RESUMO
Repetitive transcranial magnetic stimulation (rTMS) has been widely tested and shown to be effective for unipolar depression. Although it has also been investigated for bipolar depression (BD), there are only few rTMS studies with BD. Here, we investigated 56 patients with BD who received rTMS treatment until remission (defined as Hamilton Depression Rating Scores < or =7). We used simple and multiple logistic regressions to identify clinical and demographic predictors associated with duration of treatment (defined as <15 vs. >15 rTMS sessions). Age, refractoriness, number of prior depressive episodes, and severe depression at baseline were associated with a longer rTMS treatment. In the multivariate analysis, refractoriness (likelihood ratio (LR) = 4.33; p < 0.01) and baseline severity (LR = 0.18, p < 0.01) remained significant predictors. Our preliminary study showed that, in remitted patients, refractoriness and severity of index episode are associated with the need of a longer rTMS treatment; providing preliminary evidence of important factors associated with rTMS parameters adjustment.
Assuntos
Transtorno Bipolar/terapia , Transtorno Depressivo Maior/terapia , Estimulação Magnética Transcraniana , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Indução de Remissão , Estudos Retrospectivos , Resultado do TratamentoRESUMO
UNLABELLED: The use of neuromodulation as a treatment for major depressive disorder (MDD) has recently attracted renewed interest due to development of other non-pharmacological therapies besides electroconvulsive therapy (ECT) such as transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). METHOD: We convened a working group of researchers to discuss the updates and key challenges of neuromodulation use for the treatment of MDD. RESULTS: The state-of-art of neuromodulation techniques was reviewed and discussed in four sections: [1] epidemiology and pathophysiology of MDD; [2] a comprehensive overview of the neuromodulation techniques; [3] using neuromodulation techniques in MDD associated with non-psychiatric conditions; [4] the main challenges of neuromodulation research and alternatives to overcome them. DISCUSSION: ECT is the first-line treatment for severe depression. TMS and tDCS are strategies with a relative benign profile of side effects; however, while TMS effects are comparable to antidepressant drugs for treating MDD; further research is needed to establish the role of tDCS. DBS and VNS are invasive strategies with a possible role in treatment-resistant depression. In summary, MDD is a chronic and incapacitating condition with a high prevalence; therefore clinicians should consider all the treatment options including invasive and non-invasive neuromodulation approaches.
Assuntos
Transtorno Depressivo Maior/terapia , Terapia por Estimulação Elétrica/métodos , Eletroconvulsoterapia/métodos , Estimulação Magnética Transcraniana/métodos , Brasil , Estimulação Encefálica Profunda/métodos , Transtorno Depressivo Maior/fisiopatologia , Humanos , Escalas de Graduação Psiquiátrica , Estimulação do Nervo Vago/métodosRESUMO
The use of neuromodulation as a treatment for major depressive disorder (MDD) has recently attracted renewed interest due to development of other non-pharmacological therapies besides electroconvulsive therapy (ECT) such as transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). METHOD: We convened a working group of researchers to discuss the updates and key challenges of neuromodulation use for the treatment of MDD. RESULTS: The state-of-art of neuromodulation techniques was reviewed and discussed in four sections: [1] epidemiology and pathophysiology of MDD; [2] a comprehensive overview of the neuromodulation techniques; [3] using neuromodulation techniques in MDD associated with non-psychiatric conditions; [4] the main challenges of neuromodulation research and alternatives to overcome them. DISCUSSION: ECT is the first-line treatment for severe depression. TMS and tDCS are strategies with a relative benign profile of side effects; however, while TMS effects are comparable to antidepressant drugs for treating MDD; further research is needed to establish the role of tDCS. DBS and VNS are invasive strategies with a possible role in treatment-resistant depression. In summary, MDD is a chronic and incapacitating condition with a high prevalence; therefore clinicians should consider all the treatment options including invasive and non-invasive neuromodulation approaches.
O uso de técnicas de neuromodulação para o tratamento do transtorno depressivo maior (TDM) tem despertado um renovado interesse nos últimos anos com o desenvolvimento de outras intervenções não-farmacólogicas além da eletroconvulsoterapia (ECT), como a estimulação magnética transcraniana (EMT), a estimulação transcraniana por corrente continua (ETCC), a estimulação cerebral profunda (DBS) e a estimulação de nervo vago (VNS). MÉTODO: Nós organizamos um grupo de trabalho com vários pesquisadores para discutir os avanços recentes e os principais desafios para o uso da neuromodulação no tratamento do TDM. RESULTADOS: O estado-da-arte da neuromodulação foi revisado e discutido em quatro seções: [1] epidemiologia e fisiopatologia do TDM; [2] uma revisão das técnicas de neuromodulação; [3] o uso das técnicas de neuromodulação na depressão que ocorre associada ou em virtude de condições não-psiquiátricas; [4] os principais desafios da pesquisa na neuromodulação e alternativas para superá-los. DISCUSSÃO: ECT é o tratamento de primeira linha para depressão grave. EMT e ETCC são estratégias com um perfil benigno de efeitos adversos; contudo, enquanto os efeitos da EMT são comparáveis ao das drogas antidepressivas para o tratamento da TDM, a eficácia da ETCC ainda precisa ser estabelecida por mais pesquisas clínicas. DBS e VNS são intervenções invasivas com um papel possível para a depressão refratária. Em resumo, TDM é uma condição crônica, incapacitante e de alta prevalência; portanto na prática clínica todas as opções de tratamento possíveis, incluindo as farmacológicas e não-farmacológicas, devem ser consideradas.
Assuntos
Humanos , Transtorno Depressivo Maior/terapia , Terapia por Estimulação Elétrica/métodos , Eletroconvulsoterapia/métodos , Estimulação Magnética Transcraniana/métodos , Brasil , Estimulação Encefálica Profunda/métodos , Transtorno Depressivo Maior/fisiopatologia , Escalas de Graduação Psiquiátrica , Estimulação do Nervo Vago/métodosRESUMO
OBJECTIVE: We aimed to investigate the efficacy of 20 Hz repetitive transcranial magnetic stimulation (rTMS) of either right or left dorsolateral prefrontal cortex (DLPFC) as compared to sham rTMS for the relief of posttraumatic stress disorder (PTSD)-associated symptoms. METHOD: In this double-blind, placebo-controlled phase II trial conducted between October 2005 and July 2008, 30 patients with DSM-IV-diagnosed PTSD were randomly assigned to receive 1 of the following treatments: active 20 Hz rTMS of the right DLPFC, active 20 Hz rTMS of the left DLPFC, or sham rTMS. Treatments were administered in 10 daily sessions over 2 weeks. A blinded rater assessed severity of core PTSD symptoms, depression, and anxiety before, during, and after completion of the treatment protocol. In addition, a battery of neuropsychological tests was measured before and after treatment. RESULTS: Results show that both active conditions-20 Hz rTMS of left and right DLPFC-induced a significant decrease in PTSD symptoms as indexed by the PTSD Checklist and Treatment Outcome PTSD Scale; however, right rTMS induced a larger effect as compared to left rTMS. In addition, there was a significant improvement of mood after left rTMS and a significant reduction of anxiety following right rTMS. Improvements in PTSD symptoms were long lasting; effects were still significant at the 3-month follow-up. Finally, neuropsychological evaluation showed that active 20 Hz rTMS is not associated with cognitive worsening and is safe for use in patients with PTSD. CONCLUSIONS: These results support the notion that modulation of prefrontal cortex can alleviate the core symptoms of PTSD and suggest that high-frequency rTMS of right DLPFC might be the optimal treatment strategy.
Assuntos
Transtornos de Estresse Pós-Traumáticos/terapia , Estimulação Magnética Transcraniana/métodos , Adulto , Lista de Checagem/estatística & dados numéricos , Terapia Combinada , Manual Diagnóstico e Estatístico de Transtornos Mentais , Feminino , Lateralidade Funcional/fisiologia , Humanos , Acontecimentos que Mudam a Vida , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Córtex Pré-Frontal/fisiologia , Escalas de Graduação Psiquiátrica/estatística & dados numéricos , Psicometria , Psicotrópicos/uso terapêutico , Índice de Gravidade de Doença , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Resultado do TratamentoRESUMO
BACKGROUND: Several studies have shown that repetitive transcranial magnetic stimulation (rTMS) treatment is associated with a significant antidepressant effect that can last for several months. METHODS: To investigate the mean remission time and the predictors associated with its duration; we performed a large retrospective, naturalistic study with 204 patients who underwent treatment with rTMS. During the periods from 2000 to 2006, we identified and collected the data on 204 patients who underwent rTMS treatment for major depression and who remitted their depression (defined as Hamilton Depression Rating Scores less or equal to 7). Patients were followed up to 6 months after this therapy. RESULTS: Event-free remission with the end point defined as relapse (Hamilton Depression Rating Scores higher than 8) was 75.3% (73.7) at 2 months, 60.0% (74.5) at 3 months, 42.7% (74.8) at 4 months, and 22.6% (74.5) at 6 months. According to a multivariate analysis, only the age and number of sessions were independent predictors of outcome. Although depression severity and use of tricyclics also showed a significant relationship with remission duration, the model including these variables was not adequate to explain our data. CONCLUSIONS: The results of this study suggest that young age and additional rTMS sessions are associated with a ong duration of rTMS effects and therefore future trials investigating the effects of maintenance rTMS treatment need to explore further the implication of these factors for depression remission.
Assuntos
Transtorno Depressivo Maior/terapia , Estimulação Magnética Transcraniana/métodos , Adulto , Fatores Etários , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Córtex Pré-Frontal/fisiopatologia , Recidiva , Indução de Remissão , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Inquéritos e Questionários , Análise de Sobrevida , Fatores de TempoRESUMO
Objetivo: Investigar os efeitos da estimulação magnética transcranianarepetitiva em pacientes com depressão maior que se submeteram aesse tratamento durante o período de 2000 a 2006. Métodos: Realizouseum estudo retrospectivo com 204 pacientes, que se submeteramao tratamento com a estimulação magnética transcraniana repetitiva,coletando os dados daqueles que tiveram remissão do quadro(definido como escore da HAM-D menor ou igual a 7). Os pacientesforam seguidos até seis meses após o tratamento. A duração médiada remissão para essa coorte de pacientes foi 70,2 dias (± 58,4).Resultados: A única variável que foi associada com a duração daremissão no modelo de regressão linear foi o número de sessões com a estimulação magnética transcraniana repetitiva. Conclusão: Nossosachados sugerem que, quanto maior o número de sessões, maislonga a duração dos efeitos da estimulação magnética transcranianarepetitiva. Conseqüentemente, pesquisas futuras que investiguem osefeitos da estimulação magnética transcraniana de repetição precisamexplorar essa variável para maximizar os efeitos terapêuticos dessanova técnica de estimulação cerebral.