Varied Antidepressant Response and Subjective Experience Across 3 Different Repetitive Transcranial Magnetic Stimulation Devices: A Case Report
Repetitive transcranial magnetic stimulation (rTMS) is an effective treatment for major depressive disorder (MDD).1 Since 2008, there have been 4 devices cleared by the Food and Drug Administration to treat MDD: NeuroStar TMS Therapy System (Malvern, PA),1 Brainsway Deep TMS System (Jerusalem, Israel),2 Magstim Rapid2 (Wales, UK),3 and Magventure (Farum, Denmark).4 There have been limited comparisons of device efficacy in populations with MDD,5 and little is known about comparing rTMS device efficacy in a single individual across multiple depressive episodes. We report a patient presenting with treatment-resistant MDD who had 3 separate rTMS treatment courses on 3 different devices (NeuroStar, Magstim, and Brainsway).
Mr A. is a 63-year-old white man presenting with recurrent, episodic MDD since age 40 years. Over the course of 3 years, he was referred to our TMS center on 3 occasions. Prior to each induction, a psychiatrist confirmed that he met the criteria for treatment-resistant MDD, having failed at least 4 prior antidepressant treatment courses across multiple classes in this case. Each induction is composed of 30 sessions (1 session a day, 5 consecutive sessions a week) and is concluded with a brief taper phase. An individual session consists of high-frequency stimulation performed over the left dorsolateral prefrontal cortex as per each device’s recommended protocol. The 24-item Hamilton Depression Rating Scale (HAMD-24)6 was administered before and after each induction to measure response. The Beck Depression Inventory II (BDI-II)7 was also administered on a weekly basis to assess response throughout the duration of treatment.
Mr A.’s first induction was performed using the NeuroStar device and consisted of 34 sessions (37 minutes, 3000 pulses at 10 Hz, 5.5 cm anterior to motor hotspot, 110% resting motor threshold [RMT]). He remained on stable doses of his medications, which included duloxetine, vilazodone, gabapentin, and methylphenidate. After 34 sessions, Mr A. reported at his final session that he “felt like a new person” and, on numerous occasions throughout this induction, that “the heavy weight on [his] shoulders [was] not there anymore.” He initially described the treatment itself as “very uncomfortable,” noting it felt like “a hammer on [his] head.” However, he was able to acclimate to the treatment after the first 5 sessions. Clinically, Hamilton scores decreased from 26 to 16 (38.46%) with a similar Beck reduction from 32 to 22 (31.25%).
Mr A. returned to the clinic for a second induction 13 months after his first induction ended, noting that his depression had returned and had again been unresponsive to antidepressant approaches. At that time, he was taking amitriptyline, atorvastatin, clonazepam, duloxetine, gabapentin, L-methylfolate, lisinopril, metformin, methylphenidate, quetiapine, tamsulosin, tolterodine, and vortioxetine. He began this second induction again on the NeuroStar device but was switched to Magstim Rapid2 device after 1 session because of intolerable discomfort. Neither he nor our clinical staff could identify a clear reason that his comfort level dropped so dramatically between courses. The remainder of this course of treatment consisted of 36 sessions on the Magstim Rapid2 device. The treatment parameters for Magstim were the same as his first induction, with the exception of the stimulation intensity, which was set at 120% of RMT instead of 110% RMT. Subjectively, he reported on his final session feeling slightly better overall than at the start of his second induction, although he also noted that he did not experience the desired reduction in depressive symptoms from TMS as compared with his first induction. Clinically, both the Hamilton and Beck scores decreased from 24 to 20 (16.67%).
Mr A. had a third induction more than 12 months after his second induction concluded.