Efficacy of combined theta burst stimulation (TBS) and intranasal esketamine in an ECT-resistant depressive patient: A case report

Abstract

Treatment-resistant depression (TRD) presents significant clinical challenges, often requiring innovative approaches beyond conventional pharmacotherapy and psychotherapy. This case report explores the efficacy of combined repetitive Transcranial Magnetic Stimulation (rTMS) and intranasal esketamine (IN-ESK) in a patient with TRD.

A female in her 60 s with a prolonged history of recurrent endogenous-type depressive disorder presented with severe depressive symptoms, including suicidal ideation, despite numerous pharmacotherapies, psychotherapies, and 17 sessions of ECT. The patient underwent a treatment regimen combining rTMS and IN-ESK. rTMS involved continuous theta burst stimulation (cTBS) to the right dorsolateral prefrontal cortex (DLPFC) and intermittent theta burst stimulation (iTBS) to the left DLPFC. IN-ESK was administered at 56 mg for the first two sessions and 84 mg for subsequent sessions over four weeks. The combined treatment resulted in a substantial reduction in depressive and anxiety symptoms. Pre-treatment scores on the Patient Health Questionnaire-9 (PHQ-9) and Hamilton Depression Rating Scale (HDRS) indicated severe depression (PHQ-9 score of 24) and moderate depression (HDRS score of 19). Post-treatment assessments showed significant improvement, with PHQ-9 scores decreasing to 7 (mild depression) and HDRS scores dropping to 5 (remission). Suicidal ideation and anxiety levels also showed marked reduction, with the Hamilton Anxiety Scale (HAS) score decreasing from 20 to 10. The combination of rTMS and IN-ESK demonstrated significant therapeutic benefits in this ECT-resistant depressive patient. This case highlights the potential of this combined modality as a promising treatment for TRD, warranting further research to understand the underlying mechanisms and long-term efficacy.