Jerónimo Sáiz, professor at Universidad de Alcalá de Henares and head of the Psychiatric Service at Hospital Ramón y Cajal, and I, Dr. F. Sanjuán, neurosurgeon and medical director of “Neurocavis” Neuromodulation and Research Unit, traveled to New York last October 3rd on the occasion of presenting a poster at the American Psychiatric Association (APA) congress. We presented a clinical case of a 32 year old male patient diagnosed of resistant depression. He experienced an epileptic seizure of short duration while being administered deep Transcranial Magnetic Stimulation (dTMS) treatment which resulted in a positive response for his depression and without subsequent consequences.

This is a healthy patient, without a family o personal history of epileptic seizures, affected by a long-lasting resistant depression. After the administration of 20 sessions of dTMS, as recommended by the protocol, and having experienced a considerable clinical and psychometric improvement in the Hamilton Depression Rating Scale, he decided to extend the treatment to reinforce its improvement. In the first prolongation session, he experienced a generalized tonic-clonic crisis of about 15-20s of duration that gave away spontaneously. The probability of developing an epileptic seizure in patients without precedents through dTMS is estimated to be less than 0.1%

A prolonged seven-hour EEG study was performed in order to examine all his brain activity and rule out the presence of waking and/or sleep abnormalities. Given the absolute normality of the outline obtained, brain impregnation with Benzodiazepines was performed at anxiolytic doses: 15mg intramuscular of Valium the night before and 10mg orally one hour before treatment. With this guideline, another four sessions of dTMS were administered, one weekly, until the reinforce treatment was completed. His improvement allowed him to reduce his medication by only taking two out of the five medicines he was prescribed and retaking his job as a local policeman.

Conclusion

In extraordinary cases of intolerance or poor response to medication in resistant depression, aggravated by autolytic thoughts or attempts, treatment options beyond psychotherapy, meditation or physical activity are therapeutic alternatives limited to electroconvulsive therapy. Now, in an adjunctive way, we count on “non-invasive” techniques of brain neuromodulation such as Transcranial Direct Current Stimulation (tDCS) and repetitive Transcranial Magnetic Stimulation (rTMS), either superficial or deep. Among the latter, deep TMS has shown clear signs of improving the response obtained by superficial stimulation, limited to the left dorsolateral prefrontal cortex (left DLPFC). Thus, deep TMS is preferred over superficial TMS since it reaches greater subcortical regions.

The development of preliminary studies contemplating the combination of dTMS and the use of benzodiazepines in serious resistant depressions is an option to consider in future clinical trials.

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