Repetitive Transcranial Magnetic Stimulation to Maintain Treatment Response to Electroconvulsive Therapy in Depression: A Case Series

Abstract

Electroconvulsive therapy (ECT) is the most effective treatment for a refractory major depression in the context of both unipolar and bipolar affective disorders. However, the relapse rate within the first 6 months after a successful course of ECT to treat a depressive episode can be as high 50%. Evidence-based strategies to prevent relapse have partial efficacy and are associated with problematic adverse effects limiting their use as long-term treatments. Repetitive transcranial magnetic stimulation (rTMS) has demonstrated efficacy in treatment-resistant depression with a favorable adverse effect profile. Herein, we describe six patients, four with unipolar and two with bipolar depression, where rTMS was used to maintain response after a successful course of acute and continuation ECT. rTMS was administered once or twice weekly, at 120% of the resting motor threshold. Patients received sequential bilateral rTMS (low frequency right: 600 pulses, then high frequency left: 3000 pulses). The site of stimulation was 6 cm anterior and 1 cm lateral from the site of maximum stimulation of the abductor pollicis brevis muscle. Depressive symptoms were monitored with the quick inventory of depressive symptoms-self rated. Five of the six patients were able to maintain their response status from 6 to 13 months at the time of last observation. The use of rTMS may be an important relapse prevention strategy following an acute course of ECT. Controlled studies comparing rTMS to current evidence-based relapse prevention strategies are warranted.

Deep transcranial magnetic stimulation (dTMS) – beyond depression

“…The H1-coil is the most tested coil, and every dTMS center should have one. It should be used for patients with depression who have failed any number of medications before trying ECT, and it can be used after ECT as a maintenance strategy in lieu of ECT maintenance [97,98]. There is early data suggesting that higher numbers of pulses may be helpful for patients with psychotic depression or schizoaffective disorder depressive phase as well as patients who failed ECT [42,43], the H1 is helpful for the negative symptoms of schizophrenia [46,62].…”

Augmentative Repetitive Transcranial Magnetic Stimulation (rTMS) in the Acute Treatment of Poor Responder Depressed Patients: A Comparison Study Between High and Low Frequency Stimulation

“…For instance, Hadley et al [19] stressed the potential of HF-rTMS in rapidly reducing suicidal ideation, similarly to electroconvulsive therapy (ECT). Furthermore, two recent studies [7,35] evaluated the effectiveness of rTMS as maintenance treatment after acute ECT, reporting encouraging results [25].…”

Do we need to know more about repetitive transcranial magnetic stimulation in the treatment of depression?

“…Milev et al, 2016), they do not address the substitution of effective ECT. Two small case series (Cristancho et al, 2013; Noda et al, 2013) have found that rTMS may be successfully substituted (such that it maintains or improves clinical status) for maintenance ECT terminated due to tolerability issues. This suggests that consideration of a trial of rTMS in this case was perhaps appropriate, albeit somewhat experimental.…”