Fitzgerald et al. report rTMS treatment for a pharmacotherapy-resistant 41-year-old female patient with severe recurrent depression [Montgomery-Asberg Depression Rating Scale (MADRS) = 34; Inventory of Depressive Symptomology-Clinical Rated (IDS-CR) = 49] persisting for 14 years with onset following a mild closed-head TBI and no prior history of brain injury. Magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI) demonstrated no contraindication to rTMS and no presence of diffuse axonal injuries. Desvenlafaxine was held at a constant dosage 8 weeks prior to treatment and throughout the course of rTMS. Active sequential bilateral rTMS was administered to the DLPFC (right-sided low-frequency rTMS followed by left-sided high-frequency rTMS). A single stimulation train (1 Hz, 900 pulses/session) administered at 110% of resting MT during right-sided low-frequency rTMS was immediately followed by 30 trains (10 Hz, 5 s train duration, 25 s inter-train interval), at 110% of resting MT for left-sided high-frequency rTMS. The patient showed a positive response to treatment with a greater than 50% reduction in depressive symptoms (MADRS = 14; IDS-CR = 21). Neuropsychological assessments of attention, concentration, working memory, speed of information processing, verbal and visual memory, perceptual ability, and executive functioning showed no deleterious changes in cognitive performance. No adverse side effects of treatment were reported.
George et al. administered high-frequency rTMS (10 Hz, 5 s train duration, 10 s IT for 30 min) at 110% resting MT over the left prefrontal cortex to suicidal inpatients (Beck Scale of Suicidal Ideation score >=12 and >=3 on Question #3 of the Ham-D) in a randomized, sham-controlled study. Each session delivered 6000 pulses over 30 min, and sessions were repeated three times daily with 1 h between sessions for 3 days (total 9 sessions and 54,000 pulses). 41 patients with a diagnosis of either PTSD or mTBI were recruited for this study (20 active and 21 sham). Of these patients, 21 individuals had previously suffered a TBI (13 active and 11 sham). The protocol was generally well tolerated with no major side effects, although one patient suffered a first-degree scalp burn from coil overheating. The authors report a trend toward a more rapid change in SSI in the active rTMS group compared to the sham group, but there was no overall difference in the change in SSI between groups. Patients showed a reduction in how much they were bothered by thoughts of suicide, but they demonstrated no difference in future intent of suicide, thoughts of suicide, self-rated sadness, tiredness, or happiness. The authors note that patients continued to receive standard inpatient care - including changes in medication - throughout the study, so the observed results cannot be separated from any non-specific hospitalization effect. Results were not broken down between patients with PTSD and TBI, so conclusions cannot be drawn regarding the efficacy of this protocol specifically in relation to TBI. However, the fact that this rather aggressive protocol was generally well tolerated demonstrates its feasibility.