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LETTERS TO EDITOR  
Year : 2021  |  Volume : 63  |  Issue : 2  |  Page : 199-200
Combining intensive repetitive transcranial magnetic stimulation with neurofeedback in a case of treatment-resistant depression


Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy

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Date of Submission19-Apr-2020
Date of Decision29-Apr-2020
Date of Acceptance18-Aug-2020
Date of Web Publication14-Apr-2021
 

How to cite this article:
Bruno A, Celebre L, Tagliavia G, Zoccali RA, Muscatello MR. Combining intensive repetitive transcranial magnetic stimulation with neurofeedback in a case of treatment-resistant depression. Indian J Psychiatry 2021;63:199-200

How to cite this URL:
Bruno A, Celebre L, Tagliavia G, Zoccali RA, Muscatello MR. Combining intensive repetitive transcranial magnetic stimulation with neurofeedback in a case of treatment-resistant depression. Indian J Psychiatry [serial online] 2021 [cited 2021 May 13];63:199-200. Available from: https://www.indianjpsychiatry.org/text.asp?2021/63/2/199/313714




Treatment-resistant depression (TRD) represents a challenge for psychiatry due to lack of proven pharmacological treatments.[1] Neuromodulation techniques are recognized and approved treatment strategies for depression, with a good safety and tolerability profile, to be used in augmentation for improving the efficacy and rapidity of action of antidepressant drugs.[2],[3],[4],[5]

To the best of our knowledge, this is the first clinical case that evaluates the effectiveness of the intensive repetitive transcranial magnetic stimulation/neurofeedback (rTMS/NFB) combination in treating TRD as potentially synergistic strategy to broaden the therapeutic effects from either intervention.

C., a 37-year-old man, due to a prolonged depressive episode nonresponsive to pharmacotherapy, was admitted to the hospital and according to the previous antidepressant treatments (citalopram, paroxetine, fluoxetine, duloxetine, mirtazapine, and clomipramine) was diagnosed as TRD. On admission, the patient was treated with fluoxetine 40 mg/day, sertraline 100 mg/day, mirtazapine 30 mg/day, lamotrigine 150 mg/day, lithium (slow-release formulation) 166 mg/day, clonazepam 3 mg/day, and pregabalin 150 mg/day. The patient provided written informed consent after a full explanation of the protocol design.

The sequential bilateral rTMS stimulation of left dorsolateral prefrontal cortex (lDLPCF) and right dorsolateral prefrontal cortex (rDLPCF) was provided twice a day over a 10-day period, for a total of 20 sessions. The lDLPFC was stimulated with a frequency of 10 Hz (3000 stimuli/session, 40 pulses/train, 75 total trains, 26 s inter-train interval) at 110% motor threshold for the hand muscles (MT). On the rDLPFC, rTMS was administered at 1 Hz frequency (1200 stimuli/session, 60 pulses/train, 20 total trains, 1 s inter-train interval) and 80% MT. NFB was administered twice daily, following each rTMS treatment, in 18/20-min sessions. The patient was trained to increase alpha and theta power at C3 and C4 in eyes open condition. Both visual and auditory feedbacks were provided.

Clinical assessment with Hamilton anxiety scale, Hamilton rating scale for depression, and Beck depression inventory was obtained at baseline (T0), after 10 rTMS/NFB sessions (day 5), and at the end of the protocol (day 10).

At baseline, the patient had severe depressive symptoms and moderate anxiety; initial results occurred after 10 rTMS/NFB, and at day 10, the patient was clinical remitted [Figure 1]. rTMS/NFB combination was safe and well tolerated; the only side effect reported by the patient was transient and mild headache at the beginning of treatment. Furthermore, due to improved clinical conditions, pharmacotherapy has been reduced (fluoxetine has been suspended; sertraline, mirtazapine, and clonazepam have been halved).
Figure 1: Clinical assessment at baseline (T0), after 10 repetitive transcranial magnetic stimulation/10 neurofeedback sessions (day 5) and at the end of treatment (day 10)

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Results from the present case demonstrated that intensive rTMS/NFB treatment, administered over the course of a 10-day period in twice sessions per day, was effective and well-tolerated, substantially improving depressive symptoms after 5 days of treatment and obtaining the total remission at the end of the observation period; a decrease in anxiety symptoms and a reduction in ongoing pharmacotherapy have also been observed. The results obtained are encouraging, although further studies are needed to better evaluate the persistence of the clinical improvement in the longer period.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Brown S, Rittenbach K, Cheung S, McKean G, MacMaster FP, Clement F. Current and common definitions of treatment-resistant depression: Findings from a systematic review and qualitative interviews. Can J Psychiatry 2019;64:380-7.  Back to cited text no. 1
    
2.
Sathappan AV, Luber BM, Lisanby SH. The dynamic duo: Combining noninvasive brain stimulation with cognitive interventions. Prog Neuropsychopharmacol Biol Psychiatry 2019;89:347-60.  Back to cited text no. 2
    
3.
Brunoni AR, Sampaio-Junior B, Moffa AH, Aparício LV, Gordon P, Klein I, et al. Noninvasive brain stimulation in psychiatric disorders: A primer. Braz J Psychiatry 2019;41:70-81.  Back to cited text no. 3
    
4.
Lantrip C, Gunning FM, Flashman L, Roth RM, Holtzheimer PE. Effects of transcranial magnetic stimulation on the cognitive control of emotion: Potential antidepressant mechanisms. J ECT 2017;33:73-80.  Back to cited text no. 4
    
5.
Marzbani H, Marateb HR, Mansourian M. Neurofeedback: A comprehensive review on system design, methodology and clinical applications. Basic Clin Neurosci 2016;7:143-58.  Back to cited text no. 5
    

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Correspondence Address:
Antonio Bruno
Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_351_20

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