Remotely Supervised Transcranial Direct Current Stimulation After ECT Improves Mood and Cognition in a Patient With Multiple Sclerosis: A Case Study

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To the Editor:
Transcranial direct current stimulation (tDCS) is an evolving investigational therapeutic technique that utilizes low-amplitude direct current delivered through electrodes placed on the scalp. It is safe and well tolerated1 and has potential for the management of mood disorders.2–4 In contrast to the cognitive involvement that may occur with electroconvulsive therapy (ECT), tDCS may enhance cognitive function.5 We have developed a remotely supervised tDCS protocol (RS-tDCS) to deliver tDCS in combination with cognitive remediation at home using videoconferencing for real-time monitoring, allowing for extended treatment sessions.
Mood disorders are a common comorbidity in multiple sclerosis (MS), with symptoms often including depression as well as cognitive impairment. Interventions beyond or in addition to pharmacological management are needed. Here, we report the benefits of extended tDCS treatments in a patient with MS after repeated courses of both unilateral and bilateral ECT treatments. The patient was a 54-year-old woman with a 20-year history of MS (secondary progressive subtype; moderate neurological disability) and severe recurrent episodes of depression in the context of bipolar I disorder. The patient experienced a decline in cognitive functioning marked by memory loss after the bilateral ECT treatments.
She was enrolled in an ongoing, open-label clinical trial administering 40 RS-tDCS sessions (RS-tDCS; 2.0 mA × 20 minutes, dorsolateral prefrontal cortex left anodal montage) combined with cognitive training during the stimulation. Transcranial direct current stimulation was well tolerated with only minimal and transient tingling and itchiness at site of electrodes. There was high compliance with all sessions completed successfully.
Cognitive testing, mood, and symptom inventories (Positive and Negative Affect Schedule or PANAS, PROMIS Fatigue) were administered at baseline and follow-up, along with daily pre- and post-session mood and fatigue ratings. She progressed through working memory and information processing adaptive cognitive training exercises completed during stimulation. After completion of all sessions, the Hamilton Depression Rating Scale score dropped from 15 to 11 and mood improved across sessions as shown by linear increases in positive affect. Cognitive testing was administered at the baseline and follow-up visits and included information processing tests (Cogstate Battery and Symbol Digit Modalities Test) and story and list learning memory tasks for verbal learning. The scores on all measures consistently and significantly improved from baseline to after the completion of tDCS study sessions.

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