This is a proposal presented in the 1st IBRO/APRC Iranian Associate School of Cognitive Neuroscience “Functional Human Brain Mapping”, Tehran, Iran, May 22-28, 2015 aimed: 1. To evaluate the effect of EEG-biofeedback rTMS on Mood in major depressed patients compare to EEG biofeedback and rTMS 2. To evaluate the maintenance of EEG-biofeedback rTMS on working memory in major depressed patients compare to EEG biofeedback and rTMS

1. Effect and maintenance of
"EEG-biofeedback rTMS" on mood and
working memory in patients with
drug resistant major depression:
comparison with rTMS and EEG biofeedback
Amin Asadollahpour Kargar
Karma Terzin
Elnaz Mosanezhad
Fariba Yadolahi
Hamed Ghazvini
Tehran IBRO School
May 2015

2. Idea giving and presenting by:
 Amin Asadollahpour Kargar
 PhD candidate of cognitive neuroscience, Tabriz University, Iran
 Email: Amin.psychologist@gmail.com

4. Aims:
 To evaluate the effect of EEG-biofeedback rTMS on Mood in major depressed
patients compare to EEG biofeedback and rTMS
 To evaluate the maintenance of EEG-biofeedback rTMS on working memory in
major depressed patients compare to EEG biofeedback and rTMS

5. What is Major Depressive Disorder(MDD)?
 Major depressive disorder (MDD) is a disabling condition that adversely affects
quality of life (American Medical Network, 2011; Muray & Lopez, 1996)
 Decreased mood and impaired working memory are also characteristic aspect
of depression (Christopher and MacDonald, 2005)
 the overall current prevalence of MDD in Iran is high and females are at the
greater risk of disease (Sadeghirad et.al, 2010).
 DSM crieteria…

6. Treatment
There are various kind of treatments for MDD…
Medication
Psychotherapy like Cognitive Behavior Therapy (CBT)
EEG Biofeedback (Neurofeedback)
rTMS

7. Introduction and Rationale of the Study
There are increasing evidences of positive effects of
 rTMS (Ren et.al, 2014; Chen et. al, 2013)
 EEG biofeedback (Koo et.al, 2014)
On Major Depressed Patients

8. Introduction and Rationale of the
Study(continue)
Generally,
 rTMS has acute (significant) beneficial effect but its maintenance is questionable
(Ren et.al, 2014; Chen et.al, 2013).
 EEG biofeedback (Neurofeedback) does not have that acute effect on depression
but its maintenance is relatively better.
 So we want to have a therapy that has long term positive
effect on Depression with minimum relapse.

9. Introduction and Rationale of the
Study(continue)
 EEG-biofeedback rTMS (Micoulaud-Franchi, 2011) is a new technique which uses
rTMS pulses
 based on reward band's amplitude threshold
 to magnify the targeted brain wave
 to help brain to regulate itself more faster.

10. Introduction and Rationale of the
Study(continue)
 This technique is very useful in people who have difficulties in regulating their
brain waves with slow progress.
 In this study, we will compare the effects of EEG-biofeedback rTMS on mood and
working memory in patients with drug resistant major depression and compare it
in patients who receive only rTMS or EEG biofeedback.

11. Research question
 Is there any significant difference in effect and maintenance among patients
who receive EEG biofeedback rTMS, EEG biofeedback or rTMS alone in drug
resistant major depressed patients?

12. HYPOTHESIS:
 The EEG biofeedback rTMS has better effect on the drug resistant major
depressed patients in comparison with EEG biofeedback and rTMS alone.
 The EEG biofeedback rTMS has better maintenance of the drug resistant
major depressed patients in comparison with EEG biofeedback and rTMS
alone.

13. Research design and Methods:
 Design:
 Experimental study
 3 groups
 15 patients in each group
 Group 1 - rTMS
 Group 2 – EEG biofeedback
 Group 3 – EEG biofeedback rTMS

14. Research design and Methods
(Continue):
 Methods:
 45 Diagnosed MDD patients with no co-morbid disorders
 Drug resistant cases
 Convenient sampling technique
 All groups – 30 minutes session, frequency of 5 days/week, total of 20 sessions in 4
weeks
 Group 1 - stimulus at F3 at 10 Hz for 4 seconds followed by 26 seconds of rest period
 Group 2 – 30 minutes of beta (15-18 Hz) activating protocol on Fp1
 Group 3 – EEG biofeedback rTMS, EEG biofeedback on Fp1 and rTMS on F3 sites.

15. Research design and Methods
(Continue):
 Group 3,
 We will make the connection between the rTMS pulse generation and the beta
wave threshold on EEG by use of software.
 That is, each time beta wave threshold is passed on EEG biofeedback, the rTMS
will produce a 10 Hz stimulus
 but it is limited to four 10 Hz stimulus every 30 seconds.
 This stimulus will cause activation of beta waves more frequently

16. Assessment tools
 Beck Depression Inventory(BDI)
 Wechsler Memory Scale (WMS)

17. Procedure:
 Patient information, education and informed written consent
 For pre test – BDI and WMS in all patients
 For intervention – all patients will undergo rTMS and EEG biofeedback as
prescribed by protocol for different groups
 For post test, BDI and WMS will be performed again

18. Analysis of Data:
 multivariate analysis of variance (MANOVA) test for BDI and WMS
 Chi-square test for number and percent of relapsing patients in each group
after 6 months follow up

19. Ethical Considerations:
 Ethical approval will be obtained from the Institutional review board (IRB)
prior to beginning the study.
 Proper patient education and also informed written consent will be taken.
 Patients will be given the right and autonomy to withdraw any time during
the study.
 During the period of the study the patients will receive all their routine
medications.

20. Limitations:
 The control group can not be included in this study, because the intervention
groups would receive prescribed interventions
 whereas the control group would not receive any form interventions for
duration of 6 months
 which would be unethical
 due to the fact that the major depressed patients are very high risk
population.
Therefore, we decided to have no control group for
the study.

21. Expected outcomes:
 Group receiving EEG biofeedback rTMS will show less BDI scores and higher
scores in Wechsler memory scale after treatment and in follow up period.
 The EEG biofeedback rTMS group will also show less relapse

22. Time table:

23.  Chen, J., Zhou, C., Wu, B., Wang, Y., Li, Q., Wei, Y., ... & Xie, P. (2013). Left versus right
repetitive transcranial magnetic stimulation in treating major depression: a meta-analysis of
randomised controlled trials. Psychiatry research, 210(3), 1260-1264.
 Christopher, G., & MacDonald, J. (2005). The impact of clinical depression on working
memory. Cognitive Neuropsychiatry, 10(5), 379-399.
 Hammond, D. C. (2000). Neurofeedback treatment of depression with the Roshi. Journal of
Neurotherapy, 4(2), 45-56.
 Koo, B., Lee, J. B., Seo, W. S., Cheon, E. J., Lee, K. H., Sung, H. M., ... & Chae, J. H. (2014). P.
2. f. 002 The effect of EEG biofeedback on electrophysiological disturbances and symptoms in
patients with depressive disorder. European Neuropsychopharmacology, 24, S452.
 Major Depressive Disorder (2011). American Medical Network, Inc. Retrieved 15 January.
 Micoulaud-Franchi, J. A., & Vion-Dury, J. (2011). One step more toward new therapeutic
options in brain stimulation: two models of EEG-based rTMS—from “EEG-contingent rTMS” to
“EEG-biofeedback rTMS”. Brain stimulation, 4(2), 122-123.
 Murray, C. J., & Lopez, A. D. (1996). Evidence-Based Health Policy Lessons from the Global
Burden of Disease Study. Science, 274(5288), 740-743.
 Rose, E. J., & Ebmeier, K. P. (2006). Pattern of impaired working memory during major
depression. Journal of Affective Disorders, 90(2), 149-161.
 Sadeghirad, B., Haghdoost, A. A., Amin-Esmaeili, M., Ananloo, E. S., Ghaeli, P., Rahimi-
Movaghar, A., ... & Barooti, E. (2010). Epidemiology of major depressive disorder in Iran: a
systematic review and meta-analysis.International journal of preventive medicine, 1(2), 81.
References:

24. Thank you for your attention