Grisaru et al. (1) reported antimanic effects from rapid transcranial magnetic stimulation of the right prefrontal cortex. In a 14-day double-blind trial, right and left prefrontal stimulations were compared in patients receiving repeated rapid transcranial magnetic stimulation in addition to antimanic drug therapy. We report here on a patient with euphoric mania that was refractory to treatment with sulthiame (2) who experienced marked improvement during monotherapy with right prefrontal rapid transcranial magnetic stimulation.
Ms. A was a 59-year-old woman with a diagnosis of bipolar I disorder. After her first and only depressive episode, which developed postpartum at age 35, she experienced at least four severe manic episodes. Eight weeks before hospital admission she developed euphoric mania despite lithium treatment. Lithium treatment was discontinued, and a trial with the antiepileptic drug sulthiame was initiated—unfortunately, with no effect after 3 weeks of treatment. Sulthiame treatment was tapered off, and monotherapy with rapid transcranial magnetic stimulation was begun. Right prefrontal stimulation was performed, as suggested by Grisaru et al. (1): 20 trains per session, a frequency of 20 Hz for 2 seconds per train, and an intertrain interval of 1 minute.
Ms. A was given five consecutive sessions during weeks 1 and 2 and three sessions during weeks 3 and 4. Her range of motor threshold was 66%–76%. Her scores on the Bech-Rafaelsen Mania Scale (3) slowly but continuously fell (28 on day 0, 24 on day 7, 15 on day 14, 10 on day 21, and 8 on day 28). Her sleep disturbance and thought disorder seemed to respond particularly well to rapid transcranial magnetic stimulation. Ms. A was dismissed from the hospital ward. Prophylactic treatment with the third-generation, putative mood-stabilizing anticonvulsant topiramate (4) was initiated for Ms. A for obesity.
Although new strategies in the treatment of acute mania are clearly needed (5), Grisaru et al.’s observation (1) that add-on treatment with right prefrontal rapid transcranial magnetic stimulation is effective in treating mania (showing laterality opposite to the proposed effect of rapid transcranial magnetic stimulation in depression) deserves particular interest. In this case, repeated monotherapy with right prefrontal rapid transcranial magnetic stimulation was effective and well tolerated in a patient with euphoric mania. Further systematic studies are needed.