Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of repetitive transcranial magnetic stimulation.

OBJECTIVES: To provide guidance for the optimal administration of repetitive transcranial magnetic stimulation, based on scientific evidence and supplemented by expert clinical consensus. METHODS: Articles and information were sourced from existing guidelines and published literature. The findings were then formulated into consensus-based recommendations and guidance by the authors. The guidelines were subjected to rigorous successive consultation within the RANZCP, involving the Section of ECT and Neurostimulation (SEN) Committee, its broader membership and expert committees. RESULTS: The RANZCP professional practice guidelines (PPG) for the administration of rTMS provide up-to-date advice regarding the use of rTMS in clinical practice. The guidelines are intended for use by psychiatrists and non-psychiatrists engaged in the administration of rTMS to facilitate best practice to optimise outcomes for patients. The guidelines strive to find the appropriate balance between promoting best evidence-based practice and acknowledging that evidence for rTMS use is a continually evolving. CONCLUSION: The guidelines provide up-to-date advice for psychiatrists and non-psychiatrists to promote optimal standards of rTMS practice.

Do benzodiazepines reduce the efficacy of transcranial magnetic stimulation?

OBJECTIVE: To investigate the effect of concomitant use of benzodiazepines on the efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with treatment-resistant major depressive disorder (TR-MDD). METHODS: This is a retrospective study comparing rTMS treatment outcomes between patients taking benzodiazepines (n = 59) and those who were not (n = 136). Participants completed the HAM-A, HAM-D17, MADRS and ZUNG at baseline and at the end of treatment. RESULTS: Patients taking benzodiazepines during rTMS treatment did not show any difference in partial response, response or remission rates compared to patients not treated with benzodiazepines. There was a significant decrease (p < .0001) in depression and anxiety scores from baseline to post-treatment among both groups. CONCLUSIONS: Concomitant benzodiazepine treatment had no effect on the efficacy of rTMS treatment of TRD, contrary to previous research.

Electroconvulsive Therapy Credentialing for Psychiatrists-Review of Required Standards Across States and Territories in Australia.

ABSTRACT: Electroconvulsive therapy (ECT) is a complex medical procedure, the delivery of which requires specialist knowledge and skills. We reviewed the standards required for ECT credentialing in different jurisdictions in Australia. We reviewed the Chief Psychiatrist guidelines and statewide policy standards on ECT and focused on standards required for initial credentialing and ongoing privileging in ECT. We compared the credentialing requirements within these documents with the standards specified in the Royal Australian and New Zealand College of Psychiatrists professional practice guideline for ECT. Most of the jurisdictions had specific standards for initial credentialing and maintenance of this credentialing; however, there was significant variance in the credentialing process and standards required. It would be useful to have a minimum standard for credentialing for ECT psychiatrists and prescribers. This standard would be relevant for practice of ECT internationally. States and territories would have the responsibility for implementation of these standards. Appropriate training and establishing good clinical governance processes are essential to the provision of high quality ECT.

Attitudes of South Australian psychiatrists towards attention deficit hyperactivity disorder in adults.

OBJECTIVE: A lack of access to psychiatric services for adult ADHD is a recognised issue in South Australia and nationally. This study aims to explore the practices of local psychiatrists and their attitudes towards adult ADHD, with a view to determining any barriers influencing accessibility to treatment. METHODS: We developed an online survey to examine the aims of the study. Free text boxes were included to obtain qualitative data. Quantitative data were tallied and presented as percentages. Qualitative data (free text responses) were analysed thematically. RESULTS: 73 out of 322 psychiatrists responded (22.7%). The greatest barrier to seeing adult ADHD was the fear of being inundated with cases (68.5%), followed by lack of experience managing ADHD (32.9%), and potential drug-seeking behaviour of patients (31.5%). Two overarching qualitative themes were identified: practical barriers and attitudinal barriers. CONCLUSION: ADHD service provision is complex and relates to many systemic factors such as public versus private, funding, and service organisation. More psychiatrists need to become involved in treating ADHD so that the work is more widely spread. Increased training in ADHD is also needed to increase confidence in managing the condition.

Prescribing electroconvulsive therapy for depression: Not as simple as it used to be.

In the last century, prescribing electroconvulsive therapy usually involved considering the relative merits of unilateral versus bilateral electroconvulsive therapy, with most other parameters fixed. However, research over the last 30 years has discovered that several parameters of the electroconvulsive therapy stimulus can have a significant impact on efficacy and cognitive side effects. The stimulus dose relative to seizure threshold was shown to significantly affect efficacy, especially for right unilateral electroconvulsive therapy, where suprathreshold doses in the vicinity of 5-6 times seizure threshold were far more efficacious than doses closer to threshold. However, this did not hold for bitemporal electroconvulsive therapy, where near-threshold stimuli were equally effective as suprathreshold stimuli. Then, changes in stimulus pulse width were found to also have a significant impact on both efficacy and side effects, with ultrabrief pulse widths of 0.3 ms having significantly fewer cognitive side effects in unilateral electroconvulsive therapy than standard brief pulse widths of 1.0 ms, with only slightly reduced efficacy. Therefore, choosing the optimum electroconvulsive therapy prescription for an individual patient now requires consideration of placement, pulse width and stimulus dose relative to seizure threshold, and how these three interact with each other. This viewpoint aims to raise awareness of these issues for psychiatrists involved in electroconvulsive therapy practice.

Seizure EEG Quality in Right Unilateral Ultrabrief ECT.

OBJECTIVE: The aims of this study were to compare threshold and suprathreshold ictal electroencephalograms (EEGs) in right unilateral (RUL) ultrabrief (UB) electroconvulsive therapy (ECT) and to identify the differences between these EEGs. METHODS: This study is a retrospective review of 125 pairs EEGs from titration and subsequent sessions across a 2-year period. All EEGs were independently rated for by 2 assessors using a scale based on qualities of an EEG used to guide ECT treatment dose adequacy, for example, midictal amplitude, regularity, interhemispheric coherence, seizure end point, and postictal suppression. The scores of threshold and suprathreshold EEGs were compared within and between groups based on 2 ECT types, that is, RUL UB ECT and RUL brief pulse (BP) ECT. RESULTS: Paired t tests showed a statistically significant difference in between threshold and suprathreshold EEG scores in RUL UB ECT. There were no statistically significant differences between corresponding scores for RUL UB ECT and RUL BP ECT threshold and suprathreshold EEGs. CONCLUSIONS: There is a significant difference between the quality of threshold and suprathreshold EEGs in RUL UB ECT when measured with an EEG rating scale. Visual rating of ictal EEGs is as reliable in discriminating between threshold and suprathreshold seizure in RUL UB ECT as it is in RUL BP ECT.

Revisiting the effectiveness of repetitive transcranial magnetic stimulation treatment in depression, again.

Following on from the publication of the Royal Australian and New Zealand Journal of Psychiatry Mood Disorder Clinical Practice Guidelines (2020) and criticisms of how these aberrantly addressed repetitive transcranial magnetic stimulation treatment of depression, questions have continued to be raised in the journal about this treatment by a small group of authors, whose views we contend do not reflect the broad acceptance of this treatment nationally and internationally. In fact, the evidence supporting the use of repetitive transcranial magnetic stimulation treatment in depression is unambiguous and substantial, consisting of an extensive series of clinical trials supported by multiple meta-analyses, network meta-analysis and umbrella reviews. Importantly, the use of repetitive transcranial magnetic stimulation treatment in depression has also been subject to a series of health economic analyses. These indicate that repetitive transcranial magnetic stimulation is a cost-effective therapy and have been used in some jurisdictions, including Australia, in support of public funding. An argument has been made that offering repetitive transcranial magnetic stimulation treatment may delay potentially effective pharmacotherapy. In fact, there is considerably greater danger of the opposite happening. Repetitive transcranial magnetic stimulation is as, if not more effective, than antidepressant medication after two unsuccessful medication trials and should be a consideration for all patients under these circumstances where available. There is no meaningful ongoing debate about the use of repetitive transcranial magnetic stimulation treatment in depression - it is a safe, effective and cost-effective treatment.

Accelerated theta burst stimulation for the treatment of depression: A randomised controlled trial.

INTRODUCTION: Theta burst pattern repetitive transcranial magnetic stimulation (TBS) is increasingly applied to treat depression. TBS's brevity is well-suited to application in accelerated schedules. Sizeable trials of accelerated TBS are lacking; and optimal TBS parameters such as stimulation intensity are not established. METHODS: We conducted a three arm, single blind, randomised, controlled, multi-site trial comparing accelerated bilateral TBS applied at 80 % or 120 % of the resting motor threshold and left unilateral 10 Hz rTMS. 300 patients with treatment-resistant depression (TRD) were recruited. TBS arms applied 20 bilateral prefrontal TBS sessions over 10 days, while the rTMS arm applied 20 daily sessions of 10 Hz rTMS to the left prefrontal cortex over 4 weeks. Primary outcome was depression treatment response at week 4. RESULTS: The overall treatment response rate was 43.7 % and the remission rate was 28.2 %. There were no significant differences for response (p = 0.180) or remission (p = 0.316) across the three groups. Response rates between accelerated bilateral TBS applied at sub- and supra-threshold intensities were not significantly different (p = 0.319). Linear mixed model analysis showed a significant effect of time (p < 0.01), but not rTMS type (p = 0.680). CONCLUSION: This is the largest accelerated bilateral TBS study to date and provides evidence that it is effective and safe in treating TRD. The accelerated application of TBS was not associated with more rapid antidepressant effects. Bilateral sequential TBS did not have superior antidepressant effect to unilateral 10 Hz rTMS. There was no significant difference in antidepressant efficacy between sub- and supra-threshold accelerated bilateral TBS.

The place of non-invasive brain stimulation in the RANZCP clinical practice guidelines for mood disorders.

Clinical practice guidelines are important documents as they have the capacity to significantly influence and shape clinical practice in important areas of therapeutics. As such, they need to be developed informed by comprehensive and quality-based systematic reviews, involve consensus deliberations representative of the appropriate experts in the field and be subject to thorough critical review. A revised clinical practice guideline for the management of patients with mood disorders was recently published under the auspices of the Royal Australian and New Zealand College of Psychiatrists. However, this clinical practice guideline was not developed in a manner that reflects the appropriate standards that should apply to clinical practice guideline development and it has critical flaws, especially as it pertains to the use of repetitive transcranial magnetic stimulation treatment for patients with depression. The revision of the college clinical practice guideline has explicitly removed clear and unequivocal evidence-based recommendations that were found in a previous version of the clinical practice guideline and replaced these with consensus-based recommendations. However, the consensus-based recommendations were developed without consultation of the appropriate expert body within the college and contradict the scientific literature. There is substantive and unequivocal evidence supporting the antidepressant use of repetitive transcranial magnetic stimulation in the treatment of patients with depression and its use after a patient with depression has failed a limited number (typically around two) of antidepressant medication trials. Readers should refer to the college Professional Practice Guidelines for repetitive transcranial magnetic stimulation published in 2018 for thorough information about the use of this important new treatment.

A comparison of 15 minute vs 30 minute repetitive transcranial magnetic stimulation sessions for treatment resistant depression - are longer treatment sessions more effective?

BACKGROUND: Repetitive Transcranial Magnetic Stimulation (rTMS) is a safe and effective treatment for treatment resistant depression (TRD). The number of patients able to be treated with rTMS is determined by the availability of the machine and staff. If treatment delivered in a shorter time were just as effective as longer treatments, then more patients could be treated with the same resources. METHOD: This naturalistic study investigated 145 first-time patients treated with 15 minute (900 pulses) or 30 minute (1800 pulses) RLF rTMS for TRD 3 days/week for 6 weeks. Response and remission rates for the two groups were compared. We investigated whether longer right unilateral low (1Hz) frequency (RLF) repetitive transcranial magnetic stimulation (rTMS) treatment sessions are more effective than shorter sessions in achieving response and remission for treatment resistant depression (TRD). RESULTS: The duration of rTMS treatment sessions had no effect on treatment outcomes over the course of 6 weeks. The group treated with 15 minute rTMS sessions showed a partial response rate of 28.2%, a response rate of 11.5% and remission rate of 21.8%, which did not differ significantly from patients receiving 30 minute sessions who had a partial response rate of 25.4%, response rate of 17.9% and remission rate of 22.4%. LIMITATIONS: Participants were not randomized and the inclusion criteria were broad and reflected the nature of patients seen in routine practice. CONCLUSIONS: Fifteen minute rTMS sessions 3 days/week for 6 weeks were as effective as 30 minute sessions, providing a pragmatic advantage for shorter treatments.

Up-to-date review of psychotherapy via videoconference: implications and recommendations for the RANZCP Psychotherapy Written Case during the COVID-19 pandemic.

OBJECTIVE: There has been a surge in videoconferencing technology use in response to the COVID-19 pandemic. RANZCP registrars engaged in the Psychotherapy Written Case are met with new challenges in navigating the psychodynamic processes that can occur when transitioning from in-person to videoconferencing psychotherapy. There is also a myriad of videoconferencing platforms to choose from. CONCLUSION: It has become necessary to adapt our clinical practice to the current COVID-19 pandemic and physical distancing regulations. The literature recognises videoconferencing psychotherapy as a valid therapeutic medium which can facilitate healthy psychological maturation, but there are theoretical drawbacks. A transition to videoconferencing psychotherapy requires patient agreeability, consistency and reflection upon patient-therapist dynamics; this will aide in the Psychotherapy Written Case submission. Registrars must balance usability, digital security and patient preferences when choosing videoconferencing platforms.

Efficacy of repetitive transcranial magnetic stimulation in the treatment of depression with comorbid anxiety disorders.

BACKGROUND: The presence of comorbid anxiety is generally associated with poorer treatment outcomes in people with depression. Repetitive transcranial magnetic stimulation (rTMS) has been shown to be effective for treatment resistant depression, but there has been little research examining rTMS in depressed patients with comorbid anxiety disorders. This study aimed to investigate the efficacy of rTMS in patients with treatment resistant Major Depressive Disorder (MDD) and comorbid anxiety disorders. METHODS: This study included 248 patients with treatment resistant MDD who were treated with rTMS. Of these, 172 patients had one or more comorbid anxiety disorders, so their outcomes were compared with patients who did not have comorbid anxiety. RESULTS: Patients both with and without comorbid anxiety disorders showed improvement in depression ratings after rTMS treatment, with no significant difference in remission rates between groups. In those with comorbid anxiety disorders, 23.3% met criteria for remission and 39.5% met response criteria. For each anxiety disorder diagnosis, there was a significant reduction in HAM-A, HAM-D21, MADRS and ZUNG scores (p = <0.001 for all). LIMITATIONS: This was not a sham-controlled study, so placebo response rates are not known. Patients were referred by private psychiatrists so are not representative of all patients with depression. CONCLUSION: Our study indicates that rTMS is an effective treatment for Major Depressive Disorder in people who have comorbid anxiety disorders.

Clinical Practice Recommendations for Continuation and Maintenance Electroconvulsive Therapy for Depression: Outcomes From a Review of the Evidence and a Consensus Workshop Held in Australia in May 2017.

OBJECTIVES: Continuation or maintenance electroconvulsive therapy (ECT) is often provided as a strategy for post-ECT relapse prevention. However, the evidence has been insufficient until recently to produce clear consensus on what best practice maintenance ECT (mECT) should be like in a real world ECT clinical service. The aims of this article are to help fill this gap and to provide a comprehensive set of practical, clinically-based recommendations for ECT clinicians and services. METHODS: A workshop was held at the Royal Australian and New Zealand College of Psychiatry Congress in Adelaide on April 30, 2017. This workshop was hosted by the authors. After a presentation on the state of the evidence, the 30 participants were asked to work in small groups to develop consensus recommendations on different aspects of mECT. These were then collated into one comprehensive set of clinical recommendations for the practice of mECT. RESULTS: These best practice recommendations are set out below. CONCLUSIONS: These recommendations will assist ECT services and clinicians to provide best practice mECT according to currently available evidence.

Does rTMS reduce depressive symptoms in young people who have not responded to antidepressants?

AIM: Depression is common in young people, and there is a need for safe, effective treatments. This study examined the efficacy of repetitive transcranial magnetic stimulation in a sample of young people aged 17 to 25 years. METHODS: This retrospective study included 15 people aged 17 to 25 years referred by their private psychiatrists affiliated with Ramsay Health Care, South Australia Mental Health Services. All patients met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for treatment-resistant Major Depressive Disorder. Eleven patients received right unilateral treatment and four patients received bilateral treatment. Patients were assessed at baseline and after treatment. RESULTS: There was a significant improvement on the Hamilton Rating Scale for Depression (t(14) = 4.71, P < 0.0001); Montgomery-Åsperg Depression Rating Scale (t(14) = 3.96, P < 0.01) and the Zung Self-Rating Depression Scale (t(14) = 4.13, P < 0.01). There was no difference in response by gender or age. The response rates in these young people did not differ significantly from those of adults aged 25 to 82 years. CONCLUSION: This open label, naturalistic study suggests that repetitive transcranial magnetic stimulation is an effective treatment in young adults who have treatment-resistant depression. Randomized sham-controlled studies are needed to further investigate the efficacy of this treatment in this age group.

Facilitated Learning Groups: an initiative to enhance psychiatric training in South Australia.

OBJECTIVES:: Facilitated Learning Groups (FLGs) were introduced by the South Australian Psychiatry Branch Training Committee in 2016 to provide support for trainees. These incorporated Balint group principles but also had roles that extended beyond a traditional Balint group. This paper reports an evaluation of these groups after their first 12 months. METHODS:: An evaluation form was sent to all trainee participants, seeking quantitative and qualitative feedback about their experience. RESULTS:: The majority of trainees found the FLGs to be beneficial. A thematic analysis of the written feedback revealed several key benefits for the participants, including having access to a senior psychiatrist who was outside of training and supervision, mixing with trainees across years and regions, and the capacity to discuss difficult work environments. CONCLUSIONS:: A forum for trainees to develop reflective practice and discuss challenging issues, which is not involved in their assessment, was experienced positively by the majority of participants and should be considered for wider adoption across Australia and New Zealand.

A Comparison of Right Unilateral and Sequential Bilateral Repetitive Transcranial Magnetic Stimulation for Major Depression: A Naturalistic Clinical Australian Study.

BACKGROUND: A great deal of research has established the efficacy of repetitive transcranial magnetic stimulation (rTMS) in the treatment of depression. However, questions remain about the optimal method to deliver treatment. One area requiring consideration is the difference in efficacy between bilateral and unilateral treatment protocols. OBJECTIVE: This study aimed to compare the effectiveness of sequential bilateral rTMS and right unilateral rTMS. METHODS: A total of 135 patients participated in the study, receiving either bilateral rTMS (N = 57) or right unilateral rTMS (N = 78). Treatment response was assessed using the Hamilton depression rating scale. RESULTS: Sequential bilateral rTMS had a higher response rate than right unilateral (43.9% vs 30.8%), but this difference was not statistically significant. This was also the case for remission rates (33.3% vs 21.8%, respectively). Controlling for pretreatment severity of depression, the results did not indicate a significant difference between the protocols with regard to posttreatment Hamilton depression rating scale scores. CONCLUSIONS: The current study found no statistically significant differences in response and remission rates between sequential bilateral rTMS and right unilateral rTMS. Given the shorter treatment time and the greater safety and tolerability of right unilateral rTMS, this may be a better choice than bilateral treatment in clinical settings.