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ANZJP Correspondence

How safe is repetitive Transcranial Magnetic Stimulation? Patrick Clarke1,2, Shane Gill1,2, Benjamin Carnell2 and Cherrie Galletly1-3 1Discipline

of Psychiatry, School of Medicine, University of Adelaide, Adelaide, Australia 2Ramsay Mental Health Services (SA), Ramsay Health Care, Adelaide, Australia 3Northern Adelaide Local Health Network, Australia Corresponding author: Cherrie Galletly, The Adelaide Clinic, Suite 13, 33 Park Tce, Gilberton, SA 5081, Australia. Email: [email protected] DOI: 10.1177/0004867414563192

To the Editor There is considerable support for the efficacy of repetitive Transcranial Magnetic Stimulation (rTMS) in the treatment of depression (Gaynes et  al., 2014). However, there is less literature available regarding its safety in clinical use. We report data from an rTMS clinical service operating since August 2008 (see Galletly et al., 2010). In seven years of operation, both bilateral and unilateral treatment protocols were used. In unilateral treatments, continuous low frequency (1Hz) rTMS was applied to the right dorsolateral prefrontal corte (DLPFC) for 15 minutes, whilst bilateral treatments also included intermittent high frequency rTMS (10Hz) applied to the left DLPFC for 15 minutes. All treatment intensities were delivered at 110% of the motor threshold using a MagPro R30 machine and MCF B65

Could modafinil be a drug of dependence? Rohan Dhillon1, Xiaowen Wu2, Tarun Bastiampillai3 and Prashant Tibrewal1 of Psychiatry, The University of Adelaide, Adelaide, South Australia, Australia 2The University of Adelaide, Adelaide, South Australia, Australia 3Department of Psychiatry, Flinders University, Adelaide, South Australia, Australia

figure-of-eight coil (MagVenture A/S, Denmark). In acute courses, either 18 or 20 treatments were administered over six or four weeks respectively, whilst maintenance treatments were delivered every one to four weeks. Patients were offered earplugs, or listened to relaxation or mindfulness recordings, during treatment. Two hundred and five individual patients have been treated, 45 more than once (262 courses in total). There have been a total of 6,155 rTMS treatments; 5,008 (81.4%) acute course treatments, and 1,147 (18.6%) maintenance treatments. There were no serious adverse events – in particular, there have been no seizures and no manic episodes associated with rTMS. More than two thirds of patients (69.4%) indicated that they experienced no side-effects. Only 4.3% reported side-effects that were severe enough to interfere with functioning, with just one patient indicating that the therapeutic benefit was outweighed by the side-effects experienced. The remaining patients said they were aware of side-effects but that these did not interfere with functioning. Consistent with the literature (Rossi et al., 2009), the side-effects commonly reported were mild, mostly localised discomfort at the site of stimulation and headaches. Some patients also reported tiredness following treatment sessions. Discomfort at the site was addressed by reducing the intensity of the stimulus. Overall, only 8.0% of patients dropped out before completing their course, often because of side-effects or lack of efficacy. One patient cited nausea and dizziness as the reason.

Patients were referred by their treating psychiatrists, and people with comorbid medical conditions (except epilepsy) were not excluded. People with psychiatric comorbidities, other than drug and alcohol use disorders, were also accepted for treatment. The present report therefore provides naturalistic Australian data about the safety of rTMS, in a clinical setting. Drop-out rates and incidences of troublesome side-effects were low, and treatment was generally well accepted.

Corresponding author: Xiaowen Wu, The University of Adelaide, 11 Garnet Crescent, Flagstaff Hill, Adelaide, South Australia 5159, Australia. Email: [email protected]

activating and cognitive enhancing effects, there is an expanding list of off-label use, including the treatment of methamphetamine and cocaine withdrawal. Although modafinil was previously thought to be nonaddictive (Jasinski, 2000),we present a possible case of modafinil dependence. Mr A is a 23-year old man prescribed modafinil 200 mg for 6 weeks as an adjunctive treatment for

DOI: 10.1177/0004867414565480

1Department

Modafinil is a novel, nonamphetaminebased wake promoting medication approved for narcolepsy and obstructive sleep apnoea. Owing to its

Acknowledgements The authors wish to acknowledge Carol Turnbull, CEO of The Adelaide Clinic and the rTMS Unit clinical staff.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References Galletly C, Fitzgerald P, Gill S, et  al. (2010) A practical guide to setting up a repetitive Transcranial Magnetic Stimulation (rTMS) service. Australasian Psychiatry 18: 314–317. Gaynes BN, Lloyd SW, Lux L, et  al. (2014) Repetitive transcranial magnetic stimulation for treatment-resistant depression: a systematic review and meta-analysis. The Journal of Clinical Psychiatry 75: 477–489. Rossi S, Hallett M, Rossini PM, et al. (2009) Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clinical Neurophysiology 120: 2008–2039.

Australian & New Zealand Journal of Psychiatry, 49(5)

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How safe is repetitive Transcranial Magnetic Stimulation?

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