German Journal of Psychiatry
Repetitive transcranial magnetic stimulation (rTMS) in Major Depressive Episode with Postpartum Onset - a case study
Michael Ogden 1, William Lyndon 2, Saxby Pridmore 1,3
1 Department of Psychological Medicine, Royal Hobart Hospital, Tasmania, Australia
2 University of Sydney and Mood Disorders Unit, The Northside Clinic, Sydney, NSW, Australia
3 Department of Psychiatry, University of Tasmania, Australia
Corresponding author: Prof Pridmore, DPM, RHH, firstname.lastname@example.org
Objective: We report the effect of rTMS in a case of Major Depressive Episode with Psychotic Features and Postpartum Onset. Clinical Picture: The patient was 40 years of age. She had a past history of Major Depressive Episode with Postpartum Onset and presented following attempted infanticide. Treatment: She was treated with 13 sessions of 20 Hz rTMS 13 over 15 days. Outcome: Remission and good mother-child relationship was achieved. Conclusion: rTMS is a potential treatment of this condition (German J Psychiatry 1999;2:43-45)
Key words: transcranial magnetic stimulation, Major Depressive Episode with Postpartum Onset
Received: July 12, 1999
Published: September 7, 1999
Depression in the postpartum period develops in more than 10% of women in the year following childbirth and may carry serious consequences for the mother, family and child. Somatic treatment is frequently required, but medication for breast feeding mothers remains a concern and electroconvulsive treatment (ECT) is stigmatising and unacceptable to many.
Transcranial magnetic stimulation (TMS) is a new clinical technology which is believed to provide antidepressant effects. George and colleagues (1999) have reviewed the field. A recent case study indicated efficacy and safety in the treatment of depression occurring during pregnancy (Nahas et al, 1999).
The patient (Mrs X) was a married 40 year old law clerk and mother or two. She voluntarily presented to the Accident and Emergency Department of the hospital after attempting infanticide. She had placed a pillow over the head of her four week old daughter (Helen) for an unknown period of time. She was interrupted by family members and when the pillow was removed Helen was grey and limp. Mrs X called the ambulance and police. Helen was alive and admitted to the paediatric ward for assessment.
One examination Mrs Xs clothes and hair were untidy. She was co-operative but her eyes were downcast and there was psychomotor retardation (slow movement, speech and thinking). Voice was monotonous and face was expressionless. Affect was unreactive. Thought content was delusional. Mrs X claimed that Helen was ugly, that she (Mrs X) could not be a good mother and therefore it would be better if either one or both of mother and daughter were dead. Mrs X did not want to see Helen, repeating that the child was ugly and that she did not want to be her mother or have any further contact. Mrs X believed that she might be being punished in some way, but could not give details. Judgement and insight were poor, Mrs X blamed Helens recent sleeping difficulties for the current events and was unable to accept that she (Mr X) was suffering a mental disorder. Nevertheless, good rapport was established.
Helen was born by elective lower segment caesarean section at 39 weeks gestation as the first stage of labour had not progressed satisfactorily and "the cervix was unfavourable". Helen was well at birth but did not sleep well and was described by obstetric staff as "unsettled". From first contact Mrs X thought Helen was ugly. Mrs X thought Helen was not feeding properly and did not have tender feelings toward the baby. They were discharged five days post partum. It was thought Mrs X may need assistance, thus she and her husband and daughter went first to stay with her parents for two weeks and then with her husbands parents for one week. During this time Helen had disturbed nights and Mrs X worried that she was performing poorly. She lost her appetite for food, lost weight and ceased breast feeding. She suffered initial insomnia and could not return to sleep once woken. It was stated that Mrs X was unable to get any sleep in the three days prior to admission.
Resentful thoughts occurred. Mrs X thought that Helen had ruined her life and wished for a cot death. Concurrently, she regarded herself as a "terrible mother" and worried, "How could my baby be raised by such a terrible person ?". Mrs X thought of suicide by motor accident but resisted as she did not want to abandon her husband and four year old. She started to think, "Its either her or me."
Mrs Xs only other child was born four years previously. Birth was followed by Major Depressive Episode with similar features except the attempted infanticide. Mrs X had thought her child was ugly and had wanted to reject her. She received psychiatric care and the crisis passed and she became a loving and responsible mother. She sought to manage her follow-up with her general practitioner and took a small amount of paroxetine sporadically. Her account indicated that she had remained at least moderately depressed for two years until spontaneous remission.
Premorbidly Mrs X was mildly anxious and obsessional by disposition, but was capable, responsible and able to establish enduring relationships. She had been married once previously. She had travelled and worked overseas. She married Mr X six years previously. They had some financial problems due to a failed business enterprise, but Mr X had work and they had a strong relationship.
The diagnosis was Major Depressive Episode with Psychotic Features and Postpartum Onset. Because of the need for a rapid response and the desirability of avoiding medication we suggested electroconvulsive therapy (ECT). This was unacceptable to the patient and her husband. A trial of repetitive transcranial magnetic stimulation (rTMS) was is progress and the patients was invited and agreed to participate. This study was approved by the Royal Hobart Hospital ethics committee and the patient gave written informed consent. Treatment was provided with a Magstim Super Rapid (Magstim Inc.) and applied to the left prefrontal cortex at 100% of motor threshold, at 20 Hz, two second trains separated by 28 second rest periods, a total of 30 trains per day, given five days per week.. The design allowed rTMS to be continued until remission or change of treatment. Respiridone 0.5 mg per day was administered.
The trial called for blind 17 item Hamilton Depression Rating Scale (HDRS) assessment at entry and exit, Beck Depression Inventory (BDI) assessment at entry and exit and visual analogue (VAS) assessment at entry, exit and three times per week.
The patient was treated on 13 of 15 days of hospitalisation. Risperidone was ceased on day 7 and citalopram 20 mg per day was commenced (to function as maintenance treatment on discharge) on day 11. The blind HDRS score fell from 29 to 3, the BDI from 48 to 13 and the VAS from 8.2 to 3.4 (see Figure 1 for details). The patient complained of no side effects.
At the end of the first week Mrs X no longer blocked the suggestion that she should visit her daughter on the paediatric ward, "just to keep your options open". She found the experience enjoyable. Helen then came to the mother and baby unit in the Department of Psychological Medicine. After some trial leave Mrs X was caring for her daughter (whom she had come to regard as beautiful) and was discharged from hospital.
A week after discharge Mrs X who had been managing well complained of low energy and motivation, lack of enjoyment and poor sleep for 48 hours. Whether this represented the beginning of a relapse is not known. The citalopram was immediately increased to 40 mg daily. Follow up two months later revealed no symptoms of depression and mother and daughter were enjoying a close relationship.
This account indicates that rTMS may have a place in the treatment of Major Depressive Episode with Postpartum Onset with Psychotic Features. A very small amount of an antipsychotic was used for the first six days and an antidepressant was used in the last four days; while probably helpful, it is unlikely that these agents were primarily responsible for the rapid and comprehensive improvement. The same could be said of hospitalisation. Spontaneous remission in this time frame is also unlikely and in an earlier less severe episode, for this mother, remission took two years.
Medication and ECT may be contraindicated or unacceptable in some circumstances. rTMS appears to lack side effects, but with the currently employed stimulus parameters it may be slower to take full effect than ECT. The new mother is usually exhausted and this complicates caring for her baby and recovery. rTMS does not require anaesthetic or impose seizure, thus does not add sedation and the work of a seizure to the already compromised patient. As George et al (1999) point out, rTMS is a promising treatment but further controlled studies are required.
George M, Lisanby S, Sackeim H. Transcranial Magnetic Stimulation. Applications in Neuropsychiatry. Archives General Psychiatry 1999;56:300-311.
Nahas Z, Bohning D, Oustz J, Risch S, George M. Safety and feasibility of repetitive transcranial magnetic stimulation in the treatment of anxious depression in pregnancy: a case report. Journal of Clinical Psychiatry 1999;60:50-52.