As I mentioned in my previous blog, many of our patients have various psychiatric conditions along with major depression. Inevitably, sometimes we may have to use our best judgement as clinicians when we have clients with more complicated psychiatric presentations. Jim (not a real name), a single male in his forties, has been diagnosed with sub-chronic schizophrenia and autism spectrum disorder. His depression was characterized by extreme withdrawal, difficulty coping with his daily life and anergia. His schizoid symptoms were under control with an Abilify Maintena injection, but his depression continued to linger even after a trial of several antidepressants and augmenting agents. Jim was referred to us by his therapist with the hope that we could find alternative methods to manage his depression.

Jim had a blunted affect and was extremely withdrawn and reserved during his first TMS session––his PHQ-9 score was 20, indicating severe depression. However, a few sessions later, a remarkable transformation took place. Suddenly, Jim was full of energy, became very responsive and his eyes were full of life. As a clinician, one needs to be careful to recognize if your patients are truly responding or if they are experiencing a placebo effect early on in treatment. The best way to test this is continued observation for a sustained effect. Jim continued to show signs of euthymia throughout the remainder of his treatment. He was always very pleasant and cooperative, and his PHQ-9 score were constantly in the mild category. His final assessment carried an astonishing “0.” What is most encouraging was that his caretakers and therapist all concur that TMS put his depression in remission. It is too early to tell the long-term effect of TMS, but so far it looks rather promising. He seems to have a reactive affect and is more spontaneous social after TMS among other benefits he received.

It is important to note that not every patient with psychotic features is a good candidate for TMS, nor have we attempted to treat his/her psychosis with TMS. The procedure was done strictly to alleviate depression-related symptoms. However, one of our criteria for inclusion is whether the psychotic symptoms are managed well. Lastly, this is only one case and we hope that we will have more success stories with how TMS helps with depression in patients who have had a history of psychosis or other complex mental illness.