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Importance: Treatment-resistant depression (TRD) is common in older adults. Bilateral repetitive transcranial magnetic stimulation (rTMS) of the dorsolateral prefrontal cortex for 48 minutes has demonstrated efficacy in TRD. Theta burst stimulation (TBS), a newer form of rTMS, can also be delivered bilaterally using left intermittent TBS and right continuous TBS for only 4 minutes.Objective: To establish the effectiveness and tolerability of TBS compared with standard rTMS in older adults with TRD.Design, Setting, and Participants: In this randomized noninferiority trial with open treatment and blinded assessors, recruitment occurred between December 2016 and March 2020. The trial was conducted at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada and included outpatients 60 years and older with a diagnosis of depression, moderate severity, and nonresponse to 1 or more antidepressant trial of adequate dosage and duration or intolerance of 2 or more trials.Interventions: Participants were randomized to receive a course of 4 to 6 weeks of either bilateral standard rTMS or TBS.Main Outcomes and Measures: The primary outcome measure was change in Montgomery-Åsberg Depression Rating Scale; secondary outcome measures included the 17-item Hamilton Rating Scale for Depression, Quick Inventory of Depressive Symptomatology (16-item) (self-report), and dropout rates. A noninferiority margin of 2.75 points was used for the primary outcome. All participants who attained the primary completion point of 4 weeks were analyzed.Results: A total of 87 participants (mean [SD] age, 67.1 [6.7] years; 47 [54.0%] female) were randomized to standard bilateral rTMS and 85 (mean [SD] age, 66.3 [5.3] years; 45 [52.9%] female) to TBS, of whom 85 (98%) and 79 (93%) were assessed for the primary outcome, respectively, whereas tolerability was assessed in all randomized participants. In the rTMS group, 4 (4.6%) were American Indian, reported other, or preferred not to answer; 5 (5.8%) were Asian; and 78 (89.7%) were White. In the TBS group, 6 (7.1%) were Asian, 2 (2.4%) were Black or reported other, and 77 (90.3%) were White. Mean (SD) Montgomery-Åsberg Depression Rating Scale total scores improved from 25.6 (4.0) to 17.3 (8.9) for rTMS and 25.7 (4.7) to 15.8 (9.1) for TBS (adjusted difference, 1.55; lower 95% CI -0.67), establishing noninferiority for TBS. The all-cause dropout rates were relatively similar between groups (rTMS: 2 of 87 [2.3%]; TBS: 6 of 85 [7.1%]; P = .14; χ2 = 2.2).Conclusions and Relevance: In older adults with TRD, bilateral TBS compared with standard bilateral rTMS achieved noninferior reduction in depression symptoms. Both treatments had low and similar dropout rates. Using TBS rather than rTMS could increase access to treatment several-fold for older adults with TRD.Trial Registration: ClinicalTrials.gov Identifier: NCT02998580. [ABSTRACT FROM AUTHOR]

Objectives: Repetitive transcranial magnetic stimulation (rTMS) is commonly used in unipolar depression; yet, its evidence in bipolar disorder (BD) is limited. We sought to review the evidence on the use of rTMS across the different stages of BD. Methods: MEDLINE database was systematically searched using the PubMed interface following the PRISMA guidelines. Inclusion criteria were as follows: (i) randomized clinical trials (RCTs), open‐label studies, and case series; (ii) specific evaluation of the treatment outcomes using psychometric scales; (iii) clinical studies in adults; and (iv) articles in the English language. The systematic review has been registered on PROSPERO (CRD42020192788). Results: Thirty‐one papers were included in the review. Most studies included participants diagnosed with a bipolar depressive episode (N = 24), have yielded mixed findings, and have yet to reach a consensus on the most effective rTMS protocol. Few studies examined the effect of rTMS during manic (N = 5) or mixed episode (N = 1), or as maintenance treatment (N = 1). The limited data thus far suggest rTMS to be relatively safe and well tolerated. Small sample sizes, heterogeneity among study designs, patients and control groups recruited, rTMS parameters, and outcome measures are among the most significant limitations to these studies. Conclusion: The current data regarding the application of rTMS in BD patients remain limited. More adequately powered sham‐controlled studies are required to verify its efficacy. Large‐scale clinical trials are needed to also determine whether its effects extend to manic and mixed episodes, as well as its role in mood stabilization and amelioration of suicidal behavior. [ABSTRACT FROM AUTHOR]

Background Patients with schizophrenia are often found incapable to consent to psychiatric treatment. We evaluated clinical outcomes for incapable and capable patients with schizophrenia treated with electroconvulsive therapy (ECT). Methods We conducted a chart review of all inpatients treated with an acute course of ECT between 2010 and 2018 at the Centre for Addiction and Mental Health, Toronto, Canada. Short-term outcomes included treatment response and cognitive impairment. We assessed whether incapable patients regained the capacity to consent to treatment. Long-term outcomes included readmissions and subsequent courses of acute or maintenance ECT. Results A total of 159 (67%) incapable and 79 (33%) capable patients were included. Patients experienced treatment response (incapable, n = 108, 67.9%; capable, n = 52, 65.8%; P =.771) and few experienced cognitive impairment (incapable, n = 21, 13.2%; capable, n = 19, 24.1%; P =.043). A minority of patients were treated with a subsequent course of acute ECT (incapable, n = 46, 28.9%; capable, n = 16, 20.3%; P =.162). Incapable patients were more likely to be treated with maintenance ECT for at least 6 months (incapable, n = 46, 28.9%; capable, n = 13, 16.5%; P =.039). Both groups had similar readmission rates (incapable, n = 70, 44.0%; capable, n = 35, 44.3%; P = 1.000). Eight (5.0%) incapable patients regained capacity and 7 consented to further treatment. Conclusions Irrespective of treatment capacity, the majority of patients demonstrated clinical improvement. Incapable patients experienced less cognitive side effects when compared with capable patients, though they had fewer treatments overall. This study informs clinicians, patients, and substitute decision-makers about the outcomes and challenges of ECT in patients with schizophrenia. [ABSTRACT FROM AUTHOR]

Background: Despite the advances in the use of repetitive transcranial magnetic stimulation (rTMS) for the treatment of major depressive disorder (MDD), there is relatively little information about its effect on comorbid anxiety symptoms. Methods: Data from a large randomized noninferiority trial comparing intermittent theta‐burst stimulation (iTBS) and high‐frequency (10 Hz) rTMS delivered to the left dorsolateral prefrontal cortex (HFL) were analyzed. The primary aim was assessing changes in anxiety/somatization items from the 17‐item Hamilton Depression Rating Scale (HAM‐D) and the Brief Symptom Inventory (BSI‐A), using baseline‐adjusted change with an analysis of covariance (ANCOVA), with the final scores as the outcome and baseline scores as the adjustment covariates. Results: The analytical cohort comprised 388 participants (189 in HFL and 199 in iTBS groups). From baseline to the end of the rTMS course, the combined score from the anxiety items from the HAM‐D dropped from 7.43 (SD = 2.15) to 4.24 (SD = 2.33) in the HFL group, and 7.33 (SD = 2.13) to 3.76 (SD = 2.23) in the iTBS group. The ANCOVA resulted in an effect from time (p <.0001), but not from group allocation (p =.793) or time × group interaction (p =.976). We observed mean changes in the BSI‐A of −3.5 (SD = 5.4) and −3.2 (SD = 4.8), with significant effect of time (p <.0001) in the ANCOVA, but not group allocation (p =.793) or group × time interaction (.664). Conclusions: Our findings suggest that both 10 Hz and iTBS may yield potential reductions in anxiety symptoms when used for the treatment of MDD. Our findings warrant future research into the effects of left‐sided rTMS on depressed patients struggling with concurrent anxiety symptoms. [ABSTRACT FROM AUTHOR]

Occupational therapy is an essential component of psychiatric treatment. The purpose of this naturalistic cohort study is to evaluate the impact of a structured occupational therapy program in an acute mental health setting (AMHS) on psychiatric inpatients' function and occupational performance. The participants (N = 397) attended the structured occupational therapy program during their hospitalization in an AMHS. Function and occupational performance were evaluated with the Occupational Abilities and Performance Scale. The results indicate a positive therapeutic role in the structured occupational therapy program. An interesting finding is related to the adequate duration of patient participation needed to improve their function and occupational performance. The inclusion of structured, purposeful, and comprehensive occupational therapy programs of adequate duration in the daily routine of an AMHS could be a valuable therapeutic component of the treatment armamentarium, as it may enhance patients' occupational performance, social functioning, and well-being. [Psychiatr Ann. 2021;51(3):131–139.] [ABSTRACT FROM AUTHOR]

The article presents a case study related to 46-year-old man with severe obesity has admitted for hospitalization in the psychiatric department of a general hospital because of behavioral disorders and constant suicidal and homicidal ideation.

Background: Intermittent theta burst stimulation (iTBS) is a form of repetitive transcranial magnetic stimulation (rTMS) that can be administered in a fraction of the time of standard rTMS. Applying multiple daily iTBS sessions (ie, accelerated iTBS) may enable patients to achieve remission more rapidly. However, questions remain regarding the optimal time interval between treatment sessions., Objective: The overall aim of this study was to compare the efficacy and tolerability of two accelerated bilateral iTBS protocols (ie, 30-min or 60-min intervals) and a once-daily bilateral iTBS protocol (ie, 0-min interval) while the number of pulses was held constant, in patients with treatment-resistant depression (TRD)., Methods: 182 patients with TRD were randomised to receive two sessions per day of bilateral iTBS of the dorsomedial prefrontal cortex (DMPFC) at 60-min, 30-min or 0-min intervals. Sham treatments were delivered using a shielded 'sham coil' which produced the auditory and tactile sensations of stimulation. The primary outcome measure was a change in depression scores on the 17-item Hamilton Rating Scale for Depression (HRSD-17) after 20 days of treatment., Results: HRSD-17 scores improved across all groups; however, these improvements did not significantly differ between the three groups after 20 days of treatment. Similarly, response and remission rates did not differ between the treatment groups., Conclusions: These results suggest that contrary to our original hypothesis, implementing a 30-min or 60-min interval between two treatment sessions of DMPFC-iTBS does not lead to a more rapid improvement in symptoms, than once-daily iTBS administration., Trial Registration Number: NCT02778035., Competing Interests: Competing interests: FM reports grants from Mitacs, outside the submitted work. LS reports grants from Ontario Mental Health Foundation, outside the submitted work. TSK has received research support from CIHR and the AFP Innovation Fund. JD has received research and equipment in-kind support for an investigator-initiated study through Brainsway and Magventure. He is also on the scientific advisory board for Brainsway. His work has been supported by the National Institutes of Mental Health (NIMH), the Canadian Institutes of Health Research (CIHR), Brain Canada and the Temerty Family and Grant Family Foundations. JD has received research support from NIH, CIHR, Brain Canada, Ontario Brain Institute, the Klarman Family Foundation, the Krembil Foundation, Arrell Family Foundation and the Buchan Family Foundation, in-kind equipment support for investigator-initiated trials from MagVenture, is an advisor for BrainCheck, Arc Health Partners and Salience Neuro Health, and is a co-founder of Ampa Health. DMB receives research support from CIHR, NIMH (R01MH112815;R21MH128815; R01MH1192850), Brain Canada and the Temerty Family through the CAMH Foundation and the Campbell Family Research Institute. He received research support and in-kind equipment support for an investigator-initiated study from Brainsway. He was the site principal investigator for three sponsor-initiated studies for Brainsway. He also received in-kind equipment support from Magventure for two investigator-initiated studies. He received medication supplies for an investigator-initiated trial from Indivior. He is a scientific advisor for Sooma Medical. He is the Co-Chair of the Clinical Standards Committee of the Clinical TMS Society (unpaid). APT, GK and MG declares no conflicts of interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. Published by BMJ.)

Objective: To quantitatively synthesize the literature on the effects of repetitive transcranial magnetic stimulation (rTMS) on suicidal ideation (SI) in patients with treatment-resistant depression., Data Sources: A literature search was conducted using PubMed, SCOPUS, Ovid, MEDLINE, Embase, and Web of Science from inception to January 11, 2021, for the keywords repetitive transcranial magnetic stimulation, suicidal ideation, suicidality, treatment-resistant depression, refractory depression, transcranial magnetic stimulation, and brain stimulation ., Study Selection: A total of 16 publications were eligible for inclusion. Studies were included that investigated the effects of rTMS in adolescents and/or adults 16 years or older diagnosed with unipolar or bipolar depression with suicidal ideation data before and after rTMS intervention., Data Extraction: Data were extracted and managed using Covidence. Extracted data included authors, publication year, country of origin, study design, patient demographics, primary diagnosis, comorbidities, mean age, outcome assessment instruments, detailed stimulation parameters, sham control procedures, and any serious adverse events related to SI., Results: A quantitative analysis of effect size using Hedges g was calculated for both randomized controlled trials and all other uncontrolled trials. We found a decrease in SI scores in randomized controlled trials ( g  = 0.158, 95% confidence interval [CI] = -0.078 to 0.393, P  = .191), although the effect was not significant. There was a significant decrease in suicidal ideation scores for uncontrolled trials ( g  = 0.692, 95% CI = 0.463 to 0.922, P  < .001)., Conclusions: Our findings suggest that rTMS may be an effective treatment for SI in individuals with treatment-resistant depression, although further investigation is warranted., (© Copyright 2022 Physicians Postgraduate Press, Inc.)