TBI, TMS, and the perfect timing

Abstract: Treatment with Transcranial Magnetic Stimulation (TMS) for patients with Traumatic Brain Injury (TBI) is an ongoing area of research. While TMS has been utilized for unipolar depression, treatment-resistant depression, and other psychiatric disorders, its potential in treating the cognitive aspects of TBI, such as attention, memory, and executive function, have recently garnered attention. By targeting specific areas of the brain implicated in TBI pathophysiology, such as the dorsolateral prefrontal cortex (DLPFC), TMS interventions seek to modulate neural circuits and mitigate TBI-related deficits. The long-term consequences of chronic neuroplastic changes, however, are what is thought to result in persistent changes in cognition and emotion that characterizes the behavioral impairments in severe TBI that are well known to clinicians. These maladaptive changes in behavior ultimately can lead to road-blocks in terms of functional recovery, resulting in long-term disability.

This appears to be especially true in one such 54-year old male with a history of TBI with loss of consciousness who consulted his psychiatrist for severe depression 6 years later. His medical history included hypertension, prior DVT/PE, CHF, CVA (x2) with seizures, as well as recent TIAs within the last 3 months. The patient, who had concomitant diagnoses of GAD, PTSD, and panic disorder, did struggle with suicidal thoughts and had endorsed a history of 3 prior suicide attempts 16 years prior. Nevertheless, while psychiatric medications had at one time resulted in moderate improvements, the patient’s response to medications post-TBI was short-lived. Despite numerous medication trials and optimization of his medication regimen for depression and anxiety in the last 5 years, with trials including Topamax, Seroquel, Depakote, Prozac, Zoloft, Lamictal, Tegretol, Abilify, Thorazine, Lithium, Ativan, Klonopin, and Valium, his response and progress has proven to be minimal. Non-pharmacological avenues, such as trauma-based therapy and hypnotherapy had been utilized, and while they did result in short-term improvements, the patient never seemed to demonstrate tangible improvements. After 10 months, TMS was determined to be a viable option for treatment of his refractory depression and PTSD. After 6 weeks of Magstim TMS treatments, the patient noticed new onset mood lability and even endorsed rage episodes. Several weeks into the treatment, the patient endorsed, for the first time in several months, reported that his depression had lifted, and that he was “feeling hope.” For the first time in 12 months the patient left his home and engaged in social gatherings.

This case study attempts to highlight the importance of understanding the dynamic nature of neuroplasticity following TBI in order to target interventions aimed at promoting recovery and mitigating long-term disability in those with severe TBI. The consult liaison psychiatrist who comes across the severe TBI patient with refractory mood-related changes is encouraged to offer comprehensive assessments, collaborate care with team members, and consider the temporal evolution of neuroplasticity to better interpret and tailor treatment plans accordingly.