Treatment-Resistant Depression Resolved with 6 Weeks of rTMS

PRESENTING COMPLAINT — A 42-year-old male presented with a two-year history of pervasive low mood, anhedonia, sleep disturbance, and diminished professional functioning. Despite adequate trials of two SSRIs (escitalopram 20 mg for 10 weeks; sertraline 150 mg for 12 weeks) with concurrent CBT, symptoms persisted with only partial benefit. ASSESSMENT — MADRS score 32 (severe). No psychotic features. Negative for bipolar spectrum on MDQ. Metabolic and thyroid panels normal. MRI brain unremarkable. Family history significant for maternal depression. INTERVENTION — Following full informed consent, a 30-session course of high-frequency (10 Hz) rTMS was delivered over the left dorsolateral prefrontal cortex at 120% of resting motor threshold, five days per week for six weeks. Existing SSRI continued at maintenance dose. OUTCOME — MADRS reduced to 8 by week 4 and to 3 by week 6 (remission). Return to full occupational functioning at week 5. At 6-month follow-up, gains sustained on maintenance sertraline alone, with two monthly rTMS booster sessions. DISCUSSION — This case illustrates rTMS as a well-tolerated, evidence-based intervention for treatment-resistant depression, particularly when patients prefer to avoid ECT or additional pharmacological load.