Transcranial magnetic stimulation for treatment of major depression during pregnancy: a review

Approach to Diagnosis and Management of Treatment-Resistant Depression

Major depressive disorder is a chronic and recurrent illness that affects 20% of adults during their lifetime and is one of the leading causes of suicide in the United States. A systematic measurement-based care approach is the essential first step in the diagnosis and management of treatment-resistant depression (TRD) by promptly identifying individuals with depression and avoiding delays in treatment initiation. As comorbidities may be associated with poorer outcomes to commonly used antidepressants and increase risk of drug-drug interactions, their recognition and treatment is an essential component of management of TRD.

Peripheral endocannabinoid serum level in association with repetitive transcranial magnetic stimulation (rTMS) treatment in patients with major depressive disorder

Repetitive transcranial magnetic stimulation (rTMS) is an effective and well tolerable biological intervention in major depressive disorder (MDD) contributing to rapid symptom improvement. Molecular mechanisms underpinning the therapeutic effects of rTMS have still not been clarified. Recently published animal data implicated relevant associations with changes in endocannabinoid (eCB) brain levels during rTMS treatment, human studies, however, have not been published. In our study we assessed the detailed phenotypic spectrum of MDD and serum 2-arachidnoylglycerol (2-AG) and anandamide (AEA) levels in 18 patients with treatment-resistant depression before, immediately following, and two weeks after completion of a 10-day rTMS treatment. We found significant associations between serum 2-AG level changes from pretreatment to 2 weeks after treatment and symptom reduction. The greater the increase of 2-AG levels, the greater the improvement of depressive (p = 0.031), anxious (p = 0.007) and anhedonia symptoms (p = 0.047). Here we report for the first time a significant association of human circulating eCB and antidepressant effect of rTMS. Our data may indicate that direct stimulation of targeted brain areas can rapidly alleviate depressive complaints via activation of the eCB system.

Repetitive transcranial magnetic stimulation treatment for peripartum depression: systematic review & meta-analysis

Background

Peripartum depression is a common disorder with very high potential hazards for both the patients and their babies. The typical treatment options include antidepressants and electroconvulsive therapy. However, these treatments do not ensure the safety of the fetus. Recently, repetitive transcranial magnetic stimulation has emerged as a promising treatment for neuropathies as well as depression. Nevertheless, many studies excluded pregnant women. This systematic review was conducted to confirm whether repetitive transcranial magnetic stimulation was a suitable treatment option for peripartum depression.

Methods

We performed a systematic review that followed the PRISMA guidelines. We searched for studies in the MEDLINE, PsycINFO, EMBASE, and Cochrane library databases published until the end of September 2020. Eleven studies were selected for the systematic review, and five studies were selected for quantitative synthesis. Data analysis was conducted using Comprehensive Meta-Analysis 3 software. The effect size was analyzed using the standardized mean difference, and the 95% confidence interval (CI) was determined by the generic inverse variance estimation method.

Results

The therapeutic effect size of repetitive transcranial magnetic stimulation for peripartum depression was 1.394 (95% CI: 0.944–1.843), and the sensitivity analysis effect size was 1.074 (95% CI: 0.689–1.459), indicating a significant effect. The side effect size of repetitive transcranial magnetic stimulation for peripartum depression was 0.346 (95% CI: 0.214–0.506), a meaningful result. There were no severe side effects to the mothers or fetuses.

Conclusions

From various perspectives, repetitive transcranial magnetic stimulation can be considered an alternative treatment to treat peripartum depression to avoid exposure of fetuses to drugs and the severe side effects of electroconvulsive therapy. Further research is required to increase confidence in the results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03600-3.

Efficacy and safety of repetitive transcranial magnetic stimulation for peripartum depression: A meta-analysis of randomized controlled trials

This study aims to summarize and systematically review the efficacy and safety of repetitive transcranial magnetic stimulation (rTMS) for women with peripartum depression (PPD). Several databases (Wanfang, CNKI, VIP, CBM, PubMed, Embase, Cochrane Library, PsyINFO, Web of Science, and Clinical trial) were searched from inception until April 12, 2020. In total, ten randomized controlled trials (RCTs) met the eligibility criteria and were included in this systematic review. We calculated the combined effect size (standardized mean difference [SMD] and odds ratio [OR]) for the corresponding effects models. The aggregated result of 10 trials indicated a significant benefit of rTMS on PPD, and the aggregated result of remission showed significantly positive effects of Test group VS. Control group. In terms of treatment adverse effects, the aggregated result showed no statistical significance of headache and dry mouth between the two groups. The results of the meta-analysis suggest that rTMS is an effective and safe intervention for PPD. Owing to poor methodological quality among the included studies, high-quality multicenter RCTs are needed to further verify the effects of this treatment.

The impact of repetitive transcranial magnetic stimulation and fluoxetine on the brain lipidome in a rat model of chronic unpredictable stress

The antidepressant effect of repetitive transcranial magnetic stimulation (rTMS) has been extensively studied; growing evidence suggests that changes in lipid composition may be involved in the pathogenesis of depression and may be a targeted mechanism for treatment. However, the influence of rTMS on lipid composition and the differences between these effects compared to antidepressants like fluoxetine (Flx) have never been investigated. Using a chronic unpredictable stress (CUS) model in rats, we assessed the antidepressive effects of rTMS and Flx treatments and evaluated changes in lipid composition in the hippocampus and prefrontal cortex (PFC) using a mass spectrometry-based lipidomic approach. Both rTMS and Flx treatments ameliorated depressive-like behaviors induced by CUS. Moreover, changes in lipid composition, especially glycerophospholipids, sphingolipids, and glycerolipids induced by CUS in the hippocampus were more robust than those observed in the PFC. CUS led to decreased levels of 20 carbon-containing fatty acyls and polyunsaturated fatty acyls in the PFC, and decreased levels of acyl carnitines (AcCa) in both the hippocampus and PFC. Notably, rTMS treatment had higher impact than Flx on composition of glycerophospholipids and sphingolipids in the hippocampus that were altered by CUS, while Flx attenuated CUS-induced changes in the PFC to a greater extent than rTMS. However, neither was able to restore fatty acyls and AcCa to baseline levels. Altogether, modulation of the brain lipidome may be involved in the antidepressant action of rTMS and Flx, and the degree to which these treatments induce changes in lipid composition within the hippocampus and PFC might explain their differential antidepressant effects.

Transcranial magnetic stimulation in the treatment of depression during pregnancy: a review

The aim of this study is to elucidate the role of repetitive transcranial magnetic stimulation (rTMS) for treating depression during pregnancy. The treatment of depression in pregnant women poses a number of therapeutic challenges. Psychotherapy can be beneficial but is associated with limited availability and possibly an onset of effect which may be too long to be acceptable. Pharmacotherapy is limited by concerns of fetotoxicity, both real and possibly exaggerated in the view of patients and caregivers alike. While efficacy and safety of rTMS are well established for the treatment of depression, the available data for use in pregnancy is still sparse. We reviewed the available literature on the topic on PubMed. In addition to a number of case reports, three studies concerning the treatment of depressed pregnant women with rTMS are available. According to the data, rTMS seems to be safe for both the pregnant woman and her unborn offspring. No obstetric complications or adverse postnatal effects on development have been reported. rTMS alleviated depressive symptoms better than sham treatment in one study. rTMS seems to be safe and effective in treating depression in pregnant women. Further studies with larger numbers of participants are warranted to further clarify the significance of rTMS for the treatment of depression in pregnancy.

"A systematic review of non-invasive neurostimulation for the treatment of depression during pregnancy"

BACKGROUND

Antidepressant use in pregnancy is associated with high levels of decision-making difficulty for patients, and psychotherapy may not be effective for severe symptoms. Alternative treatment options are needed. We conducted a systematic review of the clinical effects and tolerability of non-invasive neurostimulation: repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), transcranial alternating current stimulation (tACS), trigeminal nerve stimulation (TNS), and transcutaneous vagus nerve stimulation (tVNS) for the treatment of antenatal depression.

METHODS

We searched PubMed, Google Scholar and Scopus for published articles in English (1990 to June 2019). Two reviewers reviewed full-text articles, assessed quality, and extracted data on maternal psychiatric, pregnancy and neonatal outcomes.

RESULTS

Of 565 articles, 21 met inclusion criteria: two RCTs (1 rTMS; 1 tDCS), four open-label studies (3 rTMS; 1 tDCS), three case series (3 rTMS), and twelve case reports (9 rTMS; 1 tDCS; 1 tACS; 1 TNS). In all but one published study (1 rTMS), non-invasive neurostimulation resulted in either response or remission of antenatal depression. Minor maternal side effects were reported in rTMS and tDCS studies, but not in other modalities. Fetal adverse effects were not reported in any intervention. A small proportion of participants dropped out of treatment (rTMS, tDCS).

LIMITATIONS

Very few randomized trials have been conducted and there is significant heterogeneity in the parameters of the modalities that have been studied.

CONCLUSIONS

Non-invasive neurostimulation holds promise as a potentially effective and feasible alternative treatment for antenatal depression. Strategies to enhance recruitment of pregnant women into non-invasive neurostimulation trials that have longitudinal follow-up are needed.

Repetitive high-frequency transcranial magnetic stimulation reverses depressive-like behaviors and protein expression at hippocampal synapses in chronic unpredictable stress-treated rats by enhancing endocannabinoid signaling

The anti-depressant effect of repetitive transcranial magnetic stimulation (rTMS), a clinically-useful treatment for depression, is associated with changes to the endocannabinoid system (ECS). However, it is currently unknown whether different frequencies of rTMS alter the ECS differently. To test this, rats exposed to chronic unpredictable stress (CUS) were treated with rTMS at two different frequencies (5 (high) or 1 Hz (low), 1.26 Tesla) for 7 consecutive days. Twenty-four hours after the final rTMS treatment, we evaluated depressive-like behaviors and the expression of several synaptic proteins and ECS-related proteins in the hippocampus. In addition, we knocked-down diacylglycerol lipase alpha (DAGLα) and cannabinoid type 1 receptor (CB1R), two important components of the ECS, and measured depressive-like behaviors and synaptic protein expression following rTMS. Furthermore, we measured the expression levels of several components of the ECS system in hippocampal-derived astrocytes and neurons exposed to repetitive magnetic stimulation (rMS) with different parameters (5 or 1 Hz, 0.84 or 1.26 Tesla). Interestingly, we found that only high-frequency rTMS ameliorated depressive-like behaviors and normalized the expression of hippocampal synaptic proteins in CUS-treated rats; this effect was eliminated by knockdown of DAGLα or CB1R. Moreover, we found that rMS at 5 Hz increased the expression of DAGLα and CB1R in hippocampal astrocytes and neurons. Collectively, our results suggest that high-frequency rTMS exerts its anti-depressant effect by up-regulating DAGLα and CB1R.

Repetitive transcranial magnetic stimulation treatment for depressive disorders: current knowledge and future directions

PURPOSE OF REVIEW

After three decades of clinical research on repetitive transcranial magnetic stimulation (rTMS), major depressive disorder (MDD) has proven to be the primary field of application. MDD poses a major challenge for health systems worldwide, emphasizing the need for improving clinical efficacy of existing rTMS applications and promoting the development of novel evidence-based rTMS treatment approaches.

RECENT FINDINGS

Several promising new avenues have been proposed: novel stimulation patterns, targets, and coils; combinatory treatments and maintenance; and personalization and stratification of rTMS parameters, and treatment of subpopulations.

SUMMARY

This opinion review summarizes current knowledge in the field and addresses the future direction of rTMS treatment in MDD, facilitating the establishment of this clinical intervention method as a standard treatment option and continuing to improve response and remission rates, and take the necessary steps to personalize rTMS-based treatment approaches.

Efficacy of repetitive transcranial magnetic stimulation in treatment-resistant depression: the evidence thus far

Depression is a common mental disorder, which attributes to significant morbidity, disability and burden of care. A significant number of patients with depression still remain symptomatic after adequate trials of antidepressant treatment as well as psychotherapy, which is often referred to as treatment-resistant depression. Neuromodulation techniques-like electroconvulsive therapy, vagus nerve stimulation, transcranial magnetic stimulation (TMS) and transcranial direct current stimulation, may be useful augmenting techniques in depression, mostly recommended for treatment-resistant cases. Robust evidence exists regarding the efficacy of electroconvulsive therapy in the management of treatment-resistant depression; however, other techniques are understudied. TMS has been increasingly studied in various psychiatric disorders including depression. It has been approved by the US Food and Drug Administration for use in major depressive disorder. Over the past two decades, TMS has been studied in diverse groups of the population with depression using several research designs. This article gives an overview of the efficacy of repetitive TMS in treatment-resistant depression with the recent evidence.

A systematic review of the safety and effectiveness of repetitive transcranial magnetic stimulation in the treatment of peripartum depression

BACKGROUND

Repetitive Transcranial Magnetic Stimulation (rTMS) is an efficacious treatment for major depressive disorder (MDD), however there is limited safety and efficacy data in the peripartum period. The purpose of this review is to systematically examine the safety, acceptability and effectiveness of rTMS administered during the peripartum period as an intervention for MDD.

METHODS

We searched MEDLINE, EMBASE and PsychINFO from 2008 to January 2019 to identify peer reviewed publications evaluating rTMS during the peripartum period as an intervention for peripartum MDD. We systematically extracted reported adverse events, side effects, rates of discontinuation, as well as clinical response and remission.

RESULTS

Data was synthesized from 1 randomized control trial, 3 uncontrolled trials, 3 case series and 5 case studies, representing a total of 87 patients. No serious adverse events were reported. Side effects occurred at rates comparable to those observed in the non-peripartum population, and obstetric and neonatal complications are infrequent and do not separate from sham-rTMS. Randomized controlled data suggests antidepressant efficacy with an effect size of 0.87. Uncontrolled studies report rates of clinical response between 41.4% and 71.4%, and rates of clinical remission between 20.7 and 30.0%. The treatment appears acceptable, with few patients opting to discontinue treatment.

LIMITATIONS

Due to the paucity of research in this population, majority of data comes from sources with inherently higher risk of bias.

CONCLUSIONS

rTMS in the peripartum period appears to be efficacious, acceptable and well tolerated. Additional research is required, however rTMS's risk benefit profile may be attractive to women in the peripartum period.

The Effect of sequential bilateral low-frequency rTMS over dorsolateral prefrontal cortex on serum level of BDNF and GABA in patients with primary insomnia

OBJECTIVE

This study aimed to investigate the effect of sequential bilateral low-frequency repetitive transcranial magnetic stimulation (rTMS) over dorsolateral prefrontal cortex (DLPFC) on patients with primary insomnia (PI).

METHODS

A total of 32 eligible right-handed participants diagnosed by PI according to International classification of sleep disorders (ICD-3) were recruited into this study. Participants received 10 daily sessions of sequential bilateral 1 Hz rTMS over DLPFC. Before and after the whole procedure of rTMS, patients were assessed by Pittsburgh Sleep Quality Index (PSQI) for the severity of sleep disturbance. Meanwhile, serum concentration of brain-derived neurotrophic factor (BDNF) and gamma-aminobutyric acid (GABA) in patients was measured by ELISA and UPLC, respectively. Moreover, the amplitude of MEPs reflecting the right cortical excitability was examined. Finally, Pearson correlation analysis was performed to evaluate the correlation among the change of these variables.

RESULTS

After rTMS treatment, the PSQI score was markedly decreased as compared to pre-rTMS; the concentrations of serum BDNF and GABA were significantly higher; the amplitude of MEPs was markedly reduced. Pearson correlation analysis revealed that the change of PSQI score was negatively associated with the alteration of serum BDNF level and serum GABA level, and positively associated with the change of MEPs amplitude; the change of MEPs amplitude was negatively associated with fold change in the serum BDNF level and the serum GABA level; the increase in serum GABA level was positively associated with the serum BDNF level.

CONCLUSIONS

A sequential bilateral low-frequency rTMS over DLPFC significantly improves primary insomnia probably by increasing the level of BDNF and GABA in the brain and reducing cortical excitability.

Transcranial Direct Current Stimulation (tDCS) for Depression during Pregnancy: Scientific Evidence and What Is Being Said in the Media-A Systematic Review

Major depression is the most frequent morbidity in pregnancy. The first-line therapies, psychopharmacologic treatment and psychotherapy, are either insufficient or may cause severe or teratogenic adverse events. As a result of its local limitation to the patient’s brain, transcranial direct current stimulation (tDCS) could potentially be an ideal treatment for pregnant women with depression. A literature search was conducted in medical databases, globally published newspapers, search engines, and clinical trial registers to collect all articles on tDCS for the treatment of depression during pregnancy. The aim of this review was to investigate the scientific evidence of tDCS use for depression during pregnancy and to compare these results with the textual and emotional perception in the media as interventions during pregnancy are under particular surveillance. We detected 13 medical articles dealing with tDCS for depression in pregnancy. Overall, the scientific evidence as well as articles in the media for tDCS in pregnancy are sparse, but promising. Further studies are required in this specifically vulnerable population of pregnant women to generate evidence. It is likely that public interest will increase when the results of a pilot study in Canada are published.

Oscillatory Activities in Neurological Disorders of Elderly: Biomarkers to Target for Neuromodulation

Non-invasive brain stimulation (NIBS) has been under investigation as adjunct treatment of various neurological disorders with variable success. One challenge is the limited knowledge on what would be effective neuronal targets for an intervention, combined with limited knowledge on the neuronal mechanisms of NIBS. Motivated on the one hand by recent evidence that oscillatory activities in neural systems play a role in orchestrating brain functions and dysfunctions, in particular those of neurological disorders specific of elderly patients, and on the other hand that NIBS techniques may be used to interact with these brain oscillations in a controlled way, we here explore the potential of modulating brain oscillations as an effective strategy for clinical NIBS interventions. We first review the evidence for abnormal oscillatory profiles to be associated with a range of neurological disorders of elderly (e.g., Parkinson's disease (PD), Alzheimer's disease (AD), stroke, epilepsy), and for these signals of abnormal network activity to normalize with treatment, and/or to be predictive of disease progression or recovery. We then ask the question to what extent existing NIBS protocols have been tailored to interact with these oscillations and possibly associated dysfunctions. Our review shows that, despite evidence for both reliable neurophysiological markers of specific oscillatory dis-functionalities in neurological disorders and NIBS protocols potentially able to interact with them, there are few applications of NIBS aiming to explore clinical outcomes of this interaction. Our review article aims to point out oscillatory markers of neurological, which are also suitable targets for modification by NIBS, in order to facilitate in future studies the matching of technical application to clinical targets.