ABSTRACT
There is increasing interest in the use of non-invasive neurostimulation in the treatment of depressive disorder. A recent meta-analysis compared different forms of neurostimulation, and concluded that the effectiveness of different forms of this therapy, for example repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS), was similar to electroconvulsive therapy (ECT). In this comment we discuss these different techniques; we also stress that an unfair comparison has been made between the different forms of neurostimulation. In daily practice, techniques such as ECT, rTMS, and tDCS are used in different patient groups. ECT, in particular, is highly effective in patients suffering from a major depressive disorder with psychotic features, but this patient group has not been sufficiently included in the studies incorporated with a consequent negative bias towards ECT in this meta-analysis.
Subject(s)
Depressive Disorder, Major/therapy , Electroconvulsive Therapy/methods , Outcome Assessment, Health Care/methods , Transcranial Direct Current Stimulation/methods , Transcranial Magnetic Stimulation/methods , Female , Humans , Male , Meta-Analysis as Topic , Treatment OutcomeABSTRACT
BACKGROUND: Since 2017, repetitive transcranial magnetic stimulation (rTMS) has become eligible for reimbursement for the treatment of therapy-resistant depression in the Dutch healthcare system.
AIM: To initiate a guideline in the Netherlands and Belgium for the safe and effective application of rTMS for the treatment of depression.
METHOD: Based on literature review, existing guidelines and consensus among Dutch rTMS experts, recommendations were developed regarding the implementation of rTMS as a treatment of depression. All available evidence was weighed and discussed among all co-authors and recommendations were reached by consensus among the group.
RESULTS: rTMS targeting the dorsolateral prefrontal cortex (DLPFC) should be seen as a first choice in the treatment of depression using high-frequency rTMS (left) or, as an alternative, low-frequency rTMS (right). Stimulation protocols should use more than 1000 pulses per session for an average of 20-30 sessions, offered in 2-5 sessions per week. Contraindications for rTMS include epilepsy, intracranial presence of (magnetisable) metals, pacemaker and cochlear implant.
CONCLUSION: rTMS, performed by competent professionals is an effective and safe treatment for depression.
Subject(s)
Depressive Disorder, Major/therapy , Depressive Disorder, Treatment-Resistant/therapy , Transcranial Magnetic Stimulation/methods , Belgium , Consensus , Humans , Netherlands , Treatment OutcomeABSTRACT
BACKGROUND: At present, the use of repetitive transcranial magnetic stimulation (rtms) for treatment-resistant depression is sufficiently substantiated to be applied in clinical practice. In the Netherlands, it will be reimbursed when offered in combination with cognitive behavior therapy.
AIM: Proposal for a clinical treatment protocol for rtms in The Netherlands.
METHOD: A study of the literature and a critical appraisal of available international guidelines for rtms.
RESULTS: rtms is a safe treatment for patients suffering from a moderate to severe depressive disorder that is relatively treatment-resistant. The duration of the effect is still unknown. It is advised to stimulate the left dorsolateral prefrontal cortex using an intensity of 120% of the resting motor threshold, with a frequency of 10 Hz and using 3000 pulses per session during a total of 20-30 sessions.
CONCLUSION: The proposed treatment protocol is favored based on the available evidence when rtms is used as a treatment aimed to acutely decrease the severity of depressive symptoms. It is further proposed to systematically collect technical and outcome data on treatment with rtms to further improve treatment with rtms in clinical practice.
Subject(s)
Depressive Disorder, Treatment-Resistant/therapy , Transcranial Magnetic Stimulation/methods , Clinical Protocols , Humans , Netherlands , Treatment OutcomeABSTRACT
BACKGROUND: Mood disorders constitute a high burden for both patients and society. Notwithstanding the large arsenal of available treatment options, a considerable group of patients does not remit on current antidepressant treatment. There is an urgent need to develop alternative treatment strategies. Recently, low-strength transcranial pulsed electromagnetic field (tPEMF) stimulation has been purported as a promising strategy for such treatment-resistant depression (TRD). The mode of action of this new technique is however largely unknown. METHODS: We searched PubMed for literature reports on the effects of tPEMF and for information regarding its working mechanism and biological substrate. RESULTS: Most studies more or less connect with the major hypotheses of depression and concern the effects of tPEMF on brain metabolism, neuronal connectivity, brain plasticity, and the immune system. Relatively few studies paid attention to the possible chronobiologic effects of electromagnetic fields. LIMITATIONS: We reviewed the literature of a new and still developing field. Some of the reports involved translational studies, which inevitably limits the reach of the conclusions. CONCLUSION: Weak magnetic fields influence divergent neurobiological processes. The antidepressant effect of tPEMF may be specifically attributable to its effects on local brain activity and connectivity.
Subject(s)
Brain/metabolism , Depression/therapy , Transcranial Magnetic Stimulation/methods , Humans , PubMed/statistics & numerical dataABSTRACT
The in vivo photodegradation of chlorpromazine (CPZ) in the skin was investigated after systemic administration of 3H-CPZ to shaven Wistar rats and exposure to UV-A. Promazine (PZ) and 2-hydroxy-promazine (2-OH-PZ) appeared to be formed in irradiated rats, but not in the skin of rats kept in the dark. This indicates that upon irradiation with UV-A the PZ-radical is formed which can be held responsible for the photobinding to eye and skin constituents as observed earlier [Schoonderwoerd and Beijersbergen von Henegouwen (1987) Photochem. Photobiol. 46, 501-505]. Chlorpromazine-sulfoxide (CPZSO) is a major metabolite of CPZ. Less CPZSO was found in the skin of irradiated rats compared to those kept in the dark. As this appeared not to be caused by photobinding or photodegradation of CPZSO it can be concluded that CPZSO is not a photoproduct of CPZ under these experimental conditions. This study shows that the in vivo photodegradation of CPZ proceeds via the promazinyl radical rather than via the radical cation.
