A retrospective analysis of bipolar depression treated with transcranial magnetic stimulation

Eric L Goldwaser, Kathy Daddario, Scott T Aaronson, Eric L Goldwaser, Kathy Daddario, Scott T Aaronson

Abstract

Introduction: Treatment options are limited for patients with bipolar depression. Antidepressants added to mood stabilizers even carry risks of precipitating mixed/manic episodes. Transcranial magnetic stimulation (TMS) may provide a safe and effective option for these patients.

Methods: Database analysis of the TMS Service at Sheppard Pratt Health System identified patients with bipolar disorder type I (BD1) or II (BD2) in a pure depressive phase at initiation of TMS. Records were reviewed for response and remission rates based on MADRS scores, time to effect, and adverse events, notably treatment-emergent affective switching. All had failed at least two prior treatments for depression, were currently on at least one mood stabilizer and off antidepressants. Stimulation parameters targeted left dorsolateral prefrontal cortex: 120% motor threshold, 10 pulses per second (pps) × 4s, intertrain interval (ITI) 26s, 75 trains (37.5 min/session) for 3,000 pps total, 5 sessions/week for 30 total treatments, or until remission criteria were met.

Results: A total of 44 patients with BD were identified, representing 15% of the total TMS population. 77% of those who completed a course of TMS met response criteria, and 41% of subjects who completed at least 25 treatments met remission criteria. Subjects with BD1 were more likely to respond, remit, or suffer an adverse event than those with BD2. No patient met clinical criteria for a manic/mixed episode, but four (10%) discontinued due to concerns of activation.

Conclusions: TMS is effective in the bipolar depressed population where episode focused intervention can be specifically offered. Risk of psychomotor agitation must be closely monitored.

Keywords: bipolar depression; bipolar disorder; neuromodulation; transcranial magnetic stimulation.

Conflict of interest statement

STA is a consultant to Neuronetics, LivaNova, Janssen, Genomind, and Sage Therapeutics and has received honoraria from Sunovion and Janssen. He also has research support from Neuronetics and Compass Pathways. KD and ELG have no financial interests to disclose.

© 2020 The Authors. Brain and Behavior published by Wiley Periodicals LLC.

Figures

Figure 1
Figure 1
(a) Percent of patients meeting remission by MADRS (MADRS ≤ 10). (b) Percent of patients meeting response by MADRS (50% drop from baseline)

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