Elsevier

Journal of Psychiatric Research

Volume 83, December 2016, Pages 86-93
Journal of Psychiatric Research

Posture-cognitive dual-tasking: A relevant marker of depression-related psychomotor retardation. An illustration of the positive impact of repetitive transcranial magnetic stimulation in patients with major depressive disorder

https://doi.org/10.1016/j.jpsychires.2016.08.013Get rights and content

Abstract

This study examined whether postural control variables, particularly the center-of-pressure (COP) velocity-based parameters, could be a relevant hallmark of depression-related psychomotor retardation (PMR). We first aimed at investigating the interplay between the PMR scores and the COP performance in patients with major depressive disorder (MDD), as compared to age-matched healthy controls; secondly, we focused on the impact of a repetitive transcranial magnetic stimulation (rTMS) treatment on depression, PMR scores and postural performance. 16 MDD patients, and a control group of 16 healthy adults, were asked to maintain quiet standing balance during two trials with or without vision, and while backward counting (dual task). All the position and velocity-based COP variables were computed. Before and after the rTMS session (n eligible MDD = 10), we assessed the depression level with the Montgomery–Asberg Depression Rating Scale (MADRS), the PMR scores with the French Retardation Rating Scale for Depression (ERD), and postural performance. Before the treatment, significant positive partial correlations were found between the pre-ERD scores and the velocity-based COP variables, especially in the dual-task conditions (p < 0.05). In contrast, there was no significant correlation between the post-ERD scores and any postural parameter after the treatment. The MADRS and ERD scores showed a significant decrease between before and after the rTMS intervention. For the first time, the findings clearly validated the view that the assessment of postural performance - easy to envisage in clinical settings-constitutes a reliable and objective marker of PMR in MDD patients.

Introduction

By considering a two-month walking exercise program as an effective intervention for improving depression related psychomotor disorders, we recently showed that patients with major depressive disorder (MDD) improved their postural control by decreasing essentially center-of-pressure (COP) velocity-based parameters (Deschamps et al., 2015). In addition to confirming the impaired balance performance in MDD in comparison to healthy controls (Bolbecker et al., 2011, Doumas et al., 2012), we support the idea that significant changes in these COP-velocity variables while assessing balance in depressed people could be a relevant hallmark of depression-related psychomotor retardation (PMR). As a core symptom of depression, which includes motor and cognitive impairments, this PMR actually has become the subject of increasing interest in recent studies on its diagnostic, prognostic, and therapeutic relevance in MDD (Beheydt et al., 2015, Bennabi et al., 2013, Schrijvers et al., 2008, Thomas-Ollivier et al., 2016). Conventionally, most studies have used interviewer-rated scales based on observations of behavior, such as the retardation item of the Hamilton Depression Rating Scale (Hamilton, 1960) and the Salpêtrière Retardation Rating Scale (SRRS) (Montgomery and Åsberg, 1979; Widlöcher, 1983). However we recently showed that administering a comprehensive PMR battery of tests (e.g. 3-Meter Timed Up and Go test, dual-tasking postural control assessments, the handgrip strength test or verbal fluency tasks) during a repetitive transcranial magnetic stimulation (rTMS) treatment was feasible, free of adverse effects, and well tolerated by the MD patients in naturalistic conditions before or after the three-week rTMS protocol (see Thomas-Ollivier et al., 2016 for details). Beyond the confirmation of significant effects of rTMS treatment on depression (e.g., Aleman, 2013, Brunelin et al., 2014, Dell’Osso et al., 2011), another interesting finding was the positive changes in psychomotor outcome measures following the intervention, especially in balance performance.

Thus, the characterization of implicit postural control strategies in MDD patients emerged as one relevant and objective hallmark feature for clinical PMR assessment. In fact, we demonstrated an improvement in postural performance (when assessed in a dual task, namely standing balanced with eyes open or eyes closed while counting backward), evidenced by a significant decrease in COP velocity variables (e.g. mean velocity in mm/s) (Thomas-Ollivier et al., 2016). Although these results are in line with recent studies that support the clinical interest for characterizing postural instability in MDD adults or older healthy individuals with cognitive impairment (Deschamps et al., 2014, Mignardot et al., 2014), no specific PMR scale was used in this feasibility study (Thomas-Ollivier et al., 2016) to link depression-related postural sway with respect to a validated scale.

Thus, the purposes of the present study are twofold: first, it aims to take a clear look at the interplay between the PMR scores and the impaired balance performance in MDD patients, as compared to age-matched healthy controls (Deschamps et al., 2015, Bolbecker et al., 2011, Doumas et al., 2012); the exploratory nature of our second aim focuses on the impact of rTMS treatment on depression, PMR and balance assessments. In this regard, only a few studies about the neurostimulation-related effects on PMR are available in the literature, with divergent results (Baeken et al., 2010, Höppner et al., 2003, Ullrich et al., 2012). But some neurophysiological mechanisms underlying the significant effects of rTMS treatment on depression-related PMR and the disbalanced control in MDD patients make clear our expectations (Walther et al., 2012).

Changes in PMR probably arise from the alterations of limbic signals, at the interface of emotion, volition, higher-order cognitive functions, and movement. For example, a recent review on the functional neuroanatomy of PMR suggests the involvement of fronto-striatal neurocircuitry, and monoaminergic pathways and metabolism; this functional anatomical specificity of PMR “could be improved by the use of objective measurements of motor performance” (see Liberg and Rahm, 2015, p. 5). In the same way, the rTMS-induced activity has a positive effect on the limbic system and causes changes in functionally connected remote areas (Paus et al., 2001); it is also likely to facilitate the striatal dopamine release (Strafella et al., 2003) and reduce the attentional and cognitive deficits related to PMR in MDD patients (De Raedt et al., 2015), with positive impact on their postural control (Doumas et al., 2012, Thomas-Ollivier et al., 2016). Put all together, solid assumptions can be made. A significant improvement of PMR is expected following the 3-week rTMS protocol in which eligible MDD patients were stimulated to the left or right add-on to continued psychopharmacological treatment in a naturalistic clinical setting. In either left or right rTMS protocols, it has been shown that both rTMS method were equally effective therapies for MDD patients (Chen et al., 2013). This positive change in PMR may be associated with a decrease in essentially COP velocity-based parameters, as a relevant index of better postural control.

Section snippets

Participants

Sixteen patients with major depression at Nantes University Hospital (mean age 57.9 ± 13.9 years, range 28–78 years; 9 females) were compared to 16 healthy controls (HC), adults (mean age 60.7 ± 9.6 years, range 36–69 years; 12 females) who volunteered to participate in this open unblinded study. Inclusion criteria were: diagnosis of MDD according to DSM-IV; the patients had to have failed to respond to at least two previous adequate courses of antidepressants; no neurological, psychotic or

Results

All statistical results are summarized in Table 1, Table 2, Table 3, Table 4, Table 5.

Postural balance in HC vs. MDD. Firstly, there were significant differences between the groups for almost all the aforesaid position-based variables or velocity-based variables (Mann-Whitney U tests: all p values < 0.02). These findings are in accordance with the ANOVA, revealing an effect of Group [all F values > 9.6; p values < 0.01], with altered postural sway in MDD: higher COP velocity/position values

Discussion

The present study aimed at contributing to a deeper understanding of the motor performance that characterizes objectively the depression-related PMR. More specifically, we investigated the expected relationships between postural performance and PMR scores often used in a clinical setting, and the positive effects of three weeks of rTMS treatment on depression and the balance performance in MDD patients. The main finding in this study was that postural sway was associated with the ERD scores

Financial support

This research received no specific grand from any funding agency, commercial or not-for-profit sectors.

Conflict of interest

The authors report no conflicts of interest.

Ethical standards

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional guides on the care and use of laboratory animals.

Note also that in this study, no change in our current clinical

Author contributions

TD has full access to all of the data in the study, takes responsibility for the data, the analyses and interpretation and has the right to publish any and all data, separate and apart from the attitudes of the sponsor.

All authors meet all of the following criteria: (1) contributing to the conception and design, or analyzing and interpreting data; (2) drafting the article or revising it critically for important intellectual content; and (3) approving the final version to be published.

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