Intensive rTMS applications in difficult to treat psychiatric patients: some cases.

Despite adherence to treatment guidelines, some patients are resistant to several psychopharmacological interventions. Guidelines to overcome treatment resistance are scarce and new treatment modalities are needed. When confronted with psychopharmacological failure, repetitive transcranial magnetic stimulation (rTMS) therapy can be considered. In these case series a combative high frequency (HF)-rTMS protocol with frequent stimulations at suprathreshold intensity was applied for treatment-resistant depression (TRD), schizoaffective- and bipolar I disorder, mixed episode. Besides effectiveness, tolerability was closely monitored. All three patients, suffering from different psychiatric conditions were experiencing limited to excellent clinical improvement without serious side effect or adverse events. These very preliminary results suggest, along with research using comparable intensive stimulation parameters for treatment-resistant depression, that 'aggressively' targeting the left DLPFC is well tolerated and safe. Our clinical results suggest a possible beneficial treatment strategy of HF-rTMS protocols following unsuccessful. Larger sham-controlled studies are needed to substantiate our results.