A 55-year-old woman with a long history of recurrent treatment-resistant depression participates in a randomized controlled trial of daily left prefrontal transcranial magnetic stimulation and continues in the study's open-label extension.
"Mrs. M" is a 55-year-old actress with recurrent unipolar depression. Although she was dysthymic in high school, her first suicide attempt was at age 23 during an episode of depression and bulimia, for which she received counseling and medication. She partially responded but then showed a repeated pattern of partial to complete response to antidepressant medications followed by a gradual loss of efficacy. After a second suicide attempt at age 35, she was hospitalized, and she partially responded to treatment with an antidepressant and psychotherapy. She made a third suicide attempt at age 48; she was hospitalized again, and she partially responded to venlafaxine at 300 mg/day and psychotherapy.
At age 50 Mrs. M relapsed again, and over the next few years she tried the following medications, either alone or in combination: venlafaxine, lamotrigine, olanzapine, trazodone, bupropion, ziprasidone, aripiprazole, oxcarbazepine, lithium, desipramine, imipramine, fluoxetine, sertraline, citalopram, and buspirone. She was offered but refused ECT, citing concerns that the potential cognitive side effects of the treatment could affect her ability to remember her lines as an actress.
In 2007, Mrs. M enrolled in a multisite randomized trial of repetitive transcranial magnetic stimulation (rTMS) (2). After being tapered off antidepressant medications, she had an entry score of 31 on the 24-item Hamilton Depression Rating Scale. At randomization she was assigned to receive sham rTMS and was treated daily over the left prefrontal cortex for 3 weeks, with no improvement in her depressive symptoms. She then exited the double-blind phase and was offered open-label treatment with the same TMS settings as were used in the active phase (120% MT, 10 Hz, 4 seconds on and 26 seconds off over 26.7 minutes, 3,000 stimuli per day). Her symptoms improved, and she remitted after 4 weeks (Figure 1). She was then tapered from the TMS (three treatments per week for 2 weeks, then two treatments per week for 2 weeks) and restarted on venlafaxine at 300 mg/day. Although the study protocol suggested that patients be started on venlafaxine with adjunctive lithium or lamotrigine after remitting on TMS, Mrs. M declined use of adjunctive medications.
Depression Scores and Course of Improvement for a Patient Participating in a Trial of Repetitive Transcranial Magnetic Stimulation (rTMS)a
a Scores on the Inventory of Depressive Symptoms (IDS) are graphed for the first and second courses of TMS. In the first trial, in 2007, the patient initially received sham TMS, the results of which are shown to the left of the y-axis. Over 6—7 weeks, the patient responded to TMS and even remitted. The two courses were 3 years apart and had other differences, but the clinical response was similar.
Mrs. M remained in remission from depression on venlafaxine for 3 years. She resumed her acting career and remarried. At age 58, in January 2010, without changing or stopping medications, she gradually noted the return of her core depressive symptoms and recontacted our group to request another course of rTMS. Her score on the Inventory of Depressive Symptoms (IDS) was high (69 out of a possible 84 points). She then received 45 treatments of daily left prefrontal TMS for the second time, but this time while continuing to take venlafaxine. After 6 weeks of daily TMS, her IDS score was 24 (65% improvement). While being tapered from the TMS over the next 2 weeks, she was started on duloxetine at 30 mg/day, and the venlafaxine was tapered. She was then referred back to her treating psychiatrist with an exit IDS score of 7.