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Dr. Mandana Modirrousta

Dr. Mandana Modirrousta

Director
Neuromodulation and Neuropsychiatry Unit

Associate Professor
Department of Psychiatry, University of Manitoba

Overview

The Neuromodulation and Neuropsychiatry Unit at St. Boniface Hospital is a clinical research unit that specializes in treating neuropsychiatric and cognitive disorders. The unit is equipped with brain stimulation techniques including repetitive transcranial magnetic stimulation (rTMS). rTMS is a non-invasive ‘neuromodulation’ technique which has the capacity to influence activity in the brain. Specifically, we use rTMS to treat major depressive disorder and other neuropsychiatric conditions.

The unit is also committed to translational research with the ultimate goals of improving clinical rTMS techniques while also investigating the potential benefits of rTMS in new patient populations.

Research Focus

Research in the Neuromodulation and Neuropsychiatry Unit focuses on improving and expanding the application of neuromodulation as an investigational as well as a treatment tool. Successful, goal directed behaviours require optimal and effective communication between several brain regions. Disruption of brain network, either as a result of a structural abnormality (e.g. brain injury) or dysfunction can result in different neuropsychiatric disorders. Our research in “Neuromodulation and Neuropsychiatry Unit” attempts to understand how to optimally use brain stimulation techniques to treat neuropsychiatric disorders.

Why is this work important?

Many neuropsychiatric disorders and cognitive impairments leave patients with few treatment options. rTMS has long been recognized as an effective treatment for major depression, but there is still work to be done to refine and improve this technique. For example, we still don’t yet know exactly who is the ideal candidate to receive rTMS treatment, and methods to improve rates of remission and help prevent relapse are constantly being investigated. Our lab tries to apply neuroscientific findings in neuropsychiatric and mental disorders in order to discover better treatment for these illnesses using neuromodulatary techniques.Recent work from our lab and other institutions around the world has shown promising results using neuromodulation techniques to treat a number of other neuropsychiatric disorders including Functional Neurological Disorder, Obsessive-Compulsive Disorder, and Traumatic Brain Injuries.

What techniques are used in this laboratory?

  • Repetitive Transcranial Magnetic Stimulation (rTMS)
  • MRI-based neuronavigation
  • Clinical assessment
  • Neurocognitive assessment (behavioural tasks, computer-based testing, memory testing)
  • Electromyography (EMG)
  • Electroencephalography (EEG)

About Dr. Mandana Modirrousta

Dr. Modirrousta is an Associate Professor at the University of Manitoba in the Department of Psychiatry. She completed her residency in psychiatry at the University of Manitoba in 2012 before pursuing a fellowship in clinical neuropsychiatry at Massachusetts General Hospital, Harvard Medical School. Prior to her residency, Dr. Modirrousta earned a PhD in neuroscience from the Montreal Neurological Institute at McGill University and completed post-doctoral training in cognitive neuroscience and behavioral neurology. She is certified in the subspeciality of Behavioural Neurology and Neuropsychiatry by the United Council of Neurologic Subspecialties.

Dr. Modirrousta is the director of the Neuromodulation and Neuropsychiatry Unit at St. Boniface Hospital, where she uses neuropsychological and neurocognitive tools as well as repetitive transcranial magnetic stimulation (rTMS) to study the link between the brain and behaviour in a variety of neuropsychiatric disorders. In 2010, she received the Association of Chairs of Psychiatry in Canada research award and the American Psychiatric Association award (Research Colloquium for Junior Investigators). She also received several best presentation and best paper awards during her residency at the University of Manitoba.

One of Dr. Modirrousta’s main research interests is understanding the mechanisms of compulsive behaviours in Obsessive Compulsive Disorder and Frontotemporal Neurocognitive Disorder. She applies rTMS as a possible treatment intervention for these conditions. In addition, her lab is investigating biological signatures of rTMS treatment-response in neuropsychiatric disorders including depression.
Her clinical interest is exploring the concept of ‘cognitive rehabilitation’ – through cognitive training and rTMS therapy – in a variety of mild to moderate neurocognitive disorders including post-concussion syndrome and the early stages of neurodegenerative disorders.

For more information, contact:

Dr. Mandana Modirrousta
Neuromodulation and Neuropsychiatry Unit
M4-McEwen Building (4th Floor)
St. Boniface Hospital
363 Tache Avenue
Winnipeg, MB
R2H 2A6

PH: (204) 237-2606
FX: (204) 233-8051

In Detail

The research program at the Neuromodulation and Neuropsychiatry Unit focuses on three main areas of investigation:

A) Improving clinical outcomes for rTMS treatment of Major Depressive Disorder
B) Investigating the efficacy of rTMS treatment for other neuropsychiatric symptoms/disorders.
C) Investigating the underlying neurocognitive underpinning of several neuropsychiatric disorders such as Obsessive Compulsive Disorder and Non-Epileptic Seizures

Ongoing Research Projects

Neuromodulation research:

  1. Despite the proven usefulness of rTMS in treating MDD symptoms, not all patients show a clinical response to rTMS treatment. Additionally, rTMS is a very time-, labour-, and equipment-intensive procedure; one full treatment requires 30 daily sessions of stimulation. For this reason, a large portion of the unit’s research focuses on finding ways to improve rTMS protocols in order to i) increase treatment efficacy, ii) improve clinical efficiency, and iii) develop methods of screening individual patients to predict good responders prior to treatment.
  2. Investigating the efficacy of rTMS for treating Obsessive-Compulsive Disorder.
  3. Investigating the efficacy of rTMS for treating mild-cognitive impairment
  4. Investigating the efficacy of rTMS for treating psychogenic non-epileptic seizures.

Neurocognitive research:

Neurocognitive dysfunction has been shown in several neuropsychiatric disorders and in some patients there is speculated to be the underlying pathology. For example patients with OCD suffer from a series cognitive dysfunctions such as inability to inhibit their prepotent response (response inhibition) in addition to their obsessive and compulsive symptoms. Another neurocognitive research focus is trying to understand the underpinning neuropsychiatric disorders. Current projects include:

  1. Cognitive dysfunction in MDD and how they improve after successful rTMS treatment
  2. Underlying cognitive dysfunction in OCD
  3. Underlying cognitive dysfunction in non-epileptic event
  4. Underlying cognitive dysfunction in mild traumatic brain injury

Team

Dr. Mandana Modirrousta – rTMS psychiatrist

Dr. Ben Prasad – rTMS psychiatrist

Sara Wikstrom – rTMS nurse

Jean Clibbery – rTMS nurse

Paola Dubiel – rTMS nurse

Benjamin Meek – research assistant

William McPherson – research assistant

Peterson KT, Kosior R, Meek BP, Ng M, Perez DL, Modirrousta M. (2018). Right Temporoparietal Junction Transcranial Magnetic Stimulation in the Treatment of Psychogenic Nonepileptic Seizures: A Case Series. Psychosomatics. pii: S0033-3182(18)30133-6.

Modirrousta M, Meek BP, Wikstrom S. (2018). The efficacy of twice-daily versus once-daily sessions of repetitive transcranial magnetic stimulation in the treatment of major depressive disorder. Journal of Neuropsychiatric Disease and Treatment. 14:309-316.

Tachere OR, Modirrousta M. (2017). Beyond Anxiety and Agitation: A Clinical Approach to Akathisia. Australian Family Physician. 46(5):296-298.

Milev RV, Giacobbe P, Kennedy SH, Blumberger DM, Daskalakis ZJ, Downar J, Modirrousta M, Patry S, Vila-Rodriguez F, Lam RW, MacQueen GM, Parikh SV, Ravindran AV; CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 4. Neurostimulation Treatments. Canadian Journal of Psychiatry. 61(9):561-75. doi: 10.1177/0706743716660033..

Campbell DW, Wallace MG, Modirrousta M, Polimeni JO, McKeen NA, Reiss JP. (2015). The neural basis of humour comprehension and humour appreciation: The roles of the temporoparietal junction and superior frontal gyrus. Neuropsychologia. 79: 10-20.

Modirrousta M, Meek BP, Sareen J, Enns MW. (2015). Impaired trial-by-trial adjustment of cognitive control in obsessive compulsive disorder improves after deep repetitive transcranial magnetic stimulation. BMC Neuroscience. 16(63).

Dhaliwal S, Meek BP, Modirrousta M. (2015). Non-Invasive Brain Stimulation for the Treatment of Symptoms Following Traumatic Brain Injury. Frontiers in Psychiatry. 6(119).

Modirrousta M, Shams E, Katz C, Mansouri B, Moussavi Z, Sareen J, Enns M. (2015). The efficacy of deep repetitive transcranial magnetic stimulation over the medial prefrontal cortex in Obsessive Compulsive Disorder: results from an open-label study. Depression and Anxiety. 32(6): 445-50.

Modirrousta, M, Price BH, Dickerson BC. (2013). Neuropsychiatric symptoms in Primary Progressive Aphasia: Phenomenology, pathophysiology, and approach to assessment and treatment. Neurodegenerative Disorder Management. 3(2): 133-146.

Modirrousta M, Fellows LK. (2008). Dorsal medial prefrontal cortex plays a necessary role in rapid error prediction in humans. The Journal of Neuroscience. 28(51): 14000-5.

Modirrousta M, Fellows LK. (2008). Medial prefrontal cortex plays a critical and selective role in ‘feeling of knowing’ meta-memory judgments. Neuropsychologia. 46(12): 2958-65.

Modirrousta M, Mainville L, Jones BE. (2007). Dynamic changes in GABAA receptors on basal forebrain cholinergic neurons following sleep deprivation and recovery. BMC Neuroscience. 8(15).

Modirrousta M, Mainville L, Jones BE. (2005). Orexin and MCH neurons express c-Fos differently after sleep deprivation vs. recovery and bear different adrenergic receptors. The European Journal of Neuroscience. 21(10): 2807-16.

Modirrousta M, Mainville L, Jones BE. (2004). Gabaergic neurons with alpha2-adrenergic receptors in basal forebrain and preoptic area express c-Fos during sleep. Neuroscience. 129(3): 803-10.

Manns ID, Lee MG, Modirrousta M, Hou YP, Jones BE. (2003). Alpha 2 adrenergic receptors on GABAergic, putative sleep-promoting basal forebrain neurons. The European Journal of Neuroscience. 18(3): 723-27.

The Neuromodulation and Neuropsychiatry Unit was successfully granted funds by several agencies such as the Manitoba Medical Service Foundation and the St. Boniface Hospital Foundation. The granted funds have been used to improve research techniques and clinical outcomes.

Public donations and support play a key role in the growth and continued operation of the rTMS clinic at St. Boniface Hospital. We are tremendously grateful for all our past and future support; as it has enabled us to exist as we do today and help us continue to improve our ability to care the mental health of Manitobans.

We welcome any donations from the public and any donation is greatly appreciated.

To donate to the Neuromodulation and Neuropsychiatric Unit at St. Boniface Hospital follow these two steps:

Aubie Angel Young Investigator Award for Clinical Research, University of Manitoba (2017)

Best Presentation, Psychiatry Resident Research Day – University of Manitoba (2012)

Best Paper, Psychiatry Resident Research Day – University of Manitoba (2011)

Best Presentation, Psychiatry Resident Research Day – University of Manitoba (2011)

Resident Research Award, Association of Chairs of Psychiatry of Canada (2010)

Clinical Service

The Neuromodulation and Neuropsychiatry Unit provides two distinct clinical services:

  • Neuromodulation (rTMS treatment)
  • Neuropsychiatric consultation.

Neuromodulation (rTMS)

The rTMS clinic at St. Boniface Hospital was established in January 2012, with an initial treatment capacity of fewer than 10 new patients a year. Since then, the clinic has expanded, and we currently provide more than 50 new full-course treatments each year in addition to dozens of maintenance treatments for returning patients. Dr. Modirrousta is working to increase clinic efficacy and capacity while conducting educational and community outreach to increase public and clinical awareness regarding rTMS and services available through the Neuromodulation and Neuropsychiatry clinic.

What is rTMS?

rTMS stands for repetitive Transcranial Magnetic Stimulation.  It is a relatively new treatment that has the potential to treat symptoms of various neuropsychiatric disorders.  rTMS has been shown to improve mood and decrease sadness in patients with mild to moderate depression.  rTMS works by using short magnetic pulses to non-invasively influence the brain’s electrical activity. Magnetic pulses are delivered through a wire coil covered in plastic.  The coil is precisely positioned over the scalp using MRI brain images to target specific areas of the brain that are associated with the specific symptoms being treated. Since the pulses are delivered multiple times per session and a full treatment consists of multiple daily sessions, the technique is called repetitive TMS.  The doctor determines the number, strength, and length of the pulses based on the symptoms being treated.

Neuropsychiatry Clinic

Neuropsychiatry encompasses a variety of clinical services. In order to see as many patients as possible while still maintaining a high quality of care, we have established a weekly schedule for our various clinics:

Clinic Type Time
General Neuropsychiatry Clinic, Multiple Sclerosis, and Parkinson’s Disease Clinics Monday morning
Brain Injury Clinic Monday afternoon
rTMS Clinic Monday afternoon
Memory Clinic Thursday morning
Post-Stroke and Epilepsy Clinics Thursday afternoon

Dr. Modirrousta welcomes Centralized Intake consultations.


Patient FAQ

What are the benefits/advantages of rTMS treatment?

rTMS is a Health Canada approved method of treatment, and numerous clinical trials have demonstrated its effectiveness in the treatment of depression, even in people who have previously not responded to other psychotherapeutic or pharmacological treatments. Specifically, rTMS has been shown to improve mood, concentration, and energy. rTMS is non-invasive, and it does not require the use of anaesthetics, sedation, or injections/medication. Additionally, it has no known long-term side-effects. Some people experience headaches or fatigue as a result of rTMS treatment, but these effects are short-term and do not persist once treatment is finished.
rTMS is mainly performed as an outpatient treatment and you can receive rTMS without stopping antidepressant prescriptions.

What factors could make rTMS an unsafe treatment option?

  • Presence of metal plates, pumps, implants, or fragments in the head.
  • History of epilepsy
  • Brain lesions: vascular, traumatic, tumour, infection
  • Alcohol dependence or abuse
  • Use of cocaine, MDMA, ketamine, PCP, cannabis, or other street drugs
  • Withdrawal from alcohol, benzodiazepines, or barbiturates
  • Certain seizure threshold lowering medications have been shown to present a risk.

Do I have to do anything before or after treatment?

There is no need to taper off or adjust MOST medications before rTMS. The exception is medications that decrease seizure threshold levels such as antiepileptics.

It IS important to have a stable medication regimen 4 weeks prior to rTMS. It is also preferable to have a stable medication regimen for 4 weeks after treatment.

Are there any activity restrictions during rTMS treatment?

There are no activity restrictions during rTMS treatment periods. Most people do not require any recovery period after treatment and patients can drive themselves to and from the clinic. Furthermore, most patients find that they can continue work as usual as long as their employers are eble to accommodate the treatment schedule.

Who administers rTMS treatment sessions?

Treatments are administered by a specially trained nurse or rTMS technician under doctor supervision.

How many treatments sessions will I need to have?

Your doctor will decide how many treatment sessions you need, but a course of one treatment per day for up to 28-30 treatment sessions is common.

How long does each treatment session last?

Depending on the rTMS protocol that is chosen for you by your doctor, each treatment will last between 5 and 40 minutes.

What happens during the treatment?

You will be seated in a reclined chair and given earplugs to protect your hearing from the loud clicking noise made by the machine. You will also wear a head-strap that tracks and monitors the location of your head. A coil will be positioned on your head by the rTMS nurse/technician. You will have to sit still for the length of the treatment session.

Your mood will be checked at specific intervals throughout the course of treatment using standard tests.

What does rTMS feel like?

You will feel a tapping or tingling sensation when the magnetic pulses are delivered. Different people feel different levels of discomfort from the pulses. Your scalp muscles may feel tight during and for a short time after your treatment. You may develop a mild headache after treatment. You can take any over-the-counter pain relief medication for the headache. Please tell your doctor or nurse if you have pain.

What if I have to miss a treatment?

Research has shown that consistent treatments delivered over a short period of time are required for benefits to occur. Missed sessions can negatively impact the outcomes of a course of treatment by interrupting the potential response. For this reason, the course of treatment will be discontinued if two sessions are missed. Please discuss potential conflicts in scheduled treatment times with your doctor or nurse.

What are the risks involved?

Possible side effects include pain at the site of stimulation and headache. Twitches in the face muscles may occur during treatment, which can be uncomfortable. In very rare cases, seizures can be triggered by rTMS. You will be screened for factors that could put you at increased risk of seizure prior to treatment. The doctor will discuss the risks of rTMS with you before your treatment.

How long before I feel better?

Treatments do not work right away. It may take many treatment sessions before you feel better. We encourage you to discuss how you are doing with your doctor or nurse.

NB: rTMS cannot be offered on an emergency basis and should not be considered for crisis situations. Please use local crisis services as needed.

Health Care Providers FAQ

What is rTMS?

rTMS stands for repetitive transcranial magnetic stimulation. TMS is an application of the principle of electromagnetic induction first demonstrated by Michael Faraday in 1839. Electricity is the basis of brain and neuron function, as such TMS uses the magnetic field as a vector for inducing electrical current in the brain. The magnetic field in TMS noninvasively penetrates the skull to create a localized current that stimulates cortical neurons at the application site. Repetitive TMS uses repeated sequences, or trains, of stimulation administered on a daily basis over a number of weeks to produce long-lasting changes in neural activity.

How can I describe rTMS to my patients?

rTMS is a relatively novel treatment for neuropsychiatric disorders. In 2002 it was approved by Health Canada as a treatment for depression. Many individuals can find other treatment methods ineffective. rTMS treats disorders by stimulating brain regions that have been shown to be associated with that specific disorder. By applying repeated pulses of magnetic stimulation, rTMS can increase or decrease activity of the target region of the brain. By restoring normal brain function rTMS is treating the disorder.

What are the therapeutic effects of rTMS?

rTMS therapy for depression targets the dorsolateral prefrontal cortex; an area of the brain involved in mood regulation. Several meta-analyses have shown that rTMS is superior to placebo, with response rates ranging from 30-50%. Importantly, these response rates are seen in individuals who are otherwise treatment-resistant, meaning they have failed at least one course of antidepressant medication prior to trying rTMS. The desired result of rTMS protocols is selective modulation of functional connectivity both within and between the central executive network and default mode network. Its use in treating other conditions such as OCD and PTSD has been supported by the literature, and is currently under continuing investigation.

Who is a good candidate for rTMS?

  • Individuals with mild to moderate forms of depression where the episodes are shorter in duration and a low level of treatment resistance.
  • Individuals who have a history of good response to electroconvulsive therapy (ECT) and/or rTMS.
  • Individuals who present with reverse neurovegetative symptoms (i.e. oversleeping, overeating, etc.).

Is there an age limit for rTMS?

There is no age limit for rTMS; patients are not generally excluded from stimulation studies or therapies based on their age. Meta-analyses of rTMS studies reveal no strong evidence that the efficacy of rTMS is dependent on age, so the results of most studies investigating the efficacy of rTMS for the treatment of depression are applicable to adults of all ages. For example, a recent meta-analysis by Conelea and colleagues (2017) found that younger and older adult patients show no difference in response or remission rates, and age was not a significant predictor of change in depression severity, nor of clinical response or remission. However, the effects of rTMS on the developing brain are not fully understood. For this reason, rTMS is general not offered to children/adolescents.

What are the risks and side-effects of rTMS?

  • Possible side effects include pain at the site of stimulation and headache.
  • Twitches in the face muscles may occur during treatment, which can be uncomfortable.
  • Seizures (very rare); care is taken to screen patients who may be at a higher risk for seizure (medical history, family history, medications, etc.).

NB: rTMS cannot be offered on an emergency basis and should not be considered for crisis situations.

 

 

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