IMPACT OF ANXIOLYTICS AND ANTICONVULSANTS ON CLINICAL OUTCOME OF TRANSCRANIAL MAGNETIC STIMULATION TREATMENT OF DEPRESSION IN THE VA CLINICAL TMS PROGRAM

Background: 50-year-old female presenting with diagnosed treatment resistant depression, the total duration of which is 9 years.Onset was in 2014 but described having some anxiety issues before then.The current episode has been consistent for 12 months before treatment.History of psychiatric admissions and treatment with medication and ECT (electroconvulsive therapy), totaling 300 sessions.At the time of assessment, she was undergoing weekly ECT maintenance.History of suicide attempts and self-harm, most recent hospitalization May 2022.Management and Outcome: Standard depression/anxiety protocol was applied: theta burst right dorsolateral prefrontal cortex (DLPFC), at 90% resting MT followed by 10Hz at 120% resting MT over the left DLPFC.Baseline psychometrics scores were PHQ-9=18, HADS=27, GAD-7=15.She completed 30 sessions in 9 weeks.Improvements were noticeable around session 10; started sorting out things at home, making to-do lists, and meeting up with friends.The following week she had a dip in mood, increased suicidal and self-harming ideation.Resulting in a change of protocol: supplementary motor area, at 140% resting MT followed by theta burst over left DLPFC, at 90% resting MT.Session 15-27 she started to notice improvements again.By the end of treatment, she reported feeling better than she had in the last 9 years, with continued improvement in positive mood.Final psychometrics were PHQ-9=3, HADS= 3, GAD-7=0.At three months follow up her she was still in remission (PHQ-9=0, HADS=0, and GAD-7=0).