接受重复经颅磁刺激治疗抑郁、强迫、精神和创伤相关障碍患者并发物质使用的评估与管理：德尔菲共识研究与指南
Assessment and Management of Concurrent Substance Use in Patients Receiving Repetitive Transcranial Magnetic Stimulation for Depressive, Obsessive-Compulsive, Psychotic, and Trauma-Related Disorders: A Delphi Consensus Study and Guideline.
作者信息
Tang Victor M, Aaronson Scott, Abdelghani Mohamed, Baeken Chris, Barbour Tracy, Brunoni André R, Bulteau Samuel, Carpenter Linda L, Croarkin Paul E, Daskalakis Zafiris J, Fitzgerald Paul B, Kozel F Andrew, Le Foll Bernard, Mehta Urvakhsh Meherwan, Noda Yoshihiro, Padberg Frank, Plewnia Christian, Su Hang, van Eijndhoven Philip, van Exel Eric, van Oostrom Iris, Vila-Rodriguez Fidel, Voineskos Daphne, Wilson Saydra, Blumberger Daniel M
机构信息
Temerty Faculty of Medicine, University of Toronto, Toronto (Tang, Le Foll, Voineskos, Blumberger), and the Centre for Addiction and Mental Health, Toronto (Tang, Le Foll, Voineskos, Blumberger); Institute for Advanced Diagnostics and Therapeutics, Sheppard Pratt, Baltimore, and Department of Psychiatry, University of Maryland School of Medicine, Baltimore (Aaronson); Camden and Islington NHS Foundation Trust, London (Abdelghani); Faculty of Medicine and Health Sciences, Department of Head and Skin, Ghent Experimental Psychiatry Lab, Ghent University, Ghent, Belgium (Baeken); Department of Psychiatry, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels (Baeken); Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands (Baeken); Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston (Barbour); Departamento de Clínica Médica, Faculdade de Medicina da Universidade de São Paulo; Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (Brunoni); CHU Nantes Department of Addictology and Psychiatry, U1246 SPHERE INSERM, Nantes University, Nantes, France (Bulteau); Butler Hospital, Department of Psychiatry and Human Behavior, Alpert Medical School at Brown University, Providence, RI (Carpenter); Mayo Clinic College of Medicine and Science, Rochester, MN (Croarkin); Department of Psychiatry, UC San Diego Health, La Jolla (Daskalakis); School of Medicine and Psychology, Australian National University, Canberra (Fitzgerald); FSU Neuromodulation, Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, Tallahassee (Kozel); Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario (Le Foll); Department of Psychiatry, National Institute of Mental Health and Neurosciences, and National Institute of Advanced Studies, Bangalore, India (Mehta); Department of Neuropsychiatry, Keio University School of Medicine, Tokyo (Noda); Department of Psychiatry and Psychotherapy, LMU University Hospital, Munich (Padberg); German Center for Mental Health, Tübingen (Padberg, Plewnia); Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany (Plewnia); Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai (Su); Department of Psychiatry, Radboud University Medical Center, Donders Institute for Brain, Cognition, and Behavior, Nijmegen, the Netherlands (van Eijndhoven); Department of Psychiatry, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam (van Exel); Old Age Psychiatry, GGZinGeest, Amsterdam (van Exel); Amsterdam Neuroscience, Amsterdam (van Exel); Neurocare Clinics, Nijmegen, the Netherlands (van Oostrom); Spanish Consortium of Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, and Health Technology Assessment in Primary Care and Mental Health Research Group (PRISMA), Barcelona (Vila-Rodriguez); School of Biomedical Engineering, University of British Columbia, Vancouver (Vila-Rodriguez); Poul Hansen Family Centre for Depression, Toronto Western Hospital, UHN and Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto (Voineskos); Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Voineskos, Blumberger); Department of Psychiatry and Behavioral Sciences, University of Minnesota-Twin Cities, Minneapolis (Wilson).
出版信息
Am J Psychiatry. 2025 May 1;182(5):438-451. doi: 10.1176/appi.ajp.20240403. Epub 2025 Mar 19.
OBJECTIVE
Limited data are available to inform clinicians on how to manage concurrent substance use in the context of repetitive transcranial magnetic stimulation (rTMS) for the treatment of depressive, obsessive-compulsive, psychotic, or trauma-related disorders. The authors convened an international panel of 24 rTMS experts, representative of different geographic regions and subspecialities, and created a consensus guideline for clinicians and researchers on approaches to concurrent substance use in patients receiving rTMS as treatment for primary psychiatric disorders.
METHODS
A Delphi method survey and expert opinion elicited over consecutive rounds of surveys were used, with feedback and discussion after each round. Recommendation statements were established upon very high (≥80%) agreement.
RESULTS
Three rounds of surveys and feedback were sufficient to reach a consensus for most topics; where consensus could not be reached, the panel discussed limitations in the current evidence base. Informed by a synthesis of the literature and practice-based evidence, the expert panel provides several consensus recommendations on the topics of screening, monitoring, risk assessment, and mitigation associated with various degrees of substance use, and specific considerations for alcohol, cannabis, stimulants, and opioids. Instead of excluding all people who use substances, a nuanced approach should be taken based on an assessment of risk factors for clinical instability and severity of use. The most important safety risk with substance use is the presence of intoxication or withdrawal states, with the most data supporting seizure risk in unstable alcohol or nonmedical stimulant use. Although there is no evidence of reduced rTMS efficacy for a psychiatric disorder in the presence of concurrent substance use, the lack of data in this area warrants caution.
CONCLUSIONS
These recommendations can be readily implemented clinically and provide a framework for future research. In patients receiving rTMS for a primary psychiatric disorder, assessment and management of co-occurring substance use is complex, requiring greater attention, standardization, and further study.
目的
关于如何在重复经颅磁刺激（rTMS）治疗抑郁、强迫、精神或创伤相关障碍的背景下管理并发物质使用，可供临床医生参考的数据有限。作者召集了一个由24名rTMS专家组成的国际小组，这些专家代表不同地理区域和亚专业，为临床医生和研究人员制定了关于在接受rTMS治疗原发性精神障碍的患者中并发物质使用处理方法的共识指南。
方法
采用德尔菲法调查，并在连续几轮调查中征求专家意见，每轮后进行反馈和讨论。在达成非常高（≥80%）的一致意见后确定推荐声明。
结果
三轮调查和反馈足以就大多数主题达成共识；在无法达成共识的情况下，小组讨论了当前证据基础的局限性。在综合文献和基于实践的证据的基础上，专家小组就与不同程度物质使用相关的筛查、监测、风险评估和缓解等主题，以及对酒精、大麻、兴奋剂和阿片类药物的具体考虑提供了多项共识建议。不应排除所有使用物质的人，而应根据对临床不稳定风险因素和使用严重程度的评估采取细致入微的方法。物质使用最重要的安全风险是存在中毒或戒断状态，最多的数据支持在不稳定的酒精或非医疗性兴奋剂使用中存在癫痫发作风险。虽然没有证据表明在并发物质使用的情况下rTMS对精神障碍的疗效会降低，但该领域缺乏数据仍需谨慎。
结论
这些建议可在临床上轻松实施，并为未来研究提供框架。在接受rTMS治疗原发性精神障碍的患者中，并发物质使用的评估和管理很复杂，需要更多关注、标准化和进一步研究。
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