Transcranial Direct Current Stimulation as Monotherapy for the Treatment of Auditory Hallucinations During Pregnancy: A Case Report

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To the EditorsAs outlined by treatment guidelines, the exposure to antipsychotic treatment during pregnancy is associated with several potential risks, such as preterm birth, elevated rates of impaired after-birth conditions, and higher incidence of congenital malformations. Furthermore, regarding the expectant mothers, increased rates of weight gain and pregnancy-related comorbidities have been described, especially in the case of polytherapy.1 Reflecting this clinically relevant treatment situation, transcranial direct current stimulation (tDCS) is gaining importance as a novel therapeutic option for pregnant patients with psychiatric disorders, such as depression2 and schizophrenia.3 As tDCS is viewed not to induce clinically detectable systemic effects, it has been proposed for the treatment of depressive episodes during pregnancy in a pilot clinical trial.4 Recently, Shenoy et al5 reported on the case of a 25-year-old pregnant woman (18th gestational week), who had been given a diagnosis of schizophrenia 9 years before and presented with auditory hallucinations. The patient was successfully treated with a combination of antipsychotic drugs (iloperidone 12 mg/d) and twice-daily 20-minute tDCS stimulation at 2-mA intensity for a period of 5 days (total of 10 stimulations).Here, we report the first successful treatment of auditory hallucinations in a pregnant woman with schizophrenia who received enhanced tDCS without concomitant antipsychotic treatment.The 36-year-old pregnant woman (32nd gestational week) was admitted to our hospital with symptoms of persecutory delusions, commentating and imperative vocal auditory hallucinations, and thought insertions. She had a history of paranoid schizophrenia with an onset at the age of 34 years. The diagnosis had been verified with an extensive clinical diagnostic work-up including cranial magnetic resonance imaging, electroencephalography, electrocardiography, standard laboratory, and lumbar puncture. During her first episode of illness in April 2014, remission was achieved with a treatment of aripiprazole 10 mg/d. The patient had chosen to discontinue her medication before becoming pregnant and developed her second psychotic episode during the third trimester of the current pregnancy. Upon actual admission, she received no psychiatric or other neuroactive medication. Physical examination as well as electroencephalography, electrocardiography, and standard laboratory showed no pathological results. Current pregnancy displayed no acute or chronic medical risks or abnormalities as was confirmed by an obstetrician. To ensure a shared treatment decision, we informed our patient about the potential risks of antipsychotic medication during pregnancy and offered tDCS as an alternative treatment option thoroughly explaining the intended tDCS procedure, safety parameters, and experimental use during pregnancy. After obtaining written informed consent and assessing potential individual risks (eg, history of migraine, epilepsy, stroke, other psychiatric and acute or chronic somatic disorders), we applied tDCS using an Eldith DC-Stimulator (NeuroConn, Ilmenau, Germany) with the anode over the left dorsolateral prefrontal cortex (F3) and the cathode over the left temporoparietal junction (Tp3) as previously reported in schizophrenia.5,6 On the basis of recent findings regarding the feasibility and safety of tDCS twice daily in patients with depression,7 we chose a similar enhanced stimulation protocol (tDCS at 2-mA intensity, 30-minute duration, twice daily, 3-hour interval). Overall, the patient received 20 stimulations within 2 weeks sparing the weekend. Clinical parameters were measured at baseline and after 2 weeks of treatment with the Positive and Negative Syndrome Scale (PANSS),8 Auditory Hallucination Rating Scale (AHRS),9 Calgary Depression Scale in Schizophrenia (CDSS),10 Clinical Global Impression (CGI),11 and Global Assessment of Functioning (GAF).12 A follow-up visit was performed 3 weeks after completion of the stimulation series.

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