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Transcranial Magnetic Stimulation Maintenance as a Substitute for Maintenance Electroconvulsive Therapy: A Case Series

Cristancho, Mario A. MD*; Helmer, Amanda RN; Connolly, Ryan MD; Cristancho, Pilar MD§; O’Reardon, John P. MD

doi: 10.1097/YCT.0b013e31827a70ba
Original Studies

Background Transcranial magnetic stimulation (TMS) is an efficacious, well-tolerated, noninvasive brain stimulation treatment for major depressive disorder. Electroconvulsive therapy (ECT) is an effective maintenance treatment for depression but is not tolerated by some patients and declined by others.

Objective We evaluated the effectiveness of TMS as a substitution strategy for successful maintenance ECT.

Methods A consecutive clinical case series (n = 6) of maintenance ECT patients were transitioned to maintenance TMS because of adverse effects from ECT or because of specific patient request and preference. Patients were in either full remission or had clinical response to ECT at the time of transition. Primary outcome was the change in the Beck Depression Inventory (BDI) score from initiation of TMS maintenance sessions to the last observation time point. Relapse of depressive symptoms was also documented.

Results Mean age of patients was 64 years, and most were female (n = 5). The majority (5 of 6) were diagnosed with major depressive disorder. Reasons for transition from ECT to TMS were, in order of frequency, cognitive adverse effects, fear of general anesthesia, time burden, lack of remission with ECT, and stigma associated with ECT. The mean frequency of TMS sessions was 1 every 3.5 weeks. Based on BDI scores, all patients maintained or improved their clinical status achieved with ECT at 3 and 6 months of TMS treatment. At last observation (range, 7–23 months), 4 patients maintained or improved their clinical status (total BDI score remained constant or decreased by 1–8 points). Two patients had a relapse after 8 and 9 months. Stimulation was well tolerated with adverse effects limited to headache and scalp discomfort.

Conclusions In this case series, TMS was effective and safe when used as a substitution strategy for successful maintenance ECT.

From the *Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA; †Center for Mood Disorders & Neuromodulation Therapies, Department of Psychiatry, University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, Stratford, NJ; ‡VISN 4 MIRECC, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA; and §Department of Psychiatry, Washington University, St Louis, MO.

Received for publication June 2, 2012; accepted October 22, 2012.

Reprints: Mario A. Cristancho, MD, Suite 2087, 3535 Market St, Philadelphia, PA 19104 (e-mail:

Dr Cristancho is supported through the National Institute of Mental Health–funded Clinical Research Scholars Program of the Department of Psychiatry, University of Pennsylvania.

© 2013 by Lippincott Williams & Wilkins