Lack of protocols for handling missing sessions of transcranial direct current stimulation (tDCS) in depression trials: what are the risks of neglecting missing sessions?

Abstract

about the time and place, afraid, suspicious and speaking incoherently. Physical and neurological exams were otherwise normal. Initial workup included hematological, toxicological, neuroradiologic and electroencephalographic assessments, which were all within normal range. A febrile rash -followed by pruritus, myalgia, arthralgia, periocular pain and posterior cervical adenopathy, which began 14 days before the onset of the behavioral symptoms and remitted after a week -was then reported by his parents.We extended the investigation to rule out other medical conditions leading to the psychotic episode. All CSF parameters were within the normal range. In peripheral blood we detected positive dengue virus (DENV) in ELISA, IgM, and IgG tests; the NS1 antigen was undetectable and RT-PCR was negative for DENV. RT-PCRs for ZIKV resulted positive in multiple blood samples. An intense cross-reaction was observed across DENV and ZIKV ELISA titers, 3,4 leading us to conclude that this was the case. After five days of Haloperidol with no response, the prescription was changed to Risperidone 2 mg/day and remission was achieved in three days. The patient was discharged and medication was tapered off after 3 weeks. No relapse in symptoms was noted during one year of follow-up in our specialized FEP outpatient service.To the best of our knowledge, this is the first report in which psychiatric symptoms were the only complication of acute ZIKV infection. There is much evidence of psychiatric symptomatology in viral infections. Denguerelated manic and psychotic episodes have been described in which symptoms suggesting encephalitis or encephalopathy were not seen -thus supporting flavivirus' role in inducing purely behavioral symptoms. Cases in which DENV infections have led to neuropsychiatric complications are numerous, well established in the literature and more commonly diagnosed than in regular clinical practice. 5Neuroimmune mechanisms leading to psychosis during acute CNS stress is an open and prolific field for research. On the clinical front, mental health professionals dealing with emergency psychiatry and FEP must have a high grade of suspicion to avoid underrecognizing particularand self-limited -conditions.

Application of Transcranial Direct Current Stimulation in Psychiatry

“…Furthermore, the majority of trials do not provide further information about how the issue of missing sessions was dealt with in the final analysis [30]. To overcome the problem of dropouts with increasing numbers of consecutive tDCS sessions, potential and limitations of a remotely supervised tDCS treatment (“home treatment”) are currently under debate [31].…”