Abstract
Abstract Background/Objectives: Repetitive transcranial magnetic stimulation is an effective adjuvant therapy to treat depression. Recently developed double-cone shape coils could stimulate deeper regions in the brain. There is limited evidence about the efficacy of double-cone coil stimulation in patients with treatment resistant depression and comorbid severe anxiety. This study is aimed to provide preliminary evidence of efficacy of Intermitent Theta Burst over the left dorsolateral prefrontal cortex (DLPFC) followed by 1Hz over the right DLPFC on improving symptoms of depression and anxiety in a naturalistic setting. Methods: Over a 2-year period, 38 outpatients (26 male and 12 female) were recruited from "Instituto de Neuroestimulación de Lima" diagnosed with treatment resistant depression (baseline PHQ-9 ≥ 10) and severe anxiety (baseline Hamilton Rating Scale for Anxiety ≥ 20 [HAM-A]). The average of previous failed treatments was 3.92 (SD=1,74). An average of 22.26 daily sessions were scheduled over a month to deliver Theta burst triplets at 85% of resting motor threshold followed by continuous pulses of 1Hz at 120% resting motor threshold for a combined total of 29 minutes and 46 seconds using a Neuro-MSX device from Neurosoft. Pharmacological treatment used was categorized by therapeutic drug class. The average number of concomitant medications taken during bilateral rTMS treatment was 2.79 (SD=1,09). Results: 76.3% (n=29) achieved response by reducing at least 5 points in PHQ-9 scale while 47,3% (n=18) achieved response to anxiety symptoms (at least 50% reduction HAM-A). Response rate was higher among patients with increased severity at baseline (p=0.002). Although the study was not powered to find differences in concomitant treatments, patients receiving benzodiazepines (n=17) showed less decline in depression symptoms (p=0.048). Conclusion: Sequential bilateral rTMS using a double-cone coil improved depression and severe anxiety symptoms. Benzodiazepines might impair response to treatment and this should be confirmed with sham-controlled studies and larger samples. Keywords: Bilateral rTMS, Double-cone coil, Treatment resistant depression, Severe Anxiety
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