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Electroconvulsive therapy in a geriatric patient with normal pressure hydrocephalus without a shunt.

was decided that continuing a treatment that is still under investigation seemed unjustified due to D’s overall improving state. This case report joins the published literature relating to the safety of rTMS treatment in adolescent MDD. The intriguing finding is that significant clinical improvement was demonstrated in anxiety symptoms and not in clinical measures of depression. Comorbid depression with anxiety can lead to higher risk of recurrence, increased suicide attempts, greater impairment, and less favorable response to treatment than with either condition alone. It is important to investigate further the possible benefits of rTMS therapy on anxiety symptoms in addition to symptoms of depression. A possible explanation to the lack of significant improvement in depression severity scores and the stagnated suicidality scores might be D’s psychotic experiences concurrent with his MDD. A recent meta-analysis by Ren et al comparing rTMS therapy to ECT in adults with major depression revealed that rTMS therapy is less effective in psychotic depression. In fact, psychotic episodes are cited as a reason for exclusion of patients in many rTMS trials. The data gathered in this case study demonstrate a need for larger open studies that assess the efficacy and safety of rTMS in treating adolescent psychiatric illnesses as a whole with an emphasis on mood disorders and their associated comorbidities.