Sports psychiatry: a desideratum on sports arena!

The emerging field of sports psychiatry has been developing steadily in recent years. This is not just a health concern but is likely to impact sporting performance and achievement significantly. An overview of sports psychiatry is provided. Psychiatric disorders of all varieties can and do present in sporting populations. Sports psychiatry keeps evolving to drive forward the importance of good mental health in sport as in life.

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.

The evidence is in: Repetitive transcranial magnetic stimulation is an effective, safe and well-tolerated treatment for patients with major depressive disorder.

Despite more than 25 years of research establishing the antidepressant efficacy of repetitive transcranial magnetic stimulation, there remains uncertainty about the depth and breadth of this evidence base, resulting in confusion as to where repetitive transcranial magnetic stimulation fits in the therapeutic armamentarium in the management of patients with mood disorders. The purpose of this article is to provide a concise description of the evidence base supporting the use of repetitive transcranial magnetic stimulation in the context of the stages of research that typically accompanies the development of evidence for a new therapy. The antidepressant efficacy for the use of repetitive transcranial magnetic stimulation in the treatment of depression has been established through a relatively traditional pathway beginning with small case series, progressing to single-site clinical trials and then to larger multisite randomised double-blind controlled trials. Antidepressant effects have been confirmed in numerous meta-analyses followed more recently by large network meta-analysis and umbrella reviews, with evidence that repetitive transcranial magnetic stimulation may have greater efficacy than alternatives for patients with treatment-resistant depression. Finally, repetitive transcranial magnetic stimulation has been shown to produce meaningful response and remission rates in real-world samples of greater than 5000 patients. The evidence for the antidepressant efficacy of repetitive transcranial magnetic stimulation therapy is overwhelming, and it should be considered a routine part of clinical care wherever available.

Revisiting the effectiveness of repetitive transcranial magnetic stimulation treatment in depression, again.

Following on from the publication of the Royal Australian and New Zealand Journal of Psychiatry Mood Disorder Clinical Practice Guidelines (2020) and criticisms of how these aberrantly addressed repetitive transcranial magnetic stimulation treatment of depression, questions have continued to be raised in the journal about this treatment by a small group of authors, whose views we contend do not reflect the broad acceptance of this treatment nationally and internationally. In fact, the evidence supporting the use of repetitive transcranial magnetic stimulation treatment in depression is unambiguous and substantial, consisting of an extensive series of clinical trials supported by multiple meta-analyses, network meta-analysis and umbrella reviews. Importantly, the use of repetitive transcranial magnetic stimulation treatment in depression has also been subject to a series of health economic analyses. These indicate that repetitive transcranial magnetic stimulation is a cost-effective therapy and have been used in some jurisdictions, including Australia, in support of public funding. An argument has been made that offering repetitive transcranial magnetic stimulation treatment may delay potentially effective pharmacotherapy. In fact, there is considerably greater danger of the opposite happening. Repetitive transcranial magnetic stimulation is as, if not more effective, than antidepressant medication after two unsuccessful medication trials and should be a consideration for all patients under these circumstances where available. There is no meaningful ongoing debate about the use of repetitive transcranial magnetic stimulation treatment in depression - it is a safe, effective and cost-effective treatment.

Depression: A Gut "Microbiome" Feeling!

ABSTRACT: Burgeoning body of evidence from neuroscience is pouring in highlighting a potential association between gut microbiota with the pathophysiology of depression and anxiety. Manipulation of gut microbiota may be then useful to decode this role and to provide novel therapeutics for major depressive disorder (MDD), developing microbiota-related biomarkers to stratify patients at risk and to delineate more homogeneous biotypes of MDD.

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.

The impact of transcranial magnetic stimulation (TMS) on irritability occurring with acute major depressive disorder (MDD).

OBJECTIVE: To examine the impact (if any) of a course of transcranial magnetic stimulation (TMS) on irritability occurring in association with acute major depressive disorder (MDD). METHOD: In a naturalistic study, patients with MDD according to DSM-5 criteria were given 20 daily TMS treatments. A visual analogue scale for irritability (VAS-I) was developed. Objective tools included the six-item Hamilton Depression Rating Scale (HAMDS6) and the Clinical Global Impression - Severity (CGI-S). RESULTS: Fifty patients received 53 courses. Forty-seven courses achieved remission on both HAMD6 and CGI-S and six courses did not achieve remission with either. Irritability significantly reduced when MDD remission was achieved but was unchanged when remission was not achieved. CONCLUSION: TMS reduces irritability occurring in association with MDD when this treatment affects MDD remission, but not when remission is not affected.

The impact of 'cluster maintenance TMS' on irritability occurring in major depressive disorder.

OBJECTIVE: To determine the impact of clustered maintenance transcranial magnetic stimulation (TMS) on irritability occurring in treatment-resistant major depressive disorder (MDD). METHOD: A naturalistic study of 106 courses that includes pre- and posttreatment assessments of subjective and objective depression and a subjective measure of irritability developed for this study. RESULTS: Forty-six participants (35 females), mean age 43.2 years (14.3), completed 106 courses. There was a significant reduction in irritability and depression scores (p < .001). The change in irritability scores was significantly correlated with the change in depression scores, r = .40, p < .001. CONCLUSION: TMS has the capacity to reduce the irritability co-occurring with treatment-resistant MDD, known to be responsive to TMS. This increases the possibility of using TMS in the treatment of irritability co-occurring with other disorders or standing alone (should irritability be categorized as a stand-alone disorder).

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.

Impact of transcranial magnetic stimulation on the symptom profile of major depressive episode.

OBJECTIVES: This study aimed to explore the effects of a four-week course of transcranial magnetic stimulation (TMS) on the following symptoms of major depressive episode (MDE): mood, work activities, health concerns, guilt, anxiety and retardation. METHOD: Patients underwent 20 daily sessions of 10 Hz TMS (two sets of 10 daily treatments separated by two days of rest). The six-item Hamilton Depression Rating Scale (HAMD-6) was administered before and after treatment. Remission was operationalised as a HAMD-6 score of <4. Descriptive statistics and t-tests were used to compare pre/post scores on HAMD-6 subscales, and logistic regression was used to understand symptoms that predicted remission/non-remission. RESULTS: There were 104 participants (79 female; 76%), with a mean age of 44.6 years (SD=15.7 years). There was a significant improvement in the whole sample and in remitters (n=70) on all subscales. However, those who failed to remit did not achieve significant reductions in 'health concerns' and 'retardation'. There were no difference in age and sex between remitters and non-remitters. Also, there were no significant differences between the remitters and non-remitters on the pretreatment depression symptom profiles. No predictors of response were identified, as expected. CONCLUSIONS: TMS has the ability to reduce all listed MDE symptoms. No pretreatment MDE symptom profile was identified which might carry prognostic value.

Second Courses of Transcranial Magnetic Stimulation (TMS) in Major Depressive Episodes for Initial Responders and Non-Responders.

BACKGROUND: Transcranial Magnetic Stimulation (TMS) is effective in major depressive episodes (MDE). However, MDE may follow a chronic, relapsing course, and some individuals may not satisfactorily respond to a first course of TMS. OBJECTIVE: To investigate the outcome of second courses of TMS. METHOD: A naturalistic investigation-we prospectively studied 30 MDE in-patients and routinely collected information, including pre- and post-treatment with Six-item Hamilton Depression Rating Scale (HAMD6), a six-item Visual Analogue Scale (VAS6) and the Clinical Global Impression-Severity (CGI-S). Two categories of patients were considered: i) those who had remitted with a first course, but relapsed, and ii) those who had not remitted with the first course. RESULTS: Thirty individuals received a second TMS course. The mean time to the second course was 27.5 weeks. Based on the HAMD6, 26 (87%) achieved remission after the first course, and 22 (73%) achieved remission after the second course. Furthermore, based on the HAMD6 results, of the four patients who did not achieve remission with a first course, three (75%) did so with a second course. CONCLUSION: In MDE, a second course of TMS is likely to help those who remitted to a first course and then relapsed, as well as those who did not achieve remission with a first course.