A 25-year-old woman was brought to our psychiatric clinic for severe PTSD and depression with suicidal ideation. Her depressive symptoms developed at the age of 20 after she was verbally abused by a teacher and failed an important project. In addition to a depressed mood, she experienced a loss of interest, feelings of worthlessness, psychomotor retardation, and suicidal ideations. Her family brought her to a psychiatric clinic, where major depressive disorder (MDD) was diagnosed. She began taking escitalopram (10 mg/d increasing to 20 mg/d in 1 month) and receiving psychotherapy. Her symptoms of MDD gradually improved later and she could graduate from college on schedule.
However, in August 2020, she experienced unexpected verbal violence and threats from a colleague at her place of work. Her colleague often consumed alcohol, slammed doors, and swore at her, which caused her to feel stressed. She developed hyperarousal, re-experience (flashbacks and nightmares), avoidance (avoiding the office and her colleague), and transient auditory hallucinations (an unknown voice criticizing her), which persisted for more than a month. She then experienced a relapse of depression with suicidal ideation. PTSD and major depressive disorder were diagnosed according to the diagnostic and statistical manual of mental disorders-5 (DSM-5) criteria. Medications including escitalopram 20 mg per day (4 weeks), duloxetine 60 mg per day (4 weeks), venlafaxine 150 mg per day (4 weeks), and a combination of 60 mg duloxetine and 5 mg aripiprazole daily (4 weeks) were subsequentially used. She also received psychotherapy for 4 weeks. However, she did not respond well to these medications and suffered from the drug side effects including dizziness, nausea, and weight gain. She refused additional antidepressant treatment and kept venlafaxine 150 mg per day. Therefore, she was referred to our brain stimulation center for an rTMS consultation. Her family has no history of MDD or PTSD.
We used the Davidson Trauma Scale (DTS) to evaluate the severity of her PTSD. The DTS yields a frequency score (ranging from 0 to 68). The Beck Depression Inventory (BDI) was used to evaluate the severity of her depression. The Beck Anxiety Inventory (BAI) was used to measure the severity of her anxiety symptoms. The BDI and BAI yields a frequency score (both ranging from 0 to 63). The severity of PTSD, depression, and anxiety increases with the scores. Higher scores mean worse PTSD, depression, and anxiety. She scored 62, 52, and 34 points on the DTS, BDI, and BAI, respectively.
After the patient provided signed informed consent, we adopted a new rTMS treatment, theta-burst stimulation (TBS), of the bilateral DLPFC with an Apollo TMS Therapy stimulator (MAG and More, Munich, Germany) equipped with a figure-of-eight coil. First, we applied cTBS with 20 trains of 10 bursts (short bursts of 3 stimuli at 50 Hz, repeated at 5 Hz), with 600 pulses for 40 s at 80% RMT, targeting the right DLPFC. Second, we applied iTBS with 20 trains of 10 bursts (short bursts of 3 stimuli at 50 Hz, repeated at 5 Hz) given at 8 s intervals at 600 pulses for 200 s at 80% RMT, targeting the left DLPFC. After a 20-min intersessional rest period, we performed a second round of iTBS for 200 s, targeting the left DLPFC. Our design consists of 3 sessions, first two (cTBC, iTBS) being sequential and then with 20 min break before the 2nd iTBS session. The patient received 1,800 pulses in each treatment and total 18,000 pulses in the whole treatment course. The coil localization was based on the algorithm developed by Beam et al.. The Beam-F4 position was used for the right DLPFC and the Beam-F3 position was used for the left DLPFC. Because of her daily work and the COVID-19 pandemic, she cannot visit our department every day. The subsequent stimulation sessions were performed two to three times per week. We completed a total of 10-day (30 sessions) within 4 weeks (Figure 1).
The patient's PTSD and depressive symptoms gradually improved. After TBS treatment course, her symptoms improved (scores of 42, 7, and 4 on the DTS, BDI, and BAI, respectively) (Table 1). For the DTS scale assessment, symptom item 14 (increased irritability) and 15 (concentration difficulties) improved the most, from 4 to 1. The side effects of the treatment, such as dizziness or headache, were transient and disappeared after the TBS treatment finished.