Daily Left Prefrontal Repetitive Transcranial Magnetic Stimulation for Acute Treatment of Medication-Resistant Depression

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Daily left prefrontal transcranial magnetic stimulation (TMS) over several weeks was first proposed as a treatment for depression in 1993, with double-blind study beginning in 1997. TMS for the treatment of depression was approved by the U.S. Food and Drug Administration (FDA) in October 2008 (1). More recently, a large trial sponsored by the National Institutes of Health using an innovative sham treatment technique found that a course of active treatment for 3–5 weeks was superior to sham treatment (remission rates were 15% in the active treatment group and 5% in the sham treatment group) and achieved a 30% remission rate in the open-label extension. These findings led to the implementation of the first new Current Procedural Terminology codes for psychiatry since the American Medical Association launched the system in 1966. In the vignette we describe the case of a 55-year-old woman with treatment-resistant recurrent unipolar depression who was successfully treated with repetitive TMS (rTMS) in each of two episodes 3 years apart. Numerous questions remain on the use of TMS for depression, several of which are raised by the case description. They include how to most effectively deliver rTMS—for example, the appropriate scalp location, the optimal “dose” (frequency, train, number of stimuli per day, and pattern of delivery), its use in combination with medications or talking/exposure therapy, and whether one can use maintenance rTMS to prevent relapse after a patient achieves remission. Daily left prefrontal rTMS reflects a paradigm shift in psychiatry in that it uses noninvasive and nonconvulsive circuitbased physiological processes to treat depression in patients who have not responded to medications or who cannot tolerate them.