Shai Aviram

Positive effects of repetitive transcranial magnetic stimulation on attention in ADHD Subjects: A randomized controlled pilot study

Abstract Objectives. Repetitive transcranial stimulation (rTMS) affects dopaminergic secretion in the prefrontal cortex. Attention deficit hyperactivity disorder (ADHD) had been suggested to involve dopaminergic prefrontal abnormalities. Methods. In this crossover double-blind randomized, sham-controlled pilot study, patients diagnosed as having adult ADHD received either a single session of high-frequency rTMS directed to the right prefrontal cortex (real rTMS) or a single session of sham rTMS. Results. A total of 13 patients (seven males, six females) who fulfilled the criteria for adult ADHD, according to DSM-IV criteria gave informed consent and were enrolled. There was a specific beneficial effect on attention 10 minutes after a real rTMS course. The post-real rTMS attention score improved significantly (M=3.56, SD=0.39) compared to the pre-real rTMS attention score (M=3.31, SD=0.5) [t(12)=2.235, P < 0.05]. TMS had no effect on measures of mood and anxiety. The sham rTMS had no effect whatsoever. Conclusions. Our findings should encourage future research on the possibility of amelioration of attention difficulties in patients suffering from ADHD by using high frequency rTMS directed to the right dorsolateral prefrontal cortex. (NIH registry NCT00825708)

Long-term follow-up of adolescents with resistant depression treated with repetitive transcranial magnetic stimulation.

Objective There is a paucity of information about repetitive transcranial magnetic stimulation (rTMS) as a treatment for adolescent depression, and there are no data about its long-term effectiveness and safety in this age group. The aim of this study was to evaluate symptoms of depression and cognitive functioning in young people who had been treated 3 years previously with rTMS for resistant depression. Methods Eight of 9 subjects who had participated in an open-label rTMS study were reassessed using the Child and Adolescent Depression Rating Scale—Revised and the Beck Depression Inventory II. Six of the subjects were also cognitively reassessed using the Cambridge Neuropsychological Test Automated Battery. The follow-up assessments were compared with the earlier pretreatment, inter-treatment and posttreatment assessments. Results At 3-year follow-up, there was no evidence of deterioration in symptoms of depression or cognitive functioning compared to the last assessment after rTMS. Conclusion Preliminary evidence suggests that rTMS treatment of resistant depression in adolescents is not associated with long-term cognitive deterioration and that posttherapy clinical improvement can be maintained. It seems that some subjects may derive long-term benefit from the rTMS course.

The effect of age on frontal lobe related cognitive functions of unmedicated depressed patients

BACKGROUND Aging is associated with a decline in frontal lobe related cognitive functioning of healthy subjects (i.e., executive functioning and higher-order cognition). Unipolar depression is associated with dysfunctions in similar cognitive domains--deficits that impact the functioning and quality of life of these patients. The effect of age on frontal lobe related cognitive functions of depressed patients, however, has not been adequately studied. The current study therefore assessed a wide age range of depressed patients and compared their frontal lobe related cognitive functions to that of matched healthy controls. Recruitment of unmedicated patients minimized the confounding effect of psychiatric medications. METHOD Depressed patients and healthy controls were divided into three age groups (<25, 25-45, and 46-65 years of age) and matched in gender, age and education level (N total=170). Cognition was assessed using the Cambridge Neuropsychological Test Automated Battery (CANTAB). RESULTS The depressed patients had deficits in cognitive planning/organization, working memory, and sustained attention compared to the healthy controls. Aging was associated with a decrease in frontal lobe related functioning. Except for working memory, no significant interactions were found between the age groups and the study group (depressed/healthy). CONCLUSIONS Depressed patients are impaired in most domains of frontal lobe related cognitive functions. These deficits are already evident at an early age and persist in older age cohorts (despite an overall age related decline). These findings may help clarify the profile and course of cognitive deficits among depressed patients while providing tentative support for a developmental model of cognitive impairment in depression.

Repetitive Transcranial Magnetic Stimulation in Depressed Adolescents: Experience, Knowledge, and Attitudes of Recipients and Their Parents

Background Comprehensive assessment of new treatments in psychiatry should include evaluation of their acceptability to patients, and in the case of children and adolescents, this must extend to acceptability for parents. The views of young patients and their parents in relation to repetitive transcranial magnetic stimulation (rTMS) for adolescent depression have not been previously studied. Objective We sought to (1) describe the experience, knowledge, and attitudes regarding rTMS among young people who had been treated with rTMS for depression as adolescents; (2) report the views of their parents; and (3) compare these to opinions about pharmacotherapy among a group who had been treated with fluoxetine for adolescent depression. Methods Eight of 9 subjects who had participated in an open-label rTMS study, 13 of their parents, and an age-matched group of 8 subjects who had been treated with fluoxetine for depression as adolescents were assessed using detailed questionnaires. Results Repetitive TMS recipients and their parents found rTMS largely acceptable in terms of adverse effects and treatment experience, but most considered it ineffective. In contrast, most patients who had been treated with fluoxetine viewed their treatment as effective. Conclusions Transcranial magnetic stimulation is relatively well tolerated by depressed adolescents, but it is also perceived as mostly unhelpful by them and their parents. This is at odds with emerging studies suggesting that rTMS can be an effective and safe treatment in this age group, indicating that further research is required to confirm our findings and understand reasons for any disparity.

Suicidal behavior in minors-diagnostic differences between children and adolescents

Background: To date, the study of suicidal behavior among minors has focused on the age group in which it is more prevalent: adolescents. We hypothesized that suicidal behavior in children stems from a different diagnosis than suicidal behavior in adolescents, and thus merits its own investigation. Method: We studied all minors (266) who were referred to a psychiatric emergency department due to a suicide attempt or suicidal ideation during a 3-year period. Result: There was an age-related difference in diagnostic distribution among minors who were referred to the emergency department because of suicidal behavior (&khgr;2 (7) = 24.297, P < 0.01). Attention deficit hyperactivity disorder was more prevalent among children (under 12 years old), whereas mood disorders were more prevalent among adolescents (12–18 years old). Conclusion: The findings of this study highlight a diagnostic difference between suicidal children and suicidal adolescents.

Can Computerized Cognitive Tests Assist in the Clinical Diagnosis of Attention-Deficit Hyperactivity Disorder?

A group of 34 children and adolescents suspected of having attention-deficit hyperactivity disorder were referred for a computerized evaluation that included sustained attention, working memory, planning, and set-shifting. Although only sustained attention had reasonable specificity, all tests had questionable contribution to the diagnostic evaluation.

Comprehension and companionship in the emergency department as predictors of treatment adherence.

Objective: Lack of adherence to recommended treatment poses major clinical and economic challenges for psychiatry, and requires further examination. In this pilot study, we aimed to prospectively investigate the association between the level of understanding of psychiatric emergency department (ED) discharge recommendations and the presence of a companion with short-term treatment adherence. Method: Sixty subjects were evaluated twice: upon ED discharge and a month later. Instruments included a structured questionnaire based on the MacArthur Competence Assessment Tool for Treatment, Mini Mental State Examination, and corroboration of data with the computerized hospital medical file. In order to control for the possibility that evaluation of the understanding of recommendations might positively influence adherence, the 60 subjects were randomly assigned into 50 who were interviewed with the full survey tool and 10 who were not asked questions about their understanding of treatment and/or follow-up recommendations. Results: Understanding of discharge recommendations and the presence of a companion enhanced adherence. Conclusions: This preliminary study suggests that ensuring patients’ understanding of treatment recommendations and encouraging the company of patients are achievable, practical strategies that may improve adherence and thereby promote better outcomes.

Association Between Continuous Performance and Response Inhibition Tests in Adults With ADHD

Objective: The study of ADHD uses various computerized tests to assess cognitive functions. Uncertainty exists regarding the association between deficits found by different tools testing similar or different cognitive functions (e.g., continuous performance tests [CPT] and response inhibition [RI] tests).We hypothesized that different tools that measure continuous performance will be better correlated between themselves than with a tool that examines RI. Method: Thirty-six adults with ADHD performed two different CPTs and a RI task. We analyzed correlations between different measures examined by the tasks. Results: There were strong correlations between corresponding measures in the CPTs. Correlations between the results in CPT and the RI task were only minimal. Conclusion: These findings support the specificity of impairments in different cognitive domains (continuous attention vs. RI) beyond the specific test used in the study of ADHD. Also, these findings strengthen the importance of specific discriminative cognitive domains in ADHD.

The correlation between impaired attention and emotional reactivity in depressed adolescent patients.

A group of 20 drug-naïve depressed adolescents and 20 matched controls underwent cognitive evaluations and assessment of emotional reactivity. Emotional reactivity correlated only with attention and only in depressed patients. The cognitive-emotional construct may enhance the understanding of adolescent depression and aid diagnosis.

Methylphenidate Reduces State Anxiety During a Continuous Performance Test That Distinguishes Adult ADHD Patients From Controls.

Objective: We hypothesized that patients with ADHD were typified by distress more than by functional difficulties. Thus, a decline in state anxiety while performing a cognitive task when taking methylphenidate would discriminate between ADHD patients and controls. Method: State anxiety and cognitive performance on a continuous performance test were assessed in ADHD patients and controls with and without taking methylphenidate. Results: State anxiety and cognitive performance improved from baseline in 36 ADHD adults after taking methylphenidate. In 25 controls, cognitive performance improved, but state anxiety did not abate after a recess. In two additional studies, 5 controls were evaluated at baseline and after receiving methylphenidate, and showed improvement in cognitive assessment but not in state anxiety. Five ADHD adults were assessed at baseline and after a recess, and showed no improvement. Conclusion: Our results support the hypothesis that adult ADHD patients are characterized by distress and the relief of this distress under effective therapy as expressed by a decline in state anxiety while they perform a cognitive task.