[Interactive rTMS protocols in psychiatry].

J.-A. Micoulaud-Franchi, R. Richieri, C. Lancon, J. Vion-Dury
L'Encéphale. 2013-12-01; 39(6): 426-431
DOI: 10.1016/j.encep.2013.04.009

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1. Encephale. 2013 Dec;39(6):426-31. doi: 10.1016/j.encep.2013.04.009. Epub 2013 Jun

[Interactive rTMS protocols in psychiatry].

[Article in French]

Micoulaud-Franchi JA(1), Richieri R, Lancon C, Vion-Dury J.

Author information:
(1)Solaris, pôle de psychiatrie universitaire, CHU Sainte-Marguerite, 270,
boulevard Sainte-Marguerite, 13009 Marseille, France; INCM-CNRS UMR 6193,
institut de neurosciences cognitives de la Méditerranée, 31, chemin
Joseph-Aiguier, 13402 Marseille cedex 20, France; Université d’Aix-Marseille, 58,
boulevard Charles-Livon, 13284 Marseille cedex 07, France; Unité de
neurophysiologie, psychophysiologie et neurophénoménologie, pôle de psychiatrie
universitaire, CHU Sainte-Marguerite, 270, boulevard Sainte-Marguerite, 13009
Marseille, France. Electronic address: .

BACKGROUND: The efficiency of repetitive transcranial magnetic stimulation (rTMS)
in the treatment of psychiatric disorders is robust for major depressive episode
(MDE) while results are encouraging for schizophrenia. However, rTMS protocols
need to be optimized. Basic researches in TMS led to the concept of “state
dependency TMS”. This concept suggests that the neural circuits’ activation
states, before and during the stimulation, influence the pulse effect. Indeed,
TMS effect must be seen, not simply as a stimulus, but also as the result of an
interaction between a stimulus and a level of brain activity. Those data suggest
that rTMS efficiency could be increased in psychiatric disorders by triggering
patients’ neurocognitive activities during stimulation. Thus “interactive rTMS
protocols” have been submitted.
OBJECTIVES: This article provides a review and a classification of different
interactive protocols implemented in the treatment of MDE and schizophrenia.
Protocols’ interactions with cognitive activities and brain electrical activities
will be discussed.
LITERATURE FINDINGS: Interactive rTMS protocols that manipulate cognitive
activities have been developed for MDE treatments. They aim at regulating
emotional states of depressed patients during the stimulation. The patients
perform emotional tasks in order to activate cortical networks involving the left
dorsolateral prefrontal cortex (DLPFC) into a state that may be more sensitive to
the rTMS pulse effect. Simultaneous cognitive behavioral therapy (“CBT rTMS”) and
cognitive-emotional reactivation (“affective rTMS”) have thus been tested during
left DLPFC rTMS in MDE. Interactive rTMS protocols that manipulate brain
electrical activities have been developed for MDE and schizophrenia treatments.
Two categories of protocols should be identified. In the first set, personalized
brain activity has been analyzed to determine the parameters of stimulation (i.e.
frequency of stimulation) matching the patient (“personalized rTMS”).
Personalized rTMS protocols can be made “online” or “offline” depending on
whether the EEG activity is measured during or prior to rTMS. Online protocol is
called “contingent rTMS”: it consists in stimulating the brain only when a
specific EEG pattern involving the intensity of alpha rhythm is recorded and
recognized. Offline protocol is called “alpha rTMS”, and relies on ascertaining
frequency of stimulation in accordance with personalized alpha peak frequency
prior to rTMS. In the second set, electrical brain activity is modulated before
or during rTMS in order to stimulate the DLPFC in optimal conditions. Brain
activity modulation may be obtained by transcranial direct current stimulation
(“tDCS rTMS”) or EEG-biofeedack (“EEG-biofeedback rTMS”).
CONCLUSION: Interactive rTMS studies have various limitations, notably their
exploratory character on a small sample of patients. Furthermore, their
theoretical neurocognitive framework justification remains unclear. Nonetheless,
interactive rTMS protocols allow us to consider a new field of rTMS, where
cognitive and cerebral activities would no longer be considered as simple neural
noise, leading to a kind of “first person rTMS”, and certainly to innovative
therapy in psychiatry.

Copyright © 2013 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights

DOI: 10.1016/j.encep.2013.04.009
PMID: 23810752 [Indexed for MEDLINE]

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