Evidence and expert consensus based German guidelines for the use of repetitive transcranial magnetic stimulation in depression.

INTRODUCTION: Non-invasive brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) offer a promising alternative to psychotherapeutic and pharmacological treatments for depression. This paper aims to present a practical guide for its clinical implementation based on evidence from the literature as well as on the experience of a group of leading German experts in the field. METHODS: The current evidence base for the use of rTMS in depression was examined via review of the literature. From the evidence and from clinical experience, recommendations for the use of rTMS in clinical practice were derived. All members of the of the German Society for Brain Stimulation in Psychiatry and all members of the sections Clinical Brain Stimulation and Experimental Brain Stimulation of the German Society for Psychiatry, Psychotherapy, Psychosomatics and Mental Health were invited to participate in a poll on whether they consent with the recommendations. FINDINGS: Among rTMS experts, a high consensus rate could be identified for clinical practice concerning the setting and the technical parameters of rTMS treatment in depression, indications and contra-indications, the relation of rTMS to other antidepressive treatment modalities and the frequency and management of side effects.

[Deep brain stimulation: a review on current research]. / Die tiefe Hirnstimulation: Zum Stand der aktuellen Forschung - eine Übersicht.

Recently Deep brain stimulation (DBS) has found continuous use in treatment of neurological movement disorders. However DBS in psychiatric illnesses is less investigated. Its application in depression, obsessive-compulsive disorder, and therapy-resistant Tourette- Syndrome shows positive effects and offers an advanced alternative to neurosurgical therapies of the past. There are also case reports suggesting therapeutic benefits in schizophrenia and addiction. To a large extent, the mechanisms of action appear to be still unknown; the side effects seem partially modulated through the stimulation parameters. Furthermore, some ethics committees argue that DBS exhibits a relevant impact on the personality. The novel approach as well as the unknown long term effects of DBS implicate that the technique can be performed only under strict individual diagnosis and rigorous consideration of all ethical concerns.

Impact of seizure duration in maintenance electroconvulsive therapy.

Acute electroconvulsive therapy has anticonvulsive effects. The aim of the present study was to investigate the anticonvulsive efficiency of maintenance electroconvulsive therapy. Records of patients treated with maintenance electroconvulsive therapy were screened retrospectively, and the changes in seizure duration were measured. The patients were subdivided into responders and non-responders. Responders had no significant seizure duration changes within the first week of maintenance electroconvulsive therapy. In contrast, the seizure duration of the non-responder group increased significantly within the first week. It was concluded that the early increase in seizure duration at constant energy could be predictive of relapse.

[Is there a rationale in combining anticonvulsants for bipolar patients?]. / Rationale für eine Kombinationstherapie von Antikonvulsiva bei bipolaren Störungen.

High recurrence rates, chronicity and severity as well as high incidence rates of therapy refractory of bipolar disorder, different clinical manifestations of episodes, and psychiatric comorbidities demand combined drug treatment strategies. Polypharmacy is reported in more than 40 % of bipolar in- and out patients. The aim of this paper is to evaluate the incidence of combined mood stabilizer prescriptions and to delineate preclinical and clinical rationales for these treatment options. Over the last decade frequency of combination therapies with 2 or more anticonvulsants increased from 4.5 to more than 12 %. On the background of the dynamic complexity and being aware of potential side effects of such therapy paradigms, the authors provide a rationale for a thoughtful anticonvulsant combination therapy, considering the preclinical findings from epilepsy research, and clinical trials in bipolar disorder.

Combining high and low frequencies in rTMS antidepressive treatment: preliminary results.

The antidepressive potency of repetitive transcranial magnetic stimulation (rTMS) seems to depend on variables such as the stimulation placements, different frequencies, stimulus intensities, coil shape and interstimulus intervals. The aim of this pilot study was to investigate the augmentation properties of rTMS combining low and high frequencies. Thirty six depressed medicated in-patients were recruited and assigned to three different rTMS treatment modalities as an add-on strategy (each n = 12). In group 1 a stimulus intensity of 110% of the motor threshold (MT) was used with a frequency of 10 Hz over the left dorsolatero prefrontal cortex (DLPC). The right DLPC was stimulated in the same session with 110% MT at 1 Hz. In group 2 the patients were stimulated only over the left DLPC with alternating trains of 110% MT at 10 Hz and trains of 110% MT at 1 Hz in the same session. In group 3 the high frequency stimulation over the left DLPC was performed as an internal control group. None of the treatment modalities was superior but different side effects were observed. These preliminary findings suggest that rTMS, at varying frequencies and stimulation placements, evokes different psychoactive effects of clinical relevance.