Letters to the Editor
Combined Transcranial Magnetic Stimulation and Right Unilateral Electroconvulsive Therapy in
Patients With Treatment-Refractory Depression
Dear Editor:
Treating patients with refractory depression is a common challenge for psychiatrists. There are several reasons for this. First, a substantial portion of patients starting pharmacologic treatment either fail to respond or cannot tolerate the drug (1,2). Even among responders to antidepressants, residual symptoms are common (3) and have been shown to be associated with a greater likelihood of relapse and a poorer prognosis (4).
Although combination and augmentation treatments are useful in patients with resistant depression (5,6), over one-third do not benefit from multiple combination. The addition of electroconvulsive therapy (ECT), still considered to be the treatment of choice for severe depression, alone or with other pharmacologic agents, leaves 40% of patients with marked depressive symptomatology (7,8).
Transcranial magnetic stimulation (TMS) has been shown to improve depressive symptoms both in uncontrolled (9,10) and in sham-controlled studies (11,12). Pridmore substituted rapid TMS treatments for right unilateral (RUL) ECTs, showing that the TMS-substituted group did as well as the group that continued to receive ECT (13).
We describe below the first successful use of combined RUL ECT and bilateral TMS.
Case Report
The patient is a woman, aged 39 years, referred to the mood disorders service for treatment resistance. Under our care, she received adequate trials with serzone; clomipramine augmented by cytomel, lithium, and risperidone; phenelzine; parnate up to 100 mg daily augmented by quetiapine; mirtazapine with topiramate and
lithium; fluoxetine and tryptophan; nortriptyline; and citalopram augmented by lamotrigine. A full course of bifrontal ECT was associated with severe cognitive disturbances and only partial response.
Our patient, who had shown a partial response when participating in a bilateral TMS study, was offered an open trial of RUL ECT and bilateral TMS.
At the start of treatments, her Hamilton Depression Rating Scale (HDRS) and Beck Depression Inventory (BDI) scores were 35 and 55, respectively. On Mondays, Wednesdays, and Fridays, she received 10 ECTs (RUL placement, pulse width 1.0 ms, 60 to 90 Hz, 3 to 4 seconds, and 800 mamp with Mecta [Tualatin, Oregon: Customs Systems Associates]). On Tuesdays and Thursdays, she received high-frequency TMS (that is, 20 trains of 12 Hz stimulation with a train of 8 seconds at 110% of motor threshold) over the left prefrontal cortex and low frequency (that is, 2 trains of 1 Hz stimulation with a train duration of 60 seconds and an intertrain interval of 3 minutes) over the right cortex. At the end of our course, her depression remitted, with HDRS and BDI scores dropping to 4 and 11, respectively. She was discharged home. Her Mini-Mental Status Exam Score was 28 out of 30.
Discussion
Despite the advances in treatment of depression, 10% to 30% of all depression patients remain refractory to treatment. Although ECT is still considered the treatment of choice for severe depression, there is no consensus or guideline suggesting the next steps for patients who do not tolerate or do not respond to a course of ECT. We are therefore describing a treatment-refractory patient with depression who obtained full remission for the first time with a combined treatment of ECT and TMS. The combined treatments were well tolerated.
References
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10. Triggs WJ, McCoy KJ, Greer R, Rossi F, Bowers D, Kortenkamp S, and others. Effects of left frontal transcranial magnetic stimulation on depressed mood, cognition, and corticomotor threshold. Biol Psychiatry 1999;45:14406.
11. Pascual Leone A, Rubio B, Pallardo F, Catala MD. Rapid-rate transcranial magnetic stimulation of left dorsolateral prefrontal cortex in drug-resistant depression. Lancet 1996; 348:2337.
12. Klein E, Kreinin I, Chistyakov A, Koren D, Mecz L, Marmur S, and others. Therapeutic efficacy of right prefrontal slow repetitive transcranial magnetic stimulation in major depression: a double-blind controlled study. Arch Gen Psychiatry 1999;56:31520.
13. Pridmore S. Substitution of rapid transcranial magnetic stimulation treatments for electroconvulsive therapy treatments in a course of electroconvulsive therapy. Depress Anxiety 2000;12:11823.
G Abraham, MD, FRCPC
Kingston, Ontario
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