Severe suicidal behavior in the context of unrecognized progressive supranuclear palsy: temporal association with rTMS

Progressive supranuclear palsy (PSP) is a neurodegenerative tauopathy characterized by supranuclear gaze palsy, postural instability, axial rigidity, and executive dysfunction. Disturbances in cognition and behavior are core features of PSP and may precede the onset of overt motor symptoms. Here we describe a 56-year-old woman who was first managed for treatment-resistant depression and treated with repetitive transcranial magnetic stimulation (rTMS), after which she exhibited severe recurrent suicidal behavior. Further neurological assessment led to a diagnosis of PSP. This case highlights the diagnostic challenges posed by neuropsychiatric presentations of PSP and the difficulty of interpreting clinical change occurring after neuromodulatory treatment in the context of an evolving neurodegenerative disorder.