Objective: Deep transcranial magnetic stimulation (TMS) with an H-1 coil was recently approved by the U.S. Food and Drug Administration (U.S. FDA) for treatment-resistant depression (TRD) in adults. Studies assessing the safety and effectiveness of deep TMS in adolescent TRD are lacking. The purpose of this brief report is to provide a case history of an adolescent enrolled in an investigational deep TMS protocol. Methods: A case history is described of the first participant of a sham-controlled clinical trial who had a seizure in the course of deep TMS with parameter settings extrapolated from the adult studies that led to US FDA approval (H-1 coil, 120% target stimulation intensity, 18 Hz, 55 trains of 2-second duration, total 1980 pulses). Results: The participant was a 17-year-old unmedicated female, with no significant medical history and no history of seizures or of drug or alcohol use. Brain magnetic resonance imaging showed no structural abnormalities. She initially received sham, which was well tolerated. During active treatment sessions, titration began at 85% of motor threshold (MT) and increased by 5% per day. Her weekly MT measurements were stable. On her first day of 120% MT (8th active treatment), during the 48th train, the participant had a generalized, tonic-clonic seizure that lasted 90 seconds and resolved spontaneously. She had an emergency medicine evaluation and was discharged home without anticonvulsant medications. There were no further seizures reported at a 6-month follow-up. Conclusions: We report a deep TMS-induced generalized tonic-clonic seizure in an adolescent with TRD participating in a clinical trial. Given the demonstrated benefits of deep TMS for adult TRD, research investigating its use in adolescents with TRD is an important area. However, in light of this experience, additional precautions for adolescents should be considered. We propose that further dose-finding investigations are needed to refine adolescent-specific parameters that may be safe and effective for treating adolescents with TRD with deep TMS.

Case 3Patient 3 is a 58 y/o woman with 2 months of delusional thinking. According to her family, she was disorganized and unsafe in the home. She called police due to paranoid delusions and requested admission for her safety. She declined medication. She felt that her family was plotting against her and that people were watching her through hospital windows. Her husband reported that when she was entering menopause, she had a very similar episode where she became delusional and paranoid, and acted on delusional content. She was treated at an outside hospital for depression at that time, and stabilized on citalopram. She then was stable without medication for 5 years, until two months prior to this presentation. The result of her hospitalization was civil commitment for psychiatric treatment and olanzapine therapy, which was effective. She declined a first episode workup, and did not offer a reproductive history. The patient was not pregnant nor on hormone replacement therapy.

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