Department of Psychiatry, University of Toronto, Canada.
Brain Stimul. 2013 May;6(3):231-40. doi: 10.1016/j.brs.2012.08.006. Epub 2012 Sep 7.
Although rTMS is moving steadily into the mainstream as a treatment for medically refractory depression, its efficacy continues to lag behind that of more invasive neuromodulation treatments such as ECT or DBS. Here we review evidence to suggest that a fruitful, but neglected, strategy for improving rTMS efficacy may be to explore alternatives to the conventional stimulation target in the dorsolateral prefrontal cortex (DLPFC). The convergent evidence of lesion, stimulation, connectivity, and correlative neuroimaging studies suggests that the DLPFC may have a relatively peripheral role in mood regulation, at least compared to several alternative areas within the prefrontal cortex. In particular, we consider the evidence base in support of four new potential targets for rTMS in depression: dorsomedial prefrontal cortex (DMPFC), frontopolar cortex (FPC), ventromedial prefrontal cortex (VMPFC), and ventrolateral prefrontal cortex (VLPFC). Each of these regions enjoys broader support, from a more diverse evidence base, than the DLPFC in terms of its role in emotion regulation in major depression. We discuss the relative merits of each of these novel targets, including potential obstacles to stimulation using currently available technologies, and potential strategies for overcoming these obstacles. It is hoped that this detailed review will spur a more vigorous exploration of new targets for rTMS in depression. The use of new targets may help to propel rTMS across the threshold of efficacy required of a first-line treatment, to assume a more widespread role in the treatment of depressed mood.
尽管重复经颅磁刺激(rTMS)作为一种治疗药物难治性抑郁症的方法正稳步进入主流，但它的疗效仍落后于更具侵入性的神经调节治疗方法，如电惊厥疗法(ECT)或深部脑刺激(DBS)。在这里，我们回顾了一些证据，这些证据表明，一种富有成效但被忽视的提高 rTMS 疗效的策略可能是探索传统刺激靶点（背外侧前额叶皮层，DLPFC）以外的替代方案。病变、刺激、连通性和相关神经影像学研究的一致证据表明，DLPFC 在情绪调节中的作用可能相对次要，至少与前额叶皮层内的几个替代区域相比是这样。特别是，我们考虑了支持 rTMS 在抑郁症中四个新的潜在靶点的证据基础：背内侧前额叶皮层（DMPFC）、额极皮层（FPC）、腹内侧前额叶皮层（VMPFC）和腹外侧前额叶皮层（VLPFC）。与 DLPFC 相比，这些区域在调节重度抑郁症中的情绪方面都有更广泛的支持，其证据基础也更加多样化。我们讨论了这些新靶点各自的优点，包括使用当前可用技术进行刺激的潜在障碍，以及克服这些障碍的潜在策略。我们希望这篇详细的综述能够激发人们更积极地探索 rTMS 在抑郁症中的新靶点。使用新的靶点可能有助于推动 rTMS 跨过作为一线治疗所需的疗效门槛，在治疗抑郁情绪方面发挥更广泛的作用。
