Medicare Benefits Schedule item numbers for transcranial magnetic stimulation (TMS): Questions arising.

OBJECTIVE: Four Medicare Benefits Schedule item numbers for Transcranial Magnetic Stimulation (TMS) treatment of unresponsive MDD were declared in Australia in 2021. They are accompanied by rules/conditions. The aim is to consider these rules/conditions in light of recent research and real-world experience. CONCLUSIONS: While evidence supports some listed rules/conditions, others lack clinical justification and deserve to be reconsidered. These include (a) ineligibility of patients who have previously received TMS, (b) a lifetime total limit of 50 treatments, (c) a second/final course being unavailable for 4 months following the completion of the first course, and (d) the second/final course being limited to 15 treatments.

Suicide in Chinese myths and legends-Some familiar themes.

AIM: To expand our understanding of suicide by examining reports of this behavior from the Chinese mythical era (commencing circa 1200 BCE) and drawing comparisons with subsequent eras. METHOD: Four hundred recently published accounts of Chinese myths and folk tales were examined, along with supplementary material. Lists were created including one focused on attempted suicide and another on completed suicide. Comparisons were drawn with the suicide of a later era China and the current west. RESULTS: No evidence was located of suicide resulting from mental disorder. Six accounts of attempted suicide and 13 of completed suicide were located. Triggers included the death of a loved one, the loss of a valued possession, complicated relationships, and the avoidance of guilt and disgrace. These accord with current western behavior. CONCLUSION: There is at least fair agreement in the triggers of suicide in past eras in China and the current western era. This supports the view that suicide may be, in some instances, a customary response to circumstances.

Aducanumab for Alzheimer's disease: Observations and opportunities.

OBJECTIVE: To analyse the overseas approval of aducanumab for Alzheimer's disease, in order to derive lessons of potential interest to individuals and groups involved in dementia drug development and regulation in Australia. CONCLUSIONS: Opportunities were identified regarding optimising clinical trial design and solidifying regulatory responsibilities. Increased awareness of the attitudes and needs of patients and patient advocacy organisations would likely improve the patient-clinician alliance. Incorporation of these factors into research design has the potential to improve patient satisfaction with outcomes.

Transcranial Magnetic Stimulation (TMS) during pregnancy: a fetal risk factor.

OBJECTIVE: To examine reports of Transcranial Magnetic Stimulation (TMS) during pregnancy for evidence of fetal risk. METHOD: PubMed was used to locate relevant literature for the years 1998-2020 and reference lists were examined for materials not located electronically. RESULTS: Ten reports were located dealing with 67 births over 20 years. Stimulation was applied is all trimesters, at low and high frequency, and as intermittent theta-burst stimulation. No mother or baby experienced a serious event. CONCLUSIONS: Certainty awaits large, standardized studies. However, the available reports provide no evidence that TMS to mother during pregnancy has detrimental effects on the fetus.

'I can see clearly now': clarifying the role of psychiatry in global disaster.

OBJECTIVE: First, to review the principles and practice of disaster psychiatry, in light of recent global events. Second, to identify opportunities for research. METHOD: A literature review of the MEDLINE database, UpToDate and the Cochrane Library was conducted. Reference lists were also reviewed. RESULTS: Psychiatrists are well-positioned to contribute to positive outcomes at all stages of the disaster response. These contributions derive from their roles as doctors, mental illness specialists and clinical leaders. CONCLUSION: A novel framework for the psychiatrist's contributions was proposed. Specific knowledge of disaster psychiatry may be worthwhile, and establishment of a public disaster psychiatry centre is reasonable. Research should further examine the role of tele-psychiatry and pursue a best practice for community and front-line employee psychological preparedness.

A happiness magnet? Reviewing the evidence for repetitive transcranial magnetic stimulation in major depressive disorder.

OBJECTIVES: First, to conduct a historical review of the evidence for repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder and determine a clinical algorithm. Second, to identify opportunities for research. METHODS: Literature searches were conducted of the MEDLINE database, UpToDate and the Australian National University Library SuperSearch from 1 January 2000 to 30 September 2019. The search terms used were 'transcranial magnetic stimulation', 'major depressive disorder' and 'depression'. RESULTS: There were 24 meta-analyses identified, demonstrating a clear clinical effect. Left high-frequency rTMS had the most evidence. Ideal clinical parameters and study design were explored. CONCLUSION: Use of rTMS for some patients with depression is justified. Open research questions include the comparative efficacy of right low-frequency and bilateral stimulation, the role of rTMS in medication-naïve patients, and maintenance of effect.

Suicide in early China and the current West.

OBJECTIVES:: To characterize suicide in early China, as a means of extending knowledge of this behaviour. METHODS:: We examined Romance of the Three Kingdoms, and collated and considered relevant details. RESULTS:: In early China, loss of authority/status, loved ones and fortune were triggers for suicide. The expression of the intention to suicide, either by word or action, was observed and elicited a placating response. Less frequent, but nevertheless clearly recorded, were accounts of suicide completed to satisfy the wishes of others. CONCLUSIONS:: The suicide and related behaviour of early China shares many features with late Western societies, but one form (to satisfy the wishes of others) is currently undetected.

Repetitive transcranial magnetic stimulation in the treatment of depression

BACKGROUND: Transcranial magnetic stimulation (TMS)is a treatment for major depressive disorder that is otherwise resistant to treatment. Although world-leading research in TMS has been conducted in Australia, where it has had some availability for two decades, there is limited familiarity with the treatment in the general medical community. Availability, however, is increasing. OBJECTIVE: The aim of this article is to inform general practitioners of some scientific and practical aspects of TMS treatment. DISCUSSION: In TMS, an electromagnetic apparatus is used to generate small electric currents in targeted regions of the cortex. Anaesthesia is not required, patients remain conscious and there are no seizure or memory problems. TMS is a first-line treatment for treatment-resistant depression. Current evidence indicates that TMS-induced remission is associated with normalisation of connectivity in cortical-subcortical networks.

Suicide: What the General Public and the Individual Should Know.

BACKGROUND: The predominant, current western view is that all suicide is the result of mental disorder. This view is much too narrow and does not admit extensive information regarding the social, economic, and forensic factors (among many others) which may contribute to completed suicide. A consequence of this narrow view is that prevention strategies mainly focus on the detection and treatment of mental disorder. A preferred approach is to place greater emphasis on public health approaches to suicide prevention. OBJECTIVE: To develop and suggest a body of information which may be useful in a public health approach to suicide. CONCLUSION: It is suggested that the following be available to the general public: i) suicide is a fact of life which should be minimised, ii) suicide has many different triggers, iii) most people who take their lives are able to make decisions, and iv) increased public discussion and understanding of suicide is desirable. Five pieces of information that may be useful to those contemplating suicide include: i) don't murder the part of you that wants to live, ii) suicide actions may leave you alive but disabled, iii) suicide hurts other people, iv) suicidal impulses do pass if you hold on, and v) suicide is a waste.

Suicide of Australians during the Vietnam War.

OBJECTIVES: National suicide rates fall during times of war. This fits with the notion of the population coming together against a common foe. But, what happens in the case of a war which is not fully supported, which draws the population and families apart? We consider this question by examining the Australian suicide rates during the divisive Vietnam War. METHODS: We graphed and examined the Australian suicide figures for 1921-2010. RESULTS: We found clear evidence of a decrease in the suicide rate for World War II (consistent with other studies), but a marked elevation of suicide during the Vietnam War. CONCLUSIONS: The elevation of the Australian suicide rate during the Vietnam War is consistent with Durkheim's social integration model - when social integration is lessened, either by individual characteristics or societal characteristics, the risk of suicide rises.

The conundrum of hanging points in correctional facilities.

OBJECTIVE: We aimed to explore aspects of the removal of hanging points from correctional facilities. CONCLUSION: An argument can be made that individuals have a right to die/suicide. The United Nations holds that except for freedom of movement, prisoners have the same rights as non-prisoners. The rights of the individual and the duty of many custodial institutions are in conflict. This introduces a conundrum; when all hanging points are removed from correctional facilities, prisoners without mental disorder, but with a sustained wish to die, will not be able to achieve that end, while non-prisoners will be well able to do so.

The suicidal desire of Tolstoy.

AIM: To explore whether a healthy, successful individual may experience suicidal desires. METHOD: Examination of "A Confession" by Leo Tolstoy. RESULTS: Confirmation that a physically and mentally healthy, well resourced individual may experience suicidal desires. CONCLUSION: To reduce suicide rates, a broader understanding of the factors which contribute to suicidal desires is required.