Accepted Manuscript

Title: Monotherapy with tDCS for Treatment of Depressive Episode during

Pregnancy: A Case Report

Author: Vanteemar S Sreeraj, Anushree Bose, Vandita Shanbhag, Janardhanan

C. Narayanaswamy, Ganesan Venkatasubramanian, Vivek Benegal

PII: S1935-861X(16)30035-3
DOI: http://dx.doi.org/doi: 10.1016/j.brs.2016.03.007
Reference: BRS 867

To appear in: Brain Stimulation

Received date: 21-2-2016

Please cite this article as: Vanteemar S Sreeraj, Anushree Bose, Vandita Shanbhag, Janardhanan
C. Narayanaswamy, Ganesan Venkatasubramanian, Vivek Benegal, Monotherapy with tDCS for
Treatment of Depressive Episode during Pregnancy: A Case Report, Brain Stimulation (2016),
http://dx.doi.org/doi: 10.1016/j.brs.2016.03.007.

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Ms. Ref. No.: BRS-D-16-00090-R1 (Revised Submission)

Monotherapy with tDCS for Treatment of Depressive Episode during Pregnancy:

A Case Report

Vanteemar S Sreeraj, Anushree Bose, Vandita Shanbhag, Janardhanan C.

Narayanaswamy, Ganesan Venkatasubramanian*, Vivek Benegal

Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore,

India

* Corresponding author
Dr Ganesan Venkatasubramanian MD PhD
Additional Professor and Wellcome Trust / DBT India Alliance Senior Fellow
Department of Psychiatry
National Institute of Mental Health And Neurosciences (NIMHANS)
Bangalore 560029
Email – venkat.nimhans@yahoo.com

Key Words
tDCS, depression, pregnancy.

Word Count
Manuscript text: 725 words + 10 References

Acknowledgements
This work is supported by as the Department of Science and Technology (Government of India)
Research Grant (SR/CSI/158/2012) to GV. AB is supported by the Wellcome Trust / DBT India
Alliance.

Conflict of interest
There are no potential conflicts of interest to report for any of the authors

Page 1 of 5
To the Editor:

Major depressive disorder is common during pregnancy (7-15% prevalence), and

untreated depression can adversely impact maternal and fetal health 1. Antidepressants

represent the mainstay treatment for moderate to severe depressive episode; however,

when used during pregnancy, they can lead to spontaneous abortions, low birth weight,

preterm birth, neonatal cardiovascular malformations, neonatal pulmonary hypertension,

fetal death, seizures and long term risk for autism2. It has been observed that the

majority of pregnant women with depression (about 80%) do not seek treatment

possibly due to the perceived risks with antidepressants1. Alternative treatment options

like psychotherapy are limited by their suboptimal efficacy as well as longer durations

required for clinical improvement, Electroconvulsive therapy in this population is limited

by its invasiveness and hence its clinical utility is restricted to severe depression with

suicidal risk.

Given its efficacy in treating depression3, localized stimulation of the brain using

transcranial direct current stimulation (tDCS) is proposed to be a safer alternative during

pregnancy4. In this report, we describe the successful application of tDCS in treating

moderate depressive episode with anxiety symptoms during the first trimester of

pregnancy.

Ms. X, a 23-year-old married woman, during her 6th week of pregnancy, presented to us

with 2 months history of problems, suggestive of a depressive episode, characterized by

sleeplessness, reduced appetite, crying spells, negative cognitions, diminishing self-

confidence, apprehensions regarding health, marked periods of anxiety with

palpitations, tremors and restlessness and diurnal variations of mood, with marked

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psychosocial dysfunction. Moderately severe scores on the Hamilton depression and

anxiety rating scale (HAM-D and HAM-A), 18 and 32 respectively, were noted. In the

previous 3-years, she had suffered two episodes of depression that were successfully

treated with sertraline (100mg/day). Three months before the current presentation, she

was advised to stop sertraline having been in remission for one year, and because she

planned a pregnancy.

Given the potential benefits of tDCS to treat depression during pregnancy,

monotherapy with tDCS was initiated for this patient. We obtained written informed

consent (from the patient as well as her husband) after providing necessary information

about tDCS; moreover, the patient was assessed independently by an obstetrician to

rule out specific contraindications.

tDCS was delivered using a standard equipment (Neuroconn DC Stimulator Plus,

http://www.neuroconn.de/dc-stimulator_plus_en/) using stringent safety measures5. We

employed bifrontal electrode (25-cm2) placement with, anode corresponding to the F3

area and the cathode corresponding to the F4 area on the scalp (10-20 EEG system).

Rubber electrodes inserted in saline-soaked sponges were fixed with a non-conductive

headband. A direct current of 2-mA was delivered for 30 minutes, with 20 seconds fade-

in/fade-out time (i.e. current being slowly ramped-up/ramped-down over a period of 20

seconds to reduce discomfort), daily for 10 days (with a one day break after the 8th

session)6.

The patient tolerated tDCS well without any significant adverse effect as ascertained by

a structured questionnaire after each session5. The only minor adverse effect reported

was that in 3 out of the total 10 tDCS sessions, during the fade-in phase (i.e. initial

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ramp-up period of 20 seconds), the patient experienced transient, mild burning

sensations at the site of application and fleeting experience of phosphenes. A booster

session was given a week later. During the follow-up reassessment at 1- month after

the 10th tDCS session, depression and anxiety scores had further reduced to 6 and 5

respectively, suggesting clinical remission.

To the best of our knowledge, this is likely the first report of the successful application of

tDCS in a pregnant woman with depression. tDCS monotherapy resulted in significant

improvement of the depressive and anxiety symptoms during pregnancy and was

tolerated very well in this patient. This is in tune with the previous case of a pregnant

woman with auditory hallucination7 and with the excellent safety profile of tDCS

observed in laboratories across the world8. Interestingly, for pain relief during labor,

Transcranial electrical nerve stimulation (TENS) with a strength of 100mA (100-mA

current, i.e. about 50 times of tDCS) has been used safely in pregnancy for several

decades9. tDCS does not affect autonomic function, ventilation rate or core body

temperature in healthy volunteers receiving tDCS10. All these strongly suggest that non-

invasive brain stimulation using tDCS is unlikely to result in any significant risk to the

fetus. Further systematic large scale trials along the lines of ongoing studies4 are likely

to build the evidence base to strengthen the clinical utility of tDCS in pregnancy.

Page 4 of 5
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