transcranial magnetic stimulation, has potential as an instrument that can be tailored to aid cognitive processes and support functional gains. The use of iTBS enables direct stimulation of desired neural systems. iTBS, performed in conjunction with behavioral interventions (e.g., cognitive rehabilitation, psychotherapy), may result in additive success in facilitating cognitive restoration and adaptation. The purpose of this theoretical review is to illustrate how the technical and physiological aspects of iTBS may enhance other forms of neurorehabilitation for individuals with TBI. Future research on combinatorial iTBS interventions has the potential to translate to other complex neuropsychiatric conditions.

A systematic review on integrated care for traumatic brain injury, mental health, and substance use

Traumatic brain injuries (TBI) and mental health or substance use disorders (MHSU) are global public health concerns due to their prevalence and impact on individuals and societies. However, care for individuals with TBI and MHSU remains fragmented with a lack of appropriate services and supports across the continuum of healthcare. This systematic review provided an evidence-based foundation to inform opportunities to mobilize and adapt existing resources to integrate care for individuals with TBI and MHSU by comprehensively summarizing existing integrated activities and reported barriers and facilitators to care integration. MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Sociological Abstracts, and Dissertations & Theses Global were independently reviewed by two reviewers based on pre-determined eligibility criteria. Data on the integration activity, level and type of integration, reported barriers and facilitators, and the strategies aligning with the World Health Organization’s (WHO) Framework on Integrated Person-Centred Care were extracted to form the basis for a narrative synthesis. Fifty-nine peer-reviewed articles were included, describing treatments (N = 49), programs (N = 4), or screening activities (N = 7). Studies discussing clinical integration at the micro- (N = 38) and meso- (N = 10) levels, service integration at the micro- (N = 6) and meso- (N = 5) levels, and functional integration at the meso-level (N = 1) were identified. A minority of articles reported on facilitators (e.g., cognitive accommodations in treatment plans; N = 7), barriers (e.g., lack of education on cognitive challenges associated with TBI; N = 2), or both (N = 6), related to integrating care. This review demonstrated that integrated TBI and MHSU care already exists across a range of levels and types. Given the finite and competing demands for healthcare resources, cognitive accommodations across treatment plans to facilitate integrated TBI and MHSU care should be considered. Multidisciplinary teams should also be explored to provide opportunities for education among health professionals so they can be familiar with TBI and MHSU.

Trial registration: Prospero Registration: CRD42018108343.

Neuromodulation Treatments for Mild Traumatic Brain Injury and Post-concussive Symptoms

PURPOSE OF REVIEW

Mild traumatic brain injury (mTBI) can result in prolonged post-concussive symptoms (e.g., depression, headaches, cognitive impairment) that are debilitating and difficult to treat. This article reviews recent research on neuromodulation for mTBI.

RECENT FINDINGS

Transcranial magnetic stimulation (TMS) is the most studied neuromodulation approach for mTBI (four studies for depression, four for headache, one for cognitive impairment, and two for global post-concussive symptoms) with promising results for post-concussive depression and headache. Transcranial direct current stimulation (tDCS) has also been evaluated (one study for post-traumatic headache, and three for cognitive impairment), with more mixed results overall. TMS appears to be a potentially promising neuromodulation treatment strategy for post-concussive symptoms; however, integration into clinical practice will require larger sham-controlled randomized trials with longer and more consistent follow-up periods. Future studies should also explore new stimulation protocols, personalized approaches, and the role of placebo effects.

Treatment of Psychiatric Problems After Traumatic Brain Injury

Psychiatric sequelae of traumatic brain injury (TBI) can cause significant and often chronic impairment in functioning and quality of life; however, their phenomenological and mechanistic complexities continue to present significant treatment challenges. The clinical presentation is often an amalgam of syndromes and co-occurring symptoms that require a highly nuanced and systematic approach to treatment. Although few randomized controlled trials have tested treatments for psychiatric problems after TBI and the synthesis of results continues to be compromised by the heterogeneity of study populations, small samples, and differing inclusion criteria and outcome measures, an increasing body of literature supports evidence-based treatment strategies. We provide a narrative review of pharmacological, psychoeducational/behavioral, and neuromodulation treatments for psychiatric conditions in adults with TBI and discuss known or postulated mechanisms of action for these treatment approaches. Where data are available, we focus on randomized controlled trials and large case series in which a psychiatric condition provides both a selection criterion and a primary or secondary outcome. We conclude by proposing directions for future research, particularly the need for novel neuropharmacological, behavioral, and neurophysiological studies and pragmatic trials of multicomponent and adaptive models that will increase understanding of the mechanisms underlying post-TBI psychiatric disorders and accelerate dissemination and implementation of effective person-centered care.

Efficacy and Tolerability of Repetitive Transcranial Magnetic Stimulation on Suicidal Ideation: A Systemic Review and Meta-Analysis

OBJECTIVE

This study aimed to investigate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in treating suicidal ideation in patients with mental illness.

METHOD

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Major electronic databases were systematically searched from the time of their inception until July 22, 2021. The primary outcome was the mean change in the scores for suicidal ideation. The secondary outcome was the mean change in depression severity.

RESULTS

Ten randomized controlled trials were eligible with 415 participants in the active treatment group (mean age = 53.78 years; mean proportion of women = 54.5%) and 387 participants in the control group (mean age = 55.52 years; mean proportion of women = 51.78%). rTMS significantly reduced suicidal ideation (k = 10, n = 802, Hedges' g = -0.390, 95% confidence interval [CI] = -0.193 to -0.588, p <.001) and severity of depressive symptoms (k = 9, n = 761, Hedges' g = -0.698, 95% CI = -1.023 to -0.372, p < 0.001) in patients with major mental disorders. In the subgroup analysis, rTMS reduced suicidal ideation among patients with non-treatment-resistant depression (non-TRD) (-0.208) but not in those with TRD. rTMS as combination therapy had a larger effect than did monotherapy (-0.500 vs. -0.210). Suicidal ideation significantly reduced in patients receiving more than ten treatment sessions (-0.255). Importantly, the rTMS group showed favorable tolerability without major adverse events.

CONCLUSION

The study showed that rTMS was effective and well-tolerated in reducing suicidal ideation and depression severity in patients with major mental disorders.

Chronic Anxiety- and Depression-Like Behaviors Are Associated With Glial-Driven Pathology Following Repeated Blast Induced Neurotrauma

Long-term neuropsychiatric impairments have become a growing concern following blast-related traumatic brain injury (bTBI) in active military personnel and Veterans. Neuropsychiatric impairments such as anxiety and depression are common comorbidities that Veterans report months, even years following injury. To understand these chronic behavioral outcomes following blast injury, there is a need to study the link between anxiety, depression, and neuropathology. The hippocampus and motor cortex (MC) have been regions of interest when studying cognitive deficits following blast exposure, but clinical studies of mood disorders such as major depressive disorder (MDD) report that these two regions also play a role in the manifestation of anxiety and depression. With anxiety and depression being common long-term outcomes following bTBI, it is imperative to study how chronic pathological changes within the hippocampus and/or MC due to blast contribute to the development of these psychiatric impairments. In this study, we exposed male rats to a repeated blast overpressure (~17 psi) and evaluated the chronic behavioral and pathological effects on the hippocampus and MC. Results demonstrated that the repeated blast exposure led to depression-like behaviors 36 weeks following injury, and anxiety-like behaviors 2-, and 52-weeks following injury. These behaviors were also correlated with astrocyte pathology (glial-fibrillary acid protein, GFAP) and dendritic alterations (Microtubule-Associated Proteins, MAP2) within the hippocampus and MC regions at 52 weeks. Overall, these findings support the premise that chronic glial pathological changes within the brain contribute to neuropsychiatric impairments following blast exposure.

Repetitive transcranial magnetic stimulation and its role in suicidality - A systematic review

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) as a brain stimulation modality is approved for the treatment of resistant depression and its efficacy in depression is also well supported in several studies. However, its effect on suicidality is still unclear, unlike electroconvulsive therapy.

METHODOLOGY

This paper provides a systematic review of the literature published till June 2021. Studies that used rTMS as either monotherapy or adjunctive treatment in patients with suicidality, irrespective of their diagnosis, were included. The Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines was followed. A total of 20 studies (N = 1584) were included for the qualitative synthesis. The quality of studies was assessed using the Cochrane Risk of Bias tool for Randomised control trials (RCT) and the Newcastle-Ottawa Scale tool for Non-Randomised studies (NRS).

RESULTS

Of the 20 articles selected for qualitative synthesis, 11 were RCTs and 9 were NRS. The results are categorized in domains of type of the study, size of population, type of population, diagnosis, assessment scales, mode of rTMS, stimulus parameters, safety and efficacy.

CONCLUSIONS

The high frequency rTMS at left dorsolateral prefrontal cortex as an adjunct to antidepressant medication is promising in reducing suicidal behaviour in treatment resistant depression. However, role of TMS targeting other areas of stimulation in mitigating suicide risk in other disorders could not be established due to scarcity of such studies. The results should be interpreted cautiously as considerable risk of bias was present in the reviewed studies.

Effect of repetitive transcranial magnetic stimulation on depression and cognition in individuals with traumatic brain injury: a systematic review and meta-analysis

Repetitive transcranial magnetic stimulation (rTMS) is an FDA-approved therapy in major depressive disorder. However, its treatment efficacy on depression after traumatic brain injury (TBI) remains inconclusive. We conducted a meta-analysis to assess the effectiveness of executing rTMS over dorsolateral prefrontal cortex (DLPFC) on depression, cognitive impairment and post-concussion syndrome in individuals with traumatic brain injury. This study contained seven randomized controlled trials that published before April 5, 2020 in PubMed, Embase, Scopus, Cochrane, and Web of Science databases. The rTMS had significant anti-depressant effect (SMD = 1.03, p = 0.02), but the effects dissipated at 1-month follow-up (SMD = 0.39, p = 0.62). In the subgroup analysis, only applying rTMS to left DLPFC area of post-TBI patients showed significant anti-depressant effect (SMD = 0.98, p = 0.04). Moreover, current data observed that rTMS on post-TBI patients possessed substantial improvement in visuospatial memory (SMD = 0.39, p < 0.0001), but wasn't in processing speed (SMD = - 0.18, p = 0.32) and selective attention (SMD = 0.21, p = 0.31). In addition, the effect of rTMS is not superior to sham on postconcussion syndrome. In conclusion, the short-term antidepressant effect of left DLPFC rTMS in patients with TBI was significant. However, the effectiveness of rTMS on cognition and postconcussion syndrome in patients with post-TBI depression was limited.

Hypomanic/manic switch after transcranial magnetic stimulation in mood disorders: A systematic review and meta-analysis

BACKGROUND

Nowadays there is an increasing use of transcranial magnetic stimulation (TMS) both in neurological and psychiatric fields. After Food and Drug Administration approval of TMS for the therapy of treatment-resistant depression, TMS has been widely used in the context of mood disorders (MD). However, growing reports regarding the possibility of developing hypomanic/manic switch (HMS) have generated concern regarding its use in MDs.

AIM

To investigate the actual risk of developing HMS due to TMS in the treatment of MD.

METHODS

We led our research on PubMed, Scopus and Web of Science on March 22, 2020, in accordance to the PRISMA guidelines for systematic review. Only double blind/single blind studies, written in English and focused on the TMS treatment of MD, were included. A meta-analysis of repetitive TMS protocol studies including HMS was conducted using RevMan 5.4 software. The assessment of Risk of Bias was done using Cochrane risk of bias tool. This protocol was registered on PROSPERO with the CRD42020175811 code.

RESULTS

Twenty-five studies were included in our meta-analysis: Twenty-one double blind randomized controlled trials (RCT) and four single blind-RCT (no. of subjects involved in active stimulation = 576; no. of subjects involved in sham protocol = 487). The most frequently treated pathology was major depressive episode/major depressive disorder, followed by resistant depression, bipolar depression and other MD. The majority of the studies used a repetitive TMS protocol, and the left dorsolateral prefrontal cortex was the main target area. Side effects were reported in eight studies and HMS (described as greater energy, insomnia, irritability, anxiety, suicidal attempt) in four studies. When comparing active TMS vs sham treatment, the risk of developing HMS was not significantly different between conditions.

CONCLUSION

Applying the most usual protocols and the appropriate precautionary measures, TMS seems not to be related to HMS development.

A Systematic Review of Neuromodulation Treatment Effects on Suicidality

Introduction: Neuromodulation is an important group of therapeutic modalities for neuropsychiatric disorders. Prior studies have focused on efficacy and adverse events associated with neuromodulation. Less is known regarding the influence of neuromodulation treatments on suicidality. This systematic review sought to examine the effects of various neuromodulation techniques on suicidality. Methods: A systematic review of the literature from 1940 to 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was conducted. Any reported suicide-related outcome, including suicidal ideation, suicide intent, suicide attempt, completed suicide in reports were considered as a putative measure of treatment effect on suicidality. Results: The review identified 129 relevant studies. An exploratory analysis of a randomized controlled trial comparing the effects of sertraline and transcranial direct-current stimulation (tDCS) for treating depression reported a decrease in suicidal ideation favoring tDCS vs. placebo and tDCS combined with sertraline vs. placebo. Several studies reported an association between repetitive transcranial magnetic stimulation and improvements in suicidal ideation. In 12 of the studies, suicidality was the primary outcome, ten of which showed a significant improvement in suicidal ideation. Electroconvulsive therapy (ECT) and magnetic seizure therapy was also shown to be associated with lower suicidal ideation and completed suicide rates. There were 11 studies which suicidality was the primary outcome and seven of these showed an improvement in suicidal ideation or suicide intent and fewer suicide attempts or completed suicides in patients treated with ECT. There was limited literature focused on the potential protective effect of vagal nerve stimulation with respect to suicidal ideation. Data were mixed regarding the potential effects of deep brain stimulation on suicidality. Conclusions: Future prospective studies of neuromodulation that focus on the primary outcome of suicidality are urgently needed. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=125599, identifier: CRD42019125599.

Intervention Effect of Non-Invasive Brain Stimulation on Cognitive Functions among People with Traumatic Brain Injury: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aggregated and examined the treatment effect of non-invasive brain stimulation (NIBS) (transcranial direct current stimulation and transcranial magnetic stimulation) on cognitive functions in people with traumatic brain injury (TBI). A systematic search was conducted using databases (PubMed, Web of Science, Scopus, PsycINFO, EMBASE) for studies with keywords related to non-randomized and randomized control trials of NIBS among people with TBI. Nine out of 1790 NIBS studies with 197 TBI participants (103 active vs. 94 sham) that met the inclusion and exclusion criteria of the present study were finally selected for meta-analysis using Comprehensive Meta-Analysis software (version 3). Results showed that the overall effect of NIBS on cognition in people with TBI was moderately significant (g = 0.304, 95% CI = 0.055 to 0.553) with very low heterogeneity across studies (I² = 0.000, Tau = 0.000). Specifically, significant and marginally significant moderate effect sizes were found for cognitive sub-domains including attention, memory, and executive function. The present findings suggest that NIBS is moderately effective in improving cognitive functions among people with TBI. In particular, NIBS may be used as an alternative and/or an adjunct treatment to the traditional approach in rehabilitating cognitive functions in people with TBI.

The Effectiveness of Non-Invasive Brain Stimulation Alone or Combined with Cognitive Training on the Cognitive Performance of Patients With Traumatic Brain Injury: Α Systematic Review

OBJECTIVE

The present study reviewed published evidence on the effectiveness of non-invasive brain stimulation (NIBS) on the cognitive performance of patients with Traumatic brain injury (TBI).

METHOD

A systematic search of the PubMed and Google Scholar databases was carried out. Randomized Controlled Studies published before March 2020 were included. Methodological evaluation was performed based on the Risk of Bias Cochrane tool. A total of 10 placebo-controlled studies fulfilled the inclusion criteria and were involved in the qualitative analysis, two assessing NIBS combined with cognitive training (CT) and eight evaluating NIBS alone.

RESULTS

All but one retrieved article were appraised as of high-risk of bias (one paper was assessed as of unclear-risk owing to considerable underreporting). With the potential exception of attention, our findings were not indicative of a superior efficacy of NIBS-CT to CT alone, regarding the improvement of any of the rest assessed cognitive deficits. Executive function, processing speed, attention, working, and visuospatial memory were only occasionally found to benefit from NIBS alone compared to sham therapy (only one study reported relevant benefits per neuropsychological outcome). Verbal memory and verbal fluency (phonemic-semantic) were consistently found not to benefit from NIBS. Depression measures were the only outcomes associated with a beneficial effect of NIBS in more than one article.

CONCLUSION

Our findings did not provide sufficient high-quality evidence to support the exclusive use of NIBS or combined NIBS-CT to improve any impaired cognitive function in TBI patients. Owing to the suboptimum methodological quality of published studies, additional research is of potential value.

Treatment of Persistent Post-Concussion Syndrome with Repetitive Transcranial Magnetic Stimulation Using Functional Near-Infrared Spectroscopy as a Biomarker of Response: A Randomized Sham-Controlled Clinical Trial Protocol (Preprint)

Background

Approximately one-third of all concussions lead to persistent postconcussion syndrome (PPCS). Repetitive transcranial magnetic stimulation (rTMS) is a form of noninvasive brain stimulation that has been extensively used to treat refractory major depressive disorder and has a strong potential to be used as a treatment for patients with PPCS. Functional near-infrared spectroscopy (fNIRS) has already been used as a tool to assess patients with PPCS and may provide insight into the pathophysiology of rTMS treatment in patients with PPCS.

Objective

The primary objective of this research is to determine whether rTMS treatment improves symptom burden in patients with PPCS compared to sham treatment using the Rivermead postconcussion symptom questionnaire. The secondary objective is to explore the neuropathophysiological changes that occur following rTMS in participants with PPCS using fNIRS. Exploratory objectives include determining whether rTMS treatment in participants with PPCS will also improve quality of life, anxiety, depressive symptoms, cognition, posttraumatic stress, and function secondary to headaches.

Methods

A total of 44 adults (18-65 years old) with PPCS (>3 months to 5 years) will participate in a double-blind, sham-controlled, concealed allocation, randomized clinical trial. The participants will engage in either a 4-week rTMS treatment protocol or sham rTMS protocol (20 treatments). The left dorsolateral prefrontal cortex will be located through Montreal Neurologic Institute coordinates. The intensity of the rTMS treatment over the left dorsolateral prefrontal cortex will be 120% of resting motor threshold, with a frequency of 10 Hz, 10 trains of 60 pulses per train (total of 600 pulses), and intertrain interval of 45 seconds. Prior to starting the rTMS treatment, participant and injury characteristics, questionnaires (symptom burden, quality of life, depression, anxiety, cognition, and headache), and fNIRS assessment will be collected. Repeat questionnaires and fNIRS will occur immediately after rTMS treatment and at 1 month and 3 months post rTMS. Outcome parameters will be analyzed by a 2-way (treatment × time) mixed analysis of variance.

Results

As of May 6, 2021, 5 participants have been recruited for the study, and 3 have completed the rTMS protocol. The estimated completion date of the trial is May 2022.

Conclusions

This trial will expand our knowledge of how rTMS can be used as a treatment option of PPCS and will explore the neuropathophysiological response of rTMS through fNIRS analysis.

Trial Registration

ClinicalTrials.gov NCT04568369; https://clinicaltrials.gov/ct2/show/NCT04568369

International Registered Report Identifier (IRRID)

DERR1-10.2196/31308

Effects of repetitive transcranial magnetic stimulation on suicidal behavior: A systematic review

The efficacy and tolerability of repetitive transcranial magnetic stimulation (rTMS) in major depression is well-known and documented by existing studies. However, whether rTMS may be effective on suicidal behavior is unclear and needs to be further investigated. This systematic review is aimed to investigate the available literature about the effects of rTMS on suicidal behavior and provide a comprehensive overview of the available evidence. A systematic search regarding the association between rTMS and suicidal behavior was carried out. All relevant articles concerning this association were comprehensively searched on PubMed, Scopus, Science Direct, and PsycInfo databases. After a careful search, 16 articles (7 sham-controlled studies, 5 uncontrolled studies, 4 case-series) met inclusion criteria and were selected in this systematic review. Overall, the left dorsolateral prefrontal cortex (DLPFC) was identified as the most frequent stimulation target by most studies. Unfortunately, actually it is not clear whether suicidal behavior reduction may be mediated, at least in some cases, by depression attenuation. While some methodological heterogeneity was found in terms of stimulation parameters (e.g., frequency, number of sessions, intensity of stimulation), most of the analyzed articles showed that rTMS is a safe, applicable, well tolerated and reproducible method in treating suicidal behavior. The most effective treatment seems to be the bilateral rTMS as well as the combination with antidepressants. Further longitudinal studies are required in order to replicate the mentioned study results.

Treatment effect variability in brain stimulation across psychiatric disorders: A meta-analysis of variance

Noninvasive brain stimulation methods such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) are promising add-on treatments for a number of psychiatric conditions. Yet, some of the initial excitement is wearing off. Randomized controlled trials (RCT) have found inconsistent results. This inconsistency is suspected to be the consequence of variation in treatment effects and solvable by identifying responders in RCTs and individualizing treatment. However, is there enough evidence from RCTs that patients respond differently to treatment? This question can be addressed by comparing the variability in the active stimulation group with the variability in the sham group. We searched MEDLINE/PubMed and included all double-blinded, sham-controlled RCTs and crossover trials that used TMS or tDCS in adults with a unipolar or bipolar depression, bipolar disorder, schizophrenia spectrum disorder, or obsessive compulsive disorder. In accordance with the PRISMA guidelines to ensure data quality and validity, we extracted a measure of variability of the primary outcome. A total of 130 studies with 5748 patients were considered in the analysis. We calculated variance-weighted variability ratios for each comparison of active stimulation vs sham and entered them into a random-effects model. We hypothesized that treatment effect variability in TMS or tDCS would be reflected by increased variability after active compared with sham stimulation, or in other words, a variability ratio greater than one. Across diagnoses, we found only a minimal increase in variability after active stimulation compared with sham that did not reach statistical significance (variability ratio = 1.03; 95% CI, 0.97, 1.08, P = 0.358). In conclusion, this study found little evidence for treatment effect variability in brain stimulation, suggesting that the need for personalized or stratified medicine is still an open question.

Accelerated repetitive transcranial magnetic stimulation in the treatment of post-concussion symptoms due to mild traumatic brain injury: a pilot study

Objective: To investigate the feasibility, tolerability, and efficacy of twice-daily, low frequency (LF) repetitive transcranial magnetic stimulation (rTMS) over the right dorsolateral prefrontal cortex (DLPFC) in the reduction of chronic post-concussion symptoms (PCS) in patients who have suffered a mild traumatic brain injury (mTBI).Methods: 15 patients with mTBI received 30 sessions of twice-daily LF rTMS (1 Hz) over the right DLPFC. Post-concussion symptoms, pain, disability, fatigue, apathy, agitation, and mood were assessed by a psychiatrist pre- and post-treatment. Cognitive testing was also performed pre-, mid-, and post-rTMS.Results: All participants completed treatment with no serious adverse events. Significant improvements were observed in overall post-concussion symptoms, disability and pain ratings, as well as depression and anxiety symptoms. There was no significant change in overall executive functioning, fatigue severity, apathy, or agitation. Cognitive testing revealed improvements in verbal fluency, working memory, selective attention, and cognitive processing speed.Conclusions: This small-sample pilot study suggests that twice-daily, LF rTMS over the right DLPFC can be safely and tolerably applied and has the potential to improve post-concussion symptoms as well as elements of mood and cognition in patients with mTBI. Larger, sham-controlled studies will be important to confirm these observations.

Transcranial Magnetic Stimulation for the Treatment of Concussion: A Systematic Review

BACKGROUND

Post-concussive symptoms (PCSs) are common, disabling, and challenging to manage. Evolving models of concussion pathophysiology suggest evidence of brain network dysfunction that may be amenable to neuromodulation. Repetitive transcranial magnetic stimulation (rTMS) has emerged as a potential novel treatment option for PCSs.

OBJECTIVES

To systematically review rTMS trials for the treatment of symptoms following concussion/mild traumatic brain injury (mTBI).

MATERIALS AND METHODS

We conducted a systematic review of Pubmed/Medline, Embase, and PsychINFO databases were searched up to May 19, 2020. Studies were included if they were prospective rTMS treatment studies of patients with mTBI/concussion. Variables including patient demographics, study design, rTMS protocol parameters, primary outcome measures, and efficacy data were extracted and qualitatively synthesized. rTMS methodology and study quality were also evaluated.

RESULTS

Of the 342 studies identified, 11 met eligibility criteria and were included for synthesis. Forty-one percent of patients were female and age ranged from 18 to 65 (average age = 38.5 years). Post-concussive depression (seven studies) and headache (four studies) were the most commonly investigated symptoms. The majority of trials were sham-controlled with randomized control trial (RCT) designs, but all were small pilot samples (n < 30). Methodological heterogeneity and a low number of identified trials precluded quantitative meta-analysis. Regarding rTMS for post-concussive depression, positive results were found in two out of four studies with depression as a primary outcome, and all three studies that assessed depression as a secondary outcome. All four rTMS studies for post-concussive headache reported positive results.

CONCLUSIONS

rTMS for the treatment of concussion/mTBI shows promising preliminary results for post-concussive depression and headache, symptoms that otherwise have limited effective treatment options. More studies with larger sample sizes are needed to further establish potential efficacy.

Sex Differences in Neuromodulation Treatment Approaches for Traumatic Brain Injury: A Scoping Review

OBJECTIVE

Neuromodulatory brain stimulation interventions for traumatic brain injury (TBI)-related health sequelae, such as psychiatric, cognitive, and pain disorders, are on the rise. Because of disproportionate recruitment and epidemiological reporting of TBI-related research in men, there is limited understanding of TBI development, pathophysiology, and treatment intervention outcomes in women. With data suggesting sex-related variances in treatment outcomes, it is important that these gaps are addressed in emerging, neuromodulatory treatment approaches for TBI populations.

METHODS

Four research databases (PubMED, EMBASE, CINAHL, and PsycINFO) were electronically searched in February 2020.

DESIGN

This PRISMA Scoping Review (PRISMA-ScR)-guided report contextualizes the importance of reporting sex differences in TBI + neuromodulatory intervention studies and summarizes the current state of reporting sex differences when investigating 3 emerging interventions for TBI outcomes.

RESULTS

Fifty-four studies were identified for the final review including 12 controlled trials, 16 single or case series reports, and 26 empirical studies. Across all studies reviewed, 68% of participants were male, and only 7 studies reported sex differences as a part of their methodological approach, analysis, or discussion.

CONCLUSION

This review is hoped to update the TBI community on the current state of evidence in reporting sex differences across these 3 neuromodulatory treatments of post-TBI sequelae. The proposed recommendations aim to improve future research and clinical treatment of all individuals suffering from post-TBI sequelae.

Use of Repetitive Transcranial Magnetic Stimulation in the Treatment of Neuropsychiatric and Neurocognitive Symptoms Associated With Concussion in Military Populations

BACKGROUND

Since the year 2000, over 342 000 military service members have experienced a concussion, often associated with chronic neuropsychiatric and neurocognitive symptoms. Repetitive transcranial magnetic stimulation (rTMS) protocols have been developed for many of these symptoms in the general population.

OBJECTIVE

To conduct a scoping review of the literature on rTMS for neuropsychological and neurocognitive symptoms following concussion.

METHODS

PubMed and Google Scholar search engines identified 9 articles, written in English, corresponding to the search terms TBI or concussion; and TMS or rTMS; and depression, PTSD, or cognition. Studies that were not therapeutic trials or case reports, did not have neuropsychiatric or neurocognitive primary outcome measures, or described samples where 80% or more of the cohort did not have a TBI were excluded.

RESULTS

There were no reports of seizures nor difference in the frequency or quality of other adverse events as compared with the broader rTMS literature, supporting the safety of rTMS in this population. Support for the efficacy of rTMS for the treatment of neuropsychiatric and neurocognitive symptoms, in this population, is limited.

CONCLUSIONS

Large-scale, innovative, neuroscience-informed protocols are recommended to elucidate the potential utility of rTMS for the complex neuropsychiatric and neurocognitive symptoms associated with military concussions.

Transcranial magnetic stimulation to reduce suicidality - A review and naturalistic outcomes

Although there is growing interest in the use of repetitive Transcranial Magnetic Stimulation (TMS) as a treatment for suicidality, efficacy data in this area, and knowledge of potential treatment mechanisms, remains limited. The first objective of this study was to systematically review clinical trial data examining the effectiveness of TMS as a treatment for suicidal ideation. Our secondary objective was to investigate the extent to which changes in suicidality are independent of improvements in depression in a clinical sample of veterans who received TMS treatment. In Study 1, we searched the Pubmed and biRxiv databases from inception until July 2019 to identify studies that examined the efficacy of TMS for suicidal thoughts and/or behaviors. Data regarding sample characteristics, treatment parameters, and results were synthesized from six randomized controlled trials and five unblinded trials (total n = 593). Our systematic review indicated that while TMS was consistently associated with reduced depression, its impact on suicidality is unclear. Interpretation of results related to suicidality were complicated by study design elements and modest sample sizes. In Study 2, we conducted a retrospective analysis of 43 patients who received care for depression in a neuromodulation clinic at a Veteran's Affairs hospital. Results found significant decreases in suicidal ideation, and depressive symptom change did not always account for improvements in ideation. Taken together, our literature review and clinic study indicate preliminary promise of TMS for suicide, and underscore the need for more fine-grained, suicide-specific TMS research.

Treatment of Depression After Traumatic Brain Injury: A Systematic Review Focused on Pharmacological and Neuromodulatory Interventions

BACKGROUND

Depression is the most common psychiatric sequela after traumatic brain injury (TBI) and poses a variety of treatment challenges. There is a lack of clinical trials focused on biological interventions used to manage TBI depression.

OBJECTIVE

The aim of this systematic review is to summarize the current evidence of psychotropic and neuromodulatory interventions used to treat TBI depression and to provide directions for future research.

METHODS

Key words were used to describe the following search terms: "traumatic brain injury", "depression", "pharmacological/drug therapy", and "neuromodulation". Studies focused on pharmacotherapy or neuromodulation in TBI depression were identified in 5 databases: Medline (PubMed), EMBASE (Embase.com), the Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), PsycINFO (EbscoHost), and Web of Science. Article inclusion/exclusion using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-based systematic protocol of extraction and evaluation was applied. Level of evidence for each study was determined using the American Academy of Neurology criteria.

RESULTS

The initial search provided 1473 citations. Twenty-two studies met inclusion criteria. Sixteen studies explored pharmacological interventions with emphasis on serotonergic agents. Results between studies were conflicting, and interventions did not always outperform placebos, although sertraline provided the highest level of evidence for treatment of TBI depression. Six studies examining neuromodulatory interventions show preliminary evidence of efficacy with a range of interventions and modes of delivery used.

CONCLUSIONS

Additional research including large-sample randomized-controlled trials using pharmacological, neuromodulation, or combination treatment is needed. These studies should incorporate premorbid psychosocial functioning, preinjury psychiatric disease, cognitive deficits, and functional recovery when examining outcomes.

Repetitive transcranial magnetic stimulation in traumatic brain injury: Evidence from animal and human studies

We provide here the first systematic review on the studies dealing with repetitive transcranial magnetic stimulation (rTMS) for traumatic brain injury (TBI) in animals and humans. Several experimental studies in animal models have explored with promising results the use of rTMS to enhance neuroprotection and recovery after TBI. However, there are surprisingly few studies that have obtained substantial evidence regarding effects of rTMS in humans with TBI, many of them are case reports investigating the heterogeneous conditions linked to TBI. The most studies have investigated the effects of rTMS in subjects with post-traumatic depression and variable effects have been observed. rTMS has been proposed as an experimental approach for the treatment of disorders of consciousness (DOC), but in subjects with TBI therapeutic effects on DOC have also been variously documented. Beneficial effects have been reported in subjects with cognitive/emotional disturbances and auditory dysfunction (tinnitus and hallucinations), although the results are somewhat conflicting. rTMS applied over the left prefrontal cortex may relieve, at least transiently, post-traumatic headache. Isolated rTMS studies have been performed in TBI patients with motor impairment, chronic dizziness or pain. Especially whether provided in combination, rTMS and neurorehabilitation may be synergistic in the potential to translate experimental findings in the clinical practice. In order to reach definitive conclusions, well-designed randomized controlled studies with larger patient samples, improved design and optimized rTMS setup, are warranted to verify and corroborate the initial promising findings.