Safety and Efficacy of Transcranial Magnetic Stimulation for Psychiatric Disorders in Pakistan

Methods: A 52-year-old man with MDD, GAD, and ADHD presented with severe depression/anxiety while taking lorazepam, duloxetine, and adderall XR.Lorazepam was tapered and adderall switched to Azstarys before rTMS.He completed 36 sessions of 10-Hz left DLPFC rTMS (120% resting motor threshold, 3,000 pulses/ session).Results: rTMS produced marked improvement (PHQ-9 17 to 3).During the rTMS course, tirzepatide was titrated from 5 mg to 15 mg (reached after treatment).Within 1 month of rTMS completion, depressive symptoms worsened (PHQ-9 11) and involuntary movements emerged (jaw clenching, lip puckering, tongue movements, repetitive blinking, and leg twitching; AIMS 20).Holding vortioxetine and Azstarys had no effect.Lumateperone and cariprazine trials were ineffective.A second rTMS course was initiated while continuing high-dose tirzepatide and starting deutetrabenazine, resulting in near-complete remission (AIMS 5).Discussion: GLP-1 RA up-titration during/after rTMS was temporally associated with depressive relapse and dyskinesias.Clinicians should monitor for worsening of depression and new abnormal movements during GLP-1 RA dose escalation in patients receiving psychotropics.Further study is needed to clarify causality and the potential adjunctive role of rTMS in TD.