Maintenance Treatment With Transcranial Magnetic Stimulation in a Patient With Late-Onset Schizophrenia

“Ms. A,” a 55-year-old right-handed, postmenopausal woman who had DSM-IV late-onset schizophrenia with an illness duration of 2 years, was referred for transcranial magnetic stimulation treatment. She was noted to have benzodiazepine addiction involving the use of lorazepam (9 mg/day). She had been suffering from resistant auditory hallucinations for 2 years (very frequent and loud, with >5 critical and command voices). She was unresponsive to four antipsychotic medication trials lasting >4 months each, including haloperidol (5 mg/day), amisulpride (1200 mg/day), olanzapine (15 mg/day), and risperidone (8 mg/day). A detailed assessment did not reveal any other pathology or transcranial magnetic stimulation contraindications. Auditory hallucinations were assessed using the Auditory Hallucination Rating Scale (3), and positive symptoms were assessed using the Scale for the Assessment of Positive Symptoms (SAPS). Lorazepam withdrawal was completed without exacerbation of the psychotic symptoms (Auditory Hallucination Rating Scale score: 34). Four months after her initial presentation, the patient gave informed consent and was included in a transcranial magnetic stimulation protocol. Twice-a-day, 1000 low-frequency repetitive stimulations (1 Hz) were administered to the temporoparietal cortex at 100% of motor threshold over a 5-day period. The patient’s current dose of risperidone was maintained during treatment with transcranial magnetic stimulation. After the first course, auditory hallucinations were moderately improved, with a 35% reduction in her Auditory Hallucination Rating Scale score, which did not change over the next several months, as observed in a follow-up assessment. However, the patient’s general SAPS score improved, with a 30% reduction in severity.

Six months after the first course of transcranial magnetic stimulation therapy, the patient presented with a relapse of hallucinations. A new transcranial magnetic stimulation course, with the same parameters, was conducted. This second course was followed by a once-per-month, twice-daily maintenance protocol (one session in the morning, the other in the afternoon on the same day). The patient’s auditory hallucinations were greatly improved, by 80%, and her SAPS score decreased from 38 to 16. This maintenance course was associated with a remission of auditory hallucination symptoms, with a stabilization of SAPS scores at 10 over the next 6 months. Presently, more than 1 year later, Ms. A is not receiving any antipsychotic medication, and her Auditory Hallucination Rating Scale and SAPS scores remain at 0.