Neurocognitive effects of transcranial direct current stimulation in obsessive-compulsive disorder: a systematic review.

Transcranial direct current stimulation (tDCS) has been used with increasing frequency as a therapeutic tool to alleviate clinical symptoms of obsessive compulsive-disorder (OCD). However, little is known about the effects of tDCS on neurocognitive functioning among OCD patients. The aim of this review was to provide a comprehensive overview of the literature examining the effects of tDCS on specific neurocognitive functions in OCD. A literature search following PRISMA guidelines was conducted on the following databases: PubMed, PsycINFO, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science. The search yielded 4 results: one randomized, sham-controlled study (20 patients), one randomized, controlled, partial crossover trial (12 patients), one open-label study (5 patients), and one randomized, double-blind, sham-controlled, parallel-group trial (37 patients). A total of 51 patients received active tDCS with some diversity in electrode montages targeting the dorsolateral prefrontal cortex, the pre-supplementary motor area, or the orbitofrontal cortex. tDCS was associated with improved decision-making in study 1, enhanced attentional monitoring and response inhibition in study 2, improved executive and inhibitory control in study 3, and reduced attentional bias and improved response inhibition and working memory in study 4. Limitations of this review include its small sample, the absence of a sham group in half of the studies, and the heterogeneity in tDCS parameters. These preliminary results highlight the need for future testing in randomized, sham-controlled trials to examine whether and how tDCS induces relevant cognitive benefits in OCD.

DTI-derived parameters differ between moderate and severe traumatic brain injury and its association with psychiatric scores.

BACKGROUND AND AIM: Diffusion tensor imaging (DTI) parameters in the corpus callosum have been suggested to be a biomarker for prognostic outcomes in individuals with diffuse axonal injury (DAI). However, differences between the DTI parameters on moderate and severe trauma in DAI over time are still unclear. A secondary goal was to study the association between the changes in the DTI parameters, anxiety, and depressive scores in DAI over time. METHODS: Twenty subjects were recruited from a neurological outpatient clinic and evaluated at 2, 6, and 12 months after the brain injury and compared to matched age and sex healthy controls regarding the DTI parameters in the corpus callosum. State-Trace Anxiety Inventory and Beck Depression Inventory were used to assess psychiatric outcomes in the TBI group over time. RESULTS: Differences were observed in the fractional anisotropy and mean diffusivity of the genu, body, and splenium of the corpus callosum between DAI and controls (p < 0.02). Differences in both parameters in the genu of the corpus callosum were also detected between patients with moderate and severe DAI (p < 0.05). There was an increase in the mean diffusivity values and the fractional anisotropy decrease in the DAI group over time (p < 0.02). There was no significant correlation between changes in the fractional anisotropy and mean diffusivity across the study and psychiatric outcomes in DAI. CONCLUSION: DTI parameters, specifically the mean diffusivity in the corpus callosum, may provide reliable characterization and quantification of differences determined by the brain injury severity. No correlation was observed with DAI parameters and the psychiatric outcome scores.

Bipolar disorder and frontotemporal dementia: A systematic review.

OBJECTIVES: To detail the biological, clinical and neurocognitive characteristics differentiating bipolar disorder (BD) from frontotemporal dementia (FTD) and to investigate whether BD is a risk factor for FTD. METHODS: A total of 16 studies were included in this systematic review. Five studies described biological and/or neurocognitive characteristics between patients with BD and FTD, and 11 studies investigated whether BD was a risk factor for FTD. RESULTS: Individuals with FTD presented higher levels of serum neurofilament light chain, greater grey matter reduction in frontal, parietal and temporal lobes, and increased slow wave oscillations in channels F3, F4, T3, T5, T4 and T6 within an electroencephalogram (EEG), relative to individuals with BD. Patients with FTD presented greater deficits in executive function and theory of mind compared to patients with BD in a euthymic state, and more deficits in verbal fluency compared to patients with BD in a current mood episode. Patients with BD in a current mood episode showed greater impairment in attention, working memory, verbal memory and executive function relative to individuals with FTD. In addition, retrospective studies showed that 10.2%-11.6% of patients with behavioural variant FTD (bvFTD) had a preceding history of BD. CONCLUSION: Biological and neurocognitive characteristics help to distinguish between BD and FTD, and it may help to reach a more precise diagnosis. In addition, individuals with BD are at higher risk of developing FTD. More studies are needed to identify the predictors of the conversion between BD to FTD.

Protective and Risk Factors for Phantom Limb Pain and Residual Limb Pain Severity.

INTRODUCTION: The exact mechanisms underlying the development and maintenance of phantom limb pain (PLP) are still unclear. This study aimed to identify the factors affecting pain intensity in patients with chronic, lower limb, traumatic PLP. METHODS: This is a cross-sectional analysis of patients with PLP. We assessed amputation-related and pain-related clinical and demographic variables. We used univariate and multivariate models to evaluate the associated factors modulating PLP and residual limb pain (RLP) intensity. RESULTS: We included 71 unilateral traumatic lower limb amputees. Results showed that (1) amputation-related perceptions were experienced by a large majority of the patients with chronic PLP (sensations: 90.1%, n = 64; residual pain: 81.7%, n = 58); (2) PLP intensity has 2 significant protective factors (phantom limb movement and having effective treatment for PLP previously) and 2 significant risk factors (phantom limb sensation intensity and age); and (3) on the other hand, for RLP, risk factors are different: presence of pain before amputation and level of amputation (in addition to the same protective factors). CONCLUSION: These results suggest different neurobiological mechanisms to explain PLP and RLP intensity. While PLP risk factors seem to be related to maladaptive plasticity, since phantom sensation and older age are associated with more pain, RLP risk factors seem to have components leading to neuropathic pain, such as the amount of neural lesion and previous history of chronic pain. Interestingly, the phantom movement appears to be protective for both phenomena.

Transcranial Direct Current Stimulation as a Therapeutic Tool for Chronic Pain.

Transcranial direct current stimulation (tDCS) modulates spontaneous neuronal activity that can generate long-term neuroplastic changes. It has been used in numerous therapeutic trials showing significant clinical effects especially when combined with other behavioral therapies. One area of intensive tDCS research is chronic pain. Since the initial tDCS trials for chronic pain treatment using current parameters of stimulation, more than 60 clinical trials have been published testing its effects in different pain syndromes. However, as the field moves in the direction of clinical application, several aspects need to be taken into consideration regarding tDCS effectiveness and parameters of stimulation. In this article, we reviewed the evidence of tDCS effects for the treatment of chronic pain and critically analyzed the literature pertaining its safety and efficacy, and how to optimize tDCS clinical effects in a therapeutic setting. We discuss optimization of tDCS effects in 3 different domains: (i) parameters of stimulation, (ii) combination therapies, and (iii) subject selection. This article aims to provide insights for the development of future tDCS clinical trials.

Chronicling the Transition to Competency-Based Medical Education in a Small Subspeciality Program.

Background As medical education programs transition to competency-based medical education (CBME), experiences transitioning in the context of small subspecialty programs remain unknown, yet they are needed for effective implementation and continual improvements. Objective To examine faculty and resident experiences transitioning to CBME in a small subspeciality program. Methods Using a qualitative descriptive approach and constructivist lens, faculty and residents in McMaster University's geriatric psychiatry subspecialty program were interviewed about their transition experiences between November 2021 and February 2022, after the program's soft launch of CBME in 2020. Interviews were transcribed and data were analyzed using thematic analysis. Reflexive memo writing and investigator and data triangulation strategies were employed to ensure rigor and trustworthiness of the data. Results Ten of the 17 faculty members (59%) and 3 residents (100%) participated. Six themes were developed: (1) Both faculty and residents see themselves as somewhat knowledgeable about CBME, but sources of knowledge vary; (2) More frequent feedback is beneficial; (3) Aspects of CBME that are challenging for residents are beneficial for faculty; (4) Competence committees are perceived positively despite most participants' limited firsthand experience with them; (5) Small program size is both a barrier and facilitator to providing and receiving feedback; and (6) Suggestions for improvement are centered on helping manage faculty and resident workload imposed by CBME. Conclusions Incongruent expectations surrounding entrustable professional activity management were highlighted as an area requiring support. Collegial relationships among faculty and residents made it difficult for faculty to provide constructive feedback but improved residents' perceptions of the feedback.

Clinical efficacy of deep transcranial magnetic stimulation (dTMS) in psychiatric and cognitive disorders: A systematic review.

Deep transcranial magnetic stimulation (dTMS) has gained attention as an enhanced form of traditional TMS, targeting broader and deeper regions of the brain. However, a fulsome synthesis of dTMS efficacy across psychiatric and cognitive disorders using sham-controlled trials is lacking. We systematically reviewed 28 clinical trials comparing active dTMS to a sham/controlled condition to characterize dTMS efficacy across diverse psychiatric and cognitive disorders. A comprehensive search of APA PsycINFO, Cochrane, Embase, Medline, and PubMed databases was conducted. Predominant evidence supports dTMS efficacy in patients with obsessive-compulsive disorder (OCD; n = 2), substance use disorders (SUDs; n = 8), and in those experiencing depressive episodes with major depressive disorder (MDD) or bipolar disorder (BD; n = 6). However, the clinical efficacy of dTMS in psychiatric disorders characterized by hyperactivity or hyperarousal (i.e., attention-deficit/hyperactivity disorder, posttraumatic stress disorder, and schizophrenia) was heterogeneous. Common side effects included headaches and pain/discomfort, with rare but serious adverse events such as seizures and suicidal ideation/attempts. Risk of bias ratings indicated a collectively low risk according to the Grading of Recommendations, Assessment, Development, and Evaluations checklist (Meader et al., 2014). Literature suggests promise for dTMS as a beneficial alternative or add-on treatment for patients who do not respond well to traditional treatment, particularly for depressive episodes, OCD, and SUDs. Mixed evidence and limited clinical trials for other psychiatric and cognitive disorders suggest more extensive research is warranted. Future research should examine the durability of dTMS interventions and identify moderators of clinical efficacy.

Next-generation cognitive assessment: Combining functional brain imaging, system perturbations and novel equipment interfaces.

Conventional cognitive assessment is widely used in clinical and research settings, in educational institutions, and in the corporate world for personnel selection. Such approaches involve having a client, a patient, or a research participant complete a series of standardized cognitive tasks in order to challenge specific and global cognitive abilities, and then quantify performance for the desired end purpose. The latter may include a diagnostic confirmation of a disease, description of a state or ability, or matching cognitive characteristics to a particular occupational role requirement. Metrics derived from cognitive assessments are putatively informative about important features of the brain and its function. For this reason, the research sector also makes use of cognitive assessments, most frequently as a stimulus for cognitive activity from which to extract functional neuroimaging data. Such "task-related activations" form the core of the most widely used neuroimaging technologies, such as fMRI. Much of what we know about the brain has been drawn from the interleaving of cognitive assessments of various types with functional brain imaging technologies. Despite innovation in neuroimaging (i.e., quantifying the neural response), relatively little innovation has occurred on task presentation and volitional response measurement; yet these together comprise the core of cognitive performance. Moreover, even when cognitive assessment is interleaved with functional neuroimaging, this is most often undertaken in the research domain, rather than the primary applications of cognitive assessment in diagnosis and monitoring, education and personnel selection. There are new ways in which brain imaging-and even more importantly, brain modulation-technologies can be combined with automation and artificial intelligence to deliver next-generation cognitive assessment methods. In this review paper, we describe some prototypes for how this can be done and identify important areas for progress (technological and otherwise) to enable it to happen. We will argue that the future of cognitive assessment will include semi- and fully-automated assessments involving neuroimaging, standardized perturbations via neuromodulation technologies, and artificial intelligence. Furthermore, the fact that cognitive assessments take place in a social/interpersonal context-normally between the patient and clinician-makes the human-machine interface consequential, and this will also be discussed.

Challenges and potential solutions for physician suicide risk factors in the COVID-19 era: psychiatric comorbidities, judicialization of medicine, and burnout.

INTRODUCTION: Suicide among physicians constitutes a public health problem that deserves more consideration. A recently performed meta-analysis and systematic review evaluated suicide mortality in physicians by gender and investigated several related risk factors. It showed that the post-1980 suicide mortality was 46% higher in female physicians than among women in the general population, while the risk in male physicians was 33% lower than among men in general, despite an overall contraction in physician mortality rates in both genders. METHODS: This narrative review was conducted by searching and analyzing articles/databases that were relevant to addressing questions raised by a prior meta-analysis and how they might be affected by COVID-19. This process included unstructured searches on Pubmed for physician suicide, burnout, judicialization of medicine, healthcare organizations, and COVID-19, and Google searches for relevant databases and medical society, expert, and media commentaries on these topics. We focus on three factors critical to addressing physician suicides: epidemiological data limitations, psychiatric comorbidities, and professional overload. RESULTS: We found relevant articles on suicide reporting, physician mental health, the effects of healthcare judicialization, and organizational involvement on physician and patient health, and how COVID-19 may impact such factors. This review addresses information sources, underreporting/misreporting of physician suicide rates, inadequate diagnosis and management of psychiatric comorbidities and the chronic effects on physicians' work capacity, and, finally, judicialization of medicine and organizational failures increasing physician burnout. We discuss these factors in general and in relation to the COVID-19 pandemic. CONCLUSIONS: We present an overview of the above factors, discuss possible solutions, and specifically address how COVID-19 may impact such factors.

Examining differences in brain metabolism associated with childhood maltreatment and suicidal attempt in euthymic patients with bipolar disorder: A PET and Machine Learning Study.

OBJECTIVE: Childhood maltreatment (CM) is a significant risk factor for the development and severity of bipolar disorder (BD) with increased risk of suicide attempts (SA). This study evaluated whether a machine learning algorithm could be trained to predict if a patient with BD has a history of CM or previous SA based on brain metabolism measured by positron emission tomography. METHODS: Thirty-six euthymic patients diagnosed with BD type I, with and without a history of CM were assessed using the Childhood Trauma Questionnaire. Suicide attempts were assessed through the Mini International Neuropsychiatric Interview (MINI-Plus) and a semi-structured interview. Resting-state positron emission tomography with 18F-fluorodeoxyglucose was conducted, electing only grey matter voxels through the Statistical Parametric Mapping toolbox. Imaging analysis was performed using a supervised machine learning approach following Gaussian Process Classification. RESULTS: Patients were divided into 18 participants with a history of CM and 18 participants without it, along with 18 individuals with previous SA and 18 individuals without such history. The predictions for CM and SA were not significant (accuracy = 41.67%; p = 0.879). CONCLUSION: Further investigation is needed to improve the accuracy of machine learning, as its predictive qualities could potentially be highly useful in determining histories and possible outcomes of high-risk psychiatric patients.

Clinical Efficacy of Deep Transcranial Magnetic Stimulation in Psychiatric and Cognitive Disorders: Protocol for a Systematic Review.

BACKGROUND: Transcranial magnetic stimulation (TMS) is a widely used noninvasive brain stimulation technique for psychiatric and cognitive disorders. In recent years, deep TMS (dTMS) has shown promise as an enhanced form of TMS able to stimulate deeper brain structures and target broader networks. Various magnetic Hesed-coil (H-coil) designs-a novel feature of dTMS-have been used to stimulate brain regions implicated in the pathophysiology of specific psychiatric and cognitive disorders, thereby producing therapeutic effects. Given the novelty of dTMS in psychiatry, little is known about the clinical efficacy of dTMS across psychiatric and cognitive disorders-that is, whether dTMS performs superiorly to sham or control. OBJECTIVE: In this paper, we outline a protocol for a systematic review investigating the clinical efficacy of dTMS. The primary objective is to conduct a systematic review of the literature on dTMS for psychiatric and cognitive disorders and, if feasible, a meta-analysis to compare the efficacy of active dTMS versus sham/control for psychiatric disorders. Dementia and related cognitive disorders will also be examined. A secondary objective will be to examine subgroup differences (by age, sex, H-coil design, and dTMS parameters [ie, pulses per session, percentage of motor threshold, etc]) to evaluate whether dTMS differentially influences clinical outcomes based on these factors. METHODS: A comprehensive search of the APA PsycINFO, Embase, MEDLINE, and PubMed databases will be conducted using keywords such as "H-coil" and "dTMS." Two authors (AD and MD) will be responsible for screening relevant articles, assessing article eligibility (according to predetermined inclusion and exclusion criteria), and data extraction. All included articles will undergo a quality and risk of bias assessment. Data from included articles will be summarized qualitatively in a systematic review. If a sufficient number of equivalent studies are available, a meta-analysis will be performed to (1) determine the effect of active versus sham dTMS (or another control arm) across psychiatric and cognitive disorders, and (2) examine subgroup effects of clinical outcomes. RESULTS: The preliminary search rendered a total of 1134 articles from the APA PsycINFO, Embase, and MEDLINE databases. After full-text screening, 21 eligible articles remained. One additional article was identified from the references section of an existing systematic review. In total, 22 eligible articles were included. Data extraction and quality of assessment procedures are ongoing. CONCLUSIONS: We will outline the evidence relating to the clinical efficacy of dTMS in various psychiatric and cognitive disorders. The results of the prospective systematic review will provide clinicians with valuable insight into the clinical (ie, participant age, sex, psychiatric or cognitive disorder, etc) and methodological factors (ie, H-coil design, dTMS parameters, etc) which may contribute to dTMS efficacy, and thereby may assist clinicians in their decision to prescribe dTMS for specific psychiatric and cognitive disorders. TRIAL REGISTRATION: PROSPERO CRD42022360066; https://tinyurl.com/5ev6byrn. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/45213.

Evaluating vision-specific quality of life and functional vision in a Brazilian population with Stargardt disease.

PURPOSE: To compare the vision-specific quality of life (QoL) of individuals with Stargardt disease (STGD) with that of healthy individuals and to investigate the association between vision-specific QoL and functional vision. METHODS: This cross-sectional study included 41 patients with STGD and 46 healthy volunteers matched by age and gender. Best corrected visual acuity (BCVA) was used to calculate the Functional Acuity Score (FAS) and Goldmann perimetry the Functional Field Score (FFS). These scores were combined to obtain the Functional Vision Score (FVS). Vision-specific QoL was assessed using the 25-item version of the National Eye Institute Visual Function Questionnaire (NEI VFQ-25). RESULTS: The groups had similar sociodemographic and clinical characteristics. There were significant differences in BCVA, vision-specific QoL assessed by the NEI VFQ-25, and FVS (p < 0.001) between individuals with STGD and controls. The final total score and all the subscales of the NEI VQF-25 questionnaire were significantly lower in the STGD group (p < 0.001), except for the subscales general health, color vision, and ocular pain. NEI VFQ-25 results in the STGD group were positively correlated with family income, FVS, and FFS. FVS was the score best correlated with the NEI VFQ-25 total score. CONCLUSIONS: Individuals with STGD had significant impairment of vision-specific QoL and functional vision compared with controls and the FVS was the objective evaluation method most correlated with vision-specific QoL in this population.

Physician suicide demographics and the COVID-19 pandemic.

OBJECTIVE: To identify suicide rates and how they relate to demographic factors (sex, race and ethnicity, age, location) among physicians compared to the general population when aggravated by the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We searched U.S. databases to report global suicide rates and proportionate mortality ratios (PMRs) among U.S. physicians (and non-physicians in health occupations) using National Occupational Mortality Surveillance (NOMS) data and using Wide-ranging Online Data for Epidemiologic Research (WONDER) in the general population. We also reviewed the effects of age, suicide methods and locations, COVID-19 considerations, and potential solutions to current challenges. RESULTS: Between NOMS1 (1985-1998) and NOMS2 (1999-2013), the PMRs for suicide increased in White male physicians (1.77 to 2.03) and Black male physicians (2.50 to 4.24) but decreased in White female physicians (2.66 to 2.42). CONCLUSIONS: The interaction of non-modifiable risk factors, such as sex, race and ethnicity, age, education level/healthcare career, and location, require further investigation. Addressing systemic and organizational problems and personal resilience training are highly recommended, particularly during the additional strain from the COVID-19 pandemic.

EEG modulation by different transcranial direct current stimulation (tDCS) montages: a randomized double-blind sham-control mechanistic pilot trial in healthy participants.

Background: Based on our Phantom study on transcranial direct current stimulation (tDCS), we hypothesized that EEG band power and field confinement would be greater following left dorsolateral prefrontal cortex (DLPFC - F3) tDCS using circular vs. rectangular electrodes.Methods: Double-blind-randomized trial comparing tDCS with anode over left DLPFC (groups: rectangular electrodes, circular electrodes, sham) and 2 active subgroup references (right shoulder vs. right DLPFC).Results: Twenty-four randomized participants were assessed. We indeed found higher average EEG power spectral density (PSD) across bands for circular vs. rectangular electrodes, largely confined to F3 and there was a significant increase at AF3 for low alpha (p = 0.037). Significant differences included: increased PSD in low beta (p = 0.024) and theta bands (p = 0.021) at F3, and in theta (p = 0.036) at FC5 for the right DLPFC vs. shoulder with no coherence changes. We found PSD differences between active vs. sham tDCS at Fz for alpha (p = 0.043), delta (p = 0.036), high delta (p = 0.030); and at FC1 for alpha (p = 0.031), with coherence differences for F3-Fz in beta (p = 0.044), theta (p = 0.044), delta (p = 0.037) and high delta (p = 0.009).Conclusion: This pilot study despite low statistical power given its small sample size shows that active left DLPFC tDCS modulates EEG frontocentrally and suggests that electrode shapes/reference locations affect its neurophysiological effects, such as increased low alpha power at AF3 using circular vs. rectangular electrodes. Further research with more participants is warranted.

Effects of Combined and Alone Transcranial Motor Cortex Stimulation and Mirror Therapy in Phantom Limb Pain: A Randomized Factorial Trial.

Phantom limb pain (PLP) is a frequent complication in amputees, which is often refractory to treatments. We aim to assess in a factorial trial the effects of transcranial direct current stimulation (tDCS) and mirror therapy (MT) in patients with traumatic lower limb amputation; and whether the motor cortex plasticity changes drive these results. In this large randomized, blinded, 2-site, sham-controlled, 2 × 2 factorial trial, 112 participants with traumatic lower limb amputation were randomized into treatment groups. The interventions were active or covered MT for 4 weeks (20 sessions, 15 minutes each) combined with 2 weeks of either active or sham tDCS (10 sessions, 20 minutes each) applied to the contralateral primary motor cortex. The primary outcome was PLP changes on the visual analogue scale at the end of interventions (4 weeks). Motor cortex excitability and cortical mapping were assessed by transcranial magnetic stimulation (TMS). We found no interaction between tDCS and MT groups (F = 1.90, P = .13). In the adjusted models, there was a main effect of active tDCS compared to sham tDCS (beta coefficient = -0.99, P = .04) on phantom pain. The overall effect size was 1.19 (95% confidence interval: 0.90, 1.47). No changes in depression and anxiety were found. TDCS intervention was associated with increased intracortical inhibition (coefficient = 0.96, P = .02) and facilitation (coefficient = 2.03, P = .03) as well as a posterolateral shift of the center of gravity in the affected hemisphere. MT induced no motor cortex plasticity changes assessed by TMS. These findings indicate that transcranial motor cortex stimulation might be an affordable and beneficial PLP treatment modality.

Appraising the effectiveness of electrical and magnetic brain stimulation techniques in acute major depressive episodes: an umbrella review of meta-analyses of randomized controlled trials.

Electrical and magnetic brain stimulation techniques present distinct mechanisms and efficacy in the acute treatment of depression. This was an umbrella review of meta-analyses of randomized controlled trials of brain stimulation techniques for managing acute major depressive episodes. A systematic review was performed in the PubMed/MEDLINE databases from inception until March 2020. We included the English language meta-analysis with the most randomized controlled trials on the effects of any brain stimulation technique vs. control in adults with an acute depressive episode. Continuous and dichotomous outcomes were assessed. A Measurement Tool to Assess Systematic Reviews-2 was applied and the credibility of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework. Seven meta-analyses were included (5,615 patients), providing evidence for different modalities of brain stimulation techniques. Three meta-analyses were evaluated as having high methodological quality, three as moderate, and one as low. The highest quality of evidence was found for high frequency-repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation, and bilateral rTMS. There is strong clinical research evidence to guide future clinical use of some techniques. Our results confirm the heterogeneity of the effects across these techniques, indicating that different mechanisms of action lead to different efficacy profiles.

Male and Female Physician Suicidality: A Systematic Review and Meta-analysis.

Importance: Population-based findings on physician suicide are of great relevance because this is an important and understudied topic. Objective: To evaluate male and female physician suicide risks compared with the general population from 1980 to date and test whether there is a reduction of SMR in cohorts after 1980 compared with before 1980 via a meta-analysis, modeling studies, and a systematic review emphasizing physician suicide risk factors. Data Sources: This study uses studies retrieved from PubMed, Scielo, PsycINFO, and Lilacs for human studies published by October 3, 2019, using the search term "(((suicide) OR (self-harm) OR (suicidality)) AND ((physicians) OR (doctors)))." Databases were also searched from countries listed in articles selected for review. Data were also extracted from an existing article by other authors to facilitate comparisons of the pre-1980 suicide rate with the post-1980 changes. Study Selection: Original articles assessing male and/or female physician suicide were included; for the meta-analysis, only cohorts from 1980 to the present were included. Data Extraction and Synthesis: The preregistered systematic review and meta-analysis followed Cochrane, PRISMA, and MOOSE guidelines. Data were extracted into standardized tables per a prespecified structured checklist, and quality scores were added. Heterogeneity was tested via Q test, I2, and τ2. For pooled effect estimates, we used random-effects models. The Begg and Egger tests, sensitivity analyses, and meta-regression were performed. Proportional mortality ratios were presented when SMR data could not be extracted. Main Outcomes and Measures: Suicide SMRs for male and female physicians from 1980 to the present and changes over time (before and after 1980). Results: Of 7877 search results, 32 articles were included in the systematic review and 9 articles and data sets in the meta-analysis. Meta-analysis showed a significantly higher suicide SMR in female physicians compared with women in general (1.46 [95% CI, 1.02-1.91]) and a significantly lower suicide SMR in male physicians compared with men in general (0.67 [95% CI, 0.55-0.79]). Male and female physician SMRs significantly decreased after 1980 vs before 1980 (male physicians: SMR, -0.84 [95% CI, -1.26 to -0.42]; P < .001; female physicians: SMR, -1.96 [95% CI, -3.09 to -0.84]; P = .002). No evidence of publication bias was found. Conclusions and Relevance: In this study, suicide SMR was found to be high in female physicians and low in male physicians since 1980 but also to have decreased over time in both groups. Physician suicides are multifactorial, and further research into these factors is critical.

Motor Cortex Reorganization in Limb Amputation: A Systematic Review of TMS Motor Mapping Studies.

Purpose: The purpose of this systematic review is to evaluate motor cortex reorganization in amputees as indexed by transcranial magnetic stimulation (TMS) cortical mapping and its relationship with phantom limb pain (PLP). Methods: Pubmed database were systematically searched. Three independent researchers screened the relevant articles, and the data of motor output maps, including the number of effective stimulation sites, center of gravity (CoG) shift, and their clinical correlations were extracted. We calculated a pooled CoG shift for motor cortex TMS mapping. Results: The search yielded 468 articles, 11 were included. Three studies performed correlation between the cortical changes and PLP intensity, and only one study compared cortical mapping changes between amputees with pain and without pain. Results showed (i) enlarged excitable area and a shift of CoG of neighboring areas toward the deafferented limb area; (ii) no correlation between motor cortex reorganization and level of pain and (iii) greater cortical reorganization in patients with PLP compared to amputation without pain. Conclusion: Our review supports the evidence for cortical reorganization in the affected hemisphere following an amputation. The motor cortex reorganization could be a potential clinical target for prevention and treatment response of PLP.

Childhood-maltreatment subtypes in bipolar patients with suicidal behavior: systematic review and meta-analysis.

OBJECTIVE: Patients with bipolar disorders have a high risk of suicidal behavior. Childhood maltreatment is a well-established risk factor for suicidal behavior. The objective of this study was to examine the association between childhood-maltreatment subtypes and vulnerability to suicide attempts in bipolar disorder using the Childhood Trauma Questionnaire (CTQ). METHODS: A literature review was performed using the MEDLINE, Embase, and PsycINFO databases. Thirteen studies met the selection criteria. In the meta-analysis, the Childhood Trauma Questionnaire (CTQ) was used to assess a wide range of childhood maltreatment subtypes, which were analyzed by using a random-effects model to account for the likely variations of true effect sizes between the included studies. RESULTS: In the systematic review, 13 studies met the selection criteria. The CTQ was selected for the meta-analysis to increase the homogeneity of assessment and to encompass a wide range of childhood-maltreatment subtypes. The data were analyzed using a random-effects model. Compared to bipolar non-attempters, bipolar suicide attempters had experienced childhood maltreatment with a significantly higher frequency and had higher total CTQ scores (Hedges' g = -0.38, 95%CI -0.52 to -0.24, z = -5.27, p < 0.001) and CTQ sub-scores (sexual abuse: g = -0.39, 95%CI -0.52 to -0.26, z = -5.97; physical abuse: g = -0.26, 95%CI -0.39 to -0.13, z = -4.00; emotional abuse: g = -0.39, 95%CI -0.65 to -0.13, z = -2.97; physical neglect: g = -0.18, 95%CI -0.31 to -0.05, z = -2.79; emotional neglect: g = -0.27, 95%CI -0.43 to -0.11, z = -3.32). CONCLUSIONS: Childhood maltreatment, as assessed by the CTQ, may contribute to an increased risk of suicidal behavior among people with bipolar disorders. Recognizing maltreatment as an etiological risk factor is a crucial step toward furthering science-based preventive psychiatry.