L’efficacité thérapeutique de la stimulation magnétique transcrânienne répétée (rTMS) dans la prise en charge des troubles psychiatriques est avérée pour l’épisode dépressif majeur (EDM) et très encourageante pour la schizophrénie. Pourtant les protocoles de rTMS restent à optimiser. Les recherches fondamentales en TMS, ayant conduit au concept de state dependency TMS, suggèrent que l’effet d’une impulsion est influencé par l’état d’activation des circuits neuronaux précédant ou accompagnant la stimulation. L’effet de la TMS doit alors être considéré non pas simplement comme une stimulation mais comme le résultat d’une interaction entre un stimulus et un niveau d’activité cérébrale. Ces données suggèrent qu’il faudrait manipuler les activités neurocognitives des patients durant la stimulation afin d’optimiser l’efficacité de la rTMS sur les troubles psychiatriques. Des protocoles thérapeutiques de rTMS interactives ont donc été envisagés. Cet article propose une revue des différents protocoles interactifs mis en place principalement dans le traitement des EDM mais également de la schizophrénie. Les protocoles avec interactions avec les activités cognitives puis avec interactions avec les activités électriques cérébrales seront abordés. Ces études présentent différentes limitations, notamment du fait de leur caractère exploratoire sur un faible échantillon de patients et de leur cadre théorique neurocognitif de justification encore imprécis. Cependant ces protocoles de rTMS interactives permettent de passer en quelque sorte d’une rTMS en troisième personne à une rTMS en première personne où les activités cognitives et cérébrales propres aux sujets ne seraient pas occultées sous prétexte qu’il ne s’agirait que de bruit neuronal et ouvriraient des perspectives novatrices pour la rTMS en psychiatrie.

The efficiency of repetitive transcranial magnetic stimulation (rTMS) in the treatment of psychiatric disorders is robust for major depressive episode (MDE) while results are encouraging for schizophrenia. However, rTMS protocols need to be optimized. Basic researches in TMS led to the concept of “state dependency TMS”. This concept suggests that the neural circuits’ activation states, before and during the stimulation, influence the pulse effect. Indeed, TMS effect must be seen, not simply as a stimulus, but also as the result of an interaction between a stimulus and a level of brain activity. Those data suggest that rTMS efficiency could be increased in psychiatric disorders by triggering patients’ neurocognitive activities during stimulation. Thus “interactive rTMS protocols” have been submitted.

This article provides a review and a classification of different interactive protocols implemented in the treatment of MDE and schizophrenia. Protocols’ interactions with cognitive activities and brain electrical activities will be discussed.

Interactive rTMS protocols that manipulate cognitive activities have been developed for MDE treatments. They aim at regulating emotional states of depressed patients during the stimulation. The patients perform emotional tasks in order to activate cortical networks involving the left dorsolateral prefrontal cortex (DLPFC) into a state that may be more sensitive to the rTMS pulse effect. Simultaneous cognitive behavioral therapy (“CBT rTMS”) and cognitive-emotional reactivation (“affective rTMS”) have thus been tested during left DLPFC rTMS in MDE.

Interactive rTMS protocols that manipulate brain electrical activities have been developed for MDE and schizophrenia treatments. Two categories of protocols should be identified. In the first set, personalized brain activity has been analyzed to determine the parameters of stimulation (i.e. frequency of stimulation) matching the patient (“personalized rTMS”). Personalized rTMS protocols can be made “online” or “offline” depending on whether the EEG activity is measured during or prior to rTMS. Online protocol is called “contingent rTMS”: it consists in stimulating the brain only when a specific EEG pattern involving the intensity of alpha rhythm is recorded and recognized. Offline protocol is called “alpha rTMS”, and relies on ascertaining frequency of stimulation in accordance with personalized alpha peak frequency prior to rTMS. In the second set, electrical brain activity is modulated before or during rTMS in order to stimulate the DLPFC in optimal conditions. Brain activity modulation may be obtained by transcranial direct current stimulation (“tDCS rTMS”) or EEG-biofeedack (“EEG-biofeedback rTMS”).

Interactive rTMS studies have various limitations, notably their exploratory character on a small sample of patients. Furthermore, their theoretical neurocognitive framework justification remains unclear. Nonetheless, interactive rTMS protocols allow us to consider a new field of rTMS, where cognitive and cerebral activities would no longer be considered as simple neural noise, leading to a kind of “first person rTMS”, and certainly to innovative therapy in psychiatry.