Repetitive transcranial magnetic stimulation (rTMS) received US Food and Drug Administration (FDA) approval in 2008 for the treatment of major depression nonresponsive to multiple medications. The ...original rTMS protocol requires about 45 minutes of setup and administration time using 10 Hz at 110% of the motor threshold over the left dorsolateral prefrontal cortex, with one session a day for 20-30 days. This method of administration is both cumbersome for patients and costly to administer. Theta burst stimulation (TBS) delivers single bursts of rTMS at 50 Hz with a stimulation pattern that mimics endogenous theta rhythms and induces a key feature integral to the therapeutic benefit of TMS: long term potentiation/depression of neuronal synaptic connections. In preclinical experiments, TBS was shown to have a longer lasting effect on synaptic plasticity, with a shorter application period than rTMS. The advantages of TBS were recognized as allowing clinical investigators using therapeutic intermittent TBS (iTBS) to decrease the treatment time by increasing the number of stimulations in a shorter period of time than rTMS while potentially providing a more durable therapeutic effect.
Objective:The authors conducted a systematic review and meta-analysis of ketamine and other N-methyl-d-aspartate (NMDA) receptor antagonists in the treatment of major depression.Method:Searches of ...MEDLINE, PsycINFO, and other databases were conducted for placebo-controlled, double-blind, randomized clinical trials of NMDA antagonists in the treatment of depression. Primary outcomes were rates of treatment response and transient remission of symptoms. Secondary outcomes included change in depression symptom severity and the frequency and severity of dissociative and psychotomimetic effects. Results for each NMDA antagonist were combined in meta-analyses, reporting odds ratios for dichotomous outcomes and standardized mean differences for continuous outcomes.Results:Ketamine (seven trials encompassing 147 ketamine-treated participants) produced a rapid, yet transient, antidepressant effect, with odds ratios for response and transient remission of symptoms at 24 hours equaling 9.87 (4.37–22.29) and 14.47 (2.67–78.49), respectively, accompanied by brief psychotomimetic and dissociative effects. Ketamine augmentation of ECT (five trials encompassing 89 ketamine-treated participants) significantly reduced depressive symptoms following an initial treatment (Hedges’ g=0.933) but not at the conclusion of the ECT course. Other NMDA antagonists failed to consistently demonstrate efficacy; however, two partial agonists at the NMDA coagonist site, d-cycloserine and rapastinel, significantly reduced depressive symptoms without psychotomimetic or dissociative effects.Conclusions:The antidepressant efficacy of ketamine, and perhaps D-cycloserine and rapastinel, holds promise for future glutamate-modulating strategies; however, the ineffectiveness of other NMDA antagonists suggests that any forthcoming advances will depend on improving our understanding of ketamine’s mechanism of action. The fleeting nature of ketamine’s therapeutic benefit, coupled with its potential for abuse and neurotoxicity, suggest that its use in the clinical setting warrants caution.
The increase in frequency and intensity of urban flooding is a global challenge. Flooding directly impacts residents of industrialized cities with aging combined sewer systems, as well as cities with ...less centralized infrastructure to manage stormwater, fecal sludge, and wastewater. Green infrastructure is growing in popularity as a sustainable strategy to mimic nature-based flood management. Although its technical performance has been extensively studied, little is known about the effects of green stormwater infrastructure on human health and social well-being.
We conducted a multidisciplinary systematic review of peer-reviewed and gray literature on the effects of green infrastructure for stormwater and flood management on individuals', households', and communities’ a) physical health; b) mental health; c) economic well-being; and d) flood resilience and social acceptance of green infrastructure. We systematically searched databases such as PubMed, Web of Science, and Scopus; the first 300 results in Google Scholar; and websites of key organizations including the United States Environmental Protection Agency. Study quality and strength of evidence was assessed for included studies, and descriptive data were extracted for a narrative summary.
Out of 21,213 initial results, only 18 studies reported health or social well-being outcomes. Seven of these studies used primary data, and none allowed for causal inference. No studies connected green infrastructure for stormwater and flood management to mental or physical health outcomes. Thirteen studies were identified on economic outcomes, largely reporting a positive association between green infrastructure and property values. Five studies assessed changes in perceptions about green infrastructure, but with mixed results. Nearly half of all included studies were from Portland, Oregon.
This global systematic review highlights the minimal evidence on human health and social well-being relating to green infrastructure for stormwater and flood management. To enable scale-up of this type of infrastructure to reduce flooding and improve ecological and human well-being, widespread acceptance of green infrastructure will be essential. Policymakers and planners need evidence on the full range of benefits from different contexts to enable financing and implementation of instfrastructure options, especially in highly urbanized, flood-prone settings around the world. Therefore, experts in social science, public health, and program evaluation must be integrated into interdisciplinary green infrastructure research to better relate infrastructure design to tangible human outcomes.
•No studies were found on human health impacts of green stormwater infrastructure•Most economic studies focused on property value and green stormwater infrastructure•Social and health research is key to understand and scale‐up green infrastructure•Rigorous program evaluation will strengthen the evidence base for policymakers
There is increasing evidence for the efficacy of neuromodulation in the treatment of resistant mood disorders and emerging data supporting the use of neuromodulation in cognitive disorders. A ...significant minority of depressed elders do not respond to pharmacotherapy and/or psychotherapy. This has led clinicians to recommend the increasing use of electroconvulsive therapy (ECT) in the treatment of medication-resistant or life-threatening geriatric depression. Multiple studies have supported the safety and efficacy of ECT in the elderly, yet ECT is associated with side effects including cardiovascular and cognitive side effects. Neuromodulation therapies have the potential for providing effective treatment for treatment-resistant older adults with reduced side effects and this review will outline the risks and benefits of neuromodulation treatment in geriatric psychiatry. There is also emerging evidence of the efficacy of neuromodulation devices in the treatment of cognitive disorders. Pharmacotherapy has been largely ineffective in changing the course of neurodegenerative diseases causing dementia and other treatments are clearly needed. This review will outline the available evidence for neuromodulation in the treatment of mood and cognitive disorders in the elderly.
Major depressive disorder is a common psychiatric disorder associated with marked suffering, morbidity, mortality, and cost. The World Health Organization projects that by 2030, major depression will ...be the leading cause of disease burden worldwide. While numerous treatments for major depression exist, many patients do not respond adequately to traditional antidepressants. Thus, more effective treatments for major depression are needed, and targeting certain hormonal systems is a conceptually based approach that has shown promise in the treatment of this disorder. A number of hormones and hormone-manipulating compounds have been evaluated as monotherapies or adjunctive treatments for major depression, with therapeutic actions attributable not only to the modulation of endocrine systems in the periphery but also to the CNS effects of hormones on non-endocrine brain circuitry. The authors describe the physiology of the hypothalamic-pituitary-adrenal (HPA), hypothalamic-pituitary thyroid (HPT), and hypothalamic-pituitary-gonadal (HPG) axes and review the evidence for selected hormone-based interventions for the treatment of depression in order to provide an update on the state of this field for clinicians and researchers. The review focuses on the HPA axis-based interventions of corticotropin-releasing factor antagonists and the glucocorticoid receptor antagonist mifepristone, the HPT axis-based treatments of thyroid hormones (T
and T
), and the HPG axis-based treatments of estrogen replacement therapy, the progesterone derivative allopregnanolone, and testosterone. While some treatments have largely failed to translate from preclinical studies, others have shown promising initial results and represent active fields of study in the search for novel effective treatments for major depression.
Concern over climate change has led the U.S. to consider a cap-and-trade system to regulate emissions. Here we illustrate the land-use impact to U.S. habitat types of new energy development resulting ...from different U.S. energy policies. We estimated the total new land area needed by 2030 to produce energy, under current law and under various cap-and-trade policies, and then partitioned the area impacted among habitat types with geospatial data on the feasibility of production. The land-use intensity of different energy production techniques varies over three orders of magnitude, from 1.9-2.8 km(2)/TW hr/yr for nuclear power to 788-1000 km(2)/TW hr/yr for biodiesel from soy. In all scenarios, temperate deciduous forests and temperate grasslands will be most impacted by future energy development, although the magnitude of impact by wind, biomass, and coal to different habitat types is policy-specific. Regardless of the existence or structure of a cap-and-trade bill, at least 206,000 km(2) will be impacted without substantial increases in energy efficiency, which saves at least 7.6 km(2) per TW hr of electricity conserved annually and 27.5 km(2) per TW hr of liquid fuels conserved annually. Climate policy that reduces carbon dioxide emissions may increase the areal impact of energy, although the magnitude of this potential side effect may be substantially mitigated by increases in energy efficiency. The possibility of widespread energy sprawl increases the need for energy conservation, appropriate siting, sustainable production practices, and compensatory mitigation offsets.
Objective:The authors provide an evidenced-based summary of the literature on the clinical application of psychedelic drugs in psychiatric disorders.Methods:Searches of PubMed and PsycINFO via Ovid ...were conducted for articles in English, in peer-reviewed journals, reporting on “psilocybin,” “lysergic acid diethylamide,” “LSD,” “ayahuasca,” “3,4-methylenedioxymethamphetamine,” and “MDMA,” in human subjects, published between 2007 and July 1, 2019. A total of 1,603 articles were identified and screened. Articles that did not contain the terms “clinical trial,” “therapy,” or “imaging” in the title or abstract were filtered out. The 161 remaining articles were reviewed by two or more authors. The authors identified 14 articles reporting on well-designed clinical trials investigating the efficacy of lysergic acid diethylamide (LSD), 3,4-methylenedioxymethamphetamine (MDMA), psilocybin, and ayahuasca for the treatment of mood and anxiety disorders, trauma and stress-related disorders, and substance-related and addictive disorders as well as in end-of-life care.Results:The most significant database exists for MDMA and psilocybin, which have been designated by the U.S. Food and Drug Administration (FDA) as “breakthrough therapies” for posttraumatic stress disorder (PTSD) and treatment-resistant depression, respectively. The research on LSD and ayahuasca is observational, but available evidence suggests that these agents may have therapeutic effects in specific psychiatric disorders.Conclusions:Randomized clinical trials support the efficacy of MDMA in the treatment of PTSD and psilocybin in the treatment of depression and cancer-related anxiety. The research to support the use of LSD and ayahuasca in the treatment of psychiatric disorders is preliminary, although promising. Overall, the database is insufficient for FDA approval of any psychedelic compound for routine clinical use in psychiatric disorders at this time, but continued research on the efficacy of psychedelics for the treatment of psychiatric disorders is warranted.
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