Treatment of bipolar mania with right prefrontal rapid transcranial magnetic stimulation

doi:10.1016/S0165-0327(02)00308-7

Journal of Affective Disorders

Volume 78, Issue 3, March 2004, Pages 253-257

https://doi.org/10.1016/S0165-0327(02)00308-7 Get rights and content

Abstract

Background: Transcranial magnetic stimulation (TMS) has been suggested for the treatment of a variety of CNS disorders including depression and mania. Methods: Nine bipolar (I) in-patients diagnosed with mania were treated with right prefrontal rapid TMS in an open and prospective study. Eight of nine patients received TMS as add-on treatment to an insufficient or only partially effective drug therapy. Results: During the 4 weeks of TMS treatment a sustained reduction of manic symptoms as measured by the Bech-Rafaelsen mania scale (BRMAS) was observed in all patients. Limitations: Due to the open and add-on design of the study, a clear causal relationship between TMS treatment and reduction of manic symptoms cannot be established. Conclusions: Our data suggest that right prefrontal rapid TMS is safe and efficacious in the add-on treatment of bipolar mania showing laterality opposed to the proposed effect of rapid TMS in depression.

Introduction

In the last decade, transcranial magnetic stimulation (TMS) has developed from a primarily diagnostic tool into a therapeutic strategy in neuropsychiatry (George et al., 1999). The therapeutic use of TMS has been suggested in a wide range of psychiatric disorders including posttraumatic stress disorder (McCann et al., 1998), catatonia (Grisaru et al., 1998a), obsessive compulsive disorder (Greenberg et al., 1997) and mood disorders (Kolbinger et al., 1995, Yaroslavsky et al., 1999). While left prefrontal rapid TMS has been described as a successful antidepressant strategy in most (George et al., 1995, George et al., 1997, Pascual-Leone et al., 1996a, Pascual-Leone et al., 1996b, Avery et al., 1999), but not all studies (Loo et al., 1999, Padberg et al., 1999), Grisaru et al. (1998b) have reported antimanic effects for rapid TMS of the right prefrontal cortex.

To test the possible effects of this therapeutic strategy, nine bipolar (I) in-patients diagnosed with mania were treated for 4 weeks with right prefrontal rapid TMS in an open and prospective study at the Mood Disorders Unit of the Psychiatric Department of Münster University Hospital.

Section snippets

Methods

As opposed to Grisaru et al.’s (1998b) 14-day treatment, our patients were given five sessions during weeks 1 and 2; and three sessions during weeks 3 and 4. Rapid TMS was carried out with a Dantec MagPro 16E62 magnetic stimulator (20 trains per session, frequency of 20 Hz for 2 s per train, intertrain interval of 1 min). The motor magnetic threshold (Hallett and Cohen, 1989) was assessed in each patient before the first TMS treatment; 80% of this motor threshold was then administered at all

Results

Both TMS monotherapy and add-on-treatment with TMS were safe treatment strategies with little subjective side effects. During the 4 weeks of treatment with right prefrontal rapid TMS, a sustained reduction of manic symptoms as measured by BRMAS was observed in all nine patients (Table 1).

Discussion

Our data obtained in a prospective, open trial show that right prefrontal rapid TMS is safe and efficacious in the treatment of bipolar mania. While double-blind controlled studies are essential in the evaluation of novel treatment strategies, methodologically well performed open studies are generally considered to be valid (Sulzbacher, 1973; Pajonk et al., 2000). In our study, BRMAS scores were stable between days −7 and 0 and showed a reduction after addition of TMS. Nevertheless, it should

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Citation Excerpt :
Compared with sham, however, right-sided stimulation did not provide any benefit in mania symptoms. Subsequently in 2004, there were 2 small case series using 10-Hz and 20-Hz rTMS over the right DLPFC that reported significant improvements in mania symptoms.52,53 Providing conflicting evidence regarding the usefulness of rTMS to treat mania, there have been 2 subsequent randomized controlled trials of high-frequency rTMS over the right DLPFC.

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Brief reportTreatment of bipolar mania with right prefrontal rapid transcranial magnetic stimulation

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Neuropharmacology

Psychiatry Res.

Lancet

J. Affect. Disord.

Electroencephalogr. Clin. Neurophysiol.

Delineating irritable and hyperthymic variants of the cyclothymic temperament

J. Pers. Disord.

The distinctive mixed states of bipolar I, II and III

Clin. Neuropharmacol.

Cyclothymic temperamental disorders

Psychiatr. Clin. North Am.

Switch from depression to mania, or from mania to depression: role of psychotropic drugs

Psychopharmacol. Bull.

Repetitive transcranial magnetic stimulation in the treatment of medication-resistant depression: preliminary data

J. Nerv. Ment. Dis.

Right prefrontal TMS vs sham TMS in mania

Bipolar Disord.

Euphoric mania and rapid transcranial magnetic stimulation

Am. J. Psychiatry

Acute manic symptomatology during repetitive transcranial magnetic stimulation in a patient with bipolar depression

Br. J. Psychiatry

Transcranial magnetic stimulation: applications in neuropsychiatry

Arch. Gen. Psychiatry

Mood improvement following daily left prefrontal repetitive transcranial magnetic stimulation in patients with depression: a placebo-controlled crossover trial

Am. J. Psychiatry

Brief report
Treatment of bipolar mania with right prefrontal rapid transcranial magnetic stimulation