Stanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial.

OBJECTIVE: Depression is the leading cause of disability worldwide, and half of patients with depression have treatment-resistant depression. Intermittent theta-burst stimulation (iTBS) is approved by the U.S. Food and Drug Administration for the treatment of treatment-resistant depression but is limited by suboptimal efficacy and a 6-week duration. The authors addressed these limitations by developing a neuroscience-informed accelerated iTBS protocol, Stanford neuromodulation therapy (SNT; previously referred to as Stanford accelerated intelligent neuromodulation therapy, or SAINT). This protocol was associated with a remission rate of ∼90% after 5 days of open-label treatment. Here, the authors report the results of a sham-controlled double-blind trial of SNT for treatment-resistant depression. METHODS: Participants with treatment-resistant depression currently experiencing moderate to severe depressive episodes were randomly assigned to receive active or sham SNT. Resting-state functional MRI was used to individually target the region of the left dorsolateral prefrontal cortex most functionally anticorrelated with the subgenual anterior cingulate cortex. The primary outcome was score on the Montgomery-Åsberg Depression Rating Scale (MADRS) 4 weeks after treatment. RESULTS: At the planned interim analysis, 32 participants with treatment-resistant depression had been enrolled, and 29 participants who continued to meet inclusion criteria received either active (N=14) or sham (N=15) SNT. The mean percent reduction from baseline in MADRS score 4 weeks after treatment was 52.5% in the active treatment group and 11.1% in the sham treatment group. CONCLUSIONS: SNT, a high-dose iTBS protocol with functional-connectivity-guided targeting, was more effective than sham stimulation for treatment-resistant depression. Further trials are needed to determine SNT's durability and to compare it with other treatments.

Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression.

OBJECTIVE: New antidepressant treatments are needed that are effective, rapid acting, safe, and tolerable. Intermittent theta-burst stimulation (iTBS) is a noninvasive brain stimulation treatment that has been approved by the U.S. Food and Drug Administration for treatment-resistant depression. Recent methodological advances suggest that the current iTBS protocol might be improved through 1) treating patients with multiple sessions per day at optimally spaced intervals, 2) applying a higher overall pulse dose of stimulation, and 3) precision targeting of the left dorsolateral prefrontal cortex (DLPFC) to subgenual anterior cingulate cortex (sgACC) circuit. The authors examined the feasibility, tolerability, and preliminary efficacy of Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT), an accelerated, high-dose resting-state functional connectivity MRI (fcMRI)-guided iTBS protocol for treatment-resistant depression. METHODS: Twenty-two participants with treatment-resistant depression received open-label SAINT. fcMRI was used to individually target the region of the left DLPFC most anticorrelated with sgACC in each participant. Fifty iTBS sessions (1,800 pulses per session, 50-minute intersession interval) were delivered as 10 daily sessions over 5 consecutive days at 90% resting motor threshold (adjusted for cortical depth). Neuropsychological testing was conducted before and after SAINT. RESULTS: One participant withdrew, leaving a sample size of 21. Nineteen of 21 participants (90.5%) met remission criteria (defined as a score <11 on the Montgomery-Åsberg Depression Rating Scale). In the intent-to-treat analysis, 19 of 22 participants (86.4%) met remission criteria. Neuropsychological testing demonstrated no negative cognitive side effects. CONCLUSIONS: SAINT, an accelerated, high-dose, iTBS protocol with fcMRI-guided targeting, was well tolerated and safe. Double-blinded sham-controlled trials are needed to confirm the remission rate observed in this initial study.

Reduced connectivity between mentalizing and mirror systems in autism spectrum condition.

The mentalizing system and mirror system are thought to play important roles in inferring the internal mental states of others - a process known as mentalizing. Autism spectrum condition (ASC) is associated with difficulties in mentalizing. The aim of this study was to determine whether the behavioural difficulties in mentalizing associated with ASC can be explained by changes in functional connectivity between the mentalizing and mirror system. We recruited 40 adult participants (20 with ASC and 20 typically-developing). Brain activity was monitored using functional magnetic resonance imaging while participants watched videos in which actors performed hand actions. The videos were shown in separate mentalizing and non-mentalizing blocks. During mentalizing blocks, participants were asked to indicate whether hand actions were clumsy or spiteful (i.e. to judge the intent of the action). During non-mentalizing blocks, participants indicated whether the actions were successful or unsuccessful (i.e. to judge the outcome of the action). Higher activity during the mentalizing blocks compared to non-mentalizing blocks was found in regions associated with the mentalizing system: the dorsal medial prefrontal cortex (dmPFC) and the temporo-parietal junction (TPJ), as well as in regions typically associated with the mirror system: the inferior frontal gyrus (IFG) and the inferior parietal lobe (IPL). Next, functional connectivity between regions was evaluated as a function of task. During mentalizing blocks, there was increased functional connectivity between the dmPFC and the mirror system in typically developing participants. In contrast, there was no increase in functional connectivity between these regions in ASC participants. Connectivity between the dmPFC and IFG was negatively correlated with autistic traits. The reduced connectivity in ASC participants was consistent with behavioural performance on the mentalizing task, which was also negatively correlated with the level of autistic traits. Together, these data emphasise the importance of functional connectivity between the mentalizing and mirror systems when inferring social intentions and show that reduced connectivity between these systems may explain some of the behavioural difficulties experienced by adults with ASC.

Timing of mirror system activation when inferring the intentions of others.

Neuroimaging studies have shown mirror system (MS) activation when participants infer internal states e.g. emotions, intentions or beliefs (known as 'mentalizing') from others' actions. However, the exact role of the MS in mentalizing tasks is unknown. Dysfunctional MS activation may underlie mentalizing deficits experienced by adults with autism spectrum disorder (ASD). This study investigated the timing of MS activity when inferring intentions in order to delineate between existing models of MS involvement. Single-pulse transcranial magnetic stimulation (TMS) was applied to the primary motor cortex at different time points during the observation of hand actions whilst participants inferred intentions (mentalizing task) and performed a non-mentalizing task. Electromyographic activity in the contralateral hand was used as an indirect measure of MS activity. Greater corticospinal activity was found during the mentalizing task than the non-mentalizing task, but only at the end of observed actions, suggesting late MS involvement in processing intentions. Enhanced corticospinal activity was not related to autistic traits or behavioural performance suggesting the MS has a more automatic role in processing others' intentions, irrespective of mentalizing ability. Our results extend current knowledge of MS activation when mentalizing, allowing initial delineation between different models of MS involvement in mentalizing.

Investigating Mirror System (MS) Activity in Adults with ASD When Inferring Others' Intentions Using Both TMS and EEG.

ASD is associated with mentalizing deficits that may correspond with atypical mirror system (MS) activation. We investigated MS activity in adults with and without ASD when inferring others' intentions using TMS-induced motor evoked potentials (MEPs) and mu suppression measured by EEG. Autistic traits were measured for all participants. Our EEG data show, high levels of autistic traits predicted reduced right mu (8-10 Hz) suppression when mentalizing. Higher left mu (8-10 Hz) suppression was associated with superior mentalizing performances. Eye-tracking and TMS data showed no differences associated with autistic traits. Our data suggest ASD is associated with reduced right MS activity when mentalizing, TMS-induced MEPs and mu suppression measure different aspects of MS functioning and the MS is directly involved in inferring intentions.

Abilities to Explicitly and Implicitly Infer Intentions from Actions in Adults with Autism Spectrum Disorder.

Previous research suggests that Autism Spectrum Disorder (ASD) might be associated with impairments on implicit but not explicit mentalizing tasks. However, such comparisons are made difficult by the heterogeneity of stimuli and the techniques used to measure mentalizing capabilities. We tested the abilities of 34 individuals (17 with ASD) to derive intentions from others' actions during both explicit and implicit tasks and tracked their eye-movements. Adults with ASD displayed explicit but not implicit mentalizing deficits. Adults with ASD displayed typical fixation patterns during both implicit and explicit tasks. These results illustrate an explicit mentalizing deficit in adults with ASD, which cannot be attributed to differences in fixation patterns.