We previously identified a cognitive biotype of depression characterized by treatment resistance, impaired cognitive control behavioral performance and dysfunction in the cognitive control circuit, comprising the dorsolateral prefrontal cortex (dLPFC) and dorsal anterior cingulate cortex (dACC). Therapeutic transcranial magnetic stimulation (TMS) to the left dLPFC is a promising option for individuals whose depression does not respond to pharmacotherapy. Here, 43 veterans with treatment-resistant depression were assessed before TMS, after early TMS and post-TMS using functional magnetic resonance imaging during a Go–NoGo paradigm, behavioral cognitive control tests and symptom questionnaires. Stratifying veterans at baseline based on task-evoked dLPFC–dACC connectivity, we demonstrate that TMS-related improvement in cognitive control circuit connectivity and behavioral performance is specific to individuals with reduced connectivity at baseline (cognitive biotype +), whereas individuals with intact connectivity at baseline (cognitive biotype −) did not demonstrate significant changes. Our findings show that dLPFC–dACC connectivity during cognitive control is both a promising diagnostic biomarker for a cognitive biotype of depression and a response biomarker for cognitive improvement after TMS applied to the dLPFC.

The Houston Conference Guidelines (Hannay et al., 1998) provided an initial framework for North American neuropsychology training that served the specialty well for several decades. Subsequent advances in technology, increased diversity of the U.S. and Canadian populations, and the adoption of competency-based training models within Health Service Psychology have created a need to update neuropsychology training guidelines. Therefore, in 2022, the Minnesota Conference to Update Education and Training Guidelines in Clinical Neuropsychology began a two-year drafting process leading to the currently proposed update. A Steering Committee worked with content experts, consultants, and delegates representing North American neuropsychological organizations and specialists. The final version of the guidelines was developed after reviewing neuropsychological training literature, gathering feedback from specialists, and making iterative revisions of earlier drafts to reach consensus. The resulting "Minnesota Guidelines" include five foundational (Neuroscience and Brain Behavior Relationships; Integration of Science and Practice; Ethics, Standards, Laws, and Policies; Diversity; and Professional Relationships) and eight functional (Assessment; Intervention; Interdisciplinary Systems and Consultation; Research and Scholarship; Technology and Innovation; Teaching, Supervision, and Mentoring; Health and Professional Advocacy; and Administration, Management, and Business) areas of competency required for entry level specialty practice. While consensus was not achieved, a majority of voting delegates recommended the Guidelines for adoption and the Guidelines have been endorsed by six neuropsychology education and board certification organizations. The American Academy of Clinical Neuropsychology has not endorsed the Minnesota Guidelines and will not make an endorsement decision until three months after online publication.

Objective: Teleneuropsychology (TeleNP) and the ethical guidance related to TeleNP is not new. However, the emergence of the coronavirus-2019 (COVID-19) has generated renewed interest in the potential utility and feasibility of transitioning the clinical practice of neuropsychological assessment from an in-person evaluation to one that occurs at least partially via telehealth. Recent surveys of neuropsychologists practicing in the early stages of COVID-19 indicate that, while most clinicians will or currently engage in TeleNP services, many have concerns about ethical issues related to providing TeleNP. Despite the presence of APA guidelines for telepsychology, no formal APA ethical guidelines or standards of practice exist for TeleNP. We provide ethical considerations and suggestions for potential practitioners of TeleNP based on new models of practice derived in response to the COVID-19 pandemic. Method: We provide operational definitions of TeleNP and its models including: In-Clinic, Home, and Hybrid TeleNP models. Results: We outline ethical considerations and suggestions in general and by model related to: issues of competence, education and training, benefits and risks of conducting TeleNP, health disparities, informed consent, patient privacy, confidentiality, test security, and administration and interpretation of standardized assessments. Conclusions: The decision of which TeleNP model to use is a difficult one. Providers must balance several ethical considerations to complete an accurate assessment while managing numerous inherent challenges. Future efforts should focus on the creation of formal ethical guidelines and standards for the practice of TeleNP through joint task force efforts (e.g., APA, Inter Organizational Practice Committee).

Mild traumatic brain injury (mTBI) is a signature injury of military conflicts and is prevalent in veterans with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). Although therapeutic transcranial magnetic stimulation (TMS) can reduce symptoms of depression and PTSD, whether traumatic brain injury (TBI) affects TMS responsiveness is not yet known. We hypothesized mTBI would be associated with higher pretreatment symptom burden and poorer TMS response. We investigated a registry of veterans (N = 770) who received TMS for depression across the US Veterans Affairs system. Of these, 665 (86.4%) had data on TBI and lifetime number of head injuries while 658 had complete data related to depression outcomes. Depression symptoms were assessed using the nine-item Patient Health Questionnaire and PTSD symptoms using the PTSD Checklist for DSM-5. Linear mixed effects models and t-tests evaluated whether head injuries predicted symptom severity before treatment, and how TBI status affected clinical TMS outcomes. Of the 658 veterans included, 337 (50.7%) reported previous mTBI, with a mean of three head injuries (range 1-20). TBI status did not predict depressive symptom severity or TMS-associated changes in depression (all p's > 0.1). TBI status was associated with a modest attenuation of TMS-associated improvement in PTSD (in patients with PTSD Checklist for DSM-5 scores > 33). There was no correlation between the number of head injuries and TMS response (p > 0.1). Contrary to our hypothesis, presence of mTBI did not meaningfully change TMS outcomes. Veterans with mTBI had greater PTSD symptoms, yet neither TBI status nor cumulative head injuries reduced TMS effectiveness. Limitations include those inherent to retrospective registry studies and self-reporting. Although these findings are contrary to our hypotheses, they support the safety and effectiveness of TMS for MDD and PTSD in patients who have comorbid mTBI.

Clinical transcranial magnetic stimulation (TMS) for depression routinely relies on the scalp-based BeamF3 targeting method to identify stimulation targets in the dorsolateral prefrontal cortex (dLPFC). Scalp-based targeting offers a low-cost and easily implemented method for TMS coil placement, enhancing treatment availability. However, limited anatomical and functional specificity of the BeamF3 method may affect treatment outcomes, motivating assessment of the clinical standard. In a naturalistic clinical trial of TMS conduced at four Veterans Affairs hospitals, the authors evaluate the BeamF3 method using neuroimaging incorporated before TMS, after five treatment sessions, and after all thirty sessions. Personalized anatomical and electric field (E-field) models were developed to assess target location and network engagement, as well as subsequent effects on clinical outcomes. Anatomical models demonstrate that the BeamF3 method produced reliable targets in the dLPFC across individuals and repeated treatment sessions. E-field models revealed that baseline anticorrelation between the stimulation center and the sgACC was associated with antidepressant symptom response after five TMS sessions () and at the end of treatment (). Relatedly, E-field magnitude at the sgACC-anticorrelated peak in the prefrontal cortex correlated with symptom response throughout treatment (early treatment: ; end of treatment: ). This work establishes that scalp-based targeting can produce reliable targets in the dLPFC and be successfully evaluated using a combination of neuroimaging and E-field modeling in pragmatic, multisite applications. Importantly, this investigation also found that significant network effects occur early in treatment and that BeamF3 targets can engage functional mechanisms in TMS.