Introduction: rTMS(Repetitive Transcranial Magnetic Stimulation) is an effective non-invasive cortical stimulation method that is being used in the treatment of drug resistant major depressive disorder. The underlying mechanism of effect of rTMS has not been fully understood yet. Neuromodulation, neuroplasticity, and cortical excitability are the most accepted theories (1). Even though the post-treatment effect of rTMS in depression is well known, little is known about its lasting effect (2).Therefore in this report we investigated the effect of add-on rTMS treatment with 3 month follow-up after treatment in 3 outpatient cases diagnosed with drug resistant unipolar major depression.
Case 1: A 33 year-old female patient was diagnosed with major depressive disorder and received venlafaxine 300 mg/day for two years. An add-on 15 sessions of DLPFC rTMS (20 Hz, 110% MT, 1000p/d) was applied due to insufficient medication response. The MADRS and HAM-A scales were assessed before and the day following treatment and then 1 and 3 months after treatment. The MADRS scores were found to be 37, 11, 2 and 4, while the HAM-A scores were found to be 35, 9, 5 and 6, respectively.
Case 2: A 35 year-old male patient was diagnosed with major depressive disorder since age 12 and received escitalopram 20 mg/day for three months. An add-on 15 sessions of DLPFC rTMS (20 Hz,110% MT,1000p/d) was applied due to insufficient medication response. The MADRS and HAM-A scales were assessed before and the day following treatment and then 1 and 3 months after treatment. The MADRS scores were found to be 28, 10, 5 and 5, while the HAM-A scores were found to be 33, 18, 7 and 6, respectively.
Case 3: A 44 year-old male patient was diagnosed with major depressive disorder since age 15 and received venlafaxine 375 mg/day and ziprasidone 40 mg/day for five months. An add-on 15 sessions of DLPFC rTMS (20 Hz,110% MT,1000p/d) was applied due to insufficient medication response. The MADRS and HAM-A scales were assessed before and the day following treatment and then 1 and 3 months after treatment. The MADRS scores were found to be 29, 9, 6 and 7, while the HAM-A scores were found to be 28, 13, 10 and 8, respectively. Conclusion: Maintenance of improvement in major depression treatment has been another concern apart from efficacy of current interventions. rTMS is an effective method as monotherapy and also as add-on treatment of depression. In this study each of three patients responded favorably to rTMS. In the post-treatment course, significiant improvement was maintained at the 3-month follow-up. Given its relatively benign side effect profile, long lasting therapeutic effect, and more practical non-invasive application than ECT, we conclude that rTMS can be considered as an optional treatment before ECT in treatment-resistant depression patients.
References:
1. Pell GS, Roth Y, Zangen A.Modulation of cortical excitability induced by repetitive transcranial magnetic stimulation: Inşuence of timing and geometrical parameters and underlying mechanisms. Prog Neurobiol. 2010 Nov 5.
2. Bortolomasi M, Minelli A, Fuggetta G, Perini M, Comencini S, Fiaschi A, Manganotti P.Long-lasting effects of high frequency repetitive transcranial magnetic stimulation in major depressed patients. Psychiatry Res. 2007 Mar 30;150(2):181-6.
3. Hadley D, Anderson BS, Borckardt JJ, Arana A, Li X, Nahas Z et all. Safety, tolerability, and effectiveness of high doses of adjunctive daily left prefrontal repetitive transcranial magnetic stimulation for treatment-resistant depression in a clinical setting. J ECT. 2011 Mar;27(1):18-25. Bulletin of Clinical Psychopharmacology 2011;21(Suppl. 2):S175-6