Maintenance Treatment With Transcranial Magnetic Stimulation in a Patient With Late-Onset Schizophrenia

“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.