Electroconvulsive treatment (ECT) is often considered more effective than repetitive transcranial magnetic stimulation (rTMS). This case report concerns a patient with treatment resistant depression (TRD) on maintenance ECT since four years with only partial effect and debilitating side effects, who achieved full remission after a course of rTMS. This is a 30-year old woman, with recurrent depressive episodes (non-psychotic, non-melancholic) since five years, full-time working, mother of several children, without any co-morbidities. She had undergone treatment trials with seven different antidepressants from four different classes and four different augmenting medications including lithium, without reaching remission but experiencing troublesome side effects. She achieved remission after an initial trial of ECT four years ago, but after relapsing, subsequent ECT had only partial effect. Nevertheless, maintenance ECT at least offered some symptom alleviation, most importantly decreased suicidal ideation. She was experiencing subjective memory impairment affecting work performance and post-ECT somnolence often requiring over-night hospitalization. The past six months before rTMS she had no antidepressant medication, only maintenance ECT and weekly psychotherapy. One week after last ECT she was started on a 1Hz rTMS protocol [1Brunelin J., Jalenques I., Trojak B., e al. The efficacy and safety of low frequency repetitive transcranial magnetic stimulation for treatment-resistant depression: the results from a large multicenter French RCT Brain Stimul 2014 ;  7 (6) : 855-863 [cross-ref]

Cliccare qui per andare alla sezione Riferimenti] over F4. In the first two weeks she experienced severe fatigue, but decreased memory complaints. However, since MADRS score deteriorated her treatment was changed to a conventional 10Hz protocol over F3 [2O’Reardon J.P., Solvason H.B., Janicak P.G., e al. Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial Biol Psychiatry 2007 ;  62 (11) : 1208-1216 [cross-ref]

Cliccare qui per andare alla sezione Riferimenti]. She experienced a warm sensation during treatment sessions, fatigue persisted initially, and headache followed a few hours after each session. MADRS score gradually decreased though, and after three weeks she reached 50% reduction and remission after four weeks (Figure 1). Memory complaints had vanished by then and over-all subjective health rating had increased by 40%. Remission status was maintained without other treatment for about four months and after five months another rTMS course was applied with equally good effect. Currently still in remission after seven months.