To the Editor: Auditory hallucinations in patients with schizophrenia are severely distressing and increase the risk for violence and suicide. In up to 25% of patients, such hallucinations resist therapeutic efforts. Repetitive transcranial magnetic stimulation (rTMS) to the left temporoparietal cortex has been established as an effective new treatment option (1, 2). However, the effectiveness and sustainability of this treatment are still under debate. Bilateral stimulation and prolongation of the treatment course might enhance the size and maintenance of the effect. The use of continuous theta burst stimulation, a patterned form of rTMS with brief stimulation sessions, could improve clinical practicability (3). We report on the case of a patient who received continuous theta burst stimulation applied to the left and right temporoparietal cortex.

The observation in the present case provides the first evidence, to our knowledge, that a long-term bilateral application of continuous theta burst stimulation can achieve a complete and long-lasting elimination of auditory hallucinations and an improvement in global function. Of note, an amelioration of delusions, anxiety, tension, and unusual thought content was also accomplished. Since auditory hallucination-associated cortical activities are not limited to the left hemisphere, we opted for bilateral stimulation to optimize efficacy. Notably, improvement was achieved gradually, with complete remission, pointing toward a benefit of prolonged treatment, not occurring until 6 weeks. As intended, continuous theta burst stimulation beyond remission was followed by maintenance of the effect. However, in addition to briefer treatment sessions, an advantage of continuous theta burst stimulation relative to rTMS cannot be derived from this report. Further trials are needed to disentangle the influence of treatment duration, laterality, and stimulation paradigm in order to determine treatment efficacy, clinical practicability, and sustainability.