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1.
Lancet Psychiatry ; 7(1): 29-40, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31860455

RESUMO

BACKGROUND: Stimulation adjustment is required to optimise outcomes of deep brain stimulation (DBS) for treatment-resistant depression, but controlled data for ideal stimulation parameters are poor or insufficient. We aimed to establish the efficacy and safety of short pulse width (SPW) and long pulse width (LPW) subcallosal cingulate DBS in depression. METHODS: We did a double-blind, randomised, crossover trial in an academic hospital in Calgary, AB, Canada. Patients had DSM IV-defined major depressive disorder and bipolar depression (20-70 years old, both sexes) and did not respond to treatment for more than 1 year, with a score of 20 or more on the 17-item Hamilton Depression Rating Scale (HDRS) at recruitment. Patients underwent bilateral DBS implantation into the subcallosal cingulate white matter using diffusion tensor imaging tractography. Patients were randomly assigned 1:1 without stratification using a computerised list generator to receive either SPW (90 µs) or LPW (210-450 µs) stimulation for 6 months. Patients and the clinician assessing outcomes were masked to the stimulation group. Keeping frequency constant (130 Hz), either pulse width or voltage was increased monthly, based on response using the HDRS. Patients who did not respond to treatment (<50% reduction in HDRS from baseline) at 6 months crossed over to the opposite stimulation for another 6 months. All patients received individualised cognitive behavioural therapy (CBT) for 12 weeks. The primary outcome was change in HDRS at 6 months and 12 months using intention-to-treat analysis. This study is registered with ClinicalTrials.gov, NCT01983904. FINDINGS: Between Dec 5, 2013, and Sept 30, 2016, of 225 patients screened for eligibility, 23 patients were selected for DBS surgery. After one patient withdrew, 22 (mean age 46·4 years, SEM 3·1; 10 [45%] female, 12 [55%] male) were randomly assigned, ten (45%) to LPW stimulation and 12 (55%) to SPW stimulation. Patients were followed up at 6 months and 12 months. There was a significant reduction in HDRS scores (p<0·0001) with no difference between SPW and LPW groups (p=0·54) in the randomisation phase at 6 months. Crossover groups did not show a significant decrease in HDRS within groups (p=0·15) and between groups (p=0·21) from 6-12 months. Adverse events were equal between groups. Worsening anxiety and depression were the most common psychological adverse events. One patient in the SPW group died by suicide. INTERPRETATION: Both LPW and SPW stimulation of subcallosal cingulate white matter tracts carried similar risks and were equally effective in reducing depressive symptoms, suggesting a role for both pulse width and amplitude titration in optimising clinical outcomes in patients with treatment-resistant depression. FUNDING: Alberta Innovates Health Solutions.


Assuntos
Transtorno Bipolar/terapia , Estimulação Encefálica Profunda , Transtorno Depressivo Maior/terapia , Transtorno Depressivo Resistente a Tratamento/terapia , Imagem de Tensor de Difusão , Córtex Pré-Frontal , Canadá , Terapia Cognitivo-Comportamental , Estudos Cross-Over , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
2.
Tijdschr Psychiatr ; 61(6): 411-420, 2019.
Artigo em Holandês | MEDLINE | ID: mdl-31243751

RESUMO

BACKGROUND: Since 2017, repetitive transcranial magnetic stimulation (rTMS) has become eligible for reimbursement for the treatment of therapy-resistant depression in the Dutch healthcare system.
AIM: To initiate a guideline in the Netherlands and Belgium for the safe and effective application of rTMS for the treatment of depression.
METHOD: Based on literature review, existing guidelines and consensus among Dutch rTMS experts, recommendations were developed regarding the implementation of rTMS as a treatment of depression. All available evidence was weighed and discussed among all co-authors and recommendations were reached by consensus among the group.
RESULTS: rTMS targeting the dorsolateral prefrontal cortex (DLPFC) should be seen as a first choice in the treatment of depression using high-frequency rTMS (left) or, as an alternative, low-frequency rTMS (right). Stimulation protocols should use more than 1000 pulses per session for an average of 20-30 sessions, offered in 2-5 sessions per week. Contraindications for rTMS include epilepsy, intracranial presence of (magnetisable) metals, pacemaker and cochlear implant.
CONCLUSION: rTMS, performed by competent professionals is an effective and safe treatment for depression.


Assuntos
Transtorno Depressivo Maior/terapia , Transtorno Depressivo Resistente a Tratamento/terapia , Estimulação Magnética Transcraniana/métodos , Bélgica , Consenso , Humanos , Países Baixos , Resultado do Tratamento
3.
Prog Neurol Surg ; 34: 289-297, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31096225

RESUMO

Psychiatric illnesses create great suffering for patients and the medical solution is sometimes limited. The experience observed after treating patients with obsessive-compulsive disorder (OCD), depression, and anorexia nervosa by Gamma Knife radiosurgery (GKRS) is presented. Ten patients with medically refractory OCD, 3 patients with depression resistant to medical treatment and electroconvulsive therapy, and 5 patients with refractory anorexia nervosa have been treated. Bilateral anterior capsulotomy has been performed to treat OCD and bilateral cingulotomy has been applied to treat severe depression and anorexia nervosa. The accumulated experience about treatment of OCD by GKRS is reviewed. In our experience, 70% of OCD patients achieved a full response. We observed a significant improvement in patients with depression and anorexia nervosa evidenced by the scales of assessment (mean reduction of 40% in the Beck Depression Inventory at 1-year follow-up and 40% average increase of body mass index at 6-month follow-up). No side effects have been observed. These procedures are effective in reducing obsession, compulsion, depression, and anxiety, improving the quality of life of the patients without side effects.


Assuntos
Anorexia Nervosa/terapia , Transtorno Depressivo Resistente a Tratamento/terapia , Giro do Cíngulo , Cápsula Interna , Transtorno Obsessivo-Compulsivo/terapia , Radiocirurgia/métodos , Adulto , Anorexia Nervosa/cirurgia , Transtorno Depressivo Resistente a Tratamento/cirurgia , Feminino , Giro do Cíngulo/efeitos da radiação , Giro do Cíngulo/cirurgia , Humanos , Cápsula Interna/efeitos da radiação , Cápsula Interna/cirurgia , Masculino , Pessoa de Meia-Idade , Transtorno Obsessivo-Compulsivo/cirurgia
4.
Int J Psychiatry Clin Pract ; 23(2): 122-127, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30931656

RESUMO

Objective: The aim of this paper is to present the outcomes data from the largest United Kingdom's (UK) National Health Service (NHS) clinical rTMS service treating treatment resistant depression (TRD). Methods: The study was a retrospective investigation of routinely collected data on patients receiving rTMS between 2015 and 2017. Measures used were the clinician-rated Clinical Global Impression (CGI) and Hamilton Depression Rating Scale (HAM-D), and patient rated Beck Depression Inventory (BDI). The outcome data of 73 patients with TRD were analysed. The sample included patients with co-morbid psychiatric diagnosis. Results: Response and remission rates, respectively, were 40.4% and 25.5% for the HAM-D; 35.6% and 20.8% for the BDI; and 51.1% and 52.1% for the CGI. Effect sizes were medium (0.54, 0.52 and 0.56, respectively). Conclusions: The results show that a UK-based clinical service achieves similar results to those published internationally and that clinical rTMS can have significant impact on symptoms of depression in many patients with TRD. Health services are under pressure to make financial savings, investment in rTMS could reduce the long-term treatment costs associated with TRD.


Assuntos
Transtorno Depressivo Resistente a Tratamento/terapia , Estimulação Magnética Transcraniana/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde/estatística & dados numéricos , Estudos Retrospectivos , Reino Unido , Adulto Jovem
5.
Neurosurg Clin N Am ; 30(2): 243-256, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30898275

RESUMO

Depression is a heterogenous disorder, with roughly 30% of patients deemed resistant to conventional treatments. In these cases, neurosurgical interventions such as lesion procedures or deep brain stimulation offer possible therapeutic options. Here, we review neurosurgical interventions for treatment-resistant depression, focusing on the recent advancements and future directions of deep brain stimulation.


Assuntos
Estimulação Encefálica Profunda/métodos , Transtorno Depressivo Resistente a Tratamento/terapia , Humanos , Resultado do Tratamento
6.
Neuropsychopharmacology ; 44(7): 1224-1232, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30867553

RESUMO

Short- and long-term antidepressant effects of deep brain stimulation (DBS) in treatment-resistant depression (TRD) have been demonstrated for several brain targets in open-label studies. For two stimulation targets, pivotal randomized trials have been conducted; both failed a futility analysis. We assessed efficacy and safety of DBS of the supero-lateral branch of the medial forebrain bundle (slMFB) in a small Phase I clinical study with a randomized-controlled onset of stimulation in order to obtain data for the planning of a large RCT. Sixteen patients suffering from TRD received DBS of the slMFB and were randomized to sham or real stimulation for the duration of 2 months after implantation. Primary outcome measure was mean reduction in Montgomery-Åsberg Depression Rating Scale (MADRS) during 12 months of DBS (timeline analysis). Secondary outcomes were the difference in several clinical measures between sham and real stimulation at 8 weeks and during stimulation phases. MADRS ratings decreased significantly from 29.6 (SD +/- 4) at baseline to 12.9 (SD +/- 9) during 12 months of DBS (mean MADRS, n = 16). All patients reached the response criterion, most patients (n = 10) responded within a week; 50% of patients were classified as remitters after 1 year of stimulation. The most frequent side effect was transient strabismus. Both groups (active/sham) demonstrated an antidepressant micro-lesioning effect but patients had an additional antidepressant effect after initiation of stimulation. Both rapid onset and stability of the antidepressant effects of slMFB-DBS were demonstrated as in our previous pilot study. Given recent experiences from pivotal trials in DBS for MDD, we believe that slow, careful, and adaptive study development is germane. After our exploratory study and a large-scale study, we conducted this gateway trial in order to better inform planning of the latter. Important aspects for the planning of RCTs in the field of DBS for severe and chronic diseases are discussed including meaningful phases of intra-individual and between-group comparisons and timeline instead of single endpoint analyses.


Assuntos
Estimulação Encefálica Profunda , Transtorno Depressivo Maior/terapia , Transtorno Depressivo Resistente a Tratamento/terapia , Feixe Prosencefálico Mediano/fisiopatologia , Adulto , Idoso , Transtorno Depressivo Maior/fisiopatologia , Transtorno Depressivo Resistente a Tratamento/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
7.
Int J Geriatr Psychiatry ; 34(6): 822-827, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30854751

RESUMO

BACKGROUND: The management of late-life depression is challenged by high rates of treatment-resistance and adverse effects, along with medical comorbidities and polypharmacy. Together with the limited data on managing treatment-resistant depression in older adults, there is a need for investigating the efficacy of nonpharmacological treatment strategies. Repetitive transcranial magnetic stimulation (rTMS) is one modality that may better serve this patient population. METHODS: The present study examines data from two previous clinical trials (NCT00305045 and NCT01515215) to explore the efficacy of bilateral and unilateral high-frequency left-sided (HFL) rTMS in older adults suffering from treatment-resistant depression. A total of 43 adults aged 60 or older with a current major depressive episode were randomized to bilateral sequential, unilateral HFL, or sham. Bilateral sequential stimulation involved low-frequency (1 Hz) right dorsolateral prefrontal cortex (DLPFC) stimulation followed immediately by high-frequency (10 Hz) left DLPFC. The unilateral condition was HFL stimulation alone, and the placebo condition was either HFL or sequential bilateral form of sham. The primary outcome was remission of depression. RESULTS: Participants receiving bilateral rTMS experienced greater remission rates (40%) compared with unilateral (0%) or sham (0%) groups. Response to rTMS in the Hamilton Depression Rating Scale scores similarly favored the efficacy of bilateral rTMS. CONCLUSION: This study suggests that sequential bilateral treatment may be an optimal form of rTMS when used for treatment-resistant depression in older adults. Further large-scale comparative effectiveness trials of bilateral rTMS in this population are warranted.


Assuntos
Transtorno Depressivo Maior/terapia , Transtorno Depressivo Resistente a Tratamento/terapia , Estimulação Magnética Transcraniana/métodos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
8.
Rev. andal. med. deporte ; 12(1): 50-52, ene.-mar. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-184496

RESUMO

Se presenta un estudio de caso de un deportista de elite que desarrolló una psicopatología sobrevenida, que interfería en su carrera atlética. Tras ganar dos medallas en una competición internacional, entró en un estado de ansiedad, depresión, nerviosismo y apatía y dejó de entrenar durante cinco meses. Durante este tiempo no atendió al sistema ADAMS, y fue citado por el Control Antidopaje de la WADA para que se defendiera. Fue diagnosticado de un Trastorno Depresivo Mayor Recidivante (269.3x, DSM-IV-TR, 2002) con un GAP entre 45 y 50, y un Síndrome de Burnout. La intervención duró cinco meses con una sesión semanal basada en Psicoterapia Psicodinámica Breve, Enseñanza de estrategias adaptativas de afrontamiento y Apoyo social. Tras oír las alegaciones del psicólogo, por consenso, le permitieron volver a competir


This paper presents a case study in which an elite athlete developed a sports-associated psychopathology, interfering with his athletic career. After receiving medals in a top competition, the subject entered into an unusual state of anxiety, depression, nervousness, and apathy and he completely stopped his training for five months. During this time, he neglected ADAMS system controls, and was quoted by WADA to make legal arguments in his defense. He was diagnosed, with Relapsing Serious Depressive Disorder (269.3x, DSM-IV-TR, 2002) and a GAF between 45 and 50, and a Burnout Syndrome. An intervention was implemented over a five month period in the form of weekly sessions. It was based on Short-Term Psychodynamic Psychotherapy (ISTDP); Teaching effective use of well-adapted coping strategies and Social support. After hearing Sport Psychologist allegations by consensus, allowing him to compete


Apresenta-se um estudo de caso de um atleta de elite que desenvolveu uma psicopatologia que interferia com a sua carreira desportiva. Depois de ganhar duas medalhas numa competição internacional, entrou num estado de ansiedade, depressão e apatia, interrompendo os treinos durante cinco meses. Ao longo desse tempo não compareceu ao sistema ADAMS e foi convocado pelo Controle Anti-Doping da WADA para alegações de defesa. Foi-lhe diagnosticado um transtorno depressivo recorrente major (269,3x, DSM-IV-TR, 2002) com um GAP entre 45 e 50 e um Síndrome de Burnout. A intervenção durou cinco meses com uma sessão semanal baseada na psicoterapia psicodinâmica breve, ensino de estratégias de coping e suporte social. Na sequência das alegações do psicólogo, por consenso, foi-lhe permitido que voltasse a competir


Assuntos
Humanos , Masculino , Adulto Jovem , Transtorno Depressivo Resistente a Tratamento/terapia , Psicoterapia Psicodinâmica/métodos , Esgotamento Profissional/terapia , Atletas/psicologia , Transtorno Depressivo Resistente a Tratamento/diagnóstico , Esgotamento Profissional/diagnóstico , Adaptação Psicológica , Apoio Social , Doping nos Esportes/psicologia
9.
Am J Psychiatry ; 176(4): 275-286, 2019 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-30764648

RESUMO

OBJECTIVE: Adults with major depressive disorder frequently do not achieve remission with an initial treatment. Addition of psychotherapy for patients who do not achieve remission with antidepressant medication alone can target residual symptoms and protect against recurrence, but the utility of adding antidepressant medication after nonremission with cognitive-behavioral therapy (CBT) has received little study. The authors aimed to evaluate the acute and long-term outcomes resulting from both sequences of combination treatments. METHODS: Previously untreated adults with major depression who were randomly assigned to receive escitalopram, duloxetine, or CBT monotherapy and completed 12 weeks of treatment without achieving remission entered an additional 12 weeks of combination treatment. For patients who did not achieve remission with CBT, escitalopram was added (CBT plus medication group) to their treatment, and for those who did not achieve remission with an antidepressant, CBT was added (medication plus CBT group) to their treatment. Patients who responded to the combination treatment entered an 18-month follow-up phase to assess risk of recurrence. RESULTS: A total of 112 patients who did not achieve remission with a monotherapy entered combination treatment (41 who responded to monotherapy but did not achieve remission and 71 who did not respond to monotherapy). Overall, remission rates after subsequent combination therapy were significantly higher among patients who responded to monotherapy but did not achieve remission (61%) than among patients who did not respond to monotherapy (41%). Among patients who responded to monotherapy but did not achieve remission, the remission rate in the CBT plus medication group (89%) was higher than in the medication plus CBT group (53%). However, among patients whose depression did not respond to monotherapy, rates of response and remission were similar between the treatment arms. Higher levels of anxiety, both prior to monotherapy and prior to beginning combination treatment, predicted poorer outcomes for both treatment groups. CONCLUSIONS: The order in which CBT and antidepressant medication were sequentially combined did not appear to affect outcomes. Addition of an antidepressant is an effective approach to treating residual symptoms for patients who do not achieve remission with CBT, as is adding CBT after antidepressant monotherapy. Patients who do not respond to one treatment modality warrant consideration for addition of the alternative modality.


Assuntos
Antidepressivos/uso terapêutico , Terapia Cognitivo-Comportamental/métodos , Transtorno Depressivo Maior/terapia , Transtorno Depressivo Resistente a Tratamento/terapia , Adulto , Citalopram/uso terapêutico , Terapia Combinada , Transtorno Depressivo Maior/tratamento farmacológico , Transtorno Depressivo Resistente a Tratamento/tratamento farmacológico , Cloridrato de Duloxetina/uso terapêutico , Feminino , Humanos , Masculino , Falha de Tratamento
10.
J Affect Disord ; 249: 286-293, 2019 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-30784726

RESUMO

BACKGROUND: Low field magnetic stimulation is a potentially rapid-acting treatment for depression with mood-enhancing effects in as little as one 20-min session. The most convincing data for LFMS has come from treating bipolar depression. We examined whether LFMS also has rapid mood-enhancing effects in treatment-resistant major depressive disorder, and whether these effects are dose-dependent. OBJECTIVE/HYPOTHESIS: We hypothesized that a single 20-min session of LFMS would reduce depressive symptom severity and that the magnitude of this change would be greater after three 20-min sessions than after a single 20-min session. METHODS: In a double-blind randomized controlled trial, 30 participants (age 21-65) with treatment-resistant depression were randomized to three 20-min active or sham LFMS treatments with 48 h between treatments. Response was assessed immediately following LFMS treatment using the 6-item Hamilton Depression Rating Scale (HAMD-6), the Positive and Negative Affect Scale (PANAS) and the Visual Analog Scale. RESULTS: Following the 3rd session of LFMS, the effect of LFMS on VAS and HAMD-6 was superior to sham (F (1, 24) = 7.45, p = 0.03, Bonferroni-Holm corrected; F (1, 22) = 6.92, p = 0.03, Bonferroni-Holm corrected, respectively). There were no differences between sham and LFMS following the initial or second session with the effect not becoming significant until after the third session. CONCLUSIONS: Three 20-min LFMS sessions were required for active LFMS to have a mood-enhancing effect for individuals with treatment-resistant depression. As this effect may be transient, future work should address dosing schedules of longer treatment courses as well as biomarker-based targeting of LFMS to optimize patient selection and treatment outcomes.


Assuntos
Afeto , Transtorno Depressivo Resistente a Tratamento/terapia , Terapia de Campo Magnético , Adulto , Idoso , Transtorno Depressivo Resistente a Tratamento/psicologia , Método Duplo-Cego , Feminino , Humanos , Terapia de Campo Magnético/métodos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Resultado do Tratamento , Adulto Jovem
11.
Brain Stimul ; 12(3): 743-751, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30738778

RESUMO

BACKGROUND: Subcallosal cingulate deep brain stimulation (SCC DBS) is an experimental treatment for severe depression. Surgery is performed with awake patients and intraoperative stimulation produces acute behavioral responses in select contacts. While there have been reports on the relationship between acute intraoperative behaviors and their relation to the location of the contacts, there are no descriptions of the physiological changes that accompany them. OBJECTIVE: The present study sought to examine these physiological readouts, and their association with the anatomical substrates that generated them. METHODS: Nine patients with severe, treatment-resistant depression were tested intraoperatively. The stimulation protocol consisted of 12 three-minute, sham-controlled, double-blind trials. Changes in heart rate and skin conductance were recorded during each stimulation cycle. Probabilistic tractography between the stimulated contacts and predefined regions of the mood regulation network was performed. RESULTS: Acute intraoperative SCC stimulation produced increases in autonomic sympathetic response that correlated with the salience of the behavioral responses. The autonomic changes were observed within seconds of initiating acute stimulation and prior to verbalization of subjective experiences. The probabilistic tractography analysis suggested that structural connectivity between the stimulated area and the midcingulate cortex is the primary pathway that mediates autonomic responsivity to SCC DBS. CONCLUSIONS: These findings demonstrate that acute SCC stimulation produces autonomic and behavioral changes in the operating room that are explained by the modulation of networks associated with long term antidepressant response. Intraoperative autonomic recordings paired with careful behavioral observations and precise anatomical mapping aid in the identification and classification of the intraoperative phenomena.


Assuntos
Sistema Nervoso Autônomo/fisiopatologia , Estimulação Encefálica Profunda/métodos , Transtorno Depressivo Resistente a Tratamento/fisiopatologia , Substância Branca/fisiopatologia , Adulto , Nível de Alerta , Estimulação Encefálica Profunda/efeitos adversos , Transtorno Depressivo Resistente a Tratamento/terapia , Método Duplo-Cego , Feminino , Giro do Cíngulo/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Distribuição Aleatória
12.
Psychiatry Res ; 273: 567-574, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30711853

RESUMO

In major depressive disorder (MDD) patients, life stress events represent a risk factor for a severe, early-onset, treatment-resistant and chronic endophenotype. Treatment-resistant depression (TRD) patients who have experienced traumatic events could benefit from evidence-based trauma-focused psychotherapies. Because this topic has never been investigated, the aim of this pilot trial was to evaluate whether trauma-focused cognitive-behavioural therapy (TF-CBT) and/or eye movement desensitization and reprocessing (EMDR) can help achieve depressive symptom remission in TRD patients. We carried out a single-blind randomized controlled trial with TRD patients and we compared EMDR (N = 12) with TF-CBT (N = 10). Patients received 3 individual sessions per week over a period of 8 weeks. The symptomatological assessments were performed at 4 timepoints: baseline (T0), 4 (T4), 8 (T8) and 12 (T12) weeks. After 24 weeks, a clinical interview was carried out by phone. All TRD patients showed a significant improvement in depressive symptomatology; however, post hoc comparisons showed a significant difference between the two treatment groups, with lower depressive symptom scores in the EMDR than in the TF-CBT group at the follow-up (T12). This effect was partly maintained at 24 weeks. This pilot study suggests that evidence-based trauma-focused psychotherapies, particularly EMDR, can represent effective interventions to treat TRD patients.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Transtorno Depressivo Maior/terapia , Transtorno Depressivo Resistente a Tratamento/terapia , Dessensibilização e Reprocessamento através dos Movimentos Oculares/métodos , Transtornos de Estresse Pós-Traumáticos/terapia , Adolescente , Adulto , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/psicologia , Transtorno Depressivo Resistente a Tratamento/diagnóstico , Transtorno Depressivo Resistente a Tratamento/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Psicoterapia/métodos , Método Simples-Cego , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/psicologia , Resultado do Tratamento
14.
J Vis Exp ; (143)2019 01 07.
Artigo em Inglês | MEDLINE | ID: mdl-30663639

RESUMO

Vagus nerve stimulation (VNS) is an approved neurostimulation therapy. The purpose of the method is to treat patients with therapy-resistant depression (TRD). VNS exhibits antidepressive and stabilizing effects. This method is particularly useful as a long-term treatment, in which up to two-thirds of patients respond. The vagus nerve stimulator is positioned on the left vagus nerve during a surgical procedure and is activated telemetrically by a wand connected to a handheld computerized device. The treating physician can perform various adjustments of the vagus nerve stimulator during in-office visits (e.g., by modifying stimulation intensity or stimulation frequency) to achieve maximum therapeutic effects with low side effects. Set-up of the device usually takes several months. Typical side effects include wound infection, temporary salivation, coughing, paralysis of the vocal cords, bradycardia, or even asystole. The patient can stop the VNS by placing a magnet over the generator. The current protocol describes delivery of the specific stimulation tool and methods for adjusting the tuning parameters to achieve the best remission rates in patients with TRD.


Assuntos
Transtorno Depressivo Resistente a Tratamento/terapia , Estimulação do Nervo Vago/métodos , Humanos , Resultado do Tratamento
15.
Artigo em Inglês | MEDLINE | ID: mdl-30685322

RESUMO

Repetitive transcranial magnetic stimulation (rTMS) is a first-line option for treatment-resistant depression (TRD), but prediction of treatment outcome remains a clinical challenge. The present study aimed to compare structural and functional covariance networks (SCNs and FCNs) between remitters and nonremitters. We determined the predictive capacities of SCNs and FCNs to discriminate the two groups. Fifty TRD patients underwent a course of rTMS to the left dorsolateral prefrontal cortex. They were categorized into remitters (n = 22) and nonremitters (n = 28) based on HDRS≤7 at the end of treatment. Baseline structural and functional magnetic imaging (sMRI and fMRI) of the patients and 42 healthy controls were collected. SCNs and FCNs were defined based on structural and functional covariance of gray mater volume (GMV) and fractional amplitude of low-frequency fluctuations (fALFF) from sMRI and fMRI, respectively. Structural/functional network integrity of these networks (default mode network [DMN], central executive network [CEN] and salience network [SN]) were compared between the three groups. In patients, associations between SCNs and FCNs with clinical improvements were studied using linear correlation analysis. Receiver-operating characteristic (ROC) analysis was conducted to confirm the utility of the SCNs and FCNs in classifying clinical sub-groups. Nonremitters exhibited lower structural integrity in CEN than remitters and controls. Higher structural integrity of CEN was related to clinical improvement (r = 0.423, p = .002), and structural integrity distinguished remitters and nonremitters with a fairly high accuracy (AUC = 0.71, p = .008). No group differences or correlation with clinical changes were found in FCNs. Results suggest the CEN may play a role mediating clinical improvement in rTMS for depression. Structural covariance networks may be features to consider in prediction of clinical improvement.


Assuntos
Encéfalo/fisiopatologia , Transtorno Depressivo Resistente a Tratamento/fisiopatologia , Transtorno Depressivo Resistente a Tratamento/terapia , Estimulação Magnética Transcraniana , Adulto , Encéfalo/diagnóstico por imagem , Estudos Transversais , Transtorno Depressivo Resistente a Tratamento/diagnóstico por imagem , Função Executiva/fisiologia , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Vias Neurais/diagnóstico por imagem , Vias Neurais/fisiopatologia , Indução de Remissão , Resultado do Tratamento
16.
BMC Psychiatry ; 19(1): 46, 2019 01 28.
Artigo em Inglês | MEDLINE | ID: mdl-30691421

RESUMO

BACKGROUND: Anxiety and depressive disorders are common mental disorders. A substantial part of patients does not achieve symptomatic remission after treatment in specialized services. Current care as usual (CAU) for these patients consists of long-term supportive contacts. Termination of CAU is often not considered to be an option due to persistent symptoms, a low level of functioning, and the absence of further treatment options. A new intervention, ZemCAD, offers a program focused on rehabilitation and self-management, followed by referral back to primary care. METHODS: This multicenter randomized controlled trial was carried out in twelve specialized outpatient mental health care services in the Netherlands. Consenting and eligible patients were invited for the MINI interview and the baseline questionnaire. Assessments were done at 6 (T1), 12 (T2) and 18 (T3) months post baseline. We used linear mixed model analysis (LMM) to ascertain the effectiveness of the ZemCAD group relative to the CAU group on quality of life, symptom severity and empowerment. RESULTS: In total 141 patients were included. The results at 18-month follow-up regarding to quality of life and symptom severity, showed no significant differences between the ZemCAD group and the CAU group, except on the 'social relationships'-domain (d = 0.37). With regard to empowerment a significant difference between both groups was observed in the total empowerment score and one empowerment dimension (d = 0.45 and d = 0.39, respectively). After the ZemCAD intervention, more patients went from specialized outpatient mental health services back to a less specialized health care setting with less intensive treatment, such as primary care. CONCLUSION: The findings in this study suggest that patients with chronic and treatment-resistant anxiety and depression using the ZemCAD intervention improve on empowerment but not on symptom severity or quality of life. Since little is known about the effects of rehabilitation and self-management in patients with chronic and treatment resistant anxiety and depressive disorders, this is a first attempt to provide a proof-of-concept study in this under-researched but important field. TRIAL REGISTRATION: Netherlands Trial Register: NTR3335 , registered 7 March 2012.


Assuntos
Transtornos de Ansiedade/terapia , Transtorno Depressivo Resistente a Tratamento/terapia , Serviços de Saúde Mental , Qualidade de Vida/psicologia , Autogestão/métodos , Adulto , Idoso , Assistência Ambulatorial/métodos , Assistência Ambulatorial/psicologia , Transtornos de Ansiedade/epidemiologia , Transtornos de Ansiedade/psicologia , Doença Crônica , Transtorno Depressivo Resistente a Tratamento/epidemiologia , Transtorno Depressivo Resistente a Tratamento/psicologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Autogestão/psicologia , Inquéritos e Questionários , Resultado do Tratamento
17.
Brain Stimul ; 12(3): 714-723, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30635228

RESUMO

BACKGROUND: Electroconvulsive therapy (ECT) constitutes one of the most effective antidepressant treatment strategies in major depression (MDD). Despite its common use and uncontested efficacy, its mechanism of action is still insufficiently understood. Previously, we showed that ECT is accompanied by a global decrease of serotonin-1A receptors in MDD; however, further studies to investigate the involvement of the serotonergic system in the mechanism of action of ECT are warranted. The monoamine oxidase A (MAO-A) represents an important target for antidepressant treatments and was found to be increased in MDD. Here, we investigated whether ECT impacts on MAO-A levels in treatment-resistant patients (TRD). METHODS: 16 TRD patients (12 female, age 45.94 ±â€¯9.68 years, HAMD 25.12 ±â€¯3.16) with unipolar depression according to DSM-IV were scanned twice before (PET1 and PET2, to assess test-retest variability under constant psychopharmacotherapy) and once after (PET3) completing a minimum of eight unilateral ECT sessions using positron emission tomography and the radioligand [11C]harmine to assess cerebral MAO-A distribution volumes (VT). Age- and sex-matched healthy subjects (HC) were measured once. RESULTS: Response rate to ECT was 87.5%. MAO-A VT was found to be significantly reduced after ECT in TRD patients (-3.8%) when assessed in 27 a priori defined ROIs (p < 0.001). Test-retest variability between PET1 and PET2 was 3.1%. MAO-A VT did not significantly differ between TRD patients and HC at baseline. CONCLUSIONS: The small effect size of the significant reduction of MAO-A VT after ECT in the range of test-retest variability does not support the hypothesis of a clinically relevant mechanism of action of ECT based on MAO-A. Furthermore, in contrast to studies reporting elevated MAO-A VT in unmedicated depressed patients, MAO-A levels were found to be similar in TRD patients and HC which might be attributed to the continuous antidepressant pharmacotherapy in the present sample.


Assuntos
Encéfalo/diagnóstico por imagem , Transtorno Depressivo Resistente a Tratamento/terapia , Eletroconvulsoterapia/efeitos adversos , Monoaminoxidase/metabolismo , Adulto , Encéfalo/metabolismo , Encéfalo/fisiopatologia , Eletroconvulsoterapia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia por Emissão de Pósitrons
18.
Int J Psychiatry Clin Pract ; 23(1): 57-61, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30596524

RESUMO

OBJECTIVE: The nerves and axons of the retinal nerve fibre layer (RNFL) are similar to those in the brain and therefore retina is considered as the extension of the brain. We aimed to evaluate the RNFL thickness in the treatment-resistant major depressive patients before and after repetitive transcranial magnetic stimulation (rTMS) treatment and at least 6 months later after rTMS treatment using optical coherence tomography (OCT). METHODS: Thirty patients with treatment resistant major depression and 24 healthy controls were included in the study. rTMS was applied to the left dorsolateral prefrontal cortex (DLPFC) of the patients. RESULTS: rTMS was initiated in 28 patients. OCT assessments were performed in 24 patients at baseline and after rTMS treatment and in 19 patients at least sixth months after the rTMS treatment. We found significant increase in RNFL thickness compared with controls at the baseline and further increase in RNFL thickness after rTMS treatment. Although there was a decreasing trend in RNFL thickness 6 months after rTMS treatment, 6 months later RNFL thickness was still higher compared with controls. CONCLUSIONS: RNFL thickness is increased in treatment resistant major depression and rTMS over the left DLPFC further increases RNFL thickness in treatment resistant major depressive patients.


Assuntos
Transtorno Depressivo Maior/terapia , Transtorno Depressivo Resistente a Tratamento/terapia , Fibras Nervosas/ultraestrutura , Células Ganglionares da Retina/ultraestrutura , Estimulação Magnética Transcraniana , Adulto , Estudos de Casos e Controles , Transtorno Depressivo Maior/diagnóstico por imagem , Transtorno Depressivo Resistente a Tratamento/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Córtex Pré-Frontal/fisiopatologia , Tomografia de Coerência Óptica
19.
J ECT ; 35(1): 48-52, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29613946

RESUMO

OBJECTIVES: Magnetic seizure therapy (MST) is a novel convulsive brain stimulation method in clinical testing, which is used as an alternative for electroconvulsive therapy in patients with treatment-resistant depression (TRD). Preliminary studies have suggested that MST leads to fewer cognitive adverse effects than electroconvulsive therapy but has similar efficacy. However, the clinical predictors of response to MST have not been evaluated yet. This study aimed to investigate whether these predictors can be identified in patients with TRD. METHODS: Thirty-eight patients with TRD were included. As clinical predictors for treatment response, we used the diagnosis, sex, age, family history, and severity of depression, as well as the melancholic, psychotic, anxiety, and atypical depression symptoms. A response was defined as an improvement higher than 50% on the 28-item Hamilton Rating Scale for Depression. The binary logistic regression, stepwise linear regression, and effect sizes were calculated. RESULTS: We found that 68.4% of the patients responded to MST. The responders had significantly fewer previous depressive episodes, less severe depression, and fewer melancholic (anhedonia) and anxiety symptoms than the nonresponders. In addition, responders were more likely to have a positive family history of depression than nonresponders. In particular, the number of previous episodes and a family history of depression were significant predictors of the response to MST. CONCLUSIONS: We demonstrate that the chronicity, severity, and family history of depression, as well as the presence of melancholic and anxiety symptoms, can serve as clinical predictors of the response to MST. Further research with a larger sample size will be required to verify these preliminary findings.


Assuntos
Transtorno Depressivo Resistente a Tratamento/terapia , Terapia de Campo Magnético/métodos , Convulsões , Adulto , Idoso , Anedonia , Depressão/psicologia , Depressão/terapia , Transtorno Depressivo Resistente a Tratamento/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Escalas de Graduação Psiquiátrica , Resultado do Tratamento
20.
Brain Stimul ; 12(1): 119-128, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30344109

RESUMO

BACKGROUND: The therapeutic options for treatment-resistant depression (TRD) encompass a range of neuromodulatory techniques, including repetitive transcranial magnetic stimulation (rTMS). While rTMS is safe and has documented short-term efficacy, durability of antidepressant effects is poorly established. OBJECTIVE: Assess existing evidence regarding durability of rTMS-induced antidepressant response. METHODS: We performed a systematic review of studies reporting antidepressant outcome measures collected three or more months after the end of an induction course of rTMS for depression. Among responders to the induction course, we used a meta-analytic approach to assess response rates at 3 (m3), 6 (m6) or 12 (m12) months after induction, and studied predictors of responder rates using meta-regression. RESULTS: Nineteen studies published between 2002 and 2018 were included. Eighteen were eligible for analysis at m3 (732 patients) and m6 (695 patients) and 9 at m12 (247 patients). Among initial responders, 66.5% sustained response at m3 (95% CI = 57.1-74.8%, I2 = 27.6%), 52.9% at m6 (95% CI = 40.3-65%, I2 = 0%), and 46.3% at m12 (95% CI = 32.6-60.7%, I2 = 0%), in the absence of any major bias. Random-effects meta-regressions further demonstrated that a higher proportion of women, as well as receipt of maintenance treatment, predicted higher responder rates at specific time-points. CONCLUSIONS: rTMS is a durable treatment for depression, with sustained responder rates of 50% up to 1 year after a successful induction course of treatment. Maintenance treatment may enhance the durability of the antidepressant effects of rTMS, and should be considered in clinical practice, as well as systematically explored in future clinical trials.


Assuntos
Transtorno Depressivo Resistente a Tratamento/psicologia , Transtorno Depressivo Resistente a Tratamento/terapia , Estimulação Transcraniana por Corrente Contínua/métodos , Antidepressivos/uso terapêutico , Transtorno Depressivo Resistente a Tratamento/diagnóstico , Feminino , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento
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