TMS for Bipolar Mixed States: A Promising Off-Label Treatment
Dr. Danish and Philadelphia Integrative Psychiatry are excited to offer Transcranial Magnetic Stimulation (TMS) as a cutting-edge treatment for a variety of mental health disorders, including depression, anxiety, OCD, PTSD, and addiction. For our adult patients with ongoing depression, TMS is covered by insurance.
Bipolar disorder, especially when presenting with mixed features, poses significant treatment challenges. Mixed episodes, which involve concurrent symptoms of depression and hypomania or mania, often do not respond well to traditional medications. While TMS treatment for bipolar disorder is more complex than for unipolar depression, it remains a cautious yet viable option for some patients. This case report provides evidence that TMS can be a safe and effective treatment for a subset of patients experiencing mixed episodes of bipolar disorder, contributing to the growing body of research supporting TMS as a beneficial intervention for certain individuals with bipolar disorder.
Case Report: Rapid Symptom Resolution with TMS
Patient Background
A 68-year-old female with Bipolar Type II Disorder experienced a four-month medication-refractory major depressive episode with mixed features. Despite multiple medication trials, including lithium, valproate, lamotrigine, topiramate, and quetiapine, her symptoms persisted. She declined electroconvulsive therapy (ECT) and was referred for TMS.
TMS Treatment Protocol
The patient underwent nine daily sessions of high-frequency repetitive transcranial magnetic stimulation (rTMS) using the Neuronetics NeuroStar system. The treatment targeted the left dorsolateral prefrontal cortex (DLPFC) with standard settings of 120% motor threshold (MT), 10 Hz frequency, and 3,000 pulses per session.
Results
The patient showed a rapid and significant improvement in her symptoms. Her Montgomery-Asberg Depression Rating Scale (MADRS) score decreased from 32 to 2, and her Young Mania Rating Scale (YMRS) score dropped from 22 to 0. She reported feeling stable with minimal depression and hypomania for the first time in years.
Discussion
Mixed episodes in bipolar disorder are notoriously difficult to treat, often requiring multiple medications with limited success. This case highlights the potential of TMS as an effective treatment for mixed states, providing rapid symptom relief and sustained stability. Further research is needed to explore the optimal protocols and long-term efficacy of TMS for bipolar mixed states.
Getting in Touch with Dr. Danish and his Team
At Philadelphia Integrative Psychiatry, we are excited to offer TMS as part of our repertoire of treatment options. We continue to stay on top of the latest research related to TMS so we can provide the best quality care in a safe manner. Our holistic and integrative approach ensures that we consider all aspects of our patients' well-being in developing personalized treatment plans. If you or a loved one are seeking support for bipolar disorder or similar conditions, please text or call 610-999-6414 to learn how we can help.
Sources:
Beydler EM, Katzell L, Schmidt L, Carr BR, Holbert RC. Case report: Rapid symptom resolution of a mixed affective state with high-frequency repetitive transcranial magnetic stimulation. Front Psychiatry. 2023;14:1137055. doi: 10.3389/fpsyt.2023.1137055.https://pubmed.ncbi.nlm.nih.gov/36846231/
