Transcranial Magnetic Stimulation (TMS) in Depression – Case Study
Mr OB is a 31-year-old man who is a qualified teacher and semi-professional Actor. He has never worked full time as a teacher due to his chronic depression symptoms which have been problematic for most of the last 10 years.
He had neglected his acting opportunities and was not working at all in either amateur or professional roles in the 12 months prior.
He had a diagnosis of major chronic depression and had deteriorated markedly over previous 2 years.
Mr OB’s depression symptoms include anergia (tiredness), anhedonia (lack of pleasure), chronic low mood and avoiding virtually all social contacts. He was living with his parents who supported him and had not had any relationships in last 2 years. ( Read more about symptoms of depression )
His treating psychiatrist had been managing his Chronic depression over the last 5 years and would see Mr OB for fortnightly to monthly appointments. Mr OB was referred for Transcranial Magnetic Stimulation (TMS) treatment.
At the time of commencing TMS, his current medication was
- Lamotrigine 400mg a night,
- Agomelatine 50mg a night and
- Quetiapine 75 mg at night
Mr OB, by his own account, had “tried everything” including Zoloft (sertraline), Effexor (venlafaxine), Lithium, Epilim (valproate), Prothiaden, Dexamphetamine and Zyprexa (olanzapine) and numerous other medications for depression which he was not able to recall.
Also, Mr OB was admitted for 5 weeks to a private psychiatric hospital in 2007, and although electroconvulsive therapy (ECT) was considered, it was not proceeded with.
Mr OB did not want to consider ECT and was very concerned about cognitive effects and being hospitalised, which had led him to explore TMS as an option.
Regarding his safety profile for TMS; Mr OB had no history comorbid medical conditions, head injuries, seizures or epilepsy. He has no implantable devices, and he had previously had MRI scans of his head, at least once in the last 5 years with no complications.
Mental State Examination:
He was a neatly groomed, but depressed, weary and had poor concentration, low energy and felt his mood had been chronically low for some time.
There were no risks of suicide or self-harm at the time of initial review.
Diagnostically, Mr OB had major chronic depression. He has failed to respond to his current medication regime and indeed has tried multiple anti-depressant medications and similarly had poor results.
The initial TMS treatment plan for Mr OB was:
- 30 sessions of Left Pre-frontal Cortex 10Hz (High Frequency) TMS given over 6-8 weeks
- Monitor his progress using the Quick Inventory of Depressive Symptoms (QIDS) Self Report (SR) and Clinician (C) scales as well as the Global Assessment of Function (GAF) over the course of his treatment
rTMS is now recommended in all relevant depression treatment guidelines as an approach that should be considered in the standard care of patients with depression.
The RANZCP College guidelines advocate that consideration only be given to rTMS after: [Malhi et al., 2020]
A reasonable number of adequate trials of pharmacotherapy and psychological treatment choices and adequate trials of alternatives (including augmentation strategies and those not suitable for ECT or have chosen not to pursue this treatment) have been provided and that additionally for severe or psychotic depression, ECT is the preferred treatment.
The availability of rTMS should not interfere with the delivery of effective psychological and/or pharmacological treatment strategies and it should not delay the administration of ECT. [Malhi et al., 2021]
In our personal experience, response rates in the order of 60-70% and remission rates of 35% in high treatment-resistant depressive illness. The treatment itself is usually very well tolerated and has minimal side effects. (Read more on TMS and review of the evidence)
At the initial treatment planning session, Mr OB’s resting motor threshold (RMT) was elicited using TMS stimulus to the motor cortex to evoke a physical movement in the right Abductor Pollicis Brevis.
In Mr OB’s case, his RMT was determined to be 57%, in the mid-range of RMT’s observed in patients.
His treatment was commenced at a dose of 1.2 x RMT (68%) – High dose depression treatment.
Mr OB commenced a program of daily outpatient TMS treatment using a depression treatment TMS protocol.
As he was an outpatient, he was able to continue his day to day activities.
He responded slowly with his initial improvements being noted after about 20 sessions (approximately 4 weeks of treatment). He continued his acute treatment regime for a total of 8 week – having 40 treatments over 8 weeks.
During his TMS treatment, there was a marked improvement in his depression rating scores (graph below) demonstrating remission of chronic depression symptoms.
He continued maintenance TMS following his acute course of TMS. This was initially one treatment a week, but after 2 months this was reduced to 1 treatment every 2 weeks
Mr OB reported major changes in his daily habits. His energy levels improved, he became more social, he felt his mood lightened.
In particular, his function dramatically changed, he participated in a number of amateur acting productions and then obtained paid acting work in theatre productions.
He started seeing his friends more and commenced a new intimate relationship. His frequency of visits to his treating psychiatrist to 4-8 weekly visits.
His confidence and motivation towards making positive changes in his life increased.
Also, he noted that the usual pre-Christmas downturn in his mood that had materialised every year for the last 5 years did not occur to him following his TMS treatment.
The plan is for Mr OB to continue outpatient maintenance TMS treatment over the next 12 months and then re-assess the need for TMS towards the end of 2018.
Mr OB’s treating psychiatrist has stopped his Quetiapine and Lamotrigine.
Mr OB is still taking Agomelatine 50mg a night.
In consultation with his treating psychiatrist, Mr OB is considering stopping Agomelatine and relying entirely on TMS for his maintenance anti-depressant strategy.
If he does this, he is likely to continue maintenance TMS beyond the 12-month initial maintenance term.
Transcranial magnetic stimulation (TMS) is a safe and evidence based treatment option for depression and should be considered in patients that have not responded to medications or those that have had side effects to medications.