Transcranial Direct Current Stimulation in a Patient With Schizoaffective Disorder Manic Episode.

Abstract

Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique in which a weak current is applied through the scalp to produce changes in neuronal excitability in the underlying cerebral tissue (1). tDCS attracted the attention of clini-cians and scientists due to its powerful effect on cortical function. This technique is based on the application of weak direct electrical currents (1–2 mA) to the scalp via surface electrodes. This results in an increase or decrease of the excitability of the cortical area under-lying the electrodes. tDCS has shown to exert its effects by modu-lating membrane neuronal threshold and spontaneous neuronal activity, therefore leading to hyperpolarization or depolarization according to the polarity of stimulation (2,3). Recent clinical trials have shown promising results with left anodal prefrontal tDCS in treating depression (4). In their recent research, Brunoni et al. reported that in major depressive disorder, the combination of tDCS and sertraline increases the efficacy of each treatment. The efficacy and safety of tDCS and sertraline did not differ (5). Shiozawa et al. reported tDCS modulation of visual hallucinations in schizophrenia and a case report of using tDCS for catotonia (6,7). In a recent report, Schestatsky et al. reported that with five sessions of anodal tDCS over the right dorsolateral prefrontal cortex, there were some improvements in both agitation and manic symptoms in a patient with an episode of mania with sexual hyperactivity (8). This report investigates the answer for the question of whether tDCS can be a treatment option in manic episodes. PATIENT AND METHOD The case is a 68-year-old female Caucasian patient suffering from schizoaffective disorder manic episode, diagnosed by the struc-tured clinical interview for Diagnostic and Statistical Manual of Mental Disorders IV. She was diagnosed with schizoaffective disor-der at the age of 28. The affective episodes were predominantly manic, with episodes occurring one to two times a year. She described persecutional delusions and auditory hallucinations between the affective episodes. She was on antipsychotic medica-tion continuously for 28 years. On her manic episodes, she was experiencing days to weeks of elevated and expansive mood, increased activity, decreased need for sleep, and increased talk-ativeness and socializing. Her auditory hallucinations also increased in manic episodes. She had used almost every known mood stabi-lizers and antipsychotic with poor clinical response. From the age of 28, she needed hospitalization on nine occasions owing to worsen-ing manic symptoms. Three, six, and 12 years ago, the patient par-ticipated in three clinical trials of electroconvulsive treatment for the treatment of manic episodes. One year ago, ten sessions of repeti-tive transcranial magnetic stimulation (rTMS) was administered at 1 Hz (inhibitory frequency) at 120% motor threshold, 1500 pulses on each session over the right prefrontal cortex. Clinical response was partial to electroconvulsive treatment and poor to rTMS. A therapeutic regimen of lithium 900 mg/d (blood concentration, 0.78 mmol/L) and risperidone 4 mg/d was given with a diagnosis of schizoaffective disorder manic episode. She did not respond to treatment. Despite further reasonable mood stabilizer trials (lamotrigine, valproate, olanzapine), her clinical response was incomplete and not sustained. The patient participated in a clinical trial of tDCS for the treatment of manic episode after being assessed by her own treating psychia-trist as being capable of giving informed consent. She gave written informed consent for both trials and the publication of this case report. She underwent cathodal stimulation of the right dorsolateral pre-frontal cortex and anodal stimulation of contralateral deltoid muscle more than three weeks as an add-on treatment to a stable antipsychotic and mood stabilizer medication. Direct current was transferred by a saline-soaked pair of surface sponge electrodes (35 cm 2) and delivered by tDCS equipment (Medelec Ltd, Surrey, UK). The cathodal electrode was over F4. Patient received 2 mA tDCS for 15 min each day with a total of 20 sessions. The patient was assessed at baseline, after ten and 20 sessions of tDCS, and one month after the end of treatment. There was a significant improve-ment in manic symptoms and mania scores after treatment. Her clinical scale scores are given in Table 1. Her clinical outcome was satisfactory, and her mood returned to euthymia within a month. One month after ceasing tDCS, her mood