To the Editor: A recent meta-analysis (1) concluded that repetitive transcranial magnetic stimulation (rTMS) efficiently reduces resistant auditory hallucinations in patients with schizophrenia (effect size=0.76). Nevertheless, treatment is presently only provided over short periods of time, and little is known about longer-term impact. Maintenance treatment protocols have been developed, and we previously described a case report involving a maintenance protocol with a weekly, once-a-day stimulation (2); however, we failed to demonstrate long-term benefits. To our knowledge, the case presented below is the first report of a twice-daily transcranial magnetic stimulation as efficacious for auditory hallucinations, both in acute and maintenance treatment.
“Ms. A,” a 55-year-old right-handed, postmenopausal woman who had DSM-IV late-onset schizophrenia with an illness duration of 2 years, was referred for transcranial magnetic stimulation treatment. She was noted to have benzodiazepine addiction involving the use of lorazepam (9 mg/day). She had been suffering from resistant auditory hallucinations for 2 years (very frequent and loud, with >5 critical and command voices). She was unresponsive to four antipsychotic medication trials lasting >4 months each, including haloperidol (5 mg/day), amisulpride (1200 mg/day), olanzapine (15 mg/day), and risperidone (8 mg/day). A detailed assessment did not reveal any other pathology or transcranial magnetic stimulation contraindications. Auditory hallucinations were assessed using the Auditory Hallucination Rating Scale (3), and positive symptoms were assessed using the Scale for the Assessment of Positive Symptoms (SAPS). Lorazepam withdrawal was completed without exacerbation of the psychotic symptoms (Auditory Hallucination Rating Scale score: 34). Four months after her initial presentation, the patient gave informed consent and was included in a transcranial magnetic stimulation protocol. Twice-a-day, 1000 low-frequency repetitive stimulations (1 Hz) were administered to the temporoparietal cortex at 100% of motor threshold over a 5-day period. The patient’s current dose of risperidone was maintained during treatment with transcranial magnetic stimulation. After the first course, auditory hallucinations were moderately improved, with a 35% reduction in her Auditory Hallucination Rating Scale score, which did not change over the next several months, as observed in a follow-up assessment. However, the patient’s general SAPS score improved, with a 30% reduction in severity.
Six months after the first course of transcranial magnetic stimulation therapy, the patient presented with a relapse of hallucinations. A new transcranial magnetic stimulation course, with the same parameters, was conducted. This second course was followed by a once-per-month, twice-daily maintenance protocol (one session in the morning, the other in the afternoon on the same day). The patient’s auditory hallucinations were greatly improved, by 80%, and her SAPS score decreased from 38 to 16. This maintenance course was associated with a remission of auditory hallucination symptoms, with a stabilization of SAPS scores at 10 over the next 6 months. Presently, more than 1 year later, Ms. A is not receiving any antipsychotic medication, and her Auditory Hallucination Rating Scale and SAPS scores remain at 0.
Our case raises the question as to whether twice-daily transcranial magnetic stimulation may be useful in some patients as a possible maintenance intervention. Certainly, further research will help us to understand whether the benefits observed in this single case might also be evident in larger studies.
1.Aleman A, Sommer IE, Kahn RS: Efficacy of slow repetitive transcranial magnetic stimulation in the treatment of resistant auditory hallucinations in schizophrenia: a meta-analysis. J Clin Psychiatry 2007; 68:416–421
2.Poulet E, Brunelin J, Kallel L, Bediou B, Dalery J, D’amato T, Saoud M: Is rTMS efficient as a maintenance treatment for auditory verbal hallucinations? a case report. Schizophr Res 2006; 84:183–184
3.Hoffman RE, Hawkins KA, Gueorguieva R, Boutros NN, Rachid F, Carroll K, Krystal JH: Transcranial magnetic stimulation of left temporoparietal cortex and medication-resistant auditory hallucinations. Arch Gen Psychiatry 2003; 60:49–56
The authors report no competing interests.
This letter (doi: 10.1176/appi.ajp.2007.07060868) was accepted for publication in October 2007.