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text-gray-500 hover:text-primary underline hover:no-underline decoration-gray-400" href="/authors/coralie-eilers-md">Coralie Eilers, MD</a></span></div><button class="text-xs text-gray-500 flex items-center mt-2 xs:mt-0 xs:ml-2">+3 More<span class="ml-1"><svg stroke="currentColor" fill="currentColor" stroke-width="0" viewBox="0 0 512 512" height="1em" width="1em" xmlns="http://www.w3.org/2000/svg"><path d="M256 294.1L383 167c9.4-9.4 24.6-9.4 33.9 0s9.3 24.6 0 34L273 345c-9.1 9.1-23.7 9.3-33.1.7L95 201.1c-4.7-4.7-7-10.9-7-17s2.3-12.3 7-17c9.4-9.4 24.6-9.4 33.9 0l127.1 127z"></path></svg></span></button></div></div><div class="max-w-full"><div class="flex flex-wrap sm:flex-nowrap items-center w-fit my-2"></div><div class="w-full flex flex-col sm:flex-row justify-between mt-2"><div class="block md:hidden "><div class="mt-2 flex items-center max-w-fit"><button title="TMS for the Treatment of OCD" aria-label="facebook" class="react-share__ShareButton" 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c6.1,0,10.1,4.4,10.1,9.2c0,6.3-3.5,11-8.6,11c-1.7,0-3.4-0.9-3.9-2c0,0-0.9,3.7-1.1,4.4c-0.3,1.2-1,2.5-1.6,3.4 c1.4,0.4,3,0.7,4.5,0.7c8.8,0,16-7.2,16-16C48,23.2,40.8,16,32,16z" fill="white"></path></svg></button><button aria-label="email" class="react-share__ShareButton" style="background-color:transparent;border:none;padding:0;font:inherit;color:inherit;cursor:pointer"><svg viewBox="0 0 64 64" width="32" height="32"><circle cx="32" cy="32" r="31" fill="#7f7f7f"></circle><path d="M17,22v20h30V22H17z M41.1,25L32,32.1L22.9,25H41.1z M20,39V26.6l12,9.3l12-9.3V39H20z" fill="white"></path></svg></button><a class="print-wrap flex justify-center items-center cursor-pointer"><svg id="print" xmlns="http://www.w3.org/2000/svg" width="24" height="24" fill="currentColor" class="print bi bi-printer" viewBox="0 0 16 16"> <path d="M2.5 8a.5.5 0 1 0 0-1 .5.5 0 0 0 0 1z"></path> <path d="M5 1a2 2 0 0 0-2 2v2H2a2 2 0 0 0-2 2v3a2 2 0 0 0 2 2h1v1a2 2 0 0 0 2 2h6a2 2 0 0 0 2-2v-1h1a2 2 0 0 0 2-2V7a2 2 0 0 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video::-webkit-media-controls-play-button { -webkit-appearance: media-play-button; color: #b8dcf6; } audio::-webkit-media-controls-panel { background-color: white !important; color: #000; } audio::-webkit-media-controls-current-time-display, audio::-webkit-media-controls-time-remaining-display { font-size: 12px; } </style></div></div></div><div class=" lg:w-full flex flex-col lg:flex-row lg:items-center lg:justify-end"></div><div class="w-full flex flex-col px-4 py-4 border-t border-b border-solid border-gray-400 my-4 "><h3 class="text-primary text-xl font-semibold">Key Takeaways</h3><ul class="list-disc px-8"><li class="py-2 "> rTMS demonstrated a moderate therapeutic effect on OCD severity, with a significant treatment response rate compared to sham conditions. </li><li class="py-2 "> Improvement in depression severity, longer TMS sessions, and fewer sessions were significant moderators of rTMS treatment effect. </li><li class="py-2 hidden"> Patient demographics and intervention characteristics like rTMS frequencies and anatomical locations did not significantly impact treatment outcomes. </li><li class="py-2 hidden"> Despite publication bias, rTMS remains a promising intervention for treatment-refractory OCD, especially in patients with comorbid depression.</li></ul><span class="text-xs font-bold text-primary underline cursor-pointer mt-2 ml-4">SHOW MORE</span></div><p class="py-2 mb-2 text-sm italic text-gray-600">A new study shows that rTMS has moderate therapeutic effects on OCD severity. </p><div class="py-2"><div class="blockText_blockContent__TbCXh"><div class=""><div style="width:50%;float:left;max-width:525px;margin:0 1.5rem 1.5rem 0;clear:both;cursor:" class=" figure"><div class="flex-none relative text-center"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%276000%27%20height=%274000%27/%3e"/></span><img alt="brain lightbulb" title="brain lightbulb" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="brain lightbulb" title="brain lightbulb" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6e7deea1c577db789477d44ab9518072785d31ee-6000x4000.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 1x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6e7deea1c577db789477d44ab9518072785d31ee-6000x4000.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span></div><div id="image-caption" class="text-gray-500 italic"><div class="blockText_blockContent__TbCXh"><p class="pb-2">Dilok/AdobeStock</p></div></div><div class="top-[-100%] block w-[1px] transition-opacity duration-500 ease-in-out opacity-0 overflow-hidden"><img class="m-auto absolute inset-0 max-w-[0%] max-h-[0%] border-[3px] border-solid border-white shadow-[0px_0px_8px_rgba(0,0,0,0.3)] box-border transition ease-in-out duration-500" src="https://cdn.sanity.io/images/0vv8moc6/psychtimes/6e7deea1c577db789477d44ab9518072785d31ee-6000x4000.jpg?fit=crop&auto=format"/></div></div><style> #image-caption p{ font-size: 12px; max-width: 525px; margin: 0 auto; text-align: center; } </style></div><p class="pb-2"><strong>TRANSLATING RESEARCH INTO PRACTICE</strong></p><p class="pb-2"><em>Rajesh R. Tampi MD, MS, DFAPA, DFAAGP, Editor</em></p><p class="pb-2">While pharmacological and therapy-based treatments have shown therapeutic efficacy in obsessive-compulsive disorder (OCD), there are many patients who have inadequate responses to these treatment modalities. Repetitive transcranial magnetic stimulation (rTMS) has shown promise for treatment-refractory affective disorders. This meta-analysis included 25 randomized controlled trials (RCTs) with 860 participants. The aim was to assess the therapeutic benefit of rTMS in patients with OCD and explored the moderators of its treatment effect.</p><p class="pb-2"></p><p class="pb-2"><strong>The Study</strong></p><p class="pb-2">Steuber ER, McGuire JF. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/37343662/">A meta-analysis of transcranial magnetic stimulation in obsessive-compulsive disorder.</a> <em>Biol Psychiatry Cogn Neurosci Neuroimaging.</em> 2023;8(11):1145-1155.</p><p class="pb-2"></p><p class="pb-2"><strong>Study Funding</strong></p><p class="pb-2">None listed.</p><p class="pb-2"></p><p class="pb-2"><strong>Study Objectives</strong></p><p class="pb-2">To examine the therapeutic benefit of rTMS in patients with OCD and to explore the moderators of its treatment effect.</p><p class="pb-2"></p><p class="pb-2"><strong>Methodology</strong></p><p class="pb-2">This meta-analysis adhered to PRISMA guidelines and included studies from 1997 to December 31, 2022. Pubmed, SCOPUS, and PsycINFO databases were searched using keywords: “obsessive-compulsive disorder,” “transcranial magnetic stimulation,” and “randomized controlled trial.” Inclusion criteria were that the study had to be an RCT that compares rTMS treatment with sham condition. In addition, the participants had to meet diagnostic criteria for OCD, and there had to be sufficient data to calculate treatment effects using psychometrically supported rating scales. The authors screened a total of 159 records for eligibility. After applying inclusion criteria, 25 studies were included with 3 trials having multiple rTMS conditions. This provided a total of 28 treatment comparisons for inclusion. The Yale-Brown Obsessive-Compulsive Scale (YBOCS) was utilized to extract effect sizes for OCD severity. If multiple depression scales were reported in the RCT, the Montgomery-Asberg Depression Scale (MADRS) was favored over the Hamilton Depression Scale (HDS) and Beck Depression Inventory (BDI). To quantify treatment effects, Hedge’s <em>g </em>was selected. Effective sizes were calculated using change scores. Relative risk ratios were used to calculate the treatment response and effective size.</p><p class="pb-2"></p><p class="pb-2"><strong>Study Results</strong></p><p class="pb-2">The random effects model found that rTMS had a moderate therapeutic effect on OCD severity when compared with sham conditions. (<em>g</em>=0.65, <em>P</em><0.001). Significant heterogeneity was identified (<em>P</em><0.003) and Egger’s test indicated that publication bias was significant (<em>P</em>=0.04). Further testing using the Duval and Tweedie’s trim and fill method indicated that no studies needed to be trimmed and that a moderate therapeutic effect remained (<em>g</em>=0.65).</p><p class="pb-2">For treatment response, the average rate across trials was 39.5% for rTMS and 8.8% for sham conditions. A large treatment effect of rTMS when compared with sham conditions was found using the random effects model (Relative Risk [RR] =3.15, <em>P</em><0.001). There was little heterogeneity across trials (<em>P</em>=0.61), but publication bias was present (<em>P</em>=0.03). When Duval and Tweedie’s trim-and-fill method was used, rTMS continued to show a moderate effect (RR=2.67), although 4 studies had to be trimmed. There were no significant differences between trials that used > 25% improvement on the YBOCS scale compared with >30%, >35%, or >40% improvement (<em>P</em>=0.86).</p><p class="pb-2">Three treatment moderators were found to be statistically significant when analyzing heterogeneity. First, when patients had a greater improvement in depression severity, this was found to produce a larger treatment effect of rTMS on OCD (<em>P</em>=0.02). Second, longer TMS sessions were associated with greater improvement in OCD (<em>P</em>=0.05). And lastly, a lower number of TMS sessions were associated with greater improvement in OCD severity (<em>P</em>=0.02).</p><p class="pb-2">It is important to note that patient average age, sex, duration of OCD illness, concurrent use of serotonin reuptake inhibitor pharmacotherapy or antipsychotic pharmacotherapy, baseline OCD symptom severity, and/or use of medication free status were not statistically significant regarding the treatment effect of rTMS on OCD severity. Other intervention characteristics that were not found to be statistically significant included rTMS motor thresholds, rTMS frequencies, coils used for rTMS, total number of pulses used, and the location of rTMS treatment including the dorsolateral prefrontal cortex, orbitofrontal cortex, and supplementary motor area.</p><p class="pb-2">When looking through trial design characteristics as moderators of rTMS treatment effects, sample size, trial attrition, and year of publications were not found to be statistically significant. There was no difference between studies that used full sham conditions vs those that did not (<em>P</em>=0.75). Finally, there was no statistical significance between trials that used treatment refractory patients, vs nontreatment refractory patients (<em>P</em>=0.81).</p><p class="pb-2"></p><p class="pb-2"><strong>Study Strengths</strong></p><p class="pb-2">1. This review included 25 studies and 860 participants.</p><p class="pb-2">2. Only RCTs were included.</p><p class="pb-2">3. Trials included different rTMS coils, frequencies, motor thresholds, and anatomical locations.</p><p class="pb-2">4. There were no conflicts of interest for the authors.</p><p class="pb-2"></p><p class="pb-2"><strong>Study Limitations</strong></p><p class="pb-2">1. The studies included only focused on acute treatment outcomes.</p><p class="pb-2">2. Statistical analysis did not correct for multiple comparisons.</p><p class="pb-2">3. Limited patient characteristics were available for extraction across trials, such as whether exposure and response therapy had been trialed.</p><p class="pb-2">4. Publication bias was present.</p><p class="pb-2"></p><p class="pb-2"><strong>Conclusions</strong></p><p class="pb-2">This meta-analysis found that rTMS had a moderate therapeutic effect for the treatment of OCD. In addition, greater improvement in depression severity, longer TMS sessions, and fewer number of TMS sessions were moderators associated with greater improvement in OCD severity.</p><p class="pb-2"></p><p class="pb-2"><strong>Practical Applications</strong></p><p class="pb-2">OCD is a heterogenous disorder that can be debilitating for patients. This study shows that rTMS has moderate therapeutic effects on OCD severity.</p><p class="pb-2"></p><p class="pb-2"><strong>Bottom Line</strong></p><p class="pb-2">Clinicians should consider rTMS as an intervention to alleviate OCD symptoms, especially in those who have failed other treatments or those with comorbid depression.</p><p class="pb-2"></p><p class="pb-2"><strong>Dr Sung </strong><em>is a psychiatry second year resident at Creighton University in Omaha, Nebraska.</em><strong> Dr Eilers </strong><em>is a fourth-year psychiatry resident at Creighton University in Omaha, Nebraska.</em> <strong>Dr Schuster</strong> <em>is a fourth-year psychiatry resident at Creighton University in Omaha, Nebraska.</em> <strong>Dr Mullen</strong> <em>is an assistant professor of Psychiatry at Saint Louis University School of Medicine.</em> <strong>Dr Tampi </strong><em>is professor and Chairman of the Department of Psychiatry at Creighton University School of Medicine and Catholic Health Initiatives (CHI) Health Behavioral Health Services. He is also an adjunct professor of psychiatry at Yale School of Medicine, and he is a member of the </em>Psychiatric Times<em> editorial board.</em></p><p class="pb-2"></p><p class="pb-2"><strong>Reference</strong></p><p class="pb-2">Steuber ER, McGuire JF. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/37343662/">A meta-analysis of transcranial magnetic stimulation in obsessive-compulsive disorder.</a> <em>Biol Psychiatry Cogn Neurosci Neuroimaging.</em> 2023;8(11):1145-1155.</p></div></div><div class="flex items-center lg:w-3/4 mb-4 pb-12"></div><div class="jsx-19ede9f0a5a45918 py-4 relative bg-primary md:px-8 -ml-6 xs:ml-0 w-screen xs:w-auto"><div class="jsx-19ede9f0a5a45918 px-4 sm:px-0"><div class="flex justify-between items-center py-1 space-x-4 border-0 select-none sm:border-b border-secondary"><div class="text-3xl text-white text-lg sm:text-3xl">Related Videos</div></div></div><div style="scroll-snap-type:none" 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Bender, PharmD, MA</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/saint-itbs-protocol-shows-promise-for-bipolar-i-depression?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent"></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div></div></div></div><div class="pb-24"></div></div><script type="application/ld+json">{"@context":"https://schema.org","@type":"NewsArticle","headline":"TMS for the Treatment of OCD","datePublished":"2024-10-25T15:00:00.000Z","dateModified":"2024-10-24T20:44:47Z","inLanguage":"en-US","image":"https://cdn.sanity.io/images/0vv8moc6/psychtimes/6e7deea1c577db789477d44ab9518072785d31ee-6000x4000.jpg?fit=crop&auto=format","mainEntityOfPage":{"@type":"WebPage","@id":"https://www.psychiatrictimes.com/view/tms-for-the-treatment-of-ocd"},"publisher":{"@type":"Organization","name":"Psychiatric Times","logo":{"@type":"ImageObject","url":"https://www.psychiatrictimes.com/PsychiatricTimesLogo.png"}},"articleBody":"\n\nTRANSLATING RESEARCH INTO PRACTICE\n\nRajesh R. Tampi MD, MS, DFAPA, DFAAGP, Editor\n\nWhile pharmacological and therapy-based treatments have shown therapeutic efficacy in obsessive-compulsive disorder (OCD), there are many patients who have inadequate responses to these treatment modalities. Repetitive transcranial magnetic stimulation (rTMS) has shown promise for treatment-refractory affective disorders. This meta-analysis included 25 randomized controlled trials (RCTs) with 860 participants. The aim was to assess the therapeutic benefit of rTMS in patients with OCD and explored the moderators of its treatment effect.\n\n\n\nThe Study\n\nSteuber ER, McGuire JF. A meta-analysis of transcranial magnetic stimulation in obsessive-compulsive disorder. Biol Psychiatry Cogn Neurosci Neuroimaging. 2023;8(11):1145-1155.\n\n\n\nStudy Funding\n\nNone listed.\n\n\n\nStudy Objectives\n\nTo examine the therapeutic benefit of rTMS in patients with OCD and to explore the moderators of its treatment effect.\n\n\n\nMethodology\n\nThis meta-analysis adhered to PRISMA guidelines and included studies from 1997 to December 31, 2022. Pubmed, SCOPUS, and PsycINFO databases were searched using keywords: “obsessive-compulsive disorder,” “transcranial magnetic stimulation,” and “randomized controlled trial.” Inclusion criteria were that the study had to be an RCT that compares rTMS treatment with sham condition. In addition, the participants had to meet diagnostic criteria for OCD, and there had to be sufficient data to calculate treatment effects using psychometrically supported rating scales. The authors screened a total of 159 records for eligibility. After applying inclusion criteria, 25 studies were included with 3 trials having multiple rTMS conditions. This provided a total of 28 treatment comparisons for inclusion. The Yale-Brown Obsessive-Compulsive Scale (YBOCS) was utilized to extract effect sizes for OCD severity. If multiple depression scales were reported in the RCT, the Montgomery-Asberg Depression Scale (MADRS) was favored over the Hamilton Depression Scale (HDS) and Beck Depression Inventory (BDI). To quantify treatment effects, Hedge’s g was selected. Effective sizes were calculated using change scores. Relative risk ratios were used to calculate the treatment response and effective size.\n\n\n\nStudy Results\n\nThe random effects model found that rTMS had a moderate therapeutic effect on OCD severity when compared with sham conditions. (g=0.65, P<0.001). Significant heterogeneity was identified (P<0.003) and Egger’s test indicated that publication bias was significant (P=0.04). Further testing using the Duval and Tweedie’s trim and fill method indicated that no studies needed to be trimmed and that a moderate therapeutic effect remained (g=0.65).\n\nFor treatment response, the average rate across trials was 39.5% for rTMS and 8.8% for sham conditions. A large treatment effect of rTMS when compared with sham conditions was found using the random effects model (Relative Risk [RR] =3.15, P<0.001). There was little heterogeneity across trials (P=0.61), but publication bias was present (P=0.03). When Duval and Tweedie’s trim-and-fill method was used, rTMS continued to show a moderate effect (RR=2.67), although 4 studies had to be trimmed. There were no significant differences between trials that used > 25% improvement on the YBOCS scale compared with >30%, >35%, or >40% improvement (P=0.86).\n\nThree treatment moderators were found to be statistically significant when analyzing heterogeneity. First, when patients had a greater improvement in depression severity, this was found to produce a larger treatment effect of rTMS on OCD (P=0.02). Second, longer TMS sessions were associated with greater improvement in OCD (P=0.05). And lastly, a lower number of TMS sessions were associated with greater improvement in OCD severity (P=0.02).\n\nIt is important to note that patient average age, sex, duration of OCD illness, concurrent use of serotonin reuptake inhibitor pharmacotherapy or antipsychotic pharmacotherapy, baseline OCD symptom severity, and/or use of medication free status were not statistically significant regarding the treatment effect of rTMS on OCD severity. Other intervention characteristics that were not found to be statistically significant included rTMS motor thresholds, rTMS frequencies, coils used for rTMS, total number of pulses used, and the location of rTMS treatment including the dorsolateral prefrontal cortex, orbitofrontal cortex, and supplementary motor area.\n\nWhen looking through trial design characteristics as moderators of rTMS treatment effects, sample size, trial attrition, and year of publications were not found to be statistically significant. There was no difference between studies that used full sham conditions vs those that did not (P=0.75). Finally, there was no statistical significance between trials that used treatment refractory patients, vs nontreatment refractory patients (P=0.81).\n\n\n\nStudy Strengths\n\n1. This review included 25 studies and 860 participants.\n\n2. Only RCTs were included.\n\n3. Trials included different rTMS coils, frequencies, motor thresholds, and anatomical locations.\n\n4. There were no conflicts of interest for the authors.\n\n\n\nStudy Limitations\n\n1. The studies included only focused on acute treatment outcomes.\n\n2. Statistical analysis did not correct for multiple comparisons.\n\n3. Limited patient characteristics were available for extraction across trials, such as whether exposure and response therapy had been trialed.\n\n4. Publication bias was present.\n\n\n\nConclusions\n\nThis meta-analysis found that rTMS had a moderate therapeutic effect for the treatment of OCD. In addition, greater improvement in depression severity, longer TMS sessions, and fewer number of TMS sessions were moderators associated with greater improvement in OCD severity.\n\n\n\nPractical Applications\n\nOCD is a heterogenous disorder that can be debilitating for patients. This study shows that rTMS has moderate therapeutic effects on OCD severity.\n\n\n\nBottom Line\n\nClinicians should consider rTMS as an intervention to alleviate OCD symptoms, especially in those who have failed other treatments or those with comorbid depression.\n\n\n\nDr Sung is a psychiatry second year resident at Creighton University in Omaha, Nebraska. Dr Eilers is a fourth-year psychiatry resident at Creighton University in Omaha, Nebraska. Dr Schuster is a fourth-year psychiatry resident at Creighton University in Omaha, Nebraska. Dr Mullen is an assistant professor of Psychiatry at Saint Louis University School of Medicine. Dr Tampi is professor and Chairman of the Department of Psychiatry at Creighton University School of Medicine and Catholic Health Initiatives (CHI) Health Behavioral Health Services. He is also an adjunct professor of psychiatry at Yale School of Medicine, and he is a member of the Psychiatric Times editorial board.\n\n\n\nReference\n\nSteuber ER, McGuire JF. A meta-analysis of transcranial magnetic stimulation in obsessive-compulsive disorder. Biol Psychiatry Cogn Neurosci Neuroimaging. 2023;8(11):1145-1155.","description":"A new study shows that rTMS has moderate therapeutic effects on OCD severity. ","author":[{"@type":"Person","name":"Tommy Sung, MD"},{"@type":"Person","name":"Coralie Eilers, MD"},{"@type":"Person","name":"Haley Schuster, MD"},{"@type":"Person","name":"Mark Mullen, MD"},{"@type":"Person","name":"Rajesh R. Tampi, MD, MS, DFAPA, DFAAGP"}]}</script></div></div><div class="flex-none w-[300px] z-[9999] relative hidden md:block"><div style="top:5rem" class="sticky custom-spacing"><div class="collapse-container " style="overflow:hidden;max-height:900px;transition:max-height .4s ease-in-out"></div></div></div></div><div id="div-gpt-ad-pixel" style="width:1px;height:1px" class=""></div><noscript><iframe src="https://www.googletagmanager.com/ns.html?id=GTM-5V9L5PL" height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript><div id="footerOuterWrap" class="w-full bg-primary flex flex-col items-center justify-center"><div class="container w-[1340px]"><div id="footerInnerWrap" class="bg-primary w-full py-12"><div class="py-4 pl-4 flex flex-row items-center"><div class="flex flex-row flex-wrap w-[55%] h-full"><div class="w-[33%] p-1 my-0 cursor-pointer text-footer-text-color hover:text-footer-text-color/80 hover:underline"><a class="text-md" target="_self" 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(","_key":"46e75fb8096c0"},{"text":"g","_key":"46e75fb8096c1","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":"=0.65, ","_key":"46e75fb8096c2"},{"marks":["em"],"text":"P","_key":"46e75fb8096c3","_type":"span"},{"_type":"span","marks":[],"text":"\u003c0.001). Significant heterogeneity was identified (","_key":"46e75fb8096c4"},{"_type":"span","marks":["em"],"text":"P","_key":"46e75fb8096c5"},{"_type":"span","marks":[],"text":"\u003c0.003) and Egger’s test indicated that publication bias was significant (","_key":"46e75fb8096c6"},{"_type":"span","marks":["em"],"text":"P","_key":"46e75fb8096c7"},{"_type":"span","marks":[],"text":"=0.04). Further testing using the Duval and Tweedie’s trim and fill method indicated that no studies needed to be trimmed and that a moderate therapeutic effect remained (","_key":"46e75fb8096c8"},{"_type":"span","marks":["em"],"text":"g","_key":"46e75fb8096c9"},{"_type":"span","marks":[],"text":"=0.65).","_key":"46e75fb8096c10"}],"_type":"block","upload_doc":null,"uploadAudio":null},{"_key":"7b8acc57fb95","markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"_type":"span","marks":[],"text":"For treatment response, the average rate across trials was 39.5% for rTMS and 8.8% for sham conditions. A large treatment effect of rTMS when compared with sham conditions was found using the random effects model (Relative Risk [RR] =3.15, ","_key":"c3f01fb62ca70"},{"text":"P","_key":"c3f01fb62ca71","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":"\u003c0.001). There was little heterogeneity across trials (","_key":"c3f01fb62ca72"},{"_type":"span","marks":["em"],"text":"P","_key":"c3f01fb62ca73"},{"_type":"span","marks":[],"text":"=0.61), but publication bias was present (","_key":"c3f01fb62ca74"},{"_key":"c3f01fb62ca75","_type":"span","marks":["em"],"text":"P"},{"_type":"span","marks":[],"text":"=0.03). When Duval and Tweedie’s trim-and-fill method was used, rTMS continued to show a moderate effect (RR=2.67), although 4 studies had to be trimmed. There were no significant differences between trials that used \u003e 25% improvement on the YBOCS scale compared with \u003e30%, \u003e35%, or \u003e40% improvement (","_key":"c3f01fb62ca76"},{"_type":"span","marks":["em"],"text":"P","_key":"c3f01fb62ca77"},{"_key":"c3f01fb62ca78","_type":"span","marks":[],"text":"=0.86)."}],"_type":"block","style":"normal"},{"style":"normal","_key":"118e864d818c","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"_key":"88b9ac5f555d0","_type":"span","marks":[],"text":"Three treatment moderators were found to be statistically significant when analyzing heterogeneity. First, when patients had a greater improvement in depression severity, this was found to produce a larger treatment effect of rTMS on OCD ("},{"_type":"span","marks":["em"],"text":"P","_key":"88b9ac5f555d1"},{"_type":"span","marks":[],"text":"=0.02). Second, longer TMS sessions were associated with greater improvement in OCD (","_key":"88b9ac5f555d2"},{"_type":"span","marks":["em"],"text":"P","_key":"88b9ac5f555d3"},{"text":"=0.05). And lastly, a lower number of TMS sessions were associated with greater improvement in OCD severity (","_key":"88b9ac5f555d4","_type":"span","marks":[]},{"_key":"88b9ac5f555d5","_type":"span","marks":["em"],"text":"P"},{"marks":[],"text":"=0.02).","_key":"88b9ac5f555d6","_type":"span"}],"_type":"block"},{"children":[{"marks":[],"text":"It is important to note that patient average age, sex, duration of OCD illness, concurrent use of serotonin reuptake inhibitor pharmacotherapy or antipsychotic pharmacotherapy, baseline OCD symptom severity, and/or use of medication free status were not statistically significant regarding the treatment effect of rTMS on OCD severity. Other intervention characteristics that were not found to be statistically significant included rTMS motor thresholds, rTMS frequencies, coils used for rTMS, total number of pulses used, and the location of rTMS treatment including the dorsolateral prefrontal cortex, orbitofrontal cortex, and supplementary motor area.","_key":"45af34743b360","_type":"span"}],"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null,"style":"normal","_key":"629094e89acc","markDefs":[]},{"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null,"_key":"340d2b25eb91","markDefs":[],"children":[{"text":"When looking through trial design characteristics as moderators of rTMS treatment effects, sample size, trial attrition, and year of publications were not found to be statistically significant. There was no difference between studies that used full sham conditions vs those that did not (","_key":"3b3148c602600","_type":"span","marks":[]},{"_key":"3b3148c602601","_type":"span","marks":["em"],"text":"P"},{"_type":"span","marks":[],"text":"=0.75). Finally, there was no statistical significance between trials that used treatment refractory patients, vs nontreatment refractory patients (","_key":"3b3148c602602"},{"marks":["em"],"text":"P","_key":"3b3148c602603","_type":"span"},{"_type":"span","marks":[],"text":"=0.81).","_key":"3b3148c602604"}]},{"markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"marks":[],"text":"","_key":"eb2d1768b6a90","_type":"span"}],"_type":"block","style":"normal","_key":"cba7ec021871"},{"_type":"block","style":"normal","_key":"ee7f97e230ef","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"marks":["strong"],"text":"Study Strengths","_key":"e7b92274f3770","_type":"span"}]},{"style":"normal","_key":"e3989420e3a1","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"text":"1. This review included 25 studies and 860 participants.","_key":"41f586fa31b50","_type":"span","marks":[]}],"_type":"block"},{"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"7f0626127b21","markDefs":[],"children":[{"_type":"span","marks":[],"text":"2. Only RCTs were included.","_key":"5d8d43efed160"}]},{"_key":"18eac58de530","markDefs":[],"children":[{"_type":"span","marks":[],"text":"3. Trials included different rTMS coils, frequencies, motor thresholds, and anatomical locations.","_key":"439258ced4970"}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null},{"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null,"style":"normal","_key":"dbc8a43454d7","markDefs":[],"children":[{"_type":"span","marks":[],"text":"4. There were no conflicts of interest for the authors.","_key":"eb9bd3d137fe0"}]},{"markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"_type":"span","marks":[],"text":"","_key":"143bc959b9290"}],"_type":"block","style":"normal","_key":"a9ab2d713138"},{"medias":null,"style":"normal","_key":"bdb9dfe50669","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Study Limitations","_key":"591cc0828a2f0"}],"_type":"block","upload_doc":null,"uploadAudio":null},{"children":[{"_type":"span","marks":[],"text":"1. The studies included only focused on acute treatment outcomes.","_key":"68cab9fcd22b0"}],"_type":"block","style":"normal","_key":"a3456ec4324c","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[]},{"markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"_type":"span","marks":[],"text":"2. Statistical analysis did not correct for multiple comparisons.","_key":"a69ecb269a0c0"}],"_type":"block","style":"normal","_key":"5564852255f8"},{"_key":"ca95428eb679","markDefs":[],"children":[{"_type":"span","marks":[],"text":"3. Limited patient characteristics were available for extraction across trials, such as whether exposure and response therapy had been trialed.","_key":"174b455c00800"}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null},{"_type":"block","style":"normal","_key":"aeab51476381","markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"_type":"span","marks":[],"text":"4. Publication bias was present.","_key":"d71b26b10e6f0"}]},{"upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"2de6d4bf21ed0"}],"_type":"block","style":"normal","_key":"b4436e517e61"},{"style":"normal","_key":"0bba84d479aa","markDefs":[],"children":[{"marks":["strong"],"text":"Conclusions","_key":"5deba80fdece0","_type":"span"}],"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null},{"children":[{"_key":"1c6b83747fc30","_type":"span","marks":[],"text":"This meta-analysis found that rTMS had a moderate therapeutic effect for the treatment of OCD. In addition, greater improvement in depression severity, longer TMS sessions, and fewer number of TMS sessions were moderators associated with greater improvement in OCD severity."}],"_type":"block","style":"normal","_key":"ecf65d121661","markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null},{"style":"normal","_key":"657e07e93cda","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"80b3132b67790"}],"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null},{"_key":"4357b9c51e84","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"text":"Practical Applications","_key":"89ad068c44b50","_type":"span","marks":["strong"]}],"_type":"block","style":"normal"},{"style":"normal","_key":"7da82891fb7e","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"_type":"span","marks":[],"text":"OCD is a heterogenous disorder that can be debilitating for patients. This study shows that rTMS has moderate therapeutic effects on OCD severity.","_key":"04289f1555c50"}],"_type":"block"},{"_type":"block","style":"normal","_key":"f891977db9a1","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"a94404cf2fe70"}]},{"medias":null,"style":"normal","_key":"755657fc7115","markDefs":[],"children":[{"marks":["strong"],"text":"Bottom Line","_key":"aee38074d46b0","_type":"span"}],"_type":"block","upload_doc":null,"uploadAudio":null},{"medias":null,"_key":"bbc8eb2cb3b2","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Clinicians should consider rTMS as an intervention to alleviate OCD symptoms, especially in those who have failed other treatments or those with comorbid depression.","_key":"e51f954da3c20"}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null},{"style":"normal","_key":"110fca7774c2","markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"text":"","_key":"86267235b37a0","_type":"span","marks":[]}],"_type":"block"},{"markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"_type":"span","marks":["strong"],"text":"Dr Sung ","_key":"82fc7e49d63c0"},{"text":"is a psychiatry second year resident at Creighton University in Omaha, Nebraska.","_key":"82fc7e49d63c1","_type":"span","marks":["em"]},{"_key":"82fc7e49d63c2","_type":"span","marks":["strong"],"text":" Dr Eilers "},{"_type":"span","marks":["em"],"text":"is a fourth-year psychiatry resident at Creighton University in Omaha, Nebraska.","_key":"82fc7e49d63c3"},{"_type":"span","marks":[],"text":" ","_key":"82fc7e49d63c4"},{"_type":"span","marks":["strong"],"text":"Dr Schuster","_key":"82fc7e49d63c5"},{"_type":"span","marks":[],"text":" ","_key":"82fc7e49d63c6"},{"_type":"span","marks":["em"],"text":"is a fourth-year psychiatry resident at Creighton University in Omaha, Nebraska.","_key":"82fc7e49d63c7"},{"_type":"span","marks":[],"text":" ","_key":"82fc7e49d63c8"},{"text":"Dr Mullen","_key":"82fc7e49d63c9","_type":"span","marks":["strong"]},{"text":" ","_key":"82fc7e49d63c10","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"is an assistant professor of Psychiatry at Saint Louis University School of Medicine.","_key":"82fc7e49d63c11"},{"text":" ","_key":"82fc7e49d63c12","_type":"span","marks":[]},{"_type":"span","marks":["strong"],"text":"Dr Tampi ","_key":"82fc7e49d63c13"},{"_type":"span","marks":["em"],"text":"is professor and Chairman of the Department of Psychiatry at Creighton University School of Medicine and Catholic Health Initiatives (CHI) Health Behavioral Health Services. 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In a study of more than 300,000 veterans, a mild TBI was associated with a 56% increased risk of Parkinson disease.","_key":"5e74aaba07d00"},{"_type":"span","marks":["superscript"],"text":"8","_key":"60a6cca4bd4b"},{"marks":[],"text":" Other authors have had similar findings.","_key":"e1a818dfaeee","_type":"span"},{"_key":"63d5c6f1b8c2","_type":"span","marks":["superscript"],"text":"9-11"}],"_type":"block"},{"_type":"block","style":"normal","_key":"12741fdc85e3","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"1e6cfa8e0c3b0"}]},{"style":"normal","_key":"93b298fb0faa","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Chronic Traumatic Encephalopathy","_key":"9506be2248c40"}],"_type":"block"},{"_type":"block","style":"normal","_key":"874f9ae467e4","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Although rarely discussed 20 years ago, chronic traumatic encephalopathy (CTE) has become part of American conversations on an almost daily basis. It should be noted that CTE is a pathologic diagnosis—only officially made at autopsy. The symptoms that someone may have before succumbing to CTE are referred to as traumatic encephalopathy syndrome (TES). Nevertheless, the term CTE is widely used to describe those symptoms prior to death.","_key":"271967dfb62f0"}]},{"_type":"block","style":"normal","_key":"f2afd2800cb5","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"804acde882ea0"}]},{"children":[{"_key":"c1d72ae1bd7b0","_type":"span","marks":[],"text":"Parkinsonism and subsequent dementia occur more frequently in individuals with a pathologic diagnosis of CTE."},{"_key":"5ed054342477","_type":"span","marks":["superscript"],"text":"12"},{"_type":"span","marks":[],"text":" In a survey of 729 participants, those with a history of playing organized football had higher odds of having Parkinson disease compared with participants in other organized sports. 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An important recent discovery is that we now know that individuals with chronic TBI have significantly lower circulating concentrations of numerous amino acids, which are the building blocks of protein and brain neurotransmitters. This pattern is consistent with the concept that TBI induces a chronic state."},{"_type":"span","marks":["superscript"],"text":"16","_key":"0edc960fc852"},{"_type":"span","marks":[],"text":" Because these essential amino acids are not getting absorbed from the gut, essentially, the brain and body are starving for their nutrients.","_key":"cdc689c845ef"}],"_type":"block","style":"normal","_key":"692f3c7e3137"},{"_type":"block","style":"normal","_key":"afc886e19a1c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"634f8b82e08f0"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"We now believe that the chronic low amino acid levels are a result of an altered fecal micro biome (gut dysbiosis) in individuals with chronic TBI.","_key":"020bf0a39c5d0"},{"_type":"span","marks":["superscript"],"text":"17","_key":"b1fc84d34f33"},{"text":" These abnormalities were found to be essentially unchanged in a study at CNS that followed these individuals over 5 years.","_key":"464ed4d49b94","_type":"span","marks":[]},{"marks":["superscript"],"text":"18","_key":"68dd337b53c0","_type":"span"},{"_type":"span","marks":[],"text":" We are presently looking at ways of “normalizing” the microbiome. If successful, it might make a significant improvement in the quality of life for those with chronic TBI.","_key":"c534b7755f9f"}],"_type":"block","style":"normal","_key":"96cc74f16e7c"},{"_type":"block","style":"normal","_key":"8d50b055849a","markDefs":[],"children":[{"_key":"d5576ddcd6150","_type":"span","marks":[],"text":""}]},{"_key":"5fbfb0a31ac8","markDefs":[],"children":[{"_type":"span","marks":[],"text":"These studies have also given rise to a new syndrome of brain injury altered cognition and fatigue (BIAFAC). Individuals with BIAFAC will complain of profound fatigue and “brain fog” and have been found to have an abnormal gut microbiome and abnormal growth hormone secretion. Although they frequently respond clinically to growth hormone replacement, there is no change in their gut microbiome.","_key":"c48402dcdab60"},{"marks":["superscript"],"text":"19","_key":"72a578577951","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"6d57fb89ee920","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"1310e38f98e6"},{"children":[{"_type":"span","marks":["strong"],"text":"The Future of Brain Injury Rehabilitation","_key":"235a66d741540"}],"_type":"block","style":"normal","_key":"762aa43296f3","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Brain injury rehabilitation can move forward only if we are willing to adopt the latest research findings. To ensure these research findings do not become just an academic exercise, funding sources must be a part of this effort. Only then will patients receive the most cutting-edge care and get the best outcomes which they so readily deserve.","_key":"8a2561e7eab30"}],"_type":"block","style":"normal","_key":"164163cf3753"},{"children":[{"_type":"span","marks":[],"text":"","_key":"5edc5e6ed53e0"}],"_type":"block","style":"normal","_key":"512e78f284d4","markDefs":[]},{"style":"normal","_key":"7ac2f4be8f88","markDefs":[],"children":[{"marks":["strong"],"text":"Concluding Thoughts","_key":"b1c11cc5dae30","_type":"span"}],"_type":"block"},{"_key":"f553cac82e9d","markDefs":[],"children":[{"_type":"span","marks":[],"text":"We have learned a great deal about TBI in the past 15 years. It is now readily accepted that a brain injury is not a static event and is disease causative as well as disease accelerative. Although we clearly have a long way to go, we are on the path to put together the many pieces of the puzzle that make up a TBI. Some day, those pieces will all come together, and we will find the cure.","_key":"5a317cdfdb310"}],"_type":"block","style":"normal"},{"_key":"212172ac9fbd","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"0bd86a2839ab0"}],"_type":"block","style":"normal"},{"_key":"c44e0998fe64","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Masel ","_key":"d8284d5c194b0"},{"_type":"span","marks":["em"],"text":"is the executive vice-president for Medical Affairs with the Centre for Neuroskills and is a clinical professor of neurology at the University of Texas Medical Branch in Galveston.","_key":"d8284d5c194b1"}],"_type":"block","style":"normal"},{"children":[{"marks":[],"text":"","_key":"7d2f489950080","_type":"span"}],"_type":"block","style":"normal","_key":"ecf5e604d372","markDefs":[]},{"children":[{"_type":"span","marks":["strong"],"text":"References","_key":"6e15ebe176ff0"}],"_type":"block","style":"normal","_key":"773f161fbe87","markDefs":[]},{"_type":"block","style":"normal","_key":"361b15164d0f","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/20504161/","_key":"fe790b5af7a7"}],"children":[{"_type":"span","marks":[],"text":"1. Masel BE, DeWitt DS. ","_key":"5deddb1e84440"},{"_type":"span","marks":["fe790b5af7a7"],"text":"Traumatic brain injury: a disease process, not an event.","_key":"5deddb1e84441"},{"_key":"57750c68ea94","_type":"span","marks":[],"text":" "},{"_type":"span","marks":["em"],"text":"J Neurotrauma","_key":"5deddb1e84442"},{"_type":"span","marks":[],"text":". 2010;27(8):1529-1540.","_key":"5deddb1e84443"}]},{"children":[{"marks":[],"text":"2. Corrigan JD, Hammond FM. 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","_key":"84c7546354820"},{"_type":"span","marks":["dbc0ff082562"],"text":"Neuroinflammation and microglial activation in Alzheimer disease: where do we go from here?","_key":"84c7546354821"},{"_type":"span","marks":[],"text":" ","_key":"84c7546354822"},{"_type":"span","marks":["em"],"text":"Nat Rev Neurol.","_key":"84c7546354823"},{"marks":[],"text":" 2021;17(3):157-172.","_key":"84c7546354824","_type":"span"}]},{"_key":"16b24917c7f4","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/27178787/","_key":"727711554ccc"}],"children":[{"_type":"span","marks":[],"text":"16. Durham WJ, Foreman JP, Randolph KM, et al. ","_key":"bcf5a69e9c2a0"},{"marks":["727711554ccc"],"text":"Hypoaminoacidemia characterizes chronic traumatic brain injury.","_key":"bcf5a69e9c2a1","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"efa5871fa911"},{"_type":"span","marks":["em"],"text":"J Neurotrauma.","_key":"bcf5a69e9c2a2"},{"_type":"span","marks":[],"text":" 2017;34(2):385-390.","_key":"bcf5a69e9c2a3"}],"_type":"block","style":"normal"},{"_key":"01290a7fa515","markDefs":[{"href":"https://pubmed.ncbi.nlm.nih.gov/31724478/","_key":"d80daff80144","blank":true,"_type":"link"}],"children":[{"_type":"span","marks":[],"text":"17. Urban RJ. ","_key":"566b072e8f170"},{"_key":"566b072e8f171","_type":"span","marks":["d80daff80144"],"text":"A treatable syndrome in patients with traumatic brain injury."},{"_key":"6cd843338633","_type":"span","marks":[],"text":" "},{"_type":"span","marks":["em"],"text":"J Neurotrauma.","_key":"566b072e8f172"},{"marks":[],"text":" 2020;37(8):1124-1125.","_key":"566b072e8f173","_type":"span"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"18. Pyles RB, Miller AL, Urban RJ, et al. ","_key":"b6e81ffea7e30"},{"_type":"span","marks":["62597f295fd9"],"text":"The altered TBI fecal microbiome is stable and functionally distinct.","_key":"b6e81ffea7e31"},{"_key":"9e54c1811702","_type":"span","marks":[],"text":" "},{"_key":"b6e81ffea7e32","_type":"span","marks":["em"],"text":"Front Mol Neurosci."},{"_type":"span","marks":[],"text":" 2024:17:1341808.","_key":"b6e81ffea7e33"}],"_type":"block","style":"normal","_key":"a93551f95892","markDefs":[{"_key":"62597f295fd9","blank":true,"_type":"link","href":"https://www.frontiersin.org/journals/molecular-neuroscience/articles/10.3389/fnmol.2024.1341808/full"}]},{"_key":"4220e80d48cc","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/31976519/","_key":"7790be020fc9"}],"children":[{"text":"19. Yuen F, Thirumalai A, Pham C, et al. ","_key":"320fdb4b99f20","_type":"span","marks":[]},{"_key":"320fdb4b99f21","_type":"span","marks":["7790be020fc9"],"text":"Daily oral administration of the novel androgen 11β-MNTDC markedly suppresses serum gonadotropins in healthy men."},{"_type":"span","marks":[],"text":" ","_key":"9ca0e49f886d"},{"marks":["em"],"text":"J Clin Endocrinol Metab","_key":"320fdb4b99f22","_type":"span"},{"marks":[],"text":". 2020;105(3):e835-e847.","_key":"320fdb4b99f23","_type":"span"}],"_type":"block","style":"normal"}],"summary":"Brain injury was recently recognized as a chronic health condition. ","drugMentions":"{\"drug_mentions\": []}","published":"2024-11-25T15:00:00.000Z","title":"Brain Injury Is a Chronic Health Condition","url":"brain-injury-is-a-chronic-health-condition","contentCategory":{"_createdAt":"2020-02-06T09:15:47Z","_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory","name":"Articles","_id":"8bdaa7fc-960a-4b57-b076-75fdce3741bb","_updatedAt":"2020-02-25T09:35:56Z"},"gptTakeaways":"• TBI is now recognized as a chronic condition, influencing mortality and increasing risks of neurodegenerative diseases like dementia and Parkinson's disease.\n\n• CTE, once rarely discussed, is now a common topic, with its symptoms often preceding a pathologic diagnosis made post-mortem.\n\n• Research indicates TBI may lead to altered gut microbiomes and amino acid deficiencies, suggesting potential therapeutic targets.\n\n• Recognition by CMS is expected to improve resources for TBI research and treatment, benefiting patient care and outcomes.","audioUrl":"https://s3.us-east-1.amazonaws.com/ai-generated-audios/www.psychiatrictimes.com/e48e9a55-061f-4027-8cca-5483d5a7672d_1731961423189.8cb5bcb1-e42d-46d8-a154-469ceb27fef0.mp3","ExcludeFromPubMedXML":false,"_rev":"HG9itg5Um8jvM5zF8KubIL","_id":"e48e9a55-061f-4027-8cca-5483d5a7672d","authors":[{"displayName":"Brent Masel, MD","url":"brent-masel-md"}],"gptSummary":"Traumatic brain injury (TBI) is increasingly recognized as a chronic health condition, with significant implications for mortality, neurodegenerative diseases, and overall health. Recent studies highlight the increased risk of dementia, Parkinson's disease, and chronic traumatic encephalopathy (CTE) following TBI. The Centers for Medicare and Medicaid Services' recognition of TBI as a chronic condition is expected to enhance research and treatment resources. Emerging research links TBI to altered gut microbiomes and amino acid deficiencies, suggesting new therapeutic avenues. 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Primary outcome measures were the Patient Health Questionnaire-9 (PHQ–9) and Generalized Anxiety Disorder-7 (GAD–7).","_key":"ee667ad5886d0"},{"_type":"span","marks":["superscript"],"text":"2","_key":"c2763010d72d"},{"_type":"span","marks":[],"text":" The analyses examined outcomes from patients who completed 20 or more sessions and an intent-to-treat sample. In the completer sample (N=1169), results show that 59.4% of patients aged 12 to 19 and 36.4% of patients aged 20 to 21 met the PHQ-9 response and remission criteria, respectively. Investigators observed marked dose-response effects and antidepressant effectiveness improved with longer treatment courses (","_key":"0858f8a29cca"},{"_type":"span","marks":["em"],"text":"P","_key":"ee667ad5886d1"},{"_type":"span","marks":[],"text":" \u003c .0001). The greatest symptom reduction was seen over the first 10 sessions, with no plateau before treatment termination. The adolescent and young adult subgroup data did not differ in treatment effects.","_key":"ee667ad5886d2"}]},{"_key":"20cdbc51c957","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"91119b560b000"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"afa0bef10d10","markDefs":[],"children":[{"_key":"31d39c37c9fe0","_type":"span","marks":[],"text":"To better understand this data, "},{"marks":["em"],"text":"Psychiatric Times","_key":"31d39c37c9fe1","_type":"span"},{"_type":"span","marks":[],"text":" sat down with Melissa Fickey, MD, a board-certified psychiatrist who specializes in child, adolescent, and adult psychiatry.","_key":"31d39c37c9fe2"}]},{"_key":"5b09d65b01e9","markDefs":[],"children":[{"marks":[],"text":"","_key":"0f79286933220","_type":"span"}],"_type":"block","style":"normal"},{"_key":"6a43c92a74b9","markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Psychiatric Times","_key":"9a0d9a5b2a3e0"},{"_type":"span","marks":["strong"],"text":": Tell us a little about that data shared at the AACAP annual meeting. What is the most important takeaway from this data for practicing mental health clinicians?","_key":"9a0d9a5b2a3e1"}],"_type":"block","style":"normal"},{"style":"normal","_key":"288ea6f01d78","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Melissa Fickey, MD:","_key":"63aea03040740"},{"_key":"63aea03040741","_type":"span","marks":[],"text":" The data presented at AACAP highlights a breakthrough for teens and young adults struggling with depression and, in some cases, anxiety. This study was the most extensive of its kind, examining over 1200 young people aged 12 to 21 years old who received treatment with NeuroStar Advanced Therapy’s TMS. The results were very encouraging and showed more than 70% of those treated experienced meaningful improvements (or a 6 point or more change in their PHQ-9 score)."}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"c93602c989d70"}],"_type":"block","style":"normal","_key":"aa8057b97788"},{"markDefs":[],"children":[{"marks":[],"text":"The positive results from this study reinforce the FDA clearance, as NeuroStar is the only FDA-cleared TMS device for treating adolescents with MDD aged 15 and older. Prior data also show a 78% response rate and 48% remission rates in teens and ultimately provide compelling evidence supporting TMS as a highly effective treatment for adolescents with MDD.","_key":"34c1ca2a82990","_type":"span"}],"_type":"block","style":"normal","_key":"75b4e44cf8b3"},{"children":[{"_key":"5114760343490","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"f6fa6b776e2d","markDefs":[]},{"_type":"block","style":"normal","_key":"1b99b514171f","markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"PT","_key":"3c46129435150"},{"_type":"span","marks":["strong"],"text":": Do you think this data will help patients and families considering TMS feel more comfortable?","_key":"3c46129435151"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Fickey:","_key":"60295a859f8c0"},{"_type":"span","marks":[],"text":" This data can provide significant confidence to patients and their families who might be apprehensive about beginning treatment with TMS. As mentioned, these are the largest study results of its kind, and they reinforce the safety and effectiveness the FDA reviewed when deciding NeuroStar is a first-line add-on option for adolescents with MDD age 15 and up. Not only did most participants experience meaningful improvements in both depression and anxiety, but adverse effects were minimal. Additionally, the data show treatment made an impact after only a few sessions and results improved for those who completed a full treatment course.","_key":"60295a859f8c1"}],"_type":"block","style":"normal","_key":"18c83b0c8385"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"ddf527abee290"}],"_type":"block","style":"normal","_key":"c6e25bab60df"},{"_type":"block","style":"normal","_key":"f63aaba8ed99","markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"PT","_key":"8b5514a4753b0"},{"_key":"8b5514a4753b1","_type":"span","marks":["strong"],"text":": Treatment with TMS resulted in marked improvement in both depressive symptoms and anxiety in adolescents and young adults. There are limited approved treatment options in this age category. At what point do you determine it is time to try TMS?"}]},{"children":[{"_type":"span","marks":["strong"],"text":"Fickey: ","_key":"8a176487dd8c0"},{"_type":"span","marks":[],"text":"NeuroStar is currently the only TMS therapy that is approved as a first-line adjunct treatment for adolescents—so it can be a first-line option for adolescents aged 15 and up in conjunction with other modalities, like antidepressant medications or talk therapy. It can also be used if a patient has tried other options but is not seeing a large impact on their mental health. MDD is a substantial public health challenge impacting at least 4.3 million adolescents annually in the United States, but despite current options, symptoms do not improve in approximately 30% of adolescents who opt for traditional antidepressants, according to independent NIH studies.","_key":"8a176487dd8c1"},{"_key":"32f3f8af5811","_type":"span","marks":["superscript"],"text":"3"}],"_type":"block","style":"normal","_key":"a978b5a1f0c0","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"d91c58b666100"}],"_type":"block","style":"normal","_key":"7ed4de60cf44"},{"_type":"block","style":"normal","_key":"c51261adbc58","markDefs":[],"children":[{"_type":"span","marks":[],"text":"TMS offers a new pathway for relief without the systemic adverse effects typical of antidepressant medications, which can be a huge help to younger patients and their families. The data presented at AACAP show us that the earlier we introduce TMS in persistent cases, the better the outcomes can be.","_key":"df6576ed24ad0"}]},{"_key":"5b5b8778c684","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"820f870040390"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":["strong","em"],"text":"PT","_key":"0c330aba316c0"},{"_type":"span","marks":["strong"],"text":": NeuroStar is the only FDA-cleared TMS device to treat adolescents aged 15 and older as a first-line adjunct treatment. You are a diamond provider for NeuroStar TMS. Do you have any recommendations for mental health clinicians who might be considering utilizing TMS in their own practices?","_key":"0c330aba316c1"}],"_type":"block","style":"normal","_key":"c4b6cebab0fb","markDefs":[]},{"_key":"cce4a9708b22","markDefs":[],"children":[{"text":"Fickey: ","_key":"0e23920e28f50","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":"NeuroStar, as the only FDA-cleared device for patients aged 15 and up, stands out as a nondrug option, making a real difference for young people. I have been practicing with NeuroStar for 6 years, and the results we have seen in my practice, and from the data, show remarkable improvements in both depression and anxiety—it is an opportunity to offer a solution that can genuinely change lives.","_key":"0e23920e28f51"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"","_key":"5519098a302a0"}],"_type":"block","style":"normal","_key":"901dad6169b5","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"Beyond its clinical efficacy, integrating NeuroStar into practice offers several practical benefits that can further enhance patient care. One notable feature is the proprietary TrakStar Patient Data Management System, which streamlines patient data management. This system ensures a smooth experience for patients, from their initial consultation through treatment, fostering their engagement and commitment to the process. It also makes it easy on me and my staff to track a patient’s progress during the course of the treatment.","_key":"5de25489cf780"}],"_type":"block","style":"normal","_key":"9b09f553b4e1","markDefs":[]},{"_key":"0f3701bd3f16","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"72068972af170"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"5b11d7625a5f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Additionally, private and public insurance policies are increasingly covering it for adolescents and adult populations, reflecting a growing recognition of TMS as a valuable treatment option. This broader and rapidly increasing acceptance we have seen over the past few years—especially this year after the FDA clearance for adolescents—makes it that much easier to offer NeuroStar as an effective treatment for patients who are struggling.","_key":"17269170449a0"}]},{"children":[{"_key":"3a7f846c512e0","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"6093c8677bf1","markDefs":[]},{"children":[{"_type":"span","marks":["strong","em"],"text":"PT","_key":"70fd59ba8bfa0"},{"_type":"span","marks":["strong"],"text":": Is there anything else you would like to share?","_key":"70fd59ba8bfa1"}],"_type":"block","style":"normal","_key":"5709fdc289f0","markDefs":[]},{"children":[{"text":"Fickey: ","_key":"057fcd327ffa0","_type":"span","marks":["strong"]},{"_key":"057fcd327ffa1","_type":"span","marks":[],"text":"This study marks a pivotal moment in the treatment of depression and anxiety for adolescents and young adults. It is not just about the data—it is about opening new doors for those often underserved by traditional treatments. With such a large, real-world sample, I hope both patients and providers can see the true value of TMS—particularly how NeuroStar is transforming our approach to mental health in this age group. This research represents a beacon of progress, and I believe NeuroStar will change the landscape of adolescent mental health treatment for years to come."}],"_type":"block","style":"normal","_key":"32a44e093d06","markDefs":[]},{"style":"normal","_key":"e0b62e189f58","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"3262be7e1e450"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"PT","_key":"720e2c17fe900"},{"_type":"span","marks":["strong"],"text":": Thank you!","_key":"720e2c17fe901"}],"_type":"block","style":"normal","_key":"e405bcd8d637"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"f9d43cc9944d0"}],"_type":"block","style":"normal","_key":"d0aed13f0588"},{"children":[{"_type":"span","marks":["strong"],"text":"Dr Fickey","_key":"fcf6a268cb430"},{"_type":"span","marks":["em"],"text":" is a board-certified psychiatrist specializing in child, adolescent, and adult psychiatry and works as a forensic psychiatric consultant. She is also the founder of Embracing Life Wellness Center.","_key":"fcf6a268cb431"}],"_type":"block","style":"normal","_key":"9c6c5f82d7a5","markDefs":[]},{"_key":"01ecd5690649","markDefs":[],"children":[{"text":"","_key":"864ece3643570","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_key":"789bca0fc4aa","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"References","_key":"d974d6e2617c0"}],"_type":"block","style":"normal"},{"markDefs":[{"blank":true,"_type":"link","href":"https://ir.neuronetics.com/news-releases/news-release-details/neurostarr-oral-presentation-aacap-2024-highlights-largest-study","_key":"67dfee2e127f"}],"children":[{"_key":"64e05aaf31bb0","_type":"span","marks":[],"text":"1. NeuroStar oral presentation at AACAP 2024 highlights largest study evaluating TMS efficacy in adolescents with depression. Neuronetics. News release. October 14, 2024. Accessed October 21, 2024. "},{"marks":["67dfee2e127f"],"text":"https://ir.neuronetics.com/news-releases/news-release-details/neurostarr-oral-presentation-aacap-2024-highlights-largest-study","_key":"64e05aaf31bb1","_type":"span"}],"_type":"block","style":"normal","_key":"4f7705a79162"},{"style":"normal","_key":"349f171fb4f3","markDefs":[{"blank":true,"_type":"link","href":"https://www.jaacap.org/article/S0890-8567(24)01827-6/fulltext","_key":"f0601c0d66e4"}],"children":[{"marks":[],"text":"2. Croarkin PE, Aaronson ST, Carpenter LL, et al. ","_key":"0e8f810cd6330","_type":"span"},{"_key":"0e8f810cd6331","_type":"span","marks":["f0601c0d66e4"],"text":"A naturalistic study of transcranial magnetic stimulation treatment in adolescents and young adults with depression and anxiety."},{"marks":[],"text":" ","_key":"5b8212ddb890","_type":"span"},{"_key":"0e8f810cd6332","_type":"span","marks":["em"],"text":"J Am Acad Child Adolesc Psychiatry. "},{"_type":"span","marks":[],"text":"2024;63(10):S306.","_key":"0e8f810cd6333"}],"_type":"block"},{"_type":"block","style":"normal","_key":"44f171172423","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/37149350/","_key":"a4faf87389ef"}],"children":[{"_type":"span","marks":[],"text":"3. Ayvaci ER, Croarkin PE. ","_key":"7d66ad7ef5c60"},{"marks":["a4faf87389ef"],"text":"Special populations: treatment-resistant depression in children and adolescents.","_key":"7d66ad7ef5c61","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"1733e92d84a4"},{"_type":"span","marks":["em"],"text":"Psychiatr Clin North Am","_key":"7d66ad7ef5c62"},{"_type":"span","marks":[],"text":". 2023;46(2):359-370.","_key":"7d66ad7ef5c63"}]}],"audioUrl":"https://s3.us-east-1.amazonaws.com/ai-generated-audios/www.psychiatrictimes.com/80fe38da-e61d-48de-9682-3f13902fb601_1731603565566.51b8b2be-202f-4d51-9e46-aaecb27d1081.mp3","drugMentions":"{\"drug_mentions\": [\"NeuroStar\", \"antidepressant medications\"]}","_id":"80fe38da-e61d-48de-9682-3f13902fb601","url":"neurostar-tms-for-adolescents-with-major-depressive-disorder-a-look-at-the-new-data","summary":"According to new data, NeuroStar Advanced TMS helped nearly 60% of adolescents with major depressive disorder. 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Going beyond pharmacology, she points out that other treatment options, including mind-body interventions and diet changes, have been shown to slow AD’s progression.","_key":"3bc874e5c4fc2"}],"_type":"block","style":"normal","_key":"1367acceeacf"},{"markDefs":[],"children":[{"text":"In this conversation, ","_key":"1447bc2ec6a00","_type":"span","marks":[]},{"marks":["em"],"text":"Psychiatric Times","_key":"1447bc2ec6a01","_type":"span"},{"_key":"1447bc2ec6a02","_type":"span","marks":["superscript"],"text":"TM "},{"_key":"01f00d0f8348","_type":"span","marks":[],"text":"and Lavretsky cover:"}],"_type":"block","style":"normal","_key":"265b04f05e57"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"The aducanumab controversy","_key":"cdab4099e4d60"}],"level":1,"_type":"block","style":"normal","_key":"6911ac39e83a","listItem":"bullet"},{"level":1,"_type":"block","style":"normal","_key":"a7b81e55a02c","listItem":"bullet","markDefs":[],"children":[{"marks":[],"text":"Advice for talking to patients and caregivers about aducanumab and other novel pharmacological options","_key":"43e0b549198c0","_type":"span"}]},{"children":[{"_key":"1874c9bfecba0","_type":"span","marks":[],"text":"Mind-body and lifestyle interventions for AD"}],"level":1,"_type":"block","style":"normal","_key":"d6d40282fa21","listItem":"bullet","markDefs":[]},{"level":1,"_type":"block","style":"normal","_key":"c367123d9cd9","listItem":"bullet","markDefs":[],"children":[{"text":"AD prevention programs, including nutrition, exercise, and stress reduction","_key":"8abde66614610","_type":"span","marks":[]}]},{"listItem":"bullet","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Taking care of caregivers, including psychiatrists and other medical professionals","_key":"346324a657c80"}],"level":1,"_type":"block","style":"normal","_key":"100d606d19f9"},{"children":[{"_type":"span","marks":[],"text":"How to prescribe joy","_key":"5386380f5d250"}],"level":1,"_type":"block","style":"normal","_key":"79bc513db3fd","listItem":"bullet","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Lavretsky ","_key":"e28f8c0eed700"},{"_type":"span","marks":["em"],"text":"is a professor in-residence in the Department of Psychiatry at the University of California, Los Angeles. Her work on geriatric depression and integrative mental health using mind-body interventions has received national attention, and she has won numerous grants supporting that work. A distinguished fellow of the American Psychiatric Association and a fellow of the American College of Neuropsychopharmacology, she is also on the board of ","_key":"e28f8c0eed701"},{"_type":"span","marks":[],"text":"Psychiatric Times","_key":"e28f8c0eed702"},{"text":"TM","_key":"e28f8c0eed703","_type":"span","marks":["em","superscript"]},{"_type":"span","marks":["em"],"text":".","_key":"9b716257b994"}],"_type":"block","style":"normal","_key":"442eadddd301"}],"authors":[{"displayName":"Helen Lavretsky, MD, MS","url":"helen-lavretsky-md-ms"}],"_rev":"0qItlCDE0t7k0fmkkc9rw1","summary":"Although the new drug aducanumab has grabbed all the headlines, the future of Alzheimer treatment may be just as much about public health campaigns as it is about psychopharmacology. 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These include depression with PTSD, GAD, or ADD, and borderline personality disorder. This overlap is shown in the ","_key":"3988f7f80a0e0","_type":"span"},{"_key":"3988f7f80a0e1","_type":"span","marks":["strong","00e550146000"],"text":"Table"},{"_type":"span","marks":[],"text":" (symptoms of MDD are shown in blue).","_key":"3988f7f80a0e2"}]},{"alignment":"right","blank":true,"_type":"figure","disableTextWrap":false,"_key":"8c55210a1c6d","alt":"Table. Overlap With Common Conditions","asset":{"_ref":"image-d030bfc505bdc5e912f1a3d8da755ba41dc254b9-624x304-png","_type":"reference"},"widthP":50,"disableLightBox":true,"imgcaption":[{"markDefs":[],"children":[{"text":"Table. 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Response to previous treatments may be illuminating, but you might be the first provider.","_key":"e00ed7c5bee80"}],"_type":"block","style":"normal","_key":"5ad20716741e","markDefs":[]},{"style":"normal","_key":"dcb9e1884977","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"3cc206c717580"}],"_type":"block"},{"style":"normal","_key":"023ad74e5dc9","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Is this “farewell to differential diagnosis,” as one author lamented?9 Not necessarily; rather, one can simply acknowledge that diagnostic certainty is almost impossible to attain in the face of depression with anxiety or anger or agitation or attention problems. When dealing with these symptoms, one must think of diagnoses in this context as ","_key":"ce646d5f4c280"},{"_type":"span","marks":["em"],"text":"tentative","_key":"ce646d5f4c281"},{"_type":"span","marks":[],"text":", holding open the possibility of alternative explanations until a good outcome is obtained.","_key":"ce646d5f4c282"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"108c8aea94a00"}],"_type":"block","style":"normal","_key":"161a6beed092"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Coping With Diagnostic Uncertainty","_key":"213c27ec64940"}],"_type":"block","style":"normal","_key":"82b770c020ff"},{"style":"normal","_key":"99f8b3e29e2b","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Here are 4 steps to take or consider before initiating treatment that can help manage diagnostic uncertainty.","_key":"3fed91887d020"}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"1. ","_key":"a474ebbea0ed0"},{"_type":"span","marks":["em"],"text":"Routinely gather data","_key":"a474ebbea0ed1"},{"text":" that differentiate bipolar and unipolar depressions: family history, age of onset of depression, illness course (episodic or postpartum), and response to treatment (especially adverse responses to antidepressants).","_key":"a474ebbea0ed2","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"dd7ae6e4c1fd","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"2. ","_key":"ca62a65d4c200"},{"text":"Engage the patient","_key":"ca62a65d4c201","_type":"span","marks":["em"]},{"marks":[],"text":" (and perhaps family) in shared decision-making through psychoeducation. Help them understand that the possibility of bipolar should be approached not as a categorical yes-or-no but dimensionally, as in “how much bipolarity might you have, if any?”","_key":"ca62a65d4c202","_type":"span"}],"_type":"block","style":"normal","_key":"3551645b5866","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"3. ","_key":"1b5b081af7a70"},{"marks":["em"],"text":"Consider beginning with psychotherapy","_key":"1b5b081af7a71","_type":"span"},{"_type":"span","marks":[],"text":". If you do not offer psychotherapy yourself and cannot easily refer for it, there are now inexpensive digital therapies for depression, PTSD, anxiety, and ADD. There is also a simple initial behavioral therapy for bipolarity, social rhythm therapy.","_key":"1b5b081af7a72"}],"_type":"block","style":"normal","_key":"b17d06a2bbe9"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"4. 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Depression causes severe disability to those who suffer from bipolar I disorder, and many do not benefit or cannot tolerate current treatments for their bipolar I depression,” Bentzley said."}],"_type":"block","style":"normal","_key":"cd31ca9981c6","markDefs":[]},{"_key":"6e68f6455b3a","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"af9f2cad86d10"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"The investigators identified 14 patients with bipolar I disorder experiencing moderate to severe depression unrelieved by antidepressant treatment at the 2 study sites at Johns Hopkins University and the University of Texas at Austin. Four of the candidates were excluded due to a current mixed episode, severe ongoing cannabis abuse, an insufficient prior antidepressant trial, or a manic episode with the prior 6 months.","_key":"fea170af90180"}],"_type":"block","style":"normal","_key":"3502fd52e9df"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"7d611cf9efa70"}],"_type":"block","style":"normal","_key":"ec22241bad1f"},{"children":[{"_type":"span","marks":[],"text":"The 10 trial participants, 6 of them female, were White and ranged between 21 to 63 years of age. At screening, each of the participants was experiencing a major depressive episode (MADRS score greater than 20) while on an antidepressant and had been on an antimanic agent at adequate dose and without dose change for at least 6 weeks. Additional requirements of participation were a minimum of 6 months since the last manic or hypomanic episode and 3 months since electroconvulsive therapy.","_key":"14ff7330f7d00"}],"_type":"block","style":"normal","_key":"dbce69094cc6","markDefs":[]},{"_type":"block","style":"normal","_key":"47d50f659473","markDefs":[],"children":[{"marks":[],"text":"","_key":"f6894f1b557b0","_type":"span"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"In the SAINT protocol, participants undergo structural and resting-state functional magnetic resonance imaging (fMRI) to identify the target above the scalp to focus intermittent theta burst stimulation (iTBS) above the dorsolateral prefrontal cortex (DLPFC). Participants underwent 10 sessions of the targeted iTBS daily, with 50-minute intervals, for up to 5 days.","_key":"a27c971e3a350"}],"_type":"block","style":"normal","_key":"7a3dc5f70355"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"e4e0d3bfe4930"}],"_type":"block","style":"normal","_key":"b513c0b7de42"},{"children":[{"_type":"span","marks":[],"text":"A battery of measures was applied at baseline, immediately after completion of the iTBS series and at 1 month follow-up. The study primary outcome was change in MADRS score from baseline. Secondary outcomes included rates of clinical response (MADRS score reduction of greater than or equal to 50%) and remission (MADRS score of 10 or less). The possible emergence of mania/hypomania was evaluated with the Young Mania Rating Scale at the beginning and end of each treatment day.","_key":"d89225c875130"}],"_type":"block","style":"normal","_key":"eaf940ac9f96","markDefs":[]},{"children":[{"_key":"5288e5c5abd20","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"5d4467a1a3a7","markDefs":[]},{"_key":"94594cd5be6d","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Li and colleagues reported a mean reduction of 16.9 in MADRS scores, with a 50% response rate and 40% remission rate immediately after treatment. Remission criteria were met by 60% of participants within the 1-month follow-up period. No serious adverse events, manic episodes, or cognitive adverse effects were reported.","_key":"6370bd6c19c80"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"","_key":"e1a471b30a1d0"}],"_type":"block","style":"normal","_key":"563ce585f72a","markDefs":[]},{"_key":"19f8ac8a1a32","markDefs":[],"children":[{"_key":"cf3ab6575cfe0","_type":"span","marks":[],"text":"\"We are very pleased by the outcomes of this pilot trial, especially given that the participants all had already tried first-line medication treatments for their depression, without improvement in their conditions, even after months-to-years of treatment,\" Bentzley commented."}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"marks":[],"text":"","_key":"de3b25279b090","_type":"span"}],"_type":"block","style":"normal","_key":"ceea7b8459bb"},{"_type":"block","style":"normal","_key":"2095220c4ac3","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"SAINT iTBS Refines rTMS for Depression","_key":"efb7e41e3dd50"}]},{"children":[{"_type":"span","marks":[],"text":"In 2022, 14 years after the 2008 US Food and Drug Administration (FDA) approval of an rTMS system for treatment-resistant major depressive disorder,","_key":"5a9f21d71b150"},{"_type":"span","marks":["superscript"],"text":"4","_key":"819ec1e2bb07"},{"_type":"span","marks":[],"text":" the FDA approved the SAINT Neuromodulation System (Magnus Medical).","_key":"1e07ae634be5"},{"_type":"span","marks":["superscript"],"text":"2","_key":"2186d480fd57"},{"_type":"span","marks":[],"text":" The product name is derived from the SAINT acronym for the protocol developed by Nolan Williams, MD, and colleagues at Stanford University.","_key":"89eb6bf8e8fa"}],"_type":"block","style":"normal","_key":"638d81494f91","markDefs":[]},{"markDefs":[],"children":[{"marks":[],"text":"","_key":"1bab0497d63c0","_type":"span"}],"_type":"block","style":"normal","_key":"9c02bcdc3419"},{"_key":"154d9eb5d0c0","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Williams, a coauthor of the present study, and colleagues had found that while rTMS magnetic pulses could not directly reach the subgenual anterior cingulate cortex associated with affect, activity in that region could be modulated through stimulation pulses to the DLPFC. Identifying a target point above the scalp with fMRI to maximize effect on the DLPFC was necessary as it varies between individuals.","_key":"51c6818fb5070"}],"_type":"block","style":"normal"},{"style":"normal","_key":"d11db1097e91","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"90457e0905720"}],"_type":"block"},{"style":"normal","_key":"347462290e06","markDefs":[],"children":[{"_type":"span","marks":[],"text":"The SAINT protocol of iTBS administers the same amount of brain stimulation as the weeks-long FDA-approved rTMS regimen but does so within 5 days. Sessions last for 3 minutes compared with 37 minutes in conventional TMS. Ten sessions of iTBS are administered per day for up to 5 days, with 50 minutes separating the sessions.","_key":"a77e64645cf60"}],"_type":"block"},{"_type":"block","style":"normal","_key":"53cefb03e633","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"ab02901cb39a0"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"The administration schedule, Williams recounted in an earlier interview,","_key":"0ec39a5ff88a0"},{"text":"5","_key":"c19c1914872d","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" was designed to \"build upon one another to amplify the antidepressant effect.\"","_key":"24e50c570876"}],"_type":"block","style":"normal","_key":"3587ca8d7bcf"},{"children":[{"_type":"span","marks":[],"text":"","_key":"9c65936728b10"}],"_type":"block","style":"normal","_key":"b858937a1038","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"In that interview, Williams acknowledged that the use of the fMRI scan to pinpoint the target for stimulation adds to the cost of the procedure. He indicated, however, that it also increases its accuracy and effectiveness, which could be lifesaving in patients with refractory major depression.","_key":"6d709af2872f0"}],"_type":"block","style":"normal","_key":"e8e5411d5382"},{"style":"normal","_key":"7cb986fd9f3e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"870bd14cd5c40"}],"_type":"block"},{"_key":"94111b7fee8c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"The current study is the first to use SAINT in patients with bipolar I depression since its development at Stanford. Li and colleagues consider the findings promising and indicate that further investigation is warranted; suggesting that it be double-blinded, sham-controlled, and conducted with a larger sample size and longer follow-up.","_key":"41036e0520ad0"}],"_type":"block","style":"normal"},{"children":[{"text":"","_key":"f75db0423c650","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"650874735538","markDefs":[]},{"markDefs":[],"children":[{"_key":"cf13e68d4de10","_type":"span","marks":[],"text":"Bentzley confirmed intention to further investigate the SAINT protocol for bipolar depression. “The next step will be a larger clinical trial, and we are currently investigating the best path to undertake this next step,” he said."}],"_type":"block","style":"normal","_key":"9de0f46706ca"},{"markDefs":[],"children":[{"text":"","_key":"aedf0371cfd70","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"463f79160583"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Bender","_key":"02b213654e860"},{"_type":"span","marks":["em"],"text":" reports on medical innovations and advances in practice and edits presentations for news and professional education publications. He previously taught and mentored pharmacy and medical students, and he provided and managed pharmacy care and drug information services.","_key":"02b213654e861"}],"_type":"block","style":"normal","_key":"53b8ad5ec9c8"},{"_type":"block","style":"normal","_key":"d2eb0f2356ef","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"7336938498380"}]},{"_key":"1812d73863b3","markDefs":[],"children":[{"_key":"b368b3718f3f0","_type":"span","marks":["strong"],"text":"References"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"1. Cole EJ, Stimpson RH, Bentzley BS, et al. ","_key":"a10dac0930b00"},{"_type":"span","marks":["901377e8e724"],"text":"Stanford accelerated intelligent neuromodulatoin therapy for treatment-resistant depression.","_key":"d67f353f85cf"},{"_type":"span","marks":[],"text":" ","_key":"21f6bd6ab148"},{"text":"Am J Psychiatry. ","_key":"a10dac0930b01","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":"2020;177(8):716-726.","_key":"a10dac0930b02"}],"_type":"block","style":"normal","_key":"fdf60739d444","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/32252538/","_key":"901377e8e724"}]},{"_key":"900c93b9650c","markDefs":[{"blank":true,"_type":"link","href":"https://www.magnusmed.com/press-releases/magnus-medical-receives-fda-clearance-for-the-saint-neuromodulation-system/","_key":"f4f19a63d8b1"}],"children":[{"text":"2. Magnus Medical receives FDA clearance for the SAINT neuromodulation system for non-invasive, individualized and precise treatment of severe depression. Magnus Medical. News release. September 6, 2022. Accessed November 1, 2024. ","_key":"8ba7c544fd610","_type":"span","marks":[]},{"text":"https://www.magnusmed.com/press-releases/magnus-medical-receives-fda-clearance-for-the-saint-neuromodulation-system/","_key":"8ba7c544fd611","_type":"span","marks":["f4f19a63d8b1"]}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"c0a4dc7762cd","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/39154984/","_key":"fa440e2c6f62"}],"children":[{"_type":"span","marks":[],"text":"3. Li K, Bichlmeier A, DuPont C, et al. ","_key":"423f26e3b1f10"},{"text":"Fast depressive symptoms improvement in bipolar 1 disorder after Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT): a two-site feasibility and safety open-label trial.","_key":"423f26e3b1f11","_type":"span","marks":["fa440e2c6f62"]},{"_type":"span","marks":[],"text":" ","_key":"423f26e3b1f12"},{"_type":"span","marks":["em"],"text":"J Affect Disord. ","_key":"423f26e3b1f13"},{"_type":"span","marks":[],"text":"2024;365:359-363.","_key":"423f26e3b1f14"}]},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3159591/","_key":"afb5ed51035a"}],"children":[{"_type":"span","marks":[],"text":"4. Horvath JC, Mathews J, Demitrack MA, Pascual-Leone A. ","_key":"2414b4156fd30"},{"_type":"span","marks":["afb5ed51035a"],"text":"The NeuroStar TMS device: conducting the FDA approved protocol for treatment of depression.","_key":"2414b4156fd31"},{"_type":"span","marks":[],"text":" ","_key":"2414b4156fd32"},{"_key":"2414b4156fd33","_type":"span","marks":["em"],"text":"J Vis Exp. "},{"_type":"span","marks":[],"text":"2010;45:2345.","_key":"2414b4156fd34"}],"_type":"block","style":"normal","_key":"598ee4ac8619"},{"_key":"a541a2e66f8a","markDefs":[{"blank":true,"_type":"link","href":"https://bbrfoundation.org/content/fda-clears-saint-rapid-acting-brain-stimulation-approach-those-suffering-resistant-major","_key":"6687a258e0ef"}],"children":[{"_key":"b79063759aaf0","_type":"span","marks":[],"text":"5. Tarr P. FDA clears SAINT rapid-acting brain stimulation approach for those suffering from resistant major depression. Brain \u0026 Behavior Research Foundation. September 15, 2022. Accessed November 1, 2024. "},{"_type":"span","marks":["6687a258e0ef"],"text":"https://bbrfoundation.org/content/fda-clears-saint-rapid-acting-brain-stimulation-approach-those-suffering-resistant-major","_key":"b79063759aaf1"}],"_type":"block","style":"normal"}],"gptSummary":"The Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT) protocol, a rapid-acting repetitive transcranial magnetic stimulation (rTMS) method, shows promise in reducing depressive symptoms in bipolar I disorder. In a feasibility and safety trial, 60% of participants achieved remission within a month post-treatment, with no adverse cognitive or manic effects. The study involved 10 participants with moderate to severe depression unresponsive to antidepressants. The SAINT protocol uses fMRI to target the dorsolateral prefrontal cortex, delivering intermittent theta burst stimulation (iTBS) over five days. 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