Repetitive Transcranial Magnetic Stimulation in Early Psychosis and The Functional Connectivity Biotypes

Study Overview
=================
Brief Summary
-----------------
The present study plans to explore different cortical targets of repetitive transcranial magnetic stimulation (rTMS) for populations at the early phase of psychosis, including those at clinical high risk of psychosis and in the first episode of psychosis. The clinical augmentation efficacy will be associated with the brain functional connectivity of these populations.

Detailed Description
-----------------
Schizophrenia is a life long illness, the management of its early stage is the key in its long term outcomes. The early stage of schizophrenia includes the prodromal and first episode, during which the patients present psychotic symptoms (positive symptoms, negative symptoms) and cognition deficits. Antipsychotics are often prescribed to treat these symptoms, but more than one third patients do not respond well. Regarding cognition deficits, for example, while the visual spatial learning evaluated using Brief Visuospatial Memory Test-Revised (BVMT-R) of The Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery (MCCB) may play an important role in the conversion of psychosis in the prodromal phase, there is still no corresponding intervention. Repetitive transcranial magnetic stimulation (rTMS) is a new non-invasive brain stimulation. In previous studies, its applications mainly focus on negative symptoms and demonstrate promising findings. However, its efficacy has much needing improvement, urgently needing target optimizing and precision, especially according to the prominent complaints of patients. To solve this issue, the present project proposed to make efforts in 3 aspects: to recruit patients in early phase of illness, to administer rTMS of different protocols according to the symptoms and cognition, and to associate the biotypes of functional connectivity with rTMS's efficacy. All subjects will receive MRI scan before rTMS intervention in the present study. The clinical efficacy of rTMS of the present protocol will be applied to validate the biotypes of functional connectivity in early psychosis. The biotypes will be determined using an existing independent dataset, which include 650 available cases of resting MRI (including 400 patients in prodromal phase, 100 patients with first episode and 150 controls). Individual rTMS target will be optimized basing individual neuroimaging navigation. In the present protocol, we will recruit 300 new cases and perform a multicenter and randomized clinical trial to test the efficacy of our optimized rTMS protocols. All patients will be stratified according to their negative symptoms, positive symptom and cognition, and this will be determined by a panel of psychiatrists and rTMS therapists. It is estimated that about 100 cases in each of three subgroups. Subgroup 1 is characterized by prominent negative symptoms and will receives rTMS over cerebellum and right dorsolateral prefrontal cortex. Subgroup 2 is characterized by prominent cognition deficits and will receive rTMS over left inferior parietal lobule, navigated by individual MRI and functional connectivity map with left hippocampus. Subgroup 3 is characterized by positive symptoms and will receive deep rTMS over ACC using H7 coil. The present project, if being performed successfully, will promote the non-invasive physical therapy in psychiatry to a significantly higher level.

Official Title
-----------------
Repetitive Transcranial Magnetic Stimulation in Subjects With Early Psychosis and The Functional Connectivity Biotypes

Conditions
-----------------
Schizophrenia; Psychosis, First Episode Psychosis, Clinical High Risk

Intervention / Treatment
-----------------
* Device: repetitive transcranial magnetic stimulation (rTMS)


Participation Criteria
=================
Eligibility Criteria
-----------------
For subjects at clinical high-risk for psychosis Inclusion Criteria: Meeting the syndrome of clinical high risk of psychosis, identified by a face-to-face interview using the Chinese version of Structured Interview for Prodromal Syndromes / Scale of Prodromal Symptoms (SIPS/SOPS); Given the written consent for participation. Age between 14-45 years old; IQ>69; PANSS total scores >= 55 or BVMT-R score <= 26; Exclusion Criteria: any contraindication to TMS treatment or magnetic resonance imaging (MRI) substance or alcohol abuse within recent three months any sensorimotor disorder (e.g., hearing disorder, lose one's sight), or any neurological disease (brain injury, epilepsy ) or any other physical disease which may lead to psychotic symptoms. For subjects with first-episode schizophrenia Inclusion Criteria: Meeting the DSM-V diagnostic criteria for schizophrenia spectrum disorders; Given the written consent for participation. Age between 14-45 years old; IQ>69; during the first episode without a full remission; PANSS total scores >= 55 or BVMT-R score <= 26; within receiving rTMS, patients can receive second-generation antipsychotics except clozapine with stable dosages Exclusion Criteria: any contraindication to TMS treatment or magnetic resonance imaging (MRI) substance or alcohol abuse within recent three months any sensorimotor disorder (e.g., hearing disorder, lose one's sight), or any neurological disease (brain injury, epilepsy) or any other physical disease which may lead to psychotic symptoms.

Ages Eligible for Study
-----------------
Minimum Age: 14 Years
Maximum Age: 45 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Active TMS targeting both cerebellum and right dorsolateral prefrontal cortex.<br>Subjects identified as with prominent negative symptoms will be randomized into active group, who will receive active rTMS over cerebellum and right dorsolateral prefrontal cortex navigated by individual MRI. | Device: repetitive transcranial magnetic stimulation (rTMS)<br>* All subjects with early psychosis will be divided into three subgroups determined by their psychotic symptoms and cognition. There are three rTMS strategies: (1) For subgroup 1, characterized by negative symptoms, iTBS over cerebellum and 1 Hz over right DLPFC; (2) For subgroup 2, characterized by cognition deficits, 20 Hz over the left inferior parietal cortex; (3) For subgroup 3, characterized by positive symptoms: 10 Hz over ACC. Ten to twenty sessions of rTMS will be delivered to each patients during the intervention period.<br>|
| Sham Comparator: Sham TMS targeting both cerebellum and right dorsolateral prefrontal cortex<br>Subjects identified as with prominent negative symptoms will be randomized into sham group, who will receive sham rTMS over cerebellum and right dorsolateral prefrontal cortex navigated by individual MRI. | Device: repetitive transcranial magnetic stimulation (rTMS)<br>* All subjects with early psychosis will be divided into three subgroups determined by their psychotic symptoms and cognition. There are three rTMS strategies: (1) For subgroup 1, characterized by negative symptoms, iTBS over cerebellum and 1 Hz over right DLPFC; (2) For subgroup 2, characterized by cognition deficits, 20 Hz over the left inferior parietal cortex; (3) For subgroup 3, characterized by positive symptoms: 10 Hz over ACC. Ten to twenty sessions of rTMS will be delivered to each patients during the intervention period.<br>|
| Active Comparator: Active TMS targeting left inferior parietal lobule<br>Subjects identified with prominent cognition deficits wil be randomized into active group, who will receive active rTMS over left inferior parietal lobule, navigated by individual MRI and functional connectivity map with left hippocampus. | Device: repetitive transcranial magnetic stimulation (rTMS)<br>* All subjects with early psychosis will be divided into three subgroups determined by their psychotic symptoms and cognition. There are three rTMS strategies: (1) For subgroup 1, characterized by negative symptoms, iTBS over cerebellum and 1 Hz over right DLPFC; (2) For subgroup 2, characterized by cognition deficits, 20 Hz over the left inferior parietal cortex; (3) For subgroup 3, characterized by positive symptoms: 10 Hz over ACC. Ten to twenty sessions of rTMS will be delivered to each patients during the intervention period.<br>|
| Placebo Comparator: Sham TMS targeting left inferior parietal lobule<br>Subjects identified with prominent cognition deficits wil be randomized into sham group, who will receive sham rTMS over left inferior parietal lobule, navigated by individual MRI and functional connectivity map with left hippocampus. | Device: repetitive transcranial magnetic stimulation (rTMS)<br>* All subjects with early psychosis will be divided into three subgroups determined by their psychotic symptoms and cognition. There are three rTMS strategies: (1) For subgroup 1, characterized by negative symptoms, iTBS over cerebellum and 1 Hz over right DLPFC; (2) For subgroup 2, characterized by cognition deficits, 20 Hz over the left inferior parietal cortex; (3) For subgroup 3, characterized by positive symptoms: 10 Hz over ACC. Ten to twenty sessions of rTMS will be delivered to each patients during the intervention period.<br>|
| Active Comparator: Active deep TMS using Brainways H7 coil targeting ACC<br>Subjects identified as with positive symptoms will be randomized into active group, who will receive active deep rTMS over ACC using H7 coil. | Device: repetitive transcranial magnetic stimulation (rTMS)<br>* All subjects with early psychosis will be divided into three subgroups determined by their psychotic symptoms and cognition. There are three rTMS strategies: (1) For subgroup 1, characterized by negative symptoms, iTBS over cerebellum and 1 Hz over right DLPFC; (2) For subgroup 2, characterized by cognition deficits, 20 Hz over the left inferior parietal cortex; (3) For subgroup 3, characterized by positive symptoms: 10 Hz over ACC. Ten to twenty sessions of rTMS will be delivered to each patients during the intervention period.<br>|
| Placebo Comparator: Sham deep TMS using Brainways H7 coil targeting ACC<br>Subjects identified with positive symptoms will be randomized into sham group, who will receive sham deep rTMS over ACC using H7 coil. | Device: repetitive transcranial magnetic stimulation (rTMS)<br>* All subjects with early psychosis will be divided into three subgroups determined by their psychotic symptoms and cognition. There are three rTMS strategies: (1) For subgroup 1, characterized by negative symptoms, iTBS over cerebellum and 1 Hz over right DLPFC; (2) For subgroup 2, characterized by cognition deficits, 20 Hz over the left inferior parietal cortex; (3) For subgroup 3, characterized by positive symptoms: 10 Hz over ACC. Ten to twenty sessions of rTMS will be delivered to each patients during the intervention period.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Response rate (the number of non-responders) for subgroup 1 and subgroup 3 | Response or responder will be determined by the reduction of PANSS total scores >= 25% | Within 24 hours after the rTMS intervention | 
| Improvement on cognition for subgroup 2 | Change in BVMT-R score as measured by MCCB | Within 24 hours after the rTMS intervention | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Improvement of psychotic symptoms | The changes of PANSS scores and sub-scale scores | Within 24 hours after the rTMS intervention | 
| Improvement of prodromal symptoms | The changes of SOPS scores and sub-scale scores | Within 24 hours after the rTMS intervention | 
| Improvement of cognitive function | The changes of all cognitive domains assessed by MCCB | Within 24 hours after the rTMS intervention | 
| Improvement of global functioning | The GAF changes | Within 24 hours after the rTMS intervention | 
| Functional connectivity | changes of whole-brain functional connectivity patterns | Within 1week after the rTMS intervention | 
| side effect and safety | the frequency and severity of side effects | during and after rTMS intervention | 
| clinical outcome | remission, non-remission or relapse | 1 year | 
| The accuracy of prediction with functional connectivity biotypes at baseline | The association of clinical outcomes after rTMS intervention with functional connectivity biotypes at baseline | 1 year | 
| change in individualized psychosis risk score | For subjects at clinical high risk of psychosis, individualized psychosis risk score will be calculated using clinical symptoms and cognition, which indicate the psychosis risk in the future. | Within 24 hours after the rTMS intervention | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
schizophrenia, prodromal phase, biotypes, target optimizing, precision calculation