For professionals

This page pro­vi­des infor­ma­tion for pro­fes­sio­nals, and others inte­res­ted in the sub­ject,
about

The links below pro­vi­de

  • Instruc­tions for making a refer­ral
  • A refer­ral templa­te, which can also be prin­ted out pre-fil­led
  • tDCS info docu­ment that can be used to eva­lua­te the sui­ta­bi­li­ty of the treat­ment for the patient
  • Instruc­tions for the patient inte­res­ted of or going to the treat­ment period

The links can also be found at the bot­tom of this page.

Sooma tDCS post-treatment data

Read the latest whi­te paper from the cli­nical evi­dence of patients trea­ted for depres­sion with Soo­ma tDCSTM .

Trans-cranial Direct Current Stimulation

Trans-cra­nial Direct Cur­rent Sti­mu­la­tion (tDCS) is a non-inva­si­ve neu­ro­mo­du­la­tion tech­nique that is inc­rea­singly being used as a cli­nical tool in the treat­ment of neu­rop­syc­hiat­ric disor­ders. In the met­hod, the func­tion of the cerebral cor­tex and other super­ficial parts of the brain is affec­ted by a low-ampli­tu­de elect­ric cur­rent applied through two elect­ro­des to the sur­face of the head. Stu­dies on elect­rop­hy­sio­lo­gy and Trans-cra­nial Mag­ne­tic Sti­mu­la­tion (TMS) have shown that tDCS can modu­la­te cor­tical membra­ne vol­ta­ge in a pola­ri­ty-depen­dent man­ner.1

tDCS has been shown to modi­fy the acti­vi­ty of both the motor and visual cor­tex. Ano­dic sti­mu­la­tion inc­rea­ses the sen­si­ti­vi­ty of the cor­tex through depo­la­riza­tion. As a result, int­racor­tical faci­li­ta­tion inc­rea­ses and int­racor­tical inhi­bi­tion dec­rea­ses. Again, the effect of cat­ho­dic sti­mu­la­tion has been shown to be the oppo­si­te: it causes hyper­po­la­riza­tion, which in turn reduces the sen­si­ti­vi­ty of the cor­tex to action. Thus, tDCS does not gene­ra­te action poten­tials, but modi­fies the cerebral cor­tex sen­si­ti­vi­ty by inc­rea­sing or dec­rea­sing the ner­ve cell membra­ne poten­tial, which inc­rea­ses or dec­rea­ses the action poten­tial trig­ge­ring rate. In prac­tice, tDCS thus modi­fies the thres­hold action of a given brain region.1

tDCS in the Treatment of Depression

tDCS is an effec­ti­ve neu­ro­mo­du­la­tion the­ra­py for the symp­toms of mild, mode­ra­te, and seve­re depres­sion. Treat­ment with tDCS may be admi­nis­te­red wit­hout other treat­ment moda­li­ties or in com­bi­na­tion with drug the­ra­py and / or psyc­hot­he­ra­py, for example in the treat­ment of seve­re, pro­lon­ged or treat­ment-resis­tant depres­sion.

For example, tDCS is well sui­ted for first-line treat­ment of acu­te depres­sion, eit­her as a stand-alo­ne treat­ment or to sup­port the effect of drug the­ra­py. The­re is no need to chan­ge any exis­ting medica­tion at the start of treat­ment, and treat­ment may also be ini­tia­ted to sup­port the reduc­tion of medica­tion. Neu­ro­mo­du­la­tion is also well sui­ted for the treat­ment of a patient who is reluc­tant to recei­ve medica­tion, for example because of seve­re side effects or life circums­tances.

tDCS treat­ment seems to be most effec­ti­ve on trea­ting acu­te depres­si­ve disor­ders with anxie­ty as an accom­pa­nying symp­tom. Pre­dic­ti­ve ana­ly­sis of treat­ment res­pon­se indica­tes that treat­ment-resis­tant depres­sion reduces the like­li­hood of a res­pon­se, which should be con­si­de­red when eva­lua­ting the sui­ta­bi­li­ty of tDCS for the patient.

Trans-cra­nial DC Sti­mu­la­tion modi­fies the func­tion of the cor­tex in the dor­so­la­te­ral prefron­tal cor­tex (DLPFC), whe­re chan­ges in brain func­tion have been obser­ved in depres­sed patients. The pur­po­se of sti­mu­la­tion is to influence the sen­si­ti­vi­ty and plas­tici­ty of the cor­tex. The effect of the ano­de is direc­ted to the region of the left ante­rior lobe and is inten­ded to inc­rea­se the sen­si­ti­vi­ty of ner­ve cells in the cor­tex (attac­hed ima­ge). The effect of the cat­ho­de, in turn, is direc­ted to the area of ​​the right ante­rior block, with the aim of reducing ope­ra­tio­nal sen­si­ti­vi­ty.

The effect of the treat­ment inc­rea­ses gra­dual­ly and is usual­ly seen on the third week of treat­ment. 61% of trea­ted patients achie­ved treat­ment res­pon­se after three weeks of treat­ment with Soo­ma tDCS2. The res­pon­se was defi­ned as a reduc­tion in depres­sion sco­re to half or less.

Soo­ma tDCS treat­ment for the symp­toms of depres­sion is avai­lable from public and pri­va­te pro­vi­ders in Hel­sin­ki, Southwest Fin­land, Pir­kan­maa, Sata­kun­ta, Vaa­sa, Sout­hern Ostro­both­nia, Nort­hern Ostro­both­nia and Päi­jät-Häme, with over 20 hos­pi­tals and cli­nics throug­hout Fin­land.

Results in treatment of depression have been good.”

Kai­ja Jär­ven­taus­ta, Medical Doc­tor and Psyc­hiat­rist,
Pihlajalinna/Koskikeskus, Tam­pe­re

The Physiological Basis of Depression Treatment with tDCS

tDCS inc­rea­ses brain neu­roplas­tici­ty and modu­la­tes neu­ro­nal acti­vi­ty. Ano­dic sti­mu­la­tion is inten­ded to inc­rea­se the sen­si­ti­vi­ty of the left fron­tal cor­tex (L‑DLPFC) neu­rons, wit­hout neu­rons firing. The cat­ho­de on the right side of the fron­tal lobe (R‑DLPFC), in turn, reduces the sen­si­ti­vi­ty of ner­ve cells in the cor­tex, the­re­by reducing the like­li­hood of neu­ro­nal firing5.

Based on stu­dies, in depres­sed patients acti­vi­ty in the left and right sides of the prefron­tal cor­tex is rela­ti­ve­ly unba­lanced, so that the left side is hypoac­ti­ve6,7. The­re­fo­re, the effect of tDC Sti­mu­la­tion the­ra­py may be due to the inc­rea­sed sen­si­ti­vi­ty of the DLPFC cerebral cor­tex, which balances the dif­fe­rence in neu­ro­nal acti­vi­ty of the left and right ante­rior lobes, and thus leads to ame­lio­ra­tion of the symp­toms of depres­sion in the patient8.

Neu­ro­bio­lo­gical stu­dies have shown that tDCS indi­rect­ly affects the chain of events at the cel­lu­lar and molecu­lar levels, inclu­ding effects on glu­ta­ma­te-accep­ting N‑met­hyl-D-aspar­ta­te (NMDA) recep­tors9,10. In addi­tion to tran­sient acu­te poten­tial chan­ges of up to one hour, tDCS has been associa­ted with lon­ger-term synap­tic chan­ges11,12,13. Long-term tDCS effects are con­si­de­red to be due to alte­ra­tions in NMDA recep­tor func­tion14. Furt­her stu­dies to eluci­da­te the detai­led mec­ha­nism of action of tDCS in the­ra­peu­tic neu­ro­mo­du­la­tion are cur­rent­ly underway.

Active Treatment vs. Sham

The Roy­al Col­le­ge of Psyc­hiat­rists has publis­hed a sup­por­ti­ve sta­te­ment on the use of tDCS in the treat­ment of depres­sion15. Its evi­dence-based gui­dance ended up with a level B (pro­bable efficacy) recom­men­da­tion, and the Natio­nal Ins­ti­tu­te of Care Excel­lence (NICE) has also publis­hed gui­dance on the use of tech­no­lo­gy in 201516. Seve­ral stu­dies have been con­duc­ted on the the­ra­peu­tic effects of tDCS after repea­ted sti­mu­la­tion ses­sions17,18,19,20. A recent (publis­hed in 2017) stu­dy by 245 patients in the New England Jour­nal of Medici­ne by Bru­no­ni et al. showed that tDCS was sig­ni­ficant­ly more effec­ti­ve than place­bo. Repor­ted results for res­pon­ders were 40% (MADRS) in the acti­ve group and 23% in the place­bo group17.

A meta-ana­ly­sis of indi­vi­dual patient data from pre-2017 stu­dies sug­gests that acti­ve tDCS for depres­sion is sig­ni­ficant­ly more effec­ti­ve than place­bo in terms of res­pon­se, remis­sion, and symp­tom relief. Treat­ment res­pon­se was 34% in the acti­ve group and 19% in the place­bo group (OR = 2.44, 95%, CI 1.38–4.32, NNT = 7)3. Inte­res­tingly, com­bi­na­tion the­ra­py with SSRIs and tDCS pro­ved to be more effec­ti­ve than eit­her of the­se mea­su­res as monot­he­ra­py10 (Figu­re 2). Indeed, com­bi­na­tion the­ra­py can help sen­si­ti­ve patients achie­ve a fas­ter res­pon­se whi­le reducing medica­tion.

For bipo­lar disor­der, a meta-ana­ly­sis publis­hed by Dond et al.21 found that patients’ depres­sion sco­res were sig­ni­ficant­ly reduced after tDCS treat­ment (SMD 0.71, z = 3.00, p = 0.003). Fol­lowing this meta-ana­ly­sis, Sam­paio-Junior et al. repor­ted sig­ni­ficant­ly hig­her res­pon­se rates after acti­ve tDCS than after place­bo (67.7% vs 30.4%, NNT 2.69, 95% CI 1.84–4.99, p = 0.01)23.

I now see tDCS as an effective and safe treatment option
in psychiatry and am more than convinced
that there’s a great future for this method
.”

Mar­gus Lõo­ke­ne, Medical Doc­tor and Senior Psyc­hiat­rist,
North Esto­nia Medical Cen­ter, Tal­linn

Treatment Response

Stu­dies show that the majo­ri­ty of patients trea­ted recei­ve sig­ni­ficant help for the symp­toms of depres­sion. Based on open label post-treat­ment data, 61% of patients trea­ted with Soo­ma tDCS™ have achie­ved a res­pon­se (at least 50% reduc­tion in depres­sion sco­re)2.

The efficacy of tDCS the­ra­py has been demon­stra­ted in a num­ber of place­bo-cont­rol­led stu­dies, inclu­ding recent­ly in a lar­ger num­ber of patients. Treat­ment with tDCS pro­vi­des relief of symp­toms of depres­sion, usual­ly wit­hin about three weeks. Almost 85% of patients who have star­ted a cour­se have success­ful­ly comple­ted it2.

In the majo­ri­ty of ran­do­mized cont­rol­led trials and meta-ana­ly­ses the­reof, the efficacy of tDCS in the treat­ment of depres­sion has been shown to be simi­lar to anti­depres­sant drug the­ra­py and rTMS (repe­ti­ti­ve Trans-cra­nial Mag­ne­tic Sti­mu­la­tion) (B‑factor = 0.35)3,4.

In addi­tion to impro­ving mood, a reduc­tion in anxie­ty, often associa­ted with depres­sion, is very com­mon in patients. Many patients have also repor­ted inc­rea­sed acti­vi­ty and easier coping. Inc­rea­sed appe­ti­te and nor­ma­liza­tion of sleep pat­terns are also com­mon­ly repor­ted effects of treat­ment.2

Maintenance and Follow-up

In the majo­ri­ty of patients who start treat­ment, the symp­toms of depres­sion are sig­ni­ficant­ly reduced after three weeks of treat­ment2. After the treat­ment period, most patients con­ti­nue to recei­ve some degree of fol­low-up to pre­vent recur­rence of symp­toms. The need for and frequency of tDCS main­te­nance the­ra­py after an inten­si­ve treat­ment period is deter­mi­ned by the indi­vi­dual bene­fit achie­ved.

In a stu­dy publis­hed in Janua­ry 2019, main­te­nance treat­ment was fol­lowed for six months after the treat­ment period. Accor­ding to the indica­ti­ve result, an inten­si­ve, two-weekly regi­men resul­ted in a rela­ti­ve­ly low symp­tom recur­rence rate. Main­te­nance treat­ment was par­ticu­lar­ly effec­ti­ve in patients with non-treat­ment-resis­tant depres­sion.22

Safety of tDCS

The safe­ty of tDCS the­ra­py has been repea­ted­ly demon­stra­ted in stu­dies. The safe­ty pro­fi­le of treat­ment dif­fers mar­ked­ly from that of anti­depres­sants and, the­re­fo­re, sti­mu­la­tion the­ra­py may be con­si­de­red as an alter­na­ti­ve for patients recei­ving side effects of drug treat­ment. Accor­ding to a meta-ana­ly­sis of the stu­dy results, the­re were no dif­fe­rences between the treat­ment and place­bo groups in terms of safe­ty or accep­ta­bi­li­ty of treat­ment3,23,24,25.

The treat­ments can be done at home and are safe to do during breast­fee­ding. A safe­ty review based on more than 40000 sti­mu­la­tion ses­sions conclu­ded that tDCS is safe for both ado­lescents and the elder­ly4.

Side Effects of tDCS Treatment

tDCS for the treat­ment of depres­sion is very well tole­ra­ted and has not been shown to have any serious or sys­te­mic side effects4. Typical side effects during sti­mu­la­tion are tran­sient and mild; itc­hing at the elect­ro­des, a rapid tran­sient hea­dac­he after the sti­mu­la­tion, or red­ness at the elect­ro­des.

Treat­ments can be done safe­ly at home. A safe­ty review based on more than 40,000 ses­sions sta­tes that tDCS tech­no­lo­gy is safe for both young and older people4.

Contraindications

  • Int­rac­ra­nial metal­lic implant or other metal parts in the head area that can­not be remo­ved
  • Pace­ma­ker
  • A sur­gical ope­ra­tion per­for­med on the head area less than 6 months ago
  • Acu­te rash or ecze­ma in the sti­mu­la­tion area
  • Seve­re men­tal disor­der (eg schizoph­re­nia, other psyc­ho­ses or seve­re per­so­na­li­ty disor­der)

Amal­gam fil­lings, braces and den­tal implants are not obs­tacles to treat­ment.

…the first thing we notice is the reduced anxiety […] later on patients get more emotional,
active and after treatment we often get feedback
from patients that they are functioning better
in every day life, including work and social activities.”

Mar­gus Lõo­ke­ne, Medical Doc­tor and Senior Psyc­hiat­rist,
North Esto­nia Medical Cen­ter, Tal­linn

Tuuma Clinic

Tuu­ma Cli­nic is a pri­va­te healthca­re pro­vi­der appro­ved and super­vi­sed by the Regio­nal Govern­ment Office (avi) and staf­fed by Val­vi­ra-cer­ti­fied healthca­re pro­fes­sio­nals. We accept patients who are diag­no­sed with depres­sion and are refer­red by a specia­list in psyc­hiat­ry.

The Cli­nic pro­vi­des treat­ment for the symp­toms of depres­sion through Trans-cra­nial Direct Cur­rent Sti­mu­la­tion. The the­ra­py device, Soo­ma tDCS™ sti­mu­la­tor, is a por­table medical device (Class IIa).

Tuu­ma’s offices are loca­ted in Val­li­la, Hel­sin­ki, but we also welco­me patients from other loca­tions.

tDCS treat­ment is not cove­red by KELA reim­bur­se­ment, so the cost of treat­ment is paid by the patient.

The Treatment Period at Tuuma Clinic

Depres­sion treat­ment period at the Tuu­ma Cli­nic has been imple­men­ted by bor­rowing the treat­ment device used at home, and almost all treat­ment ses­sions of the period are done at home. At the begin­ning of the treat­ment period at Tuu­ma, the nur­se will int­ro­duce the patient to do the treat­ment and use the treat­ment device.

At the appoint­ment, a Depres­sion Symp­tom Ques­tion­nai­re (BDI) is comple­ted to mea­su­re base­li­ne. The first treat­ment event is con­duc­ted in a cont­rol­led man­ner with the nur­se and after the appoint­ment the patient bor­rows the device. The nur­se from Tuu­ma will call the patient a few days after the first appoint­ment to ensu­re that the treat­ments are as plan­ned at home.

During the treat­ment period, the nur­se con­tacts the patient accor­ding to a com­mon­ly agreed sche­du­le, usual­ly about once a week. The patient is advi­sed to con­tact the atten­ding phy­sician or the nea­rest emer­gency depart­ment imme­dia­te­ly if the con­di­tion is sig­ni­ficant­ly reduced during the treat­ment period. At the end of the period, the symp­tom que­ry is repea­ted. Sur­veys ser­ve to assess the impact of treat­ment. If the patient bene­fits from the treat­ment, the treat­ment effect can be main­tai­ned or enhanced by con­ti­nued treat­ment.

Prior to wri­ting the refer­ral, the phy­sician will eva­lua­te the sui­ta­bi­li­ty of tDCS for the patient. This docu­ment can be used to sup­port the deter­mi­na­tion of the sui­ta­bi­li­ty of the treat­ment for the patient. The­reaf­ter, the patient makes an appoint­ment for the treat­ment period at tuumamedical.com/booking. The refer­ral will be given to the patient who will bring it with them to the appoint­ment in Tuu­ma.

The cost of the treat­ment period in Tuu­ma is 500 €. The cycle inclu­des 30 ses­sions over a six-week period. Treat­ment with tDCS is not cove­red by KELA reim­bur­sable the­ra­pies, so the patient pays the cost.

The links below pro­vi­de

  • Instruc­tions for making a refer­ral
  • A refer­ral templa­te, which can also be prin­ted out pre-fil­led
  • tDCS info docu­ment that can be used to eva­lua­te the sui­ta­bi­li­ty of the treat­ment for the patient
  • Instruc­tions for the patient inte­res­ted of or going to the treat­ment period
Sooma-portaalin ja mobiilisovelluksen avulla hoitohenkilökunta pysyy helposti perillä hoidon etenemisestä

Figu­re 1. Through the Soo­ma por­tal, medical staff can fol­low the progress of treat­ment. The patient marks the treat­ment events per­for­med and the values of the selec­ted para­me­ters in the mobi­le applica­tion.

tDCS-tietoa ammattilaisille. Aivojen tasavirtastimulaatio on tehokas hoitomuoto yhdistelmähoitona lääkehoidon kanssa

Figu­re 2. In a stu­dy of Bru­non et al. (120 patients), the com­bi­na­tion of sert­ra­li­ne and tDCS pro­ved to be more effec­ti­ve than eit­her treat­ment alo­ne. Treat­ment res­pon­ses were 16,7 % for the sham group, 33 % for the sert­ra­li­ne group, 43,3 % for the sham + tDCS com­bi­na­tion group and 63.3% for the sert­ra­li­ne + tDCS group10.

Refe­rences:

  1. Thair H, Hol­loway L, New­port R, Smith A., Transc­ra­nial Direct Cur­rent Sti­mu­la­tion (tDCS): A Begin­ner’s Gui­de for Design and Imple­men­ta­tion (2017). Avai­lable onli­ne: https://www.frontiersin.org/articles/10.3389/fnins.2017.00641/full
  2. Soo­ma — Treat­ment Outco­mes (2018). Avai­lable onli­ne: https://soomamedical.com/blog/treatment-outcomes‑2/
  3. Bru­no­ni et al., Transc­ra­nial direct cur­rent sti­mu­la­tion for acu­te major depres­si­ve epi­so­des: meta-ana­ly­sis of indi­vi­dual patient data. The Bri­tish Jour­nal of Psyc­hiat­ry (2016) 208, 1–10.
  4. Bik­son M. et al., Safe­ty of Transc­ra­nial Direct Cur­rent Sti­mu­la­tion: Evi­dence Based Upda­te 2016. Brain Sti­mul. 2016 Sep-Oct; 9(5): 641–61.
  5. Tor­tel­la, G. et al. Transc­ra­nial direct cur­rent sti­mu­la­tion in psyc­hiat­ric disor­ders. World J. Psyc­hiat­ry 5, 88–102 (2015).
  6. Fitz­ge­rald, P. et al. An ana­ly­sis of func­tio­nal neu­roi­ma­ging stu­dies of dor­so­la­te­ral prefron­tal cor­tical acti­vi­ty in depres­sion. Psyc­hiat­ry Res. 148, 33–45 (2006).
  7. Grimm, S. et al. Imba­lance between Left and Right Dor­so­la­te­ral Prefron­tal Cor­tex in Major Depres­sion Is Lin­ked to Nega­ti­ve Emo­tio­nal Judg­ment: An fMRI Stu­dy in Seve­re Major Depres­si­ve Disor­der. Biol. Psyc­hiat­ry 63, 369–376 (2008).
  8. Bru­no­ni, A. et al. Neu­ro­mo­du­la­tion approac­hes for the treat­ment of major depres­sion: chal­len­ges and recom­men­da­tions from a wor­king group mee­ting. Arq. Neu­rop­siquiatr. 68, 433–451 (2010).
  9. Lie­be­tanz, D. et al. Phar­maco­lo­gical approach to the mec­ha­nisms of transc­ra­nial DC sti­mu­la­tion induced after effects of human motor cor­tex exci­ta­bi­li­ty. Brain 125, 2238–2247 (2002).
  10. Nitsche, M. et al. Modu­la­tion of cor­tical exci­ta­bi­li­ty by weak direct cur­rent sti­mu­la­tion-tech­nical, safe­ty and func­tio­nal aspects. Suppl Clin Neu­rop­hy­siol. 56, 255–76 (2003).
  11. Nitsche, M. & Pau­lus, W. Exci­ta­bi­li­ty chan­ges induced in the human motor cor­tex by weak transc­ra­nial direct cur­rent sti­mu­la­tion. The Jour­nal of Phy­sio­lo­gy 527 Pt 3, (2000).
  12. Nitsche, M. et al. Level of action of cat­ho­dal DC pola­ri­sa­tion induced inhi­bi­tion of the human motor cor­tex. Clin. Neu­rop­hy­siol. 114, 600–604 (2003).
  13. Meron, D. et al. Transc­ra­nial direct cur­rent sti­mu­la­tion (tDCS) in the treat­ment of depres­sion: Sys­te­ma­tic review and meta-ana­ly­sis of efficacy and tole­ra­bi­li­ty. Neu­rosci. Bio­be­hav. Rev. 57, 46–62 (2015).
  14. Sydän­maan­lak­ka S.  Trans­kra­ni­aa­li­nen tasa­vir­tas­ti­mu­laa­tio — sel­vi­tys mene­tel­män sovel­ta­mi­ses­ta. 2013. Säh­kö­tek­nii­kan kor­kea­kou­lu, Aal­to-yli­opis­to. Espoo.
  15. The Roy­al Col­le­ge of Psyc­hiat­rists — Posi­tion Sta­te­ment CERT04/17 (2017).
  16. Natio­nal Ins­ti­tu­te of Care Excel­lence — Inter­ven­tio­nal gui­dance IPG530 (2015). Avai­lable onli­ne: https://www.nice.org.uk/guidance/ipg530
  17. Bru­no­ni et al., Trial of Elect­rical Direct-Cur­rent The­ra­py ver­sus Esci­ta­lopram for Depres­sion. The New England Jour­nal of Medici­ne 2017; 376:2523–2533.
  18. Valien­go LC et al., Transc­ra­nial direct cur­rent sti­mu­la­tion for the treat­ment of post-stro­ke depres­sion: results from a ran­do­mi­sed, sham-cont­rol­led, double-blin­ded trial. J Neu­rol Neu­ro­surg Psyc­hiat­ry. 2017 Feb; 88(2): 170–175. Avai­lable onli­ne: https://www.ncbi.nlm.nih.gov/pubmed/?term=valiengo+2017+tdcs
  19. Sala­hi­ne­jad MA et al., Cog­ni­ti­ve cont­rol dys­func­tion in emo­tion dys­re­gu­la­tion and psyc­ho­pat­ho­lo­gy of major depres­sion (MD): Evi­dence from transc­ra­nial brain sti­mu­la­tion of the dor­so­la­te­ral prefron­tal cor­tex (DLPFC). J Affect Disord. 2017 Mar 1; 210: 241–248. Avai­lable onli­ne: https://www.ncbi.nlm.nih.gov/pubmed/28064113
  20. Bru­no­ni et al., The sert­ra­li­ne vs. elect­rical cur­rent the­ra­py for trea­ting depres­sion cli­nical stu­dy: results from a fac­to­rial, ran­do­mized, cont­rol­led trial. JAMA Psyc­hiat­ry. 2013; 70(4): 383–391 Avai­lable onli­ne: https://www.ncbi.nlm.nih.gov/pubmed/23389323
  21. Don­de C et al., Transc­ra­nial direct-cur­rent sti­mu­la­tion (tDCS) for bipo­lar depres­sion: A sys­te­ma­tic review and meta-ana­ly­sis. Prog Neu­rop­syc­hop­har­macol Biol Psyc­hiat­ry. 2017 Aug 1; 78: 123–131. Avai­lable onli­ne: https://www.ncbi.nlm.nih.gov/pubmed/28552295
  22. Apa­ricio LVM, Rosa V, Razza LM, Sam­paio-Junior P, Bor­rio­ne L, Valien­go L, Lotu­fo PA, Ben­señor IM, Fra­guas R, Mof­fa AH, Gat­taz VF, Bru­no­ni AR. 2019. Transc­ra­nial direct cur­rent sti­mu­la­tion (tDCS) for pre­ven­ting major depres­si­ve disor­der relap­se: Results of a 6‑month fol­low-up. Avai­lable onli­ne: https://doi.org/10.1002/da.22878
  23. Sam­paio-Junior B et al., Efficacy and Safe­ty of Transc­ra­nial Direct Cur­rent Sti­mu­la­tion as an Add-on Treat­ment for Bipo­lar Depres­sion: A Ran­do­mized Cli­nical Trial. JAMA Psyc­hiat­ry. 2018 Feb 1; 75(2): 158–166. Avai­lable onli­ne:  https://www.ncbi.nlm.nih.gov/pubmed/29282470
  24. Shiozawa P et al., Transc­ra­nial direct cur­rent sti­mu­la­tion for major depres­sion: an upda­ted sys­te­ma­tic review and meta-ana­ly­sis. Int J Neu­rop­syc­hop­har­macol 2014 Sep; 17(9): 1443–52. Avai­lable onli­ne: https://www.ncbi.nlm.nih.gov/pubmed/24713139
  25. Meron D et al., Transc­ra­nial direct cur­rent sti­mu­la­tion (tDCS) in the treat­ment of depres­sion: Sys­te­ma­tic review and meta-ana­ly­sis of efficacy and tole­ra­bi­li­ty. Neu­rosci Bio­be­hav Rev. 2015 Oct; 57: 46–62. Avai­lable onli­ne: https://www.ncbi.nlm.nih.gov/pubmed/?term=meron+tdcs+review

This ser­vice is not inten­ded for use in medical emer­gencies. If you sus­pect you are in a medical or psyc­ho­lo­gical emer­gency, imme­dia­te­ly call the emer­gency num­ber in the count­ry whe­re you are, or go to the nea­rest emer­gency room. In Fin­land the emer­gency num­ber is 112.

MIELI The Natio­nal Men­tal Health Associa­tion of Fin­land’s Men­tal Health Ser­vice pro­vi­des discus­sion assis­tance. In addi­tion to Fin­nish, the emer­gency pho­ne is avai­lable in Swe­dish, Ara­bic and English. The num­ber is 09 2525 0111 and is open eve­ry day and night of the year.