Transcranial magnetic intermittent theta-burst stimulation for depression in pregnancy – A case series

Anti-depressant treatment with selective serotonin reuptake inhibitors (SSRIs) is considered safe and effective during pregnancy, but response rates are fairly low, and compliance is often hampered by a subjective worry concerning the effects SSRIs may have on the fetus/newborn child [1]. Repetitive transcranial magnetic stimulation (rTMS) may be a suitable alternative treatment for depression during pregnancy, but there is a paucity of clinical data, restricted to one randomized controlled trial with 22 women, and case-reports and case-series [2,3]. Recent advances with efficient protocols of short duration such as intermittent theta-burst stimulation (iTBS) offers further feasibility of rTMS [4]. However, there is only one case-report of iTBS during pregnancy so far [5]. Here we report a case series of five consecutive cases of pregnant depressed womenwho were referred to the Brain Stimulation Unit at Uppsala University Hospital, Sweden, during 2019. The patients were referred via a well-developed collaboration between the Maternity Clinic and the Psychiatric Clinic in the University Hospital. All five patients were assessed before, during, and after the iTBS course per clinical routine, and oral and written consent was obtained from all patients after completing their treatments, to collect relevant information from their medical records and to publish their data in this case-series. The patients were first screened for rTMS safety with a modified translated version of the TASS (Rossi 2011). A resting motor threshold determination was performed through a standardized procedure, as was the localization of the treatment spot over the left prefrontal cortex (F3 in the 10e20 system). The iTBS protocol consisted of triplet 50 Hz bursts, repeated at 5 Hz; 2 s stimulation and 8 s pause; 600 pulses per session; total duration of 3 minutes 12 seconds, applied at 120% of the RMT [4]. The stimulator output was gradually ramped up initially during the treatment course to increase tolerability. We used a MagPro R30 magnetic stimulator and a Cool-B65 figure-of-eight coil (MagVenture, Farum, Denmark). Psychiatric assessment before iTBS included a clinical interview by an experienced psychiatrist (RB), collecting information for rating with theMontgomery Asberg Depression Rating Scale (MADRS) [6], Maudsley Staging Method for treatment resistant depression (MSM) [7], and Clinical Global Impression e severity (CGI-S) rated on a seven point Likert scale ranging from “normal” to “among the most extremely ill patients”. Symptom self-report was collected with MADRS-S [8], EQ Visual Analogue Scale (VAS) [9]. For further