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Choosing the optimum strategy for rTMS
  1. Toshi A Furukawa
  1. Departments of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
  1. Correspondence to Dr Toshi A Furukawa, Departments of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto 606-8501, Japan; furukawa{at}kuhp.kyoto-u.ac.jp

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Clinical case

Patient

A 45-year-old man.

Present illness

Mr A had been living a relatively eventless and successful life: after graduating from college, he found a post in the local government, got married with one of the colleagues at the office; the couple had two kids, and the patient was promoted to the section head at the age of 35 years, which is neither early nor late as a typical government employee. However, this section was in charge of the refurbishing of the old city centre, for which Mr A had to negotiate with all sorts of interested parties. The negotiation was endless while the deadline for the project was mandated by the mayor. His first major depressive episode set in, due to which he took a sickness leave for 6 months. After return to the office, he was transferred to a new section where he was exempted from important tasks. Since then he has had several major depressive episodes, with the most recent one lasting now almost 2 years. As he appeared less and less responsive to drug treatments, the psychiatrist in charge referred him to your clinic, which has recently acquired a repetitive transcranial magnetic stimulation (rTMS) device.

Present status

On presentation he was a man of medium build. He had been treated with venlafaxine up to 225 mg/day and escitalopram up to 20 mg/day, with augmentation attempts with aripiprazole and with lithium, all of which appeared somewhat effective in the beginning but every time the patient …

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