JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY

Volume 26, Number 7, 2016 Brief Report

ª Mary Ann Liebert, Inc.
Pp. 1–5
DOI: 10.1089/cap.2016.0070

Seizure Induced by Deep Transcranial Magnetic Stimulation

in an Adolescent with Depression

Kathryn R. Cullen, MD,1 Suzanne Jasberg, MD,1 Brent Nelson, MD,1

Bonnie Klimes-Dougan, PhD,1 Kelvin O. Lim, MD,1 and Paul E. Croarkin, DO, MSCS2

Abstract
Objective: Deep transcranial magnetic stimulation (TMS) with an H-1 coil was recently approved by the U.S. Food and Drug
Administration (U.S. FDA) for treatment-resistant depression (TRD) in adults. Studies assessing the safety and effectiveness
of deep TMS in adolescent TRD are lacking. The purpose of this brief report is to provide a case history of an adolescent
enrolled in an investigational deep TMS protocol.
Methods: A case history is described of the first participant of a sham-controlled clinical trial who had a seizure in the course
of deep TMS with parameter settings extrapolated from the adult studies that led to US FDA approval (H-1 coil, 120% target
stimulation intensity, 18 Hz, 55 trains of 2-second duration, total 1980 pulses).
Results: The participant was a 17-year-old unmedicated female, with no significant medical history and no history of seizures
or of drug or alcohol use. Brain magnetic resonance imaging showed no structural abnormalities. She initially received sham,
which was well tolerated. During active treatment sessions, titration began at 85% of motor threshold (MT) and increased by
5% per day. Her weekly MT measurements were stable. On her first day of 120% MT (8th active treatment), during the 48th
train, the participant had a generalized, tonic–clonic seizure that lasted 90 seconds and resolved spontaneously. She had an
emergency medicine evaluation and was discharged home without anticonvulsant medications. There were no further
seizures reported at a 6-month follow-up.
Conclusions: We report a deep TMS-induced generalized tonic–clonic seizure in an adolescent with TRD participating in a
clinical trial. Given the demonstrated benefits of deep TMS for adult TRD, research investigating its use in adolescents with
TRD is an important area. However, in light of this experience, additional precautions for adolescents should be considered.
We propose that further dose-finding investigations are needed to refine adolescent-specific parameters that may be safe and
effective for treating adolescents with TRD with deep TMS.

Introduction a rapidly oscillating electrical current is placed on the scalp, to

induce electrical currents in the brain (Roth et al. 2007). TMS is
used in neuroscientific research to investigate brain functioning,
M ajor depressive disorder frequently emerges during ado-
lescence and can be difficult to treat. Only 50%–60% of
adolescents respond to conventional treatments (e.g., antidepres-
and when used repetitively over the dorsolateral prefrontal cortex (a
brain region that is hypoactive in depression) (Mayberg 1997), has
sant medication and cognitive behavioral therapy) after 12 weeks been shown to alleviate depression symptoms (Kedzior and Reitz
(March et al. 2006; Brent et al. 2008). Expert reviews of longer 2014). In 2008, the U.S. Food and Drug Administration (US FDA)
term follow-up studies suggested that 40% of adolescents with approved the use of repetitive TMS with the Neurostar TMS sys-
depression do not achieve remission with treatment and can therefore tem, which uses a figure-8 coil, with a protocol that included spec-
be said to have ‘‘treatment-resistant depression’’ (TRD) (Maalouf ified settings regarding intensity, frequency, and number of pulses.
et al. 2011). Since these adolescents with TRD are at risk for per- Recent advances in custom coil technology led to the development of
sistent depression in adulthood, morbidity, and suicide, there is an H coils that support stimulation of deeper, nonfocal limbic structures
urgent need to develop novel interventions to relieve depression in (Roth et al. 2007) relevant to depression and other neuropsychiatric
adolescents with TRD (Maalouf et al. 2011). disease. Use of the H-1 coil has been termed ‘‘deep TMS.’’ Deep
Transcranial magnetic stimulation (TMS) is a procedure in TMS was approved by the US FDA in 2013 for adults with TRD
which a magnetic coil that generates a pulsatile magnetic field from based on pivotal studies (Berlim et al. 2014; Levkovitz et al. 2015).

1
Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota.
2
Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota.
Funding: This study was supported by the MnDRIVE Neuromodulation Innovation Grant. The study was also supported, in part, by Brainsway, who
provided the use of the deep TMS machine at no charge.

1
2 CULLEN ET AL.

The two TMS systems (with their respective protocols that have 65% of device intensity. The patient did not show any clinical
some differences in settings) have been deemed by the US FDA to be improvement. For example, raw CDRS-R scores at baseline and
equivalent with respect to efficacy and safety (www.accessdata.fda. after Phase 1 were both 60.
gov/cdrh_docs/pdf12/k122288.pdf). As per the approved protocol, the patient was given the option and
Although TMS is thought to be generally safe in children and chose to continue on in the study for Phase 2 of active treatment. On
adolescents (Krishnan et al. 2015), there is a dearth of research her first day, she did not tolerate 100% of MT intensity due to pain at
about the use of TMS as a treatment for adolescent depression. stimulation site and so was given 85% of MT intensity, which was
Initial small, open-labeled repetitive TMS studies have been con- tolerated. She was able tolerate titration increase by 5% per day. Her
ducted in adolescent TRD, using a standard figure-8 TMS coil. These MT was reassessed on her fifth day of active treatment, which was
studies suggested response rates ranging from 30% to 70% (Bloch 64% of device intensity. The titration reached the target energy of
et al. 2008; Wall et al. 2011). No results from any randomized, 120% on the eighth day of active treatment. During the 48th train, her
controlled trials testing the application of repetitive TMS (using any right zygomaticus and risorius muscles contracted and remained
coil) in adolescent TRD have yet been published. Furthermore, contracted following the train. The patient and operator were aware of
to date, no studies have examined deep TMS (with an H-1 coil) in this and the machine was stopped. She then exhibited bilateral con-
adolescent TRD. Prior commentaries have raised important concerns vulsions. The helmet was removed from the participant, the chair was
regarding the application of noninvasive brain stimulation in devel- lowered, and the rapid response medical team was called. The gen-
oping children. Dosing guidelines, relevant translational work, and eralized, tonic–clonic seizure lasted for *90 seconds and resolved
the understanding of the effects in this population are limited (Davis spontaneously. She did not bite her tongue and was not incontinent
2014). Given the limited information on safety of applying deep of urine. She was confused and disoriented following the event. She
TMS in adolescents with depression, we thought it was important to was transferred via gurney to an ambulance and delivered to the
report on an induced seizure in an adolescent with TRD from a recent Pediatric Emergency Room at the University of Minnesota Masonic
deep TMS clinical trial. Children’s hospital, where she was evaluated and discharged. A pe-
diatric neurologist was consulted who recommended that anticon-
Methods vulsant medications were not indicated. Follow-up with neurology
was not recommended. She returned for her final clinical research
We recently initiated a single-site, sham-controlled clinical trial
visit 5 days later and reported that confusion had continued inter-
to test the safety and efficacy of deep TMS as an intervention for
mittently for 2–3 days after the incident, and was resolved completely
adolescents with an H-1 coil. The protocol consists of two phases.
by the time of the visit. She also reported an improvement in mood in
Phase 1 consists of 20 treatments over 4 weeks of active treatment
the 2–3 days following the episode, but a return to baseline by the
or sham (1:1 randomization). All participants are unblinded at the
time of the visit (no substantial change in depression severity scores;
end of Phase 1. Clinical response is defined as at least a 50%
raw CDRS-R score of 57). She then exited the study. Chart review
improvement in depression symptoms as measured by the Chil-
indicates that 6 months later, the patient had no further seizures.
dren’s Depression Rating Scale, Revised (CDRS-R) (Poznanski
et al. 1985). The optional Phase 2 consists of 4 weeks of active
treatment (five times per week for nonresponders to active treat- Discussion
ment or sham, twice per week for responders to active treatment;
Very little information has been published regarding the treat-
responders to sham do not go on to Phase 2).
ment of adolescent depression with repetitive TMS. Bloch et al.
The deep TMS protocol consists of energy intensity at 120% of
(2008) studied 9 adolescents using the figure-8 coil, 80% of MT
motor threshold (MT), 55 trains (or bursts of stimulations) of
intensity, 20 minutes/day over 14 working days, 10 Hz for 2 sec-
18 Hz, each train was 2 seconds in duration, 20-second intertrain
onds per train, and intertrain interval of 58 seconds. Wall et al.
intervals, with 1980 total pulses per session. MT is defined as the
(2011) treated 8 adolescents, also using a figure-8 coil, 30 treat-
lowest stimulation intensity, delivered over the left motor cortex,
ments given 5 days per week over 6–8 weeks, using intensity 120%
which leads to either an observable muscle twitch or a motor-
of calculated MT, 10 Hz, with stimulus train duration of 4 seconds,
evoked potential in the right abductor pollicis brevis as measured
and an intertrain interval of 26 seconds, for a total of 3000 stimu-
by electromyography. All MT measurements in this case were eval-
lations per treatment session. Both studies suggested promising
uated by the same clinician (B.N.). The protocol involves an initial
effects and no seizures were reported in either of these studies. A
titration period in which the first treatment is given at 100% of MT
recent systematic review examined the acute safety and effects of
(or as low as 80% as tolerated), and increasing intensity at a maximum
repetitive TMS in 322 children and adolescents enrolled in pub-
of 10% per day to the target of 120% over a maximum titration length
lished studies. Of these participants, two (<1%) had a reported
of 2 weeks.
seizure (Krishnan et al. 2014).
Both prior published reports of a TMS-induced seizure in ado-
Results
lescents with depression involved the use of a standard figure-8 coil.
The first participant was a 17-year-old, unmedicated female with Hu et al. (2011) reported on a 15-year-old female with depression
TRD. She had previously failed trials of multiple antidepressant (concurrently taking sertraline with limited benefit) who was initiated
medications, either due to ineffectiveness or intolerability. Medical on a repetitive TMS protocol with the figure-8 coil over the left
history was notable only for a history of chronic frequent headaches dorsolateral prefrontal cortex at 100% of resting MT, 10 Hz, 60 trains
beginning in childhood, which were treated with over-the-counter of 5-second duration, 25-second intertrain interval, and 3000 total
pain relievers about once a week. She had no history of seizures, pulses. During the first treatment, she had a generalized, tonic–clonic
and there was no history of or current alcohol or substance use. A seizure. The case report noted that the patient developed some hy-
brain magnetic resonance imaging at baseline revealed no struc- pomanic symptoms on the evening following the seizure, but these
tural abnormalities. She was randomized to sham in the first phase, attenuated the next day. She did not receive further repetitive TMS
which was well tolerated. Weekly MT measurements were stable at treatments, but did continue sertraline. In 3 weeks, her depressive
SEIZURE WITH TMS IN ADOLESCENT DEPRESSION 3

symptoms improved and she was considered ‘‘clinically stable.’’ She (Bloch et al. 2008; Wall et al. 2011), may have played a role in the
did not have further seizures. Authors noted that the concurrent use of induced seizure. Krishnan et al. (2015) noted that most TMS studies
sertraline may have reduced the seizure threshold in this patient (Hu to date have used frequencies of 1–10 Hz, but three reports did use
et al. 2011). Chiamberro et al. (2013) reported on a 16-year-old girl higher frequencies. First, Graf-Guerrero et al. (2004) reported two
with depression (concurrently treated with sertraline, olanzapine, and cases of children with epilepsy (aged 7 and 11) who were treated
hydroxyzine, also with limited benefit) who was initiated in a repet- with a figure-8 coil over the left frontal cortex (the epileptogenic
itive TMS treatment protocol using the figure-8 coil over the dorso- focus), using a frequency of 20 Hz, 15 trains of 2 seconds, 600 total
lateral prefrontal cortex, at 10 Hz, with 60 trains of 5-second duration, pulses for 15 minutes, one session total. For one of the cases, au-
25-second intertrain interval, and 3000 stimuli per day, 5 days a week. thors reported using 50% of the maximum stimulator output, and
A seizure occurred on her 12th day of stimulation. It was noted that the other case, 128% of resting MT was used. No adverse effects
she had a high level of blood alcohol concentration (0.20%) in the were reported in those cases. Wu et al. (2012) examined 40 children
postseizure examination. In contrast to prior reports of adolescent aged 8–17 with Tourette Disorder or healthy controls. They used a
TMS-induced seizures, the adolescent in this report had no risk fac- figure-8 coil, 50%–80% active MT intensity, 30–50 Hz, continuous
tors, was taking no current medications, and denied any alcohol use. intermittent theta burst, intertrain interval 8 seconds, 600 total pulses,
It is critical to consider several other factors that may have 0.667 minutes per session, 43 sessions, targeting the motor cortex.
contributed to higher risk of seizure in this case, including the type No seizures were reported. Third, Oberman et al. (2014) reported on
of coil and parameter settings such as intensity and frequency. First, 19 adolescents ages 9–18 with autism. They used a figure-8 coil over
in contrast to prior reports, this study applied deep TMS using the the left motor cortex, intensity 80% of resting MT, 50 Hz frequency,
H-1 coil. This intervention has the potential to target deep limbic continuous theta burst, 600 total pulses, and one 40-second session
neurocircuitry with limitations in focality (Deng et al. 2013). The (Oberman et al. 2014). There were no induced seizures in these three
risk of seizure in adults with repetitive TMS using a figure-8 coil reports (Graff-Guerrero et al. 2004; Wu et al. 2012; Oberman et al.
has been estimated as 3/1000 per treatment, or <1% risk per overall 2014). Considering the outcome of the present report, caution is
acute treatment course (Carpenter et al. 2012). Less information is warranted in applying higher intensities and frequencies of stim-
available about seizure rates in deep TMS, since it is a newer ulation for adolescents with depression.
intervention. In the pivotal sham-controlled trial, 1 out of 101 pa- Finally, given ongoing brain development during adolescence,
tients had a seizure (Levkovitz et al. 2015). A very recent case has there may be development-dependent effects of stimulation, both
been reported in the literature of a 27-year-old man with depression with respect to efficacy and safety. Adolescents could have a
and anxiety who had a seizure during deep TMS treatment with an higher risk for TMS-induced seizure based on their earlier stage in
H-1 coil (Boes et al. 2016). It should be noted that the patient had brain development. The trajectory of cortical excitability in de-
several other seizure risk factors, including multiple past head in- velopment and the impact of depression on this trajectory have
juries, intake of a large amount of alcohol the night before treat- only recently been examined. Croarkin et al. (2012) have reported
ment, and poor sleep the night before treatment. In a review of that in adolescents with TRD, treatment with repeated TMS (using
studies to date using deep TMS in adults with depression, out of a figure-8 coil, 10 Hz, 120% MT intensity) can lead to increased
more than 7000 patients treated with the protocol used in the present cortical excitability (measured by decreased MT) after 5 weeks of
study, only eight seizures have been reported to date; all cases so far, treatment, which potentially could increase the seizure risk. In
except for one, had risk factors such as excessive doses of medica- addition, younger patients may have higher MTs (Croarkin et al.
tions that increase neuronal excitability or withdrawal from alcohol 2014). As adolescents may have lower seizure thresholds, yet
use (Dr. Yiftach Roth, Chief Scientist, Brainsway Ltd., pers. comm.). higher MTs relative to adults (Frye et al. 2008), neurodevelop-
However, the rate of deep TMS-induced seizure in adolescents with ment should be considered in future study designs. Specifically,
the H-1 is unknown. The fact that a seizure emerged in our first the selection of developmentally sensitive, optimal treatment pa-
participant in a protocol based on adult studies is concerning and rameters represents an important clinical area in need of empirical
suggests that additional caution may be necessary with deep TMS in investigation.
adolescents.
Second, it is possible that the target intensity chosen for this study
Conclusion
(selected based on the parameters that have been shown to be ef-
fective in adults) (Berlim et al. 2014; Levkovitz et al. 2015) may In conclusion, we report a generalized tonic–clonic seizure in-
have increased risk for seizure in this adolescent. The risk of TMS- duced by deep TMS in an adolescent with TRD. Given the prior
induced seizure is known to increase both with increasing intensity of experience and success of repetitive TMS in treating adult TRD,
the stimulation and with frequency of the stimulation (Rossi et al. both with a figure-8 coil and deep TMS using an H-1 coil, further
2009). In the case reported here, the adolescent participant tolerated research investigating the use of these devices in adolescent TRD
lower intensities of TMS but had the seizure during the first treatment is warranted. Furthermore, given the potential additional benefit
with the target intensity of 120%. Levkovitz et al. (2009) studied of the H-1 coil, compared to the standard figure-8 coil, based on its
different deep TMS settings in 65 adults with MDD and found that capacity to stimulate deeper structures relevant to depression, fu-
high intensity (120% of MT) but not low-intensity (110% of MT) ture studies in adolescent depression are imperative. While the case
deep TMS for 4 weeks was an effective treatment (and no partici- reported here could have represented a random event, in which case
pants in the study experienced seizures) (Levkovitz et al. 2009). modifications to the adult H-1 coil protocol may not be needed, the
Although one of the initial pilot studies in adolescents with depres- case highlights the lack of important information needed for se-
sion (using a standard, figure-8 coil) used lower intensity (Mayer lecting optimal parameters for deep TMS treatment in adolescents.
et al. 2012), the other work has used 120% intensity with no reported Thus, in light of this case report, which represents the first reported
seizures to date (Wall et al. 2011; Croarkin et al. 2016). use of deep TMS technology in adolescent TRD, we urge clinicians
Third, the frequency setting of 18 Hz in our protocol, which is and researchers to appreciate the risk of seizure and take additional
higher than that used in previous adolescent depression studies caution in selecting the coil and stimulation parameter settings for
4 CULLEN ET AL.

treatment of adolescents with depression. When considering deep resistant depression: The TORDIA randomized controlled trial.
TMS, the depth of stimulation and decreased focality relative to JAMA 299:901–913, 2008.
standard repetitive TMS may necessitate special considerations for Carpenter LL, Janicak PG, Aaronson ST, Boyadjis T, Brock DG,
selecting frequency and intensity, given the developmental differ- Cook IA, Dunner DL, Lanocha K, Solvason HB, Demitrack MA:
ences in excitatory/inhibitory balances (Deng et al. 2013). Transcranial magnetic stimulation (TMS) for major depression: A
This report also underscores broad considerations for child and multisite, naturalistic, observational study of acute treatment out-
adolescent psychiatry research. For example, the importance of comes in clinical practice. Depress Anxiety 29:587–596, 2012.
developmentally appropriate outcome and measures of illness se- Chiramberro M, Lindberg N, Isometsä E, Kähkönen S, Appelberg B:
verity are often underappreciated. As with psychopharmacologic Repetitive transcranial magnetic stimulation induced seizures in an
adolescent patient with major depression: A case report. Brain
research, there are key but frequently understated differences in
Stimul 6:830–831, 2013.
outcome and severity measures. Pharmacokinetic, pharmacody-
Croarkin PE, Nakonezny PA, Lewis CP, Zaccariello MJ, Huxsahl JE,
namic, and neurodevelopmental considerations are frequently over-
Husain MM, Kennard BD, Emslie GJ, Daskalakis ZJ: Develop-
looked in study design. The practice of extrapolating findings and mental aspects of cortical excitability and inhibition in depressed
dosing patterns from adults to youth has been problematic for and healthy youth: An exploratory study. Front Hum Neurosci
pharmacologic research (Emslie 2012), and this lesson may be even 8:669, 2014.
more important in application to brain stimulation research. Mov- Croarkin PE, Nakonezny PA, Wall CA, Murphy LL, Sampson SM,
ing forward, we suggest that dose-finding, modeling, and patient Frye MA, Port JD: Transcranial magnetic stimulation potentiates
registry studies are needed to advance the safe and ethical devel- glutamatergic neurotransmission in depressed adolescents. Psy-
opment of these potentially life-changing treatments for children chiatry Res 247:25–33, 2016.
and adolescents. Croarkin PE, Wall CA, Nakonezny PA, Buyukdura JS, Husain MM,
Sampson SM, Emslie GJ, Kozel FA: Increased cortical excitability
Clinical Significance with prefrontal high-frequency repetitive transcranial magnetic
stimulation in adolescents with treatment-resistant major depressive
This is the first case report of a deep TMS-induced seizure in an disorder. J Child Adolesc Psychopharmacol 22:56–64, 2012.
adolescent with TRD. The characterization of this event will inform Davis NJ: Transcranial stimulation of the developing brain: A plea for
future protocol development and off-label practice. extreme caution. Front Hum Neurosci 8:600, 2014.
Deng Z-D, Lisanby SH, Peterchev AV: Electric field depth-focality
Acknowledgments tradeoff in transcranial magnetic stimulation: Simulation compari-
The authors thank the adolescent and family who volunteered to son of 50 coil designs. Brain Stimul 6:1–13, 2013.
participate in this research study. Dr. Croarkin has received grant Emslie GJ: Are adults just big children? Am J Psychiatry 169:248–
support from Pfizer, Inc., the National Institute of Mental Health 250, 2012.
Frye RE, Rotenberg A, Ousley M, Pascual-Leone A: Transcranial
(NIMH) (K23 MH100266), the Brain and Behavior Research Foun-
magnetic stimulation in child neurology: Current and future di-
dation, and the Mayo Clinic Foundation. He has received in-kind
rections. J Child Neurol 23:79–96, 2008.
support for equipment and support for a multicenter trial from Neu-
Graff-Guerrero A, Gonzáles-Olvera J, Ruiz-Garcı́a M, Avila-Ordoñez U,
ronetics, Inc. The content of this report is solely the responsibility Vaugier V, Garcı́a-Reyna JC: rTMS reduces focal brain hyperperfu-
of the authors and does not necessarily represent the official views sion in two patients with EPC. Acta Neurol Scand 109:290–296, 2004.
of the US Department of Health and Human Services, the National Hu S-H, Wang S-S, Zhang M-M, Wang J-W, Hu J-B, Huang M-L,
Institutes of Health, or the NIMH. Trial Registration: clinical Wei N, et al.: Repetitive transcranial magnetic stimulation-induced
trials.gov identifier: NCT02611206; https://clinicaltrials.gov/ct2/ seizure of a patient with adolescent-onset depression: A case report
show/NCT02611206?term = Adolescent–TMS&rank = 7 and literature review. J Int Med Res 39:2039–2044, 2011.
Kedzior KK, Reitz SK: Short-term efficacy of repetitive transcranial
Disclosures magnetic stimulation (rTMS) in depression—reanalysis of data
No competing financial interests exist. from meta-analyses up to 2010. BMC Psychol 2:39, 2014.
Krishnan C, Santos L, Peterson MD, Ehinger M: Safety of noninvasive
brain stimulation in children and adolescents. Brain Stimul 8:76–87,
References
2015.
Berlim MT, Van den Eynde F, Tovar-Perdomo S, Chachamovich E, Levkovitz Y, Harel EV, Roth Y, Braw Y, Most D, Katz LN, Sheer A,
Zangen A, Turecki G: Augmenting antidepressants with deep Gersner R, Zangen A: Deep transcranial magnetic stimulation over
transcranial magnetic stimulation (DTMS) in treatment-resistant the prefrontal cortex: Evaluation of antidepressant and cognitive
major depression. World J Biol Psychiatry 15:570–578, 2014. effects in depressive patients. Brain Stimul 2:188–200, 2009.
Bloch Y, Grisaru N, Harel EV, Beitler G, Faivel N, Ratzoni G, Stein Levkovitz Y, Isserles M, Padberg F, Lisanby SH, Bystritsky A, Xia G,
D, Levkovitz Y: Repetitive transcranial magnetic stimulation in the Tendler A, et al.: Efficacy and safety of deep transcranial magnetic
treatment of depression in adolescents: An open-label study. J ECT stimulation for major depression: A prospective multicenter ran-
24:156–159, 2008. domized controlled trial. World Psychiatry 14:64–73, 2015.
Boes AD, Stern AP, Bernstein M, Hooker JE, Connor A, Press DZ, Maalouf FT, Atwi M, Brent DA: Treatment-resistant depression in
Pascual-Leone A: H-coil repetitive transcranial magnetic stimula- adolescents: Review and updates on clinical management. Depress
tion induced seizure in an adult with major depression: A case Anxiety 28:946–954, 2011.
report. Brain Stimul 2016 [Epub ahead of print]; DOI: 10.1016/ March J, Silva S, Vitiello B: The treatment for adolescents with de-
j.brs.2016.04.013. pression study (TADS): Methods and message at 12 weeks. J Am
Brent D, Emslie G, Clarke G, Wagner KD, Asarnow JR, Keller M, Acad Child Adolesc Psychiatry 45:1393–1403, 2006.
Vitiello B, et al.: Switching to another SSRI or to venlafaxine with Mayberg HS: Limbic-cortical dysregulation: Depression. J Neu-
or without cognitive behavioral therapy for adolescents with SSRI- ropsychiatry Clin Neurosci 9:471–481, 1997.
SEIZURE WITH TMS IN ADOLESCENT DEPRESSION 5

Mayer G, Faivel N, Aviram S, Walter G, Bloch Y: Repetitive tran- Wall CA, Croarkin PE, Sim LA, Husain MM, Janicak PG, Kozel FA,
scranial magnetic stimulation in depressed adolescents: Experience, Emslie GJ, Dowd SM, Sampson SM: Adjunctive use of repetitive
knowledge, and attitudes of recipients and their parents. J ECT transcranial magnetic stimulation in depressed adolescents: A pro-
28:104–107, 2012. spective, open pilot study. J Clin Psychiatry 72:1263–1269, 2011.
Oberman LM, Enticott PG, Casanova MF, Rotenberg A, Pascual- Wu SW, Shahana N, Huddleston DA, Lewis AN, Gilbert DL: Safety
Leone A, McCracken JT: Transcranial magnetic stimulation (TMS) and tolerability of theta-burst transcranial magnetic stimulation in
therapy for autism: An international consensus conference held in children. Dev Med Child Neurol 54:636–639, 2012.
conjunction with the International Meeting for Autism Research on
May 13th and 14th, 2014. Front Hum Neurosci 8:1034, 2014.
Poznanski EO, Freman LN, Mokros HB: Children’s Depression
Rating Scale-Revised. Psychopharmacol Bull 21:979–989, 1985. Address correspondence to:
Rossi S, Hallett M, Rossini PM, Pascual-Leone A; Safety of TMS Kathryn R. Cullen, MD
Consensus Group: Safety, ethical considerations, and application Department of Psychiatry
guidelines for the use of transcranial magnetic stimulation in clinical University of Minnesota
practice and research. Clin Neurophysiol 120:2008–2039, 2009. F256/2B West Building
Roth Y, Amir A, Levkovitz Y, Zangen A: Three-dimensional distri- 2450 Riverside Avenue
bution of the electric field induced in the brain by transcranial Minneapolis, MN 55454
magnetic stimulation using figure-8 and deep H-coils. J Clin Neu-
rophysiol 24:31–38, 2007. E-mail: rega0026@umn.edu