Repetitive Transcranial Magnetic Stimulation for Treatment of Depression in a Patient With Severe Traumatic Brain Injury

CASE REPORT

A 37-year-old male with a medical history of anxiety and bipolar disorder type I sustained a 60-foot fall in July 2015 from a suicide attempt. The fall resulted in a closed head injury and multiple rib and pelvic fractures. The patient was in a coma for 11-12 days with a Glasgow Coma Scale score of 3. He required an intensive care unit stay with a tracheostomy tube for respiratory support. Initial brain scans with gradient recalled echo T2-weighted imaging showed diffuse axonal injury (Figure). This type of magnetic resonance imaging (MRI) allows for greater sensitivity in detecting microhemorrhages compared to conventional MRI or computed tomograpy imaging.¹⁴ After discharge from the hospital, the patient was admitted to a neurologic rehabilitation facility where he initially endorsed cognitive decline and visual processing deficits. He also displayed signs of dysarthria, intermittent dysphagia, and retrograde and anterograde amnesia with no recollection of the accident, in addition to self-reported fatigue and insomnia. The patient physically improved at the rehabilitation facility until discharge in October 2015 but continued to endorse severe depressive symptoms with recurrent suicidal ideation. Symptoms were refractory to increased dosages of his psychiatric medications that included bupropion 300 mg daily before noon, olanzapine 5 mg at bedtime, oxcarbazepine 150 mg twice daily, and lamotrigine 100 mg daily. Trazodone 100 mg at bedtime was added to manage insomnia. A multifaceted approach was adopted in collaboration with the patient's neurologist in an attempt to control his mood symptoms, including pet therapy, supportive groups (eg, regular church attendance, National Alliance on Mental Illness group meetings), and lifestyle modifications. In March 2016, the attending psychiatrist changed the patient's medication regimen, substituting quetiapine 200 mg for olanzapine because of lack of response and adding methylphenidate 40 mg daily to improve concentration. Despite these changes, the patient continued to endorse suicidal ideation, and his ability to function (eg, live independently, interact with others in social situations) remained dramatically impaired. Because of the severity and refractory nature of his condition, he was referred to an outside psychiatrist to discuss the possibility of rTMS therapy. Of note, the patient did not endorse any manic symptoms throughout these evaluations, and he did not experience any posttraumatic seizure following the TBI.

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Figure. Gradient recalled echo sequence shows hemosiderin deposition consistent with mild diffuse axonal injury (arrows).

An rTMS treatment course was adopted using standard depression protocols.¹⁵ The patient's rTMS treatment apparatus consisted of the NeuroStar TMS Therapy System (v.2.3.3). Coil position was set at 10.3 cm anterior/posterior, zero-degree angle, and stimulus onset asynchronies of 33 degrees. The patient underwent 30 treatment sessions in the outpatient setting (5 days of therapy per week for 6 weeks) of 1-hour and 2-minute duration per session. High-frequency stimulation at 6 Hz over the left dorsolateral prefrontal cortex was used. Treatment was set at a standard motor threshold (MT) level of 1.62 with treatment intensity at 120% of MT level, a 4-second stimulation time, and a 26-second interstimulation interval for a total of 3,000 pulses administered per session. The patient completed the treatment course between March 2016 and May 2016.

The patient's mood symptoms were quantitatively evaluated throughout the treatment protocol using the Patient Health Questionnaire-9 (PHQ-9) to self-report mood symptoms during psychiatry visits. The patient scored 24 on the PHQ-9 after 1 week of rTMS therapy, placing him on the severe depression spectrum. As shown in the patient's weekly scores (Table), mood improvement was observed within 2 weeks of initiating treatment when the patient's score decreased to 16 (moderately severe depression). After 1 month of therapy, the patient reported being more functional and was able to relocate to an apartment and live by himself without further endorsement of suicidal ideation. At the end of 6 weeks of therapy, the patient's score improved to 7 (mild depression), constituting a 70.8% reduction in score from the beginning to the conclusion of his rTMS treatment protocol. The patient was regularly followed by the psychiatrist and neurologist who did not note clinical or self-reported adverse effects to the therapy.

Subsequent visits focused on community reintegration, which included defining interests, long-term life goals, and the possibility of obtaining employment. The patient was amenable to volunteering at the rehabilitation facility where he had resided during the initial treatment for his TBI. At 2-year follow-up, he has not endorsed further mood decompensations or suicidal ideation, he has not required additional hospitalizations, and he maintains functional independence by living in his own apartment. He remains on the same medication regimen and reports adequate compliance with no severe adverse effects.