Antidepressant Effect of 58 Sessions of rTMS in a Pregnant Woman With Recurrent Major Depressive Disorder

Sir: Repetitive transcranial magnetic stimulation (rTMS) has been shown to be effective in depression in many studies.We report the case of a pregnant woman with recurrent major depressive disorder and panic disorder during her second pregnancy who received substantial benefit from 58 sessions of rTMS during pregnancy before giving birth to a healthy baby.Nineteen more sessions of rTMS were given during lactation.Case report.Ms. A, a 30-year old in 2007, presented with recurrent major depressive disorder and panic disorder according to DSM-IV criteria.She had no other medical problem, no personality disorder, and no psychosocial stressor and had never used substances or alcohol.There was no significant feature in her family medical history.She had had 5 episodes of major depression (in 1995, 1997, 1999, 2002, 2004).The first one in 1995 was the only episode with psychotic features, treated with antidepressant and antipsychotic drugs.Between the first and second episode, remission had not been attained; therefore, she had had to leave the university because of loss of functioning.In 1997, she had her second severe depressive episode despite the fact that she had been receiving maintenance pharmacologic treatment.By aggressive outpatient pharmacotherapy, she attained remission that lasted until 1999, by which time she had married, discontinued her antidepressant medications under the control of a psychiatrist before a planned pregnancy, became pregnant, gave birth to her first baby, and lactated.Four months after the delivery, when she had been lactating, the third episode occurred in 1999.Having discontinued the lactation, she received pharmacotherapy and psychotherapy for 4 years, during which time she was maintained in a state of partial recovery until the fourth depressive episode, in 2002.She received her first inpatient treatment and underwent 8 sessions of electroconvulsive therapy (ECT), which alleviated symptoms but did not, however, provide remission.From the age of 18 to 27 years, she received pharmacotherapy continually except for 1.5 years (during the first pregnancy and lactation, 1998-1999), the only period in which remission had been attained.During that 9 years' course of illness, she had received monotherapy with amitriptyline 300 mg daily, sertraline 200 mg daily, and venlafaxine 600 mg daily; in addition to antidepressant medications, she had also been treated with zuclopenthixol, risperidone, olanzapine, lithium, thyroid hormone, carbamazepine, and valproic acid because of psychotic features at the first episode and the refractory nature of depression at later times.In May 2004, the fifth episode was accompanied by panic attacks.Although she received psychotherapy and pharmacotherapy (fluoxetine 80 mg daily, clomipramine 150 mg daily, carbamazepine 400 mg daily, quetiapine 25 mg daily, and clonazepam 1.5 mg daily), she did not respond to 6 weeks' treatment and the clinical table continued to follow a very severe course.Since no classical treatment, including ECT, had been able to provide remission, in June