Elsevier

Brain Stimulation

Volume 2, Issue 1, January 2009, Pages 14-21
Brain Stimulation

Original Research
Controversy: Repetitive transcranial magnetic stimulation or transcranial direct current stimulation shows efficacy in treating psychiatric diseases (depression, mania, schizophrenia, obsessive-complusive disorder, panic, posttraumatic stress disorder)

https://doi.org/10.1016/j.brs.2008.06.001Get rights and content

Brain imaging studies performed over the past 20 years have generated new knowledge about the specific brain regions involved in the brain diseases that have been classically labeled as psychiatric. These include the mood and anxiety disorders, and the schizophrenias. As a natural next step, clinical researchers have investigated whether the minimally invasive brain stimulation technologies (transcranial magnetic stimulation [TMS] or transcranial direct current stimulation [tDCS]) might potentially treat these disorders. In this review, we critically review the research studies that have examined TMS or tDCS as putative treatments for depression, mania, obsessive-complusive disorder, posttraumatic stress disorder, panic disorder, or schizophrenia. (Separate controversy articles deal with using TMS or tDCS to treat pain or tinnitus. We will not review here the large number of studies using TMS or tDCS as research probes to understand disease mechanisms of psychiatric disorders.) Although there is an extensive body of randomized controlled trials showing antidepressant effects of daily prefrontal repetitive TMS, the magnitude or durability of this effect remains controversial. US Food and Drug Administration approval of TMS for depression was recently granted. There is much less data in all other diseases, and therapeutic effects in other psychiatric conditions, if any, are still controversial. Several issues and problems extend across all psychiatric TMS studies, including the optimal method for a sham control, appropriate coil location, best device parameters (intensity, frequency, dosage, and dosing schedule) and refining what subjects should be doing during treatment (activating pathologic circuits or not). In general, TMS or tDCS as a treatment for most psychiatric disorders remains exciting but controversial, other than prefrontal TMS for depression.

Section snippets

TMS

Far and away the most research with TMS as a potential treatment has been its use as an acute treatment for depression. It is interesting to speculate why there has been so much work in depression, as there are clearly other diseases with better defined neuroanatomy and pathophysiology. Some have argued that TMS therapeutics should have been tested first in these other diseases and then later expanded to depression.9 One factor that contributes to the enthusiasm for using TMS in depression is

tDCS

There have only been two small single-site trials of tDCS in depression.72, 73 These are promising but in no way definitive. More information may emerge at the October 2008 Gottingen meeting.

OCD

OCD has a fairly well-established functional neuroanatomy involving the basal ganglia and orbitofrontal cortex. This known anatomy has been confirmed and refined by modern neuroimaging,84, 85, 86 but for many decades this circuitry served as the basis of ablative brain surgery for the disorder. With a known pathologic circuit involving cortical regions that are dysfunctional, and a history of ablative surgery as an effective treatment, early researchers hoped that focal prefrontal TMS might

PTSD

There has been intense interest regarding whether TMS might help with PTSD symptoms. As in other psychiatric disorders, initial case series90, 91 and then small studies showed promise, but there have been negative published and unpublished data as well.92 This area remains quite controversial.

Hallucinations

Auditory hallucinations are part of the positive symptoms of schizophrenia. These types of hallucinations are believed to result from aberrant activation of the language perception area at the junction of the left temporal and parietal cortices.8 Researchers hypothesized that low-frequency TMS could potentially inhibit this area in patients with schizophrenia and provide relief from auditory hallucinations.96, 97, 98, 99, 100

A recent meta-analysis looked at the efficacy of low-frequency TMS as

Negative symptoms

There have been six randomized controlled trials (RCTs) using intermittent daily prefrontal TMS to treat negative symptoms in patients with schizophrenia.14, 103, 104, 105, 106, 107 Three of these studies were positive. The jury is still out in this regard.

Summary and Conclusions

The use of TMS as a therapy for most psychiatric disorders is still controversial, as there are insufficient studies yet to firmly know whether the treatment might work. A notable exception is using daily prefrontal rTMS to treat depression, in which there is a consensus that there are antidepressant effects greater than placebo. Even with TMS as an antidepressant, there is still controversy as to the size of these effects, whether they will have clinical use in real-world settings, and what

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