presentatie dr. chris baeken
TRANSCRIPT
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Transcraniale Magnetische Stimulatie als
behandelmethode voor bipolaire stoornis en
depressie
Chris Baeken MD, PhD
UZGent: Department of Psychiatry and Medical Psychology (UGent)UZBrussel: Department of Psychiatry (VUB)
pag. 1Ups & Downs, Gent, 10 oktober 2015
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I
Neurostimulatie bij Depressie (unipolairen bipolair)
III
II
Huidig rTMS onderzoek in UZGent
Outline
pag. 2
Werking en Historiek rTMS
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pag. 3
Structuur
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4
Elektriciteit en het brein….
PhD in Medical Sciences
Chris Baeken 11-06-20092/45
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pag. 5
Elektriciteit
Galvani
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Electroconvulsietherapie (ECT)
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(repetitive)Transcranial Magnetic Stimulation (r)TMS
Elektromagnetische pulsen
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Barker, 1985
(repetitive) Transcranial Magnetic Stimulation
Barker et al., 1985, Lancet, p 1106-7
Non-invasive magnetic stimulation of
human motor cortex
SIR,-This note describes a novel method of
directly stimulating the human motor cortex by
a contactless and non-invasive technique using
a pulsed magnetic field.
(repetitive)Transcranial Magnetic Stimulation (r)TMS
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Principes rTMS
Non-invasieve techniek
•Volledig bewust
•‘pijnloos’
•geen anesthesie (itt ECT)
•Weinig neveneffecten
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CAVE: de effecten van rTMS op diepere
hersenstructuren zijn indirect….en elektrisch….
pag. 10
Paus et al., 2001, Eur. J. Neurosci
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Schedel
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25mm
15mm20mm
70x60
55x4540x30
0
5mm
Praktische overwegingen- stimulatie diepte
Stimulatie van
de
hersenschors
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Coil positioning
MC
TPJ OFCOC
VLPFC
PC
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I
Neurostimulatie bij Depressie (unipolairen bipolair)
III
II
Huidig rTMS onderzoek in UZGent
Outline
pag. 14
Werking en Historiek rTMS
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From Chemistry to Electricity….
PhD in Medical Sciences
Chris Baeken 11-06-20092/45
Some brain facts
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serotonin
dopaminenoradrenaline
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Frontal
CortexEVENWICHT
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Voorhersenen
D
L L
‘niet depressief’ Depressief
Beeldvorming
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L RBasalTMSrTMS
20 HZL R
Brain imaging and rTMS
Left prefrontal cortex
Catafau 2001, Psychiatry Res
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(r)TMS
Majeure Depressie
Auditieve Hallucinaties
Afhankelijkheid
PTSD
Tinnitus
Pijn
Beroerte
Epilepsie
...
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Non-invasive techniques
‘temporary’ electricity
Electromagnetic fields
PhD in Medical Sciences
Chris Baeken 11-06-20092/45
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pag. 22
Transcranial direct current stimulation (tDCS)
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Transcranial direct current stimulation (tDCS)
Auditieve Hallucinaties
Majeure DepressieBeroerte
AfhankelijkheidADHD
Eetstoornissen
Parkinson
Chronische Pijn
Fibromyalgie
Tinnitus
Hoofdpijn
Alzheimer
Cognitie, Geheugen
...
Geen officiele
indicaties
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Non-invasive techniques
‘temporary’ electricity
PhD in Medical Sciences
Chris Baeken 11-06-20092/45
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Electroconvulsive therapy (ECT)
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Invasive techniques
‘permanent’ electricity
PhD in Medical Sciences
Chris Baeken 11-06-20092/45
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Deep Brain Stimulation (DBS)
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Deep Brain Stimulation (DBS)
Parkinson
Dystonie
Tremoren
Chronische Pijn
Majeure Depressie
Obsessief Compulsieve Stoornis
….
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Nervus Vagus Stimulatie (VNS)
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Nervus Vagus Stimulatie (VNS)
Major Depression
Epilepsy
Obesity
Anxiety
Pain
...
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• Accuut effect: ECT rTMS
• Lange termijn: DBS VNS
• Terugvalpreventie VNS
• Combinatie neurostimulatie• Psychotherapie
• Medicatie
• Cognitieve training
• Neurostimulatie
• Priming
• …
Richtlijnen ?
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I
Neurostimulatie bij Depressie (unipolairen bipolair)
III
II
Huidig rTMS onderzoek in UZGent
Outline
pag. 32
Werking en Historiek rTMS
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Eerste luik....
Versnelde behandeling
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High Frequency -
rTMS
Low Frequency -
rTMS
DLPFC: dorsolateral prefrontal cortex
> 1Hz
‘increase
cortical
excitability’
≤ 1Hz
‘decrease
cortical
excitability’
pag. 34
Major depression
Schutter 2009, Psych Med
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rTMS consensus in treatment of Major Depression LATERALITY
pag. 35
Left DLPFC
Multiple sessions
Schutter 2009, Psych Med
Meta-analyis
Modest
HF-rTMS
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rTMS: Indicaties & Aanbevelingen
• “Positieve predictoren“
• Depressieve episode met ‘beperkte duur’
– acute fase
• ‘Beperkte’ therapie resistentie
– 1 (or 2) non succesvolle psychopharmacologische trials
– Beperkte respons gecombineerd met‘focused’ psychotherapie
• Jongere populatie
• Niet aanbevolen voor therapie resistente depressie
36
Major Depression
George & Post, 2011, Am J Psychiatry; Padberg & George.2009, Exp Neurology
Deze patienten worden doorverwezen voor rTMS behandeling… “laatste kans”….
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Stimulation period
Daily stimulation
...
5
10
20
...
S
T
A
R
T
2 weeks
3 - 4 weeks> Month (s)
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Intensive rTMS paradigms in TRD ?
Baeken & De Raedt, 2011, Dialogues Clin Neurosci
Intensive HF-rTMS treatment in medication-resistant unipolar depressed
patients
?
‘Classic’ rTMS treatment protocols in TRD modest effect sizes (30-40% responders)
50-70%
responders
in ECT
38
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Stimulation period
Daily stimulation days
...
5
10
20
...
S
T
A
R
T
2 weeks
3 - 4 weeks> Month (s)
Intensified (HF) rTMS treatment
?
< Week (s)
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Holtzheimer et al., 2010 Depress Anxiety
N = 14
Open label study
Unipolar treatment resistant major
depression
‘add on’ therapy’
15 HF-rTMS (10Hz) sessions/ 2 days
(5-10)
100% MT
40
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pag. 41
50 TRD patients
http://clinicaltrials.gov/show/NCT01832805
Left DLPFC
Intermittent Theta Burst Stimulation
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Submitted for publication
Results
At T3
In total 11 responders (HDRS<50%) => 23 %
Remission(HDRS≤7) 6 =>(13 %)
At T4
In total 18 responders (HDRS<50%) => 38%
Remission(HDRS≤7) 14 =>(30%)
Delayed clinical effects
Group Level
Individual Level
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Klassiek >< Versneld
Klinische resultaat is evenwaardig
Het verschil is tijdswinst!
1maand>< 1week
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Tweede luik....
Bipolaire depressie
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45 10-10-2015
Case– Bipolar disorderHDRS
before: 20
after day 1 and 2: 9
after day 3 and 4: 10
and again 9 after 2 weeks
Zeeuws et al., 2011
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Lefaucheur et al., 2014, Clin. Neurophysiology
Recommendation: definite antidepressant
effect of HF rTMS of the left DLPFC (Level A)
Guidelines
&
‘rTMS
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bipolar depression
1 Klasse III studie was negatief (Nahas et al., 2003)
10 andere studies hadden bipolaire patienten, maar
te heterogeen om een conclusie te stellen
GEEN evidentie dat rTMS is geassocieerd met een
verhoogd risico to manische switch wanneer
vergeleken met placebo behandeling (Xia et al., 2008)
Geen aanbeveling
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Toch kan rTMS indicatie interessant zijn voor de
gekende moeilijkheden met medicatie.
Open label studies tonen vergelijkbare klinische
effecten aan van rTMS behandeling met
bipolaire depressie als bij unipolaire depressie(Frank et al., 2011).
Meta-analyse vond geen verschil in HF rTMS
effectiviteit tussen patienten met primair
unipolaire depressie en met gemengde groepen
van unipolaire and bipolaire depressie (Berlim et al.,
2004).
bipolar depression
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The International Society for Bipolar Disorders (ISBD) Task Force report on the
nomenclature of course and outcome in bipolar disorders
Bipolar Disorders
Volume 11, Issue 5, pages 453-473, 10 JUL 2009 DOI: 10.1111/j.1399-5618.2009.00726.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1399-5618.2009.00726.x/full#f1
bipolar depression
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The International Society for Bipolar Disorders (ISBD) Task Force report on the
nomenclature of course and outcome in bipolar disorders
Bipolar Disorders
Volume 11, Issue 5, pages 453-473, 10 JUL 2009 DOI: 10.1111/j.1399-5618.2009.00726.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1399-5618.2009.00726.x/full#f1
bipolar depression
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Multidisciplinary effort
Rudi De Raedt, PhDMarie-Anne Vanderhasselt, PhD
Romain Duprat, Msc
Sarah Herremans, MDPeter Van Schuerbeek, Msc
Daniele Marrinazzo, PhDGuoRong Wu, PhD
Jonathan Remue, MscKees van Heeringen, MD, PhD
Josefien Dedoncker, MscGilbert Lemmens, MD, PhD
Thank you for your attention