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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 59-63

Short-Interval periodic transcranial direct current stimulations may induce long-term remission of symptoms in a patient with poststroke depression


1 Department of Medical Rehabilitation (Physiotherapy), College of Medical Sciences, University of Maiduguri, Maiduguri, Borno State, Nigeria
2 Department of Physiotherapy, Federal Medical Center, Nguru, Yobe State; Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Nigeria
3 Medical Rehabilitation Therapists (Reg.) Board of Nigeria, North-West Zonal Office, Kano, Kano State, Nigeria; Department of Physiotherapy, College of Health Sciences, University of Kwazulu-Natal, Durban, South Africa

Date of Submission10-Feb-2019
Date of Decision15-Mar-2020
Date of Acceptance10-May-2020
Date of Web Publication31-Jul-2020

Correspondence Address:
Mr. Musa Sani Danazumi
Department of Physiotherapy, Federal Medical Center, Nguru, Yobe State; Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Kano, Kano State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njecp.njecp_33_19

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  Abstract 


Transcranial direct current stimulation (tDCS) has been shown to be effective in the management of patients with poststroke depression (PSD) but with a high relapse rate. We present a report of a patient with PSD who had long-term mood improvement upon receiving periodic tDCS sessions with short inter-session intervals following a relapse of symptoms at 3 weeks after improvement due to stimulations with long inter-sessions intervals. A 60-year-old patient presented with moderate PSD, having a Beck Depression Inventory (BDI) score of 25. She received anodal tDCS to the left dorsolateral prefrontal cortex using two different application protocols. Initially, a stimulation session of 2 mA intensity for 20 min was given every working day for 2 weeks. After 3 weeks, she then received seven sessions of periodic stimulations of 2 mA intensity for 13 min each with 20 min inter-sessions interval. BDI score was taken before the intervention, immediately after, and at 3 weeks and 6 months postintervention. Immediately following the last session of the initial protocol of stimulation, the BDI score reduced from 25 to 7. However, the symptoms relapsed at 3 weeks postintervention to the initial BDI score of 25. There was no change in the BDI score immediately after follow-up with short interval periodic stimulations. Nevertheless, the BDI score improved to 18 at 3 weeks and later to 7 at 6 months postintervention. Series of periodic tDCS with short-intersession intervals may be more effective in inducing long-term mood improvement in patients with PSD.

Keywords: Long-term potentiation, major depression, noninvasive brain stimulation, poststroke depression, transcranial direct current stimulation


How to cite this article:
Hassan AB, Danazumi MS, Ishaku CM, Yakasai AM. Short-Interval periodic transcranial direct current stimulations may induce long-term remission of symptoms in a patient with poststroke depression. Niger J Exp Clin Biosci 2020;8:59-63

How to cite this URL:
Hassan AB, Danazumi MS, Ishaku CM, Yakasai AM. Short-Interval periodic transcranial direct current stimulations may induce long-term remission of symptoms in a patient with poststroke depression. Niger J Exp Clin Biosci [serial online] 2020 [cited 2020 Nov 28];8:59-63. Available from: https://www.njecbonline.org/text.asp?2020/8/1/59/291199




  Introduction Top


Stroke is a cerebrovascular accident that majorly presents with motor impairments as well as other nonmotor affectations. Poststroke depression (PSD) is one of the debilitating nonmotor sequels of stroke that causes cognitive deficits, poor recovery in activities of daily living, long hospitalizations, and high mortality in about 40% of patients with acute stroke.[1] Pharmacological intervention for PSD often presents mixed findings[2] and also limited by contraindications, pharmacokinetic interactions, and severe adverse effects, particularly in older individuals.[3] Thus, noninvasive brain stimulation (NIBS) has emerged as an alternative or adjunct nonpharmacological treatment.

Transcranial direct current stimulation (tDCS) is a cost-effective and safe technique of NIBS that involves the administration of a relatively weak direct current from a battery-powered stimulator through two electrodes, cathode and anode, to the brain.[4] Anodal stimulation enhances subthreshold excitability, while cathodal stimulation suppresses it.[5],[6] Anodal stimulation to the left dorsolateral prefrontal cortex (DLPFC) has been shown to improve depression symptoms in patients with major depression[7],[8],[9],[10],[11] and also in those with PSD.[12],[13],[14] tDCS is believed to exert its antidepressant effect by reversing the hypoactivity in the left DLPFC as observed in patients with depression.[15] However, the protocols of tDCS in most studies on major depression and PSD are either single session or periodical stimulations with an interval of 24 h that would normally produce remission of symptoms that lasts for few weeks. Additionally, most of those studies do not have adequate follow-ups.

tDCS elicits long-lasting aftereffect depending on the protocol employed.[16] The long-term increase of excitability following tDCS was shown to be due to N-methyl-d-aspartate receptor-dependent long-term potentiation (LTP).[17] It occurs in two stages, early LTP (e-LTP) and late LTP (l-LTP). e-LTP is defined as excitability increase lasting for about 1 h as a result of Ca2+/calmodulin-dependent kinase activation (CaMKs),[18] while l-LTP is the excitability enhancement lasting for more than 3 h due to sustained activity of CaMKs and subsequent activation of transcription factors, gene expression, and protein synthesis to accomplish alteration of synaptic strength.[19],[20] Number of stimulation sessions and the intervals between them are the two critical factors determining the elicitation of either of these types of LTP. For the induction of e-LTP in brain slices, a single stimulation session is sufficient, whereas for l-LTP generation, two or more stimulation sessions within a critical time window of about 30 min after the first stimulation are usually necessary.[20] Similarly, Monte-Silva et al.[21] induced l-LTP-like excitability enhancements in the primary motor cortex of healthy subjects by giving two sessions of spaced tDCS with a short interval of 3 or 20 min between them which was present for more than 24 h after tDCS. In contrast, the aftereffects were abolished when a wide interval of 3 or 24 h was used.

We believed that, in order to elicit long-term remission of symptoms in patients with PSD and probably major depression, spaced stimulations within the aftereffect period of each other (<30 min) should be given. Therefore, we present a report of a patient with PSD who had long-term mood improvement upon receiving periodic tDCS sessions with short inter-session intervals following relapse of symptoms at 3 weeks after improvement due to periodic stimulations with wide inter-session intervals.


  Case Report Top


The patient was a 60-year-old woman who presented to the accident and emergency unit of Federal Medical Center, Nguru, Yobe State, Nigeria, with a complaint of recurrent weakness of the right side of the body, slurring of speech, blurring of vision, and headache. A diagnosis of left hemispheric cerebrovascular accident was made, and the patient was put on antihypertensives and referred to physiotherapy department. On examinations, the patient had a score of 4/5 on the Modified Oxford Muscle Power Grading Scale on both the right upper limb and lower limbs. There was no spasticity or increase in deep tendon reflex or decrease in passive and/or active range of motions noted. She received treatment in the form of proprioceptive neuromuscular facilitation and task-oriented training, which yielded result as she started performing her basic and instrumental activities of daily living independently. However, 4 months post-diagnosis, the patient started complaining of recurrent episodes of spontaneous crying and anxiety. A psychiatrist diagnosed her as having PSD using the Mini-International Neuropsychiatry Interview for Diagnostic and Statistical Manual Fourth Edition and Beck Depression Inventory (BDI) with a score of 25 [Table 1].
Table 1: Patient characteristics

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Intervention

The patient received anodal tDCS. The anode electrode was placed on the left DLPFC, whereas the cathode was placed on the contralateral supraorbital region. The site of the stimulation was determined using 10–20 international electroencephalography system of electrode placement. She was first given periodic stimulation protocol with wide inter-session intervals, consisting of 2 mA stimulation for 20 min every working day for 2 weeks. BDI score was taken before the first session and immediately after the last session. There was remission of symptoms initially but had relapse at 3 weeks postintervention. She then received seven stimulation sessions with short inter-sessions intervals, consisting of 2 mA stimulation for 13 min with interval of just 20 min between successive sessions [Table 2]. BDI score was taken before the intervention, immediately after, and at 3 weeks and 6 months postintervention.
Table 2: Intervention

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Outcomes

The instrument used in this study was BDI which is a reliable scale consisting of 21 questions, with each having four possible responses arranged in a Likert scale of 0–3. The highest possible score is 63 and the least score is 0.[22] The interpretation of the total score is as follows: 1–10 (these ups and downs are considered normal), 11–16 (mild mood disturbance), 17–20 (borderline clinical depression), 21–30 (moderate depression), 31–40 (severe depression), and over 40 (extreme depression). Immediately following the last session of the wide inter-session interval periodic stimulations, the BDI score reduced from 25 to 7. However, the symptoms relapsed at 3 weeks postintervention to the initial BDI score of 25 [Figure 1]. There was no change in the BDI score immediately after follow-up with short-intersession periodic stimulations. Nevertheless, the BDI score improved to 18 at 3 weeks and later to 7 at 6 months postintervention [Figure 2] and [Figure 3].
Figure 1: Bar graph of Beck Depression Inventory score following long-interval periodic transcranial direct current stimulation

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Figure 2: Bar graph of Beck Depression Inventory score following short-interval periodic transcranial direct current stimulation

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Figure 3: Experimental flowchart

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  Discussion Top


There is to date no standard protocol for the application of tDCS in the management of PSD and major depression. For the first time, this study reported the effect of short-interval periodic tDCS in the management of a patient diagnosed with PSD. We believed that, series of tDCS giving within the aftereffect period of each other might have led to the activation of gene transcription and protein synthesis that caused long-term synaptic strengthening at the left DLPFC[19] and thus the resulting long-term improvement of symptoms. This has been shown previously in a study by Monte-Silva et al.[21] on healthy subjects that two sessions of tDCS, with the second stimulation given not later than 30 min after the first, induced excitation change that lasted for more than 24 h. Studies on learning and memory have also shown that low number of repetitions with short intervals in-between are better in long-term memory formation.[22],[23],[24]

All the seven sessions in this study were given in the same day, but there was no immediate improvement of symptoms after the last session. In fact, there were some residual symptoms even at 3 weeks postintervention. However, after that period, the symptoms improved significantly and remained in remission since then. This may be attributed to the fact that gene transcription does not occur immediately as it takes some hours to commence.[20] Furthermore, because LTP is the molecular mechanism behind learning and memory, the phenomenon that memory consolidation takes place during deep sleep[25],[26] might have contributed to the slow but progressive improvement of the symptoms. In contrast to the short-interval periodic tDCS, wide-interval stimulation resulted in immediate improvement after the last session but only lasted for 3 weeks. This may not be unrelated to the fact that widely spaced stimulation activates CaMKs through increase in postsynaptic calcium concentration.[17],[27] These enzymes maintain their activity through autophosphorylation for some time as the calcium gets depleted through the process of synaptic homeostasis[28],[29],[30],[31] and thus the short-term mood improvement following the tDCS.


  Conclusion Top


Series of periodic tDCS with short-intersession intervals may be more effective in inducing long-term mood improvement in patients with depression. However, this study is just a report of a single case and cannot be generalized. More studies are needed, possibly randomized controlled trials, to further explore this finding. If confirmed, this protocol will totally eliminate the need for combining tDCS with antidepressants as advocated by previous studies, in an attempt to take the advantage of quick and immediate but short-term relief provided by the tDSC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Robinson RG, Jorge RE. Post-stroke depression: A review. Am J Psychiatry 2016;173:221-31.  Back to cited text no. 1
    
2.
Chen Y, Guo JJ. Meta-analysis of antidepressant treatment for patients with post-stroke depression. Stroke 2006;37:1365-6.  Back to cited text no. 2
    
3.
Paolucci S. Role, indications, and controversies of antidepressant therapy in chronic stroke patients. Eur J Phys Rehabil Med 2013;49:233-41.  Back to cited text no. 3
    
4.
Nitsche MA, Boggio PS, Fregni F, Pascual-Leone A. Treatment of depression with transcranial direct current stimulation (tDCS): A review. Exp Neurol 2009;219:14-9.  Back to cited text no. 4
    
5.
Purpura DP, Mcmurtry JG. Intracellular activities and evoked potential changes during polarization of motor cortex. J Neurophysiol 1965;28:166-85.  Back to cited text no. 5
    
6.
Scholfield CN. Properties of K-currents in unmyelinated pre-synaptic axons of brain revealed by extracellular polarization. Brain Res 1990;507:121-8.  Back to cited text no. 6
    
7.
Fregni F, Boggio PS, Nitsche MA, Marcolin MA, Rigonatti SP, Pascual-Leone A. Treatment of major depression with transcranial direct current stimulation. Bipolar Disord 2006;8:203-4.  Back to cited text no. 7
    
8.
Palm U, Keeser D, Schiller C, Fintescu Z, Reisinger E, Baghai TC, et al. Transcranial direct current stimulation in a patient with therapy-resistant major depression. World J Biol Psychiatry 2009;10:632-5.  Back to cited text no. 8
    
9.
Loo CK, Alonzo A, Martin D, Mitchell PB, Galvez V, Sachdev P. Transcranial direct current stimulation for depression: 3-week, randomised, sham-controlled trial. Br J Psychiatry 2012;200:52-9.  Back to cited text no. 9
    
10.
Brunoni AR, Valiengo L, Baccaro A, Zanão TA, de Oliveira JF, Goulart A, et al. The sertraline versus electrical current therapy for treating depression: A clinical study results from a factorial, randomized, controlled trial. JAMA Psychiatry 2013;70:383-91.  Back to cited text no. 10
    
11.
Shiozawa P, Fregni F, Benseñor IM, Lotufo PA, Berlim MT, Daskalakis JZ, et al. Transcranial direct current stimulation for major depression: An updated systematic review and meta-analysis. Int J Neuropsychopharmacol 2014;17:1443-52.  Back to cited text no. 11
    
12.
Bueno VF, Brunoni AR, Boggio PS, Bensenor IM, Fregni F. Mood and cognitive effects of transcranial direct current stimulation in post-stroke depression. Neurocase 2011;17:318-22.  Back to cited text no. 12
    
13.
Valiengo L, Casati R, Bolognini N, Lotufo PA, Benseñor IM, Goulart AC, et al. Transcranial direct current stimulation for the treatment of post-stroke depression in aphasic patients: A case series. Neurocase 2016;22:225-8.  Back to cited text no. 13
    
14.
Valiengo LC, Goulart AC, Oliveira JF, Benseñor IM, Lotufo PA, Brunoni AR. Transcranial direct current stimulation for the treatment of post stroke depression: Results from a randomized, sham-controlled, double-blinded trial. J Neurosurg Psychiatry 2017;88:170-5.  Back to cited text no. 14
    
15.
Grim S, Beck J, Schuepbach D, Hell D, Boesiger P, Bermpohl F, et al. imbalance between left and right dorsolateral prefrontal cortex in major depression is linked to negative emotional judgement: An fMRI study in severe major depressive disorder. Biol Psychiatry 2008;63:369-76.  Back to cited text no. 15
    
16.
Wagner T, Valero-Cabre A, Pascual-Leone A. Non-invasive human brain stimulation. Annu Rev Biomed 2007;9:527-65.  Back to cited text no. 16
    
17.
Nitsche MA, Jaussi W, Liebetanz D, Lang N, Tergau F, Paulus W. Consolidation of externally induced human motor cortical neuroplasticity by D-cycloserine. Neuropsychopharmacology 2004;29:1573-8.  Back to cited text no. 17
    
18.
Malenka RC, Bear MF. LTP and LTD: An embarrassment of riches. Neuron 2004;44:5-21.  Back to cited text no. 18
    
19.
Huang YY, Pittenger C, Kandel ER. A form of long-lasting, learning-related synaptic plasticity in the hippocampus induced by heterosynaptic low-frequency pairing. Proc Natl Acad Sci U S A 2004;101:859-64.  Back to cited text no. 19
    
20.
Reymann KG, Frey JU. The late maintenance of hippocampal LTP: requirements, phase, synaptic tagging, late-associativity, and implications. Neuropharmacology 2007;52:24-40.  Back to cited text no. 20
    
21.
Monte-Silva K, Kuo MF, Hessenthaler S, Fresnoza S, Liebetanz D, Paulus W, et al. Induction of late LTP-like plasticity in the human motor cortex by repeated non-invasive brain stimulation. Brain Stimul 2013;6:424-32.  Back to cited text no. 21
    
22.
Beck AT, Garbin MG. Psychometric properties of beck depression inventory: Twenty-five years of evolution. Clin Psychol Rev 1988;8:77-100.  Back to cited text no. 22
    
23.
Overduin SA, Richardson AG, Lane CE, Bizzi E, Press DZ. Intermittent practice facilitates stable motor memories. J Neurosci 2006;26:11888-92.  Back to cited text no. 23
    
24.
Kornell N, Castel AD, Eich TS, Bjork RA. Spacing as the friend of both memory and induction in young and older adults. Psychol Aging 2010;25:498-503.  Back to cited text no. 24
    
25.
Xue G, Mei L, Chen C, Lu ZL, Poldrack R, Dong Q. Spaced learning enhances subsequent recognition memory by reducing neural repetition suppression. J Cogn Neurosci 2011;23:1624-33.  Back to cited text no. 25
    
26.
Ravassard P, Pachoud B, Comte JC, Mejia-Perez C, Scoté-Blachon C, Gay N, et al. Paradoxical (REM) sleep deprivation causes a large and rapidly reversible decrease in long-term potentiation, synaptic transmission, glutamate receptor protein levels, and ERK/MAPK activation in the dorsal hippocampus. Sleep 2009;32:227-40.  Back to cited text no. 26
    
27.
Romcy-Pereira R, Pavlides C. Distinct modulatory effect of sleep on the maintenance of hippocampal and medial prefrontal cortex LTP. Eur J Nurosci 2004;20:3453-62.  Back to cited text no. 27
    
28.
Nitsche MA, Fricke K, Henschke U, Schlitterlau A, Liebetanz D, Lang N, et al. Pharmacological modulation of cortical excitability shifts induced by transcranial direct current stimulation in humans. J Physiol 2003;553:293-301.  Back to cited text no. 28
    
29.
Pozo K, Goda Y. Unraveling mechanisms of homeostatic synaptic plasticity. Neuron 2010;66:337-51.  Back to cited text no. 29
    
30.
George MS, Lisanby SH, Avery D, McDonald WM, Durkalski V, Pavlicova M, et al. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: A sham-controlled randomized trial. Arch Gen Psychiatry 2010;67:507-16.  Back to cited text no. 30
    
31.
Hasey G. Transcranial magnetic stimulation in the treatment of mood disorder: A review and comparison with electroconvulsive therapy. Can J Psychiatry 2001;46:720-7.  Back to cited text no. 31
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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