Short communication Induction of mania by rTMS: report of two cases Pavlos Sakkas *, Panajiota Mihalopoulou, Polyxeni Mourtzouhou, Costas Psarros, Vassilios Masdrakis, Antonis Politis, George N. Christodoulou Department of Psychiatry, University of Athens, 74 Vas. Sophias Avenue, Athens 115 28, Greece Received 6 June 2001; received in revised form 27 July 2002; accepted 7 November 2002 Abstract There is some evidence that repetitive transcranial magnetic stimulation (rTMS) may be effective in treating depression. Using an intensive methodology of rTMS in two drug-resistant patients, we observed a good antidepressant effect, but also, induction of manic symptoms. © 2003 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. Keywords: rTMS; Mania; Bipolar disorder 1. Introduction Repetitive transcranial magnetic stimulation (rTMS) is a new method of selective stimulation of the brain cortex. Joining together (a) the multiple indications suggesting in- volvement of the frontal lobe in the pathophysiology of affective disorder and (b) ECT practice, Pascual-Leone and others suggested that rTMS applied on the frontal lobe might influence affect. The first studies with healthy adults pro- duced controversial effects. Application of rTMS over the left prefrontal cortex induced transient sadness, whereas over the right prefrontal cortex induced “happiness” lasting from 20 min up to 8 h [1,2]. However, there is growing consensus that rTMS may have antidepressant potential and that this potential is worth investigating [3]. Recently, rTMS applied over the left prefrontal cortex of 50 healthy volunteers has been reported to have induced hypomania in three of them for a period of a day [4]. Also, a case of appearance of manic symptoms, in a bipolar patient, during rTMS sessions has been reported [5]. The methodology of rTMS is, as yet, not consolidated [3]. In our department we apply rTMS with various methodologi- cal protocols, in an effort to determine which of them is the most effective. We report here two of our patients suffering from drug-resistant depression, who responded favorably to intensive rTMS, but also developed mania. 2. Method To induce rTMS, we used a Magstim ultra rapid device, with a figure-eight magnetic coil, applied over the left pre- frontal cortex (5 cm anterior to the primary motor area). We used 110% of the magnetic power, enough to stimulate movements of the right hand (motor threshold). Keeping standard the frequency of the stimulation (20 Hz), and the duration of each train (2 s), we gave as much trains as possible. Using two magnetic coils in a series, our Magstim device could give about 40 trains (1600 stimuli), depending on the actual magnetic power we used. We induced two sessions of rTMS daily, one in the morning and one in the afternoon, for 5 days a week. With this intensive practice, we usually observe better clinical effectiveness of rTMS, with- out any side-effect. 3. Case reports (1) A 55-year-old married man was admitted to our hospi- tal suffering from drug resistant depression. His symptoms started 3 years ago, following family problems. He was depressed, anxious, could not work, and expressed suicidal ideas. He was given 60 mg of fluoxetine for 2 months, with no effect as he attempted to jump from the second floor of his house, and was subsequently admitted to hospital. During his hospitalization he was treated with venlafaxine and his de- pression subsided to a degree that allowed him to leave the hospital without suicidal risk. However, he was still de- * Corresponding author. E-mail address: psakkas@cc.uoa.gr (P. Sakkas). European Psychiatry 18 (2003) 196–198 www.elsevier.com/locate/eurpsy © 2003 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. DOI: 10.1016/S0924-9338(03)00048-8