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Considerable research has demonstrated the efficacy of repetitive transcranial magnetic stimulation treatment (rTMS) in patients with major depressive disorder (MDD) with differences in effects related to laterality of stimulation. However, no systematic research has explored whether left-handed subjects respond in the same way as right-handed subjects. Data from 6 clinical trials (n = 310) were pooled and we explored whether left-handed patients with MDD responded in a similar manner to rTMS, including how they responded to both high-frequency left and low-frequency right-sided forms of treatment. Overall, patients with MDD who were left-handed responded to a greater degree than right-handed patients to rTMS therapy. On subgroup analysis, notably limited by small numbers in the left handed groups, this effect was seen with high-frequency left-sided treatment but not with low-frequency right-sided treatment. The overall effect of a greater response in left-handed patients was not attributable to other clinical or study variables. Standard forms of rTMS treatment appear to be effective in patients with MDD who are left-handed and there seems no justification for modifying the laterality of treatment application in these patients. [ABSTRACT FROM AUTHOR]

Biological strategies to improve treatment efficacy in clozapine-treated patients are urgently needed. Repetitive transcranial magnetic stimulation (rTMS) merits consideration as intervention for patients with persistent auditory hallucinations (AH) or negative symptoms (NS) not responding sufficiently to clozapine treatment. Data from 10 international RCTs of rTMS for patients being treated with clozapine were pooled. Two levels of symptomatic response were defined: improvement of ≥20% and ≥50% on study-specific primary endpoint scales. Changes in the positive and negative syndrome scale (PANSS) from baseline to endpoint assessment were also analysed. Analyses of 131 patients did not reveal a significant difference for ≥20% and ≥50% response thresholds for improvement of AH, negative or total symptoms between active and sham rTMS groups. The number needed to treat (NNT) for an improvement in persistent AH was nine following active rTMS. PANSS scores did not improve significantly from baseline to endpoint between active and sham groups in studies investigating NS and AH. rTMS as a treatment for persistent symptoms in clozapine-treated patients did not show a beneficial effect of active compared to sham treatment. For AH, the size of the NNTs indicates a possible beneficial effect of rTMS. [ABSTRACT FROM AUTHOR]

At the Center for Addiction and Mental Health (CAMH) Integrated Day Treatment (IDT) program, each patient attends either a morning stream or an afternoon stream, but not both. We examined whether subjective chronotype, or the time of day an individual prefers to be most active and alert, predicted treatment outcomes differentially in depressed patients attending the morning vs. afternoon IDT streams. The Horne-Östberg Morningness-Eveningness Questionnaire (MEQ) was administered before IDT treatment to 203 consecutive patients experiencing a major depressive episode. Multiple regression was used to predict change in depression and quality of life scores based on treatment stream (morning or afternoon), baseline MEQ scores and the treatment stream by MEQ interaction. The treatment stream by MEQ interaction was a highly significant predictor of both depression and quality of life change scores. Post-hoc analyses based on established MEQ categories revealed that definite evening chronotypes had significantly better responses in the morning stream than did morning chronotypes, and significantly worse responses in the afternoon stream relative to moderate evening or neutral chronotypes. There were insufficient morning chronotypes in the afternoon stream to assess clinical responses for this subgroup. In the morning stream only, there was a significant positive correlation between the change in MEQ scores after four weeks of IDT treatment (i.e. a shift to greater morningness) and the decrease in depression scores (r =.36, p =.003), consistent with a therapeutic phase advance in circadian rhythms. In sum, these preliminary data suggest that definite evening chronotypes may have the greatest relative benefit from attending the morning vs. afternoon IDT stream. As patients currently select which IDT stream they will attend, future work based on randomized treatment assignment and using passive actigraphy to assess circadian phase is currently planned to extend these preliminary findings. [ABSTRACT FROM AUTHOR]

Objectives.Preclinical studies suggest that cortical alterations within the prefrontal cortex (PFC) are critical to the pathophysiology of alcohol dependence. Combined transcranial magnetic stimulation (TMS) and electroencephalography (EEG) allows direct assessment of cortical excitability and inhibition within the PFC of human subjects. We report the first application of TMS-EEG to measure these indices within the PFC of alcohol-dependent (ALD) patients post-detoxification.Methods.Cortical inhibition was assessed in 12 ALD patients and 14 healthy controls through single and paired-pulse TMS paradigms. Long-interval cortical inhibition indexed cortical inhibition in the PFC. In the motor cortex (MC), short- interval intracortical inhibition and cortical silent period determined inhibition, while intracortical facilitation measured facilitation, resting and active motor threshold indexed cortical excitability.Results.ALD patients demonstrated altered cortical inhibition across the bilateral frontal cortices relative to controls. There was evidence of altered cortical excitability in ALD patients; however, no significant differences in MC inhibition.Conclusions.Our study provides first direct evidence of reduced cortical inhibition in the PFC of ALD patients post-detoxification. Altered cortical excitability in the MC may reflect hyper-excitability within the cortex associated with chronic alcohol consumption. These findings provide initial neurophysiological evidence of disrupted cortical excitability within the PFC of ALD patients. [ABSTRACT FROM AUTHOR]

In this trial, treatment resistant depression patients (TRD) ( I n i = 414) were randomised to either iTBS or HFL, and iTBS was found to be non-inferior to standard HFL (Blumberger et al. [1]). To the editor, Repetitive transcranial magnetic stimulation (rTMS) is an effective treatment modality for treatment-resistant depression (TRD), with demonstrated efficacy in treating depressive symptoms including suicidality; rTMS is generally targeted to the left dorsolateral prefrontal cortex (DLPFC), but may be targeted to the right or bilateral DLPFC (see e.g. (Brunoni et al. [2]; Serafini et al. [5])). [Extracted from the article]

Objectives. High frequency left-sided (HFL) and low frequency right-sided (LFR) unilateral repetitive transcranial magnetic stimulation (rTMS) are efficacious in treatment-resistant major depression (TRD). Similar benefit has been suggested for sequential bilateral rTMS (LFR then HFL). There are few published reports on the efficacy of sequential bilateral rTMS compared to HFL and sham rTMS. Therefore, this study evaluated the efficacy of HFL and sequential bilateral rTMS compared to sham in TRD. Methods. Subjects between the ages of 18 and 85 were recruited from a tertiary care university hospital. Seventy-four subjects with TRD and a 17-item Hamilton Depression Rating Scale (HDRS) greater than 21 were randomized to receive unilateral, bilateral, or sham rTMS. The rates of remission were compared among the three treatment groups. Results. The remission rates differed significantly among the three treatment groups using a modified intention to treat analysis that excluded subjects who did not respond to electroconvulsive therapy (ECT) during the current episode. The remission rate was significantly higher in the bilateral group than the sham group. The remission rate in the unilateral group did not differ from either group. Conclusion. These findings warrant larger controlled studies that compare the efficacy of sequential bilateral rTMS and HFL rTMS in TRD. [ABSTRACT FROM AUTHOR]

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation technique that is now being tested for its ability to treat addiction. This review discusses current research approaches and results of studies which measured the therapeutic use of rTMS to treat tobacco, alcohol and illicit drug addiction. The research in this area is limited and therefore all studies evaluating the therapeutic use of rTMS in tobacco, alcohol or illicit drug addiction were retained including case studies through NCBI PubMed () and manual searches. A total of eight studies were identified that examined the ability of rTMS to treat tobacco, alcohol and cocaine addiction. The results of this review indicate that rTMS is effective in reducing the level of cravings for smoking, alcohol, and cocaine when applied at high frequencies to the dorsolateral prefrontal cortex (DLPFC). Furthermore, these studies suggest that repeated sessions of high frequency rTMS over the DLPFC may be most effective in reducing the level of smoking and alcohol consumption. Although work in this area is limited, this review indicates that rTMS is a promising modality for treating drug addiction. [ABSTRACT FROM AUTHOR]

Repetitive transcranial magnetic stimulation (rTMS) is currently emerging as one of the first fundamentally new treatments in psychiatric practice for a considerable number of years. Research into the use of rTMS for the treatment of patients with depression has now been conducted for over 15 years. The aim of this article was to review the development of rTMS treatment for depression and the current state of evidence supporting its use. The vast majority of the trials conducted on the technique have evaluated the efficacy of high-frequency rTMS applied to the left dorsolateral prefrontal cortex using a set of parameters very similar to those originally described in the mid-1990s. This 'standard' form of rTMS clearly appears to have antidepressant efficacy, and its effects have now been confirmed in several large-scale clinical trials and a number of meta-analyses: response is better than that of sham stimulation, although the number of responders to treatment is relatively modest. A wide range of alternative forms of rTMS have been, or are currently being, evaluated. Low-frequency stimulation applied to the right prefrontal cortex appears to have similar efficacy to standard treatment and it is possible that the bilateral approaches may prove more effective. Novel methods of stimulation, such as priming stimulation, theta-burst stimulation and deep TMS, appear to be promising although require further evaluation. Significant benefit appears likely to accumulate through the use of methods that involve a more reliable targeting of prefrontal brain regions. Research is also required to evaluate the long-term effects of rTMS treatment, its use as a maintenance therapy and to establish reliable predictors of response to treatment. INSET: Key issues. [ABSTRACT FROM AUTHOR]