Combined transcranial magnetic stimulation and ketamine for treatment of refractory mood disorder, anxiety, and pain: A case report (original) (raw)
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Heliyon
Background: Both transcranial magnetic stimulation (TMS) and infused ketamine are recognized treatments for patients suffering from major depressive disorder (MDD). A novel therapy named combination TMS with ketamine (CTK) is introduced. This retrospective review examined the safety and clinical benefits of CTK in patients suffering from treatment-resistant depression (TRD) during the routine practice of psychiatry in a private clinic. Methods: TRD patients (N ¼ 28) received a coincident application of high-output TMS (30 minutes) with biomarker-determined ketamine infusions (20 minutes). Frequency of treatment was dependent on patient responsiveness (10-30 sessions). Clinical global impression (CGI) data was collected pre-and post-treatment and then two years later. Results: The mean reduction in CGI severity for the patient group following CTK was 4.46 AE 0.54 at a 99% confidence interval and was deemed statistically significant using a paired t-test (α ¼ 0.01, t ¼ 22.81 p < 0.0001). This reduction was sustained for two years following treatment completion and this remission was deemed statistically significant by a second paired t-test (α ¼ 0.01, t ¼ 27.36, p < 0.0001). Limitations: Retrospective review of a limited number of patients undergoing CTK in a clinical practice. Conclusions: This clinical review indicated that CTK is an effective, long-term therapy (after two years) and can be used for TRD patients. The coincident administration of ketamine allowed for higher TMS intensities than otherwise would be tolerated by patients. Further studies for optimization of CTK are warranted.
Frontiers in Psychiatry, 2022
Depression is a common mental disorder that affects many people worldwide, while a significant proportion of patients remain non-responsive to antidepressant medications. Alternative treatment options such as ketamine therapy and repetitive transcranial magnetic stimulation (rTMS) therapy are offered nowadays. This study aims to describe and compare the acute antidepressive efficacy of both, intramuscular ketamine and rTMS in depression patients seeking help in a naturalistic clinical mental health setting. The clinical records of 24 patients with treatment resistant depression were collected from the clinical base of a real life clinic. Twelve patients were treated with intramuscular ketamine, twice weekly for 8 sessions, and twelve patients were treated with 30 sessions of left dorsolateral prefrontal cortex – intermittent theta-burst stimulation (DLPFC-iTBS). Using three clinical assessments (HDRS, HAM-A, BDI-II), our data reveal that both therapies led to significant improvement...
Brain Stimulation, 2023
What is the role of intravenous ketamine in treatment-resistant major depressive disorder (MDD)? Response BACKGROUND MDD is defined as at least a 2-week period of either depressed mood or anhedonia that lasts virtually all day and nearly every day. 1 For diagnosis, patients must also have 4 or more of the following symptoms: changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation, plans, or attempts. Symptoms must be new or a clear change from baseline and must be accompanied by clinically significant distress or impairment in societal, occupational, or other essential areas of functioning. Additionally, the depressive episode should not be accompanied by manic or hypomanic periods or due to current substance abuse or other general medical conditions. 1 An estimated 10 million American adults are affected by MDD each year, with up to one third of these patients failing to achieve remission after multiple drug trials. 2 The definition of treatment-resistant MDD is controversial, although it is often defined as 2 or more failed, adequate an-tidepressants trials. 3,4 Treatment-resistant MDD is associated with significant morbidity that results in a negative impact on US health outcomes and societal productivity. 5-7 A retrospective analysis of medical claims revealed that patients with treatment-resistant MDD were twice as likely to be hospitalized and had total medical costs more than 6 times those of their non-treatment-resistant comparators. 8 The pathophysiology of MDD is not fully understood, although it is documented that central nervous system (CNS) neurotransmitters (ie, serotonin, norepinephrine,
Frontiers in Psychiatry
About a third of patients suffering from major depression develop treatment-resistant depression (TRD). Although repetitive transcranial magnetic stimulation (rTMS) and intravenous ketamine have proven effective for the management of TRD, many patients remain refractory to treatment. We present the case of a patient suffering from bipolar TRD. The patient was referred to us after failure to respond to first-and second-line pharmacotherapy and psychotherapy. After minimal response to both rTMS and ketamine alone, we attempted a combination rTMS and ketamine protocol, which led to complete and sustained remission. Various comparable and complimentary mechanisms of antidepressant action of ketamine and rTMS are discussed, which support further study of this combination therapy. Future research should focus on the feasibility, tolerability, and efficacy of this novel approach.
Journal of Affective Disorders, 2023
What is the role of intravenous ketamine in treatment-resistant major depressive disorder (MDD)? Response BACKGROUND MDD is defined as at least a 2-week period of either depressed mood or anhedonia that lasts virtually all day and nearly every day. 1 For diagnosis, patients must also have 4 or more of the following symptoms: changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation, plans, or attempts. Symptoms must be new or a clear change from baseline and must be accompanied by clinically significant distress or impairment in societal, occupational, or other essential areas of functioning. Additionally, the depressive episode should not be accompanied by manic or hypomanic periods or due to current substance abuse or other general medical conditions. 1 An estimated 10 million American adults are affected by MDD each year, with up to one third of these patients failing to achieve remission after multiple drug trials. 2 The definition of treatment-resistant MDD is controversial, although it is often defined as 2 or more failed, adequate an-tidepressants trials. 3,4 Treatment-resistant MDD is associated with significant morbidity that results in a negative impact on US health outcomes and societal productivity. 5-7 A retrospective analysis of medical claims revealed that patients with treatment-resistant MDD were twice as likely to be hospitalized and had total medical costs more than 6 times those of their non-treatment-resistant comparators. 8 The pathophysiology of MDD is not fully understood, although it is documented that central nervous system (CNS) neurotransmitters (ie, serotonin, norepinephrine,
Treatment resistant depression (TRD) is a major public health issue, with comorbid OCD contributing to the general medical costs and severity associated with TRD. Recent research has investigated the efficacy of transcranial magnetic stimulation (TMS and its variant rTMS) in ameliorating the symptoms of depression and OCD. Most studies have used TMS to facilitate electromagnetic stimulation of the dorsolateral prefrontal cortex, a region implicated in depression, or the supplemental motor area, a region implicated in OCD. However, it is difficult to achieve full remission with TMS alone. A parallel line of research has examined the effects of ketamine, an N-methyl-D-aspartate (NMDA) antagonist, on both depression and OCD. A primary benefit of ketamine is that it provides short-term but rapid relief from certain grave TRD symptoms within approximately two hours. As of yet, little is known about the possible synergistic effects of combined TMS/ketamine for comorbid TRD and OCD. Thus, I report on the case of a 32-year-old male who presented with chronic OCD with somatic fixation, depression, and generalized anxiety disorder, who was treated with a novel combined TMS/ketamine treatment for 12 weeks. Measures of depression and OCD symptoms were administered pre and post treatment. The patient showed significant reductions in depression, but not OCD symptoms, which is consistent with previous research. Keywords: Ketamine, Transcranial magnetic stimulation, Depression, OCD
The Journal of Clinical Psychiatry
Objective: To determine the extent that treatment with transcranial magnetic stimulation (TMS) in diverse clinical settings has anxiolytic and antidepressant effects in patients with major depressive disorder (MDD) and moderate-to-severe anxiety symptoms and to contrast anxious and nonanxious depression subgroups in antidepressant effects. Methods: Within the NeuroStar Advanced Therapy System Clinical Outcomes Registry, 1,820 patients were identified with a diagnosis of MDD (using ICD-9, ICD-10, or DSM-IV) who completed the Patient Health Questionnaire-9 (PHQ-9) and Global Anxiety Disoder-7 scale (GAD-7) at baseline and following at least 1 TMS treatment between May 2016 and January 2021. Anxious depression was defined as a baseline GAD-7 score of 10 or greater (n = 1,514) and nonanxious depression by GAD-7 scores below this threshold (n = 306). Intent-to-treat and Completer samples were defined for patients treated with any TMS protocol and for the subgroup treated only with high-frequency left dorsolateral prefrontal cortex stimulation. Results: Patients with anxious depression showed clinically meaningful anxiolytic and antidepressant effects, averaging approximately 50% or greater reductions in both GAD-7 and PHQ-9 scores following TMS in all samples. The anxious and nonanxious depression groups had equivalent absolute improvement in PHQ-9 scores (P values ≥ .29). However, the anxious group had higher scores both at baseline and following TMS resulting in significantly lower categorical rates of response (P values < .02) and remission (P values < .001) in depressive symptoms. Among those with anxious depression, the change in anxiety and depression symptoms strongly covaried (r 1512 = 0.75, P < .001). Conclusions: Routine TMS delivered in diverse clinical settings results in marked anxiolytic and antidepressant effects in patients with anxious depression. The extent of improvement in anxiety and depression symptoms strongly covaries.
Human Psychopharmacology: Clinical and Experimental, 1993
We report the cases of two drug-resistant major depressed psychotic patients, who were treated with 10 sessions of transcranial magnetic stimulations (TMS) and afterwards with 10 sessions of electroconvulsive therapy (ECT) without changing the concomitant neuroleptic and antidepressive medication. TMS did not exert a therapeutic effect in one patient and only a slight one in the other. However, there was a clear beneficial effect for ECT in the patient not responding to TMS and a slight therapeutic effect in the other. In summary, there was no clear-cut evidence for effectiveness of TMS as a treatment for patients with psychotic, therapy resistant depression.