Using Remotely Supervised At-Home TES for Enhancing Mental Resilience

Abstract

We are in the midst of a mental health crisis with major depressive disorder being the most prevalent among mental health disorders and up to 30% of patients not responding to first-line treatments. Noninvasive Brain Stimulation (NIBS) techniques have proven to be effective in treating depression. However, there is a fundamental problem of scale. Currently, any type of NIBS treatment requires patients to repeatedly visit a clinic to receive brain stimulation by trained personnel. This is an often-insurmountable barrier to both patients and healthcare providers in terms of time and cost. In this perspective, we assess to what extent Transcranial Electrical Stimulation (TES) might be administered with remote supervision in order to address this scaling problem and enable neuroenhancement of mental resilience at home. Social, ethical, and technical challenges relating to hardware- and software-based solutions are discussed alongside the risks of stimulation under- or over-use. Solutions to provide users with a safe and transparent ongoing assessment of aptitude, tolerability, compliance, and/or misuse are proposed, including standardized training, eligibility screening, as well as compliance and side effects monitoring. Looking into the future, such neuroenhancement could be linked to prevention systems which combine home-use TES with digital sensor and mental monitoring technology to index decline in mental wellbeing and avoid relapse. Despite the described social, ethical legal, and technical challenges, the combination of remotely supervised, at-home TES setups with dedicated artificial intelligence systems could be a powerful weapon to combat the mental health crisis by bringing personalized medicine into people’s homes.

Home-administered transcranial direct current stimulation with asynchronous remote supervision in the treatment of depression: feasibility, tolerability, and clinical effectiveness

“…The headset includes built-in safety features such as constant impedance control and current adjustment which automatically terminates the stimulation session if the electrode impedance exceeds 20 k (41, 43) resulting in a prompt in the app for the patient to adjust the headset and start a new session. To ensure correct dose control, the protocol for session duration and stimulation intensity was pre-programmed remotely in accordance with the parameters described below (see Section 2.6) and patients did not have access to these settings in the app (42). The PlatoWork tDCS headset is a fixed-montage clinical headset designed for home-administered use and does not require manual electrode measurement or fixation, as shown in Figure 1.…”

“…Finally, we recommend the use of expert ratings such as the Hamilton Depression Rating Scale or the Montgomery-Åsberg Depression Rating Scale instead of or in addition to the self-reported BDI questionnaire, which we had to select due to COVID-19 restrictions on in-person gatherings. Looking into the future, tDCS could even be integrated with data from other wearables and self-report measures, to predict relapses of depression and remotely initiate maintenance treatment (28,42,60).…”

“…However, previous home-administered tDCS studies have reported limitations such as patients experiencing difficulties with manual electrode fixation and a lack of monitoring and guidance (34,35,41) as well as risks of over-or under-stimulation (42). These early studies demonstrate the advantages of standardization of montage and treatment by trained staff in research or clinical settings (34,41).…”

“…These early studies demonstrate the advantages of standardization of montage and treatment by trained staff in research or clinical settings (34,41). To address these limitations and improve the safety of home-administered tDCS, our study followed current TES safety recommendations including providing specifically tailored patient training, educational materials and support, in addition to ongoing compliance supervision and side effects monitoring (35,(41)(42)(43). The clinicians and researchers involved in our study attended an online "Transcranial Electrical Stimulation (TES) Practitioner Certification" training course, which focused on tDCS and was closely aligned with the International Federation of Clinical Neurophysiology guidelines (44).…”

“…Additionally, we used PlatoWork 2.0 tDCS headsets (PlatoScience ApS, Denmark) with a preconfigured fixed-montage of electrodes, which eliminates the need for manual measurement or fixation by patients (39). The headsets are a registered Class I medical device under the MDD 93/42/EEC standard and comply with current TES safety guidelines by including pre-programmed dose control of each stimulation session, an inbuilt impedance control that automatically terminates stimulation when electrode impedance exceeds 20 k and three different options for the patient to safely discontinue stimulation (35,(41)(42)(43)45).…”