rTMS trial journal club

1. Journal Club
The safety and efficacy of adjunctive 20-Hz repetitive
transcranial magnetic stimulation for treatment of
negative symptoms in patients with schizophrenia: A
double-blinded, randomized, sham-controlled study
Guided by – Dr. Vijay Niranjan Sir
Assistant Professor, Department of Psychiatry
MGMMC and MYH
Presented by – Dr. Priyash Jain

2. Journal Information
• Authors
• Swarndeep Singh, Nand Kumar, Rohit Verma,
Department of Psychiatry, All India Institute of Medical Sciences
• Ashima Nehra,
Department of Clinical Neuropsychology, Neurosciences Centre, All India
Institute of Medical Sciences, New Delhi, India

3. Journal Information
• Indian Journal of Psychiatry (ISSN 0019-5545)
• Published by - Indian Psychiatric Society
• Editor - Dr. Om Prakash Singh
• Frequency - Bimonthly
• Impact factor – 1.122

4. Journal Information
• Volume 62, Issue 1,
• January-February 2020
• Financial support and sponsorship Nil.
• There are no conflicts of interest.

5. Introduction
• Negative symptoms in schizophrenia predict poor patient outcome.
• Negative symptoms not easily alleviated by even second gen Anti-
psychotics
• Difficult to treat by both pharmacological and non-pharmacological
methods

6. Introduction
• Hypoactivity in Dorsolateral Prefrontal Cortex (DLPFC)
• Impaired frontoparietal and frontostriatal network connectivity.
• lack of dopamine release in the striatal and extrastriatal brain areas
(prefrontal cortex)
• Repeated stimulation via transcranial magnetic stimulation can
stimulate these brain areas alleviating negative symptoms of
schizophrenia?

7. Aims
• The present study was planned to assess the safety and efficacy of
20-Hz rTMS over left dorsolateral prefrontal cortex (Lt-DLPFC) with
more robust stimulation parameters for adjunctive treatment of
negative symptoms in patients with schizophrenia.

8. Inclusion Criteria
Participants included in the study were
• Diagnosis of schizophrenia established by a qualified psychiatrist
based on the available history (from caregiver and medical
records), and mental status examination of the patient as per the
International Classification of Diseases-10 Diagnostic Criteria for
Research (Mini-International Neuropsychiatric Interview version
7.0)
• Receiving treatment at the psychiatry outpatient department of
the hospital at the time of the study.

9. Inclusion Criteria
Participants included in the study were
• right-handed,
• aged between 18 and 60 years,
• from either gender,
• Stabilized for at least past 4 weeks on the same antipsychotics
with significant negative symptoms (defined as Positive and
Negative Syndrome Scale (PANSS) negative subscore of at least 15
points),
• and minimum illness duration of at least 1 year.

10. Exclusion Criteria
Patients with any
• other psychiatric comorbidity,
• comorbid substance abuse or dependence (except nicotine and
caffeine),
• history of seizures or any other neurological disease,
• neurosurgical metallic implant, cardiac pacemaker or inner ear
prosthesis,
• pregnancy or unstable medical condition

11. Methodology
• This was a single-site, double-blinded, randomized, sham-controlled
study.
• Conducted at a tertiary care general hospital in northern India.
• 30 Participants. Participants were randomized to receive either active
(n = 15) or sham rTMS (n = 15) treatment.
• Allocation concealment was done by using sequentially numbered
sealed opaque envelopes, containing tokens that were randomly
allocated by an independent colleague (author R.V.).

12. Methodology
• The envelopes were opened just before the first treatment session by
the trained rTMS technician. Only the technician administering rTMS
and the doctor supervising the rTMS sessions were aware of the
treatment allocation.
• The study protocol was approved by the Institute Ethics Committee of
the All India Institute of Medical Sciences, New Delhi, India.
• The trial has been registered in the Clinical Trials Registry of India
(CTRI/2015/11/006397) before the recruitment of participants
started.
• The study was conducted in accordance with ethical principles
mentioned in the Declaration of Helsinki.

15. Methodology
• The rTMS was administered using the Magstim Rapid2 device
(Magstim Company Limited, Whitland, UK), with a 70-mm figure-of-
eight air-film coil.
• The participants in the active rTMS group received 20-Hz rTMS at
100% MT stimulation intensity, with 2000 pulses (20 trains with of 10
s duration, and 90 s of inter-train interval) per session.
• A total of 20 sessions of rTMS were administered for five consecutive
days per week over a period of 4 weeks. Thus, a total of 40,000 pulses
were delivered per treatment course.

16. Methodology
• The sham group also underwent similar procedure including
determination of resting MT and localization of Lt-DLPFC site as
described for the active group.
• Further, sham rTMS was delivered using the same parameters and
similar treatment duration to prevent unblinding.
• This coil generated similar sound as the real coil but has an insulated
coil inside preventing delivery of any substantial magnetic field at the
stimulation site

17. Methodology
• Assessment of outcome was done after 5th and 20th rTMS cycle.
• Assessment was done with the aid of various scales.
• Positive and Negative Symptoms Scale (PANSS)
• Schedule for the Assessment of Negative Symptoms (SANS)
• Calgary Depression Scale for Schizophrenia (CDSS)
• Clinical Global Impression (CGI-S)

18. Statistical Analysis
• The statistical analysis was done using SPSS version 23.0 (Armonk,
IBM, NY). Descriptive statistics was used to tabulate the demographic
and clinical characteristics of the sample.
• The data were assessed for normal distribution using normality plots
and using Q-Q plots and Kolmogorov–Smirnov test.
• Chi-square test and the Fisher’s exact test for categorical variables
and the independent t-test or Mann–Whitney U test for normal and
nonnormally distributed continuous variables, respectively.

19. Results and Conclusions
• In active rTMS group, a significant reduction of SANS and PANSS
negative symptoms subscale were observed between the first
(baseline) and second (after 5th rTMS session) assessment scores, and
between the second and third assessment scores as well.
• On the contrary, there was a significant reduction of SANS- and
PANSS-negative symptoms subscale between first and second
assessment scores, but not between second and third assessment
scores.

20. Results and Conclusions
• Further, the reduction in SANS score in the real rTMS group was
significantly greater than sham rTMS group at the end of 20th rTMS
session (third assessment).
• There were no significant differences in scores obtained on PANSS-
positive symptoms subscale and CDSS, except for the CGI-S score
between the active and control group.

21. Results and Conclusions
• There was a significant difference in the CGI-S score between two
groups at the time of third assessment, with significantly greater
reduction in the general severity of illness (CGI-S score) observed in
the active group as compared to control group.

23. S

24. Critique
Introduction
• Title is very detailed and informative about the study.
• The topic being studied is highly relevant to current clinical scenario.
• Introduction explains the study background very meticulously.

25. Critique
Inclusion and Exclusion Criteria
• Rigorous inclusion and exclusion criteria for the study.
• No definition of what “stabilised” means in the study.

26. Critique
Methodology
• Double Blinding has been done which reduces bias.
• Scales that were put to use are all standard and validated scales.
• Flowchart provided with methodology is informative and detailed.
• Sample size is less making it difficult to generalise results on a larger
population.
• Study duration is short and long term follow up of patients has not
been done putting a question mark over sustainability of the results.

27. Critique
Methodology
• Use of Mini-International Neuropsychiatric Interview version 7.0
• Although number of session are more stimulation provided in each
session is less.
• Initial population from which the patients have been screened has
not been described (Out of 66 patients seen 57 turn out to be
Schizophrenic)

28. Critique
Methodology
• Medication history of patients has not been taken into consideration
and hence impact of medications on the results remains
unaddressed.
Statistics
• Variety of statistical analysis has been performed.

29. Critique
Results
• Well described and depicted meticulously in tabulated form.
Discussion
• Detailed discussion
• Limitations of the study have been listed very well.
• Comparison with respect to similarities and dissimilarities with
previous studies has been done.

30. References
• Singh S, Kumar N, Verma R, Nehra A. The safety and efficacy of
adjunctive 20-Hz repetitive transcranial magnetic stimulation for
treatment of negative symptoms in patients with schizophrenia: A
double-blinded, randomized, sham-controlled study. Indian J
Psychiatry 2020;62:21-9

31. Thank You